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In the last decade, gay men and other men who have sex with men (MSM) have come to the fore of policy debates about AIDS prevention. In stark contrast to global AIDS policy during the first two decades of the epidemic which excluded MSM from policy outside the West, UNAIDS now identifies MSM as "marginalized but not marginal" to the global AIDS epidemic. This dissertation provides an account of this controversial reversal of global AIDS policy and uses it as a point of departure for understanding the role of intergovernmental organizations (IGOs) like UNAIDS in the formation of global health priorities.In contrast to the emergence of other health and social policy issues, various studies observe that efforts to establish a global agenda for addressing HIV and AIDS have been highly concentrated within intergovernmental organizations. How and in whose interests do new priorities emerge within AIDS IGOs? Health policy researchers argue that IGOs have considerable influence in the formation and dissemination of health policies around the world. However, there is a particularly rich debate among sociologists and political scientists about whether and how IGOs can act autonomously and pursue policy priorities that are not supported by states. Because these organizations generally lack enforcement power and are dependent on states for financial resources and legitimacy, IGOs have traditionally been conceived as lacking autonomy to pursue their own policy interests independent of the interests of states. Yet, recent interventions by sociologists have shown how IGOs strategically navigate the demands of states and even attempt to reconfigure the external environment to promote alignment with the policy interests of the IGO. Nonetheless, concerns about resources continue to plague IGOs and often constrain their agency. In this dissertation I argue that a key limitation of existing studies on the autonomy and influence of IGOs is their narrow focus on the decision-making and agenda-setting stages of policy making. I extend sociological research on the influence and autonomy of IGOs by addressing how concerns about implementation shape the particular structures and strategies that AIDS IGOs adopt in order to pursue their own policy interests. Many of these strategies are not easily understood by existing theories of IGO behavior which argue that as bureaucracies, IGOs will seek to expand their autonomy and influence in a sector. In contrast, I argue that IGOs with limited power to enforce policy implementation by states are highly sensitive to an implementation-autonomy trade off and may actually give up some autonomy in decision-making in order to facilitate broader implementation by states. IGOs also face additional barriers to implementation due to decentralization of the organization at the regional- and country-level and competition from other IGOs, nongovernmental organizations, and bilateral and private donors. Using archival data from World Health Organization's Global Programme on AIDS and its successor, the Joint United Nations Programme on HIV/AIDS (UNAIDS), two IGOs mandated by the United Nations to coordinate a global response to AIDS epidemic, I show in Chapter 1 how concerns about implementation have shaped decisions about the organizational structure of these IGOs. In addition, I show how implementation concerns have promoted the adoption of particular strategies - organizational inreach, interorganizational cooperation, evidence-based advocacy, and bidirectional pressure - to align policy preferences among states, other organizations, and even their own staff. The use of these strategies by AIDS IGOs has had consequences beyond the decision-making phase of policy development. Drawing on a novel dataset compiled from five waves of UN Country Progress Reports on HIV/AIDS (2003, 2006, 2008, 2010, and 2012), I show in Chapter 2 that the use of these strategies has promoted the alignment of national AIDS programs with UNAIDS policies on MSM over time. On the ground, IGO interest in HIV among MSM has also provided new technologies for seeing MSM in hostile political contexts. As I show in a country-case study presented in Chapter 3, claims for the recognition of same-sex sexualities in Malawi have had the most institutional success within the national AIDS programs which increasingly identifies MSM as a key target for public health intervention. Additionally, links between Malawian organizations and transnational research and advocacy networks have provided a context in which (male) same-sex sexualities have become statistically visible and institutionalized, providing a basis for future grassroots mobilization. At the same time, however, IGO interest in MSM has reinvigorated opposition to homosexuality among Malawian political elites and ordinary citizens. In Chapter 4 I introduce original household survey data collected in Malawi in 2012 (N=1491). Building on qualitative findings from Chapter 3, I use these data to quantitatively examine the effects of variation in aid allocations across Malawi's administrative districts on attitudes toward homosexuality. Results show that in districts with higher levels of annual aid per capita, individuals hold more negative views of homosexuality. Thus while IGOs have had a substantial effect on state-level and donor-level adoption of policy priorities, they have had much less success in changing public views toward homosexuality on the ground. These results suggest that models of global diffusion that utilize policy change as an indicator for cultural change may be greatly overestimating cultural change on contentious issues like homosexuality.In sum, IGOs have become central actors in the formation, diffusion, and implementation of AIDS policy concerning same-sex sexualities. They develop new policy ideas and set priorities that may diverge substantially from the interests of member states, both rich and poor. However, IGOs also face considerable barriers to implementing their policy priorities: from reluctant states to the decentralization of staff across dozens of country offices to competition from other organizations and private donors. In this dissertation I show how barriers to implementation shape the structures and strategies of IGOs. As such, this work contends that IGOs are not simply disinterested forums in which states pursue their own interests or passive collections of rules and norms, but autonomous, influential, and self-interested actors that shape the policymaking process and the world around them, sometimes in unexpected and undesirable ways.

Over the past decade, gay men and other men who have sex with men (MSM) have become a key concern in the fight against AIDS, not only in high-income Western countries but also in low- and middle-income countries where same-sex sexual transmission of HIV had rarely—if ever—been considered. My work examines how MSM emerged as a global HIV prevention priority at the transnational health policy giant UNAIDS, how this new global priority diffused to national governments around the world and what happens when global prevention priorities targeting MSM collide with local contexts and people.

Usingethnographic and archival data from Malawi, a small, heavily aid dependent country and former British colony, this paper examines Malawians' attitudes toward homosexuality vis-à-vis the country's history of colonization and the realities of Malawi's economic dependence on donor governments. I demonstrate that Malawians' understandings of same-sex sexuality go beyond homosexuality as a moral affront to conservative religious ideas. Rather, the framing of sexual diversity as a neocolonialist project has gained substantial traction among Malawians, providing a foundation for the development of an anti-Western and anti-gay Malawian national identity.

African lesbian, gay, bisexual, transgender, intersex, and queer (LGBTIQ) organizations face various strategic dilemmas in contexts characterized by political hostility to gender and sexual dissidents. In Malawi, one such context, we examine how an LGBTIQ social movement organization (SMO) in Malawi, the Centre for the Development of People (CEDEP), navigated one particular strategic dilemma—the dilemma of whether to adopt a less politicized public-health approach or a more nimble, grassroots-oriented, and social-justice approach to their advocacy work—and the consequences of the organization's strategic decisions. Scholars interpret these approaches as signifying differential political engagement among organizations, with the social-justice approach indicating political engagement and the public-health approach signaling political disengagement. This difference has led critics to argue that a public-health approach is poorly suited to generating social and legal reform because it de-politicizes LGBTIQ issues over time, while a social-justice approach exerts constant pressure on political and religious elites. Drawing on qualitative interview data with Malawian LGBTIQ activists and news media data reflecting public debate around homosexuality in the country, we illuminate how this SMO metamorphosed from an organization ostensibly focused only on public health and HIV/AIDS to one that advances social justice for gender and sexual dissidents. We argue for an understanding of the indigenous development of a hybrid strategy integrating the public-health and social-justice approaches.

This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated "lone wolf" individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time—and to prevent serious acts of violence more generally—will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special urgency to this agenda.

Throughout the 2000s, donor organizations successfully argued for the inclusion of men who have sex with men (msm) in the global response to HIV/AIDS. These efforts have had unintended consequences for msm and lesbian, gay, bisexual, and transgender (lgbt) populations in sub-Saharan Africa. Focusing on Malawi and Senegal, we find that donors' emphasis on msm provided new urgency and sources of support for nascent lgbt- and msm-identified groups to organize around sexual identities and disseminate prevention strategies to their communities. These interventions increased the visibility of msm and lgbt populations in both countries; however, this new visibility also positioned msm and lgbt organizations between Western donors and political elites, contributing to political backlash against lgbt Malawians and Senegalese by the late 2000s. Further, while some msm- and lgbt-identified organizations in Malawi and Senegal ultimately expanded their activism to include lgbt rights, other HIV organizations working with msm to gain access to new donor funding did not advocate for the rights of lgbt populations. We discuss the implications of these processes for development initiatives and argue for a more expansive definition of health in HIV and development work to address a broader set of community concerns.

AbstractWe provide the first comprehensive evidence on the effects of access to legal same‐sex marriage (SSM) on marriage and adult health using the full rollout of marriage equality across the United States. Using data from the CDC BRFSS from 2000 to 2017, we relate changes in outcomes for individuals in same‐sex households (SSH) coincident with adoption of legal SSM in two‐way fixed effects models. A substantial share of these households includes gay and lesbian couples. For men in SSH, we find robust evidence that access to legal SSM significantly increased marriage take‐up, health insurance coverage, access to care, and healthcare utilization. Results for women in SSH are inconclusive apart from a clear increase in marriage take‐up. Our results provide the first evidence that legal access to SSM significantly improved health for adult gay men.