We are creating new inequities around PrEP

When the debate about public funding for PrEP started up, I was concerned that it would go down the same path as PEP — with a set pool of funding, left to state/territory governments to administer, with de facto rationing based on sexual risk, and only available from a set number of locations. So my own position on PrEP was that it needed to be funded via the Pharmaceutical Benefits Scheme (PBS) and not rationed.

In the meantime, gay and bisexual men had two choices: importing generic medication from overseas or joining a PrEP trial like EPIC-NSW. (Full disclosure: I’ve done both. I’ve also worked on projects funded by Gilead. See my disclosures.)

A huge win in the fight against HIV/AIDS?

Australian PrEP distributor Dynamix International recently sponsored the magnificent ‘In bed with U=U’ campaign by TIM, featuring my gorgeous friends Mark, Davey and Ed, as well as an associated speaking tour with superstar advocate Bruce Richman from the Prevention Access Campaign.

At the Sydney leg of the tour, Dynamix founder Phil Joffe announced he’d been able to negotiate the cheapest price to import generic PrEP in Australia — $27/mo. This has provoked PAN to seek a better offer from its own recommended supplier.

Market forces, woo. 🙃

So I was bemused this week to see community orgs trumpeting a ‘huge victory’ in securing PBS listing for PrEP from 1st April. The mandatory PBS copayment is $39.50, or $6.40 if you receive a Centrelink payment and have a healthcare card (HCC).

We don’t know exactly what deal the government struck with the pharmaceutical companies, but the PBS advisory committed recommended a ceiling price of $240 per month. So consumers can pay more than the price to import generic medication from overseas, and it’s possible the government pays more on top of that. This problem isn’t specific to PrEP — this is a problem with the PBS copayment and the terrible deals Australia strikes with pharma companies. (Thanks Jonathan Nolan for that reference.)

This isn’t universal healthcare: it’s residualism — making public-funded PrEP available to people on a Centrelink payment and letting the free market sort out affordable access for everyone else. You can’t even get a rebate from private health insurance, because they only reimburse amounts above the PBS non-concessional copayment.

The response of some PrEP advocates on this issue has been disappointing. ‘It’s only $40 and if you care about your health you’ll pay it.’

As a PhD student I’m not eligible for Centrelink benefits, thanks to the Howard government. I get a stipend of $27K, which is a grand every fortnight — double what someone on Newstart gets. I’m living in Sydney while I do fieldwork, and for a while there I was paying 50% of my income on rent. I’ve written about living with major depression and complex trauma, and the marriage plebiscite did not help with that at all.

I have scripts for three medications — an anti-depressant, sleeping tablets, and a proton pump inhibitor. I routinely don’t get the second two scripts filled, and I put off appointments with medical specialists, because I can’t afford them. Caring for my health doesn’t change my bank balance.

There will be many people in the same situation — people on incomes too high to qualify for a healthcare card, but below a liveable wage. I’m only able to access PrEP because the EPIC-NSW trial exists.

Eliminating HIV depends on widespread access to free PrEP

Free access to PrEP via the EPIC-NSW trial has led to a 41% decrease in new HIV diagnoses among people who had good access to information about PrEP (i.e. not Aboriginal people or people born overseas). A similar drop occurred in London, although Public Health England immediately claimed this reflected early testing and early treatment for people living with HIV.

Why do I attribute that drop to PrEP? Because we saw years without any change in rates of diagnosis under a New South Wales (NSW) HIV strategy that emphasised early testing and treatment. This is confirmed by an epidemiological study presented at CROI.

Clearly, the priority for prevention strategy is making PrEP widely available for free.

In case it sounds like I’m bashing NSW, I’m not. The only reason we’re able to monitor the effectiveness of different strategies for HIV prevention in NSW is because the NSW state government committed to an ambitious and accountable prevention strategy known as Ending HIV. Targets for reduction were built into the KPIs for senior health department decision-makers, creating incentives to act. As the saying goes, ‘what gets measured gets managed’, and NSW is releasing and acting on timely data.

By contrast, the Victorian Department of Health and Human Services hasn’t made an annual BBV/STI monitoring report available on its website since 2013.

If we are serious about community ‘ownership’ of the HIV response, how is this possible when measures of prevention performance are kept secret?

We are seeing new inequities emerging around PrEP

Simply put, inequities are differences in health outcomes between groups that are preventable and therefore unfair (Whitehead 2001, cited in Braveman 2011).

When I write about preventing inequities in the gay community, people don’t get it. They feel hurt that I’m focusing on the gaps rather than acknowledging the great work they’re doing. They call me a hater.

Here’s the thing: inequities emerge because we do great work that is more easily accessible by some groups than others.

The fundamental causes of disease model suggests that inequities in health arise because some groups have more access to ‘flexible’ resources like money, literacy, education and prestige, so they can take up new opportunities for health quicker than others who have less of those resources (Link & Phelan, 1995).

This dynamic shows up again and again. It’s particularly obvious with the cancer screening programs introduced in the 1990s. And the NSW data on HIV infections shows it happening with PrEP.

In particular, overseas-born gay and bisexual men saw a 13% increase in HIV diagnoses in NSW in 2017 compared to the six-year average for this group. The 2017 data report concludes ‘PrEP uptake continues to expand, but work is needed to increase access for overseas born MSM.’

We saw this coming

I conducted community-based research on the sexual health needs of culturally diverse men who have sex with men in 2010 and the sexual and reproductive health needs of international students in 2012. I wasn’t the first to write about it — I was following in the footsteps of Maria Pallotta-Chiarolli in 1998 and Limin Mao with the Asian Gay Community Periodic Survey in 1999 and 2002. (That study restarted again recently.)

One of my own findings keeps needling my conscience. International students have much lower rates of HIV testing. Only 1/3 of international students apply for Australian permanent residence. Based on diagnoses in students applying for permanent residence Australia, I estimated that every year my home state of Victoria sends up to 18 students home with undiagnosed HIV.

It’s not a matter of translating some resources and putting them on a website or in clinic waiting rooms. It requires dedicated funding for campaigns and proactive community engagement and outreach.

(You know, the kind the marriage equality campaign didn’t do, with the result that ethnic and migrant communities got tagged, yet again, as inherently homophobic — when no attempt was made to change their hearts and minds.)

I am beyond frustrated with our failure to anticipate these inequities, to take them seriously until they show up in ‘the numbers’. And these are just the groups we count: activist movements like PASH.tm are still fighting for the right of trans MSM to be counted, accurately or in some cases at all.

There is every sign that ACON in New South Wales is already responding to the changing insights available from the epidemiology. Victoria should take note. And our next national HIV strategy better bloody emphasise widespread access to free PrEP.

Anyhow, let me end on an optimistic, inspiring and frankly emotional note with this gorgeous message from Mexican-American and Australian writer Ed Moreno.

An epidemic of bullshit – new in Overland

Two or three times a year, there’ll be a major conference on sexual health, or a report released on how many new sexually transmitted infections – STI for short – were diagnosed in the previous year. Usually there’s an up-tick in something and media coverage follows like, well, clockwork. Just as predictable are the narratives invoked to contextualise the findings.

recent article by Aisha Dow is a case in point: along with online dating and hookup apps, the article suggests that ‘complacency as a result of improvements to HIV treatment, decreased condom use and more young people travelling overseas could also play a part.’

For a long time I assumed the clinicians and epidemiologists offering these explanations were playing out a cunning media strategy. Now, I’ve come to believe they just don’t read any social research. They offer journalists the same explanations they themselves have read in the newspapers – contributing to an unchecked epidemic of bullshit.

Continue reading at Overland

L0059461 'The easy girlfriend', poster, England, 1943-1944Image credit: Reginald Mount, ‘The easy girlfriend’ (poster), Norwich: Her Majesty’s Stationery Office, 1943-44. This file comes from Wellcome Images, a website operated by Wellcome Trust, a global charitable foundation based in the United Kingdom. Refer to Wellcome blog post (archive).

Small bites (Jan ’18)

Highlights from my week on the interwebs

Victoria’s model of community visitors should be retained (The Age, 30 Dec 17)

John Chesterman, a long-time community visitor and Acting Public Advocate, offers a compelling argument for retaining the Victorian approach to a scheme that exists in a range of different models in different states and territories.

The proposed safeguards prioritise consumer protections such as complaint mechanisms, which are fine if you have the ability and confidence to voice your concerns.

These protections will certainly be important, but they are not enough. Nothing beats being able to say: “Well, we were at that house last week and Louise’s plan may well say she is supposed to go bowling, but she didn’t go bowling. She was at the house.”

This is a really nice example of The Age doing what it does best.

Does the ‘African youth crime’ panic sound familiar to you? It should.

The LNP opposition, the Labor government, the Herald-Sun and The Age have been falling over themselves to condemn ‘African youth crime’ in Victoria.

As Calla Wahlquist points out, the reality is more complicated (The Guardian, 3 Jan 18).  But trying to counter panic with facts is like bringing a banana to a knife fight.

Stopping a panic depends on telling a more compelling story. Here’s John Birmingham, writing in 2000 about the ‘Asian gangs’ panic of the 1990s:

When the first stories of (Vietnamese gang) the 5T were being laid out at the (DailyTelegraph and the (Sydney MorningHerald, the gangs were little more than groups of unemployed Vietnamese teens who had slipped through the net of the secondary school system and often had no close family to rely on. Coming from refugee camps in Hong Kong where 2000 children were kept under armed guard for months without seeing daylight, they may never have been in school. Some had seen their families killed. They arrived in Sydney, were given a few months English training if they were very lucky, then set loose to fend for themselves. April Pham, a youth worker in Cabramatta, told me that they didn’t think of themselves as having ‘low self-esteem’. They just thought of their lives as shit. They could not even cope with welfare. In March 1991, during a deep recession, the Bankstown, Cabramatta, Fairfield, Marrickville and Campsie social security officers combined had only two Indochinese aged between sixteen and eighteen receiving job search allowance. ‘Half the kids don’t have any income,’ said April. ‘The dole is a huge hassle. We virtually have to drag them in there. They live off and with their friends, a dozen in a one-bedroom flat. They share expenses. If one has fifty dollars, everyone gets it.’

This was the 5T in its earliest days. But even bullshit has a critical mass and past that point it becomes self-generating. Cut off from any other source of identity, the loudest message those young Vietnamese had beamed at them was ‘street gangs’. If they ever sat on the floor of their dismal unfurnished flats and wondered what this strange new country expected of them, they need only attend to their media image. Unfortunately that particular fantasy was powered by an alternating current. Just as the symbol of a powerful underground teen-mafia explained the suburban catastrophe of drug-fuelled crime — and offered salvation through the symbol of an unshackled police force waging their War on Drugs with a nuclear armoury of supercharged drug laws — so too did it provide a reassuring myth for their notional enemy (the 5T). Cast adrift in an alien world which obviously distrusted and feared them, the rootless beta-version outlaws were presented with an expertly crafted narrative of their own power and significance. They weren’t sloughed off failures. They weren’t pathetic. They weren’t doomed. They were the 5T. And though they might walk in the valley of the shadow of death they would fear no evil because they were the baddest motherfuckers in the valley. I mean, really, what did everyone expect them to do? Get a haircut and a job flipping patties at McDonalds?

John Birmingham (@JohnBirmingham), Leviathan Sydney: Vintage, 2000, p427-8.

I’ve written before on this blog about the role narratives and feature journalism can play in showing the linkages between the micro (incidents of crime) with the meso (lack of meaning and life opportunities) and macro (structural racism) perspectives.

These narratives are almost exclusively found in The Age — the Herald-Sun‘s tabloid format and style mitigate strongly against them. But lately Fairfax seems to have been chasing the Herald-Sun’s right-wing readership. This is a doomed effort: nobody can compete with News Corp on sensationalism, and it will hasten the exodus of its historically progressive readership over to the ABC and The Guardian.

Call Me By Your Name — a hot take

This film could have been an hour shorter, and all the better for it, if it had cut out all the butt shots (i.e. the whole first half). There’s no chemistry between the two leads, Timothée Chalamet and Armie Hammer, and for a teenage romance that’s inexcusable. The counter-narrative of straight sex and seduction highlights the timidity and sterility of the queer encounter at the heart of the film. Go and (re-)watch Moonlight instead.

Listening: Asgeir ‘In Silence’ album

I came late to this and it’s romance at its best. The English version is great — musician John Grant reportedly helped out — but the Icelandic originals are otherworldly.

Small Bites

Highlights from my week on the interwebs

People who score lower on a measure of social class tend to score higher on a measure of ‘wise reasoning’ in situations of conflict (Science, 20 Dec 17)

“people who grow up in a working-class environment have to rely on shared, communal resources more than people in the middle class, and therefore hone social techniques that smooth out conflicts with their peers. Those in the middle class, in contrast, tend to focus on education, which improves their IQ scores, but they don’t put nearly as much effort into conflict resolution skills…”

These are provocative findings and I’m not 100% sold on the explanation offered for them — but I do wonder if they can be generalised to wise reasoning in policy-making!

There is no such thing as Western civilisation (The Guardian, 9 Nov 16)

Kwame Anthony Appiah’s second BBC Reith lecture confronts the ‘clash of civilisations’ narrative. (Hat tip Chris Lemoh for this.)

In the centuries that Petrarch called the Dark Ages, when Christian Europe made little contribution to the study of Greek classical philosophy, and many of the texts were lost, these works were preserved by Muslim scholars. Much of our modern understanding of classical philosophy among the ancient Greeks we have only because those texts were recovered by European scholars in the Renaissance from the Arabs. […] So the classical traditions that are meant to distinguish western civilisation from the inheritors of the caliphates are actually a point of kinship with them.

This is a nice piece in which empiricism confounds essentialising claims to continuity:

What was England like in the days of Chaucer, father of English literature, who died more than 600 years ago? Take whatever you think was distinctive of it, whatever combination of customs, ideas, and material things that made England characteristically English then. Whatever you choose to distinguish Englishness now, it isn’t going to be that.

Many different causes for and pathways through bipolar disorder 

Remember in the 1990s we used to talk about finding ‘the gene’ for _________? Autism, homosexuality, overweight, criminality, you name it. But hunting for single causes in a complex world is a fruitless game.

A review of findings from a large cohort study of people with bipolar disorders took a ‘causal pluralist’ approach, finding that no single gene predicts onset, causal pathways interweave genetics and lived experience, and the trajectory of the disorder is not bipolar but multidimensional. See: press release; published article [open access]

Listening to: Zola Blood, ‘Infinite Games’ album (2017)

Notes and Annotations in Kindle — Sensible Tools for Scholars #1

This post is the first in an occasional series, looking at sensible tools for scholars. See more about my goals and bio at the end.


A friend recently described my postgrad study as a ‘backpacker PhD’. I applied from Melbourne, moved to Canberra for my first year, moved to Sydney for the first tranche of my fieldwork, and soon I’ll be moving again to Montreal for a fellowship. Needless to say, much as I love my paper books, they’re a hassle to lug around. So: ebooks and PDFs. They make it easy to access key texts no matter where you are.

Most of my library was purchased from Kindle. There are reasons, now, to consider alternative sources: the well-documented cruelty of Amazon towards its workers. But I have an extensive library of theory classics in Kindle format, so I’m ‘locked-in.’ Luckily, the Kindle app is getting increasingly useful for academic writers.

In this post: workflow | accessing notes and highlights later | tips for use | about


Reading — you can read on any phone or tablet device, or using the Kindle app for your laptop. You can even open Kindle in your browser, though it’s a bit clunkier this way.

Annotating — highlight some text with your finger or the mouse, and a floating box will pop-up, offering a choice of different highlight colours or the option to make a note. I use notes the way I might scribble a short comment in the margins of a book I own.

As part of a toolkit — the Kindle Notebook solves a particular problem: how to get your quotes and annotations out of a Kindle ebook. It can be combined with other tools like Evernote or Zotero (or even Atlas.ti) to bring those quotes alongside your other data. See the tips for searching your annotations below.

Accessing your notes and highlights later

For years, there was a little-known trick to access your notes and highlights — you could visit a page on the Kindle website and scroll through them there.

Recently, Amazon incorporated the Notes and Highlights function into the Kindle app for Mac (and possibly Windows, but I don’t go there).

This is what it looks like:

For each quote, you can copy the highlight text or ‘star’ it for later reference. This is useful, because many ebook apps block you from using copy and paste — or you might be reading the book on a tablet but writing on your laptop.

Tips for use

Purchasing ebooks

  • Make sure you buy Kindle books that say they have ‘real page numbers’ on the purchase page — most journals won’t let you cite location numbers.
  • Users outside North America may find that Amazon wants you to buy from a separate Kindle store for your country. Prices are usually comparable but they don’t always have the same books, due to licenses being sold separately in different copyright regions.
  • It is possible to load PDFs from your computer into Kindle, e.g. by e-mailing them to an e-mail address specified in your account settings. However, I prefer to use Preview to annotate PDFs. In another post I’ll show you how a little tool called Zotfile can extract PDF annotations into Zotero, my citation manager of choice.

Making annotations

  • There’s a skill to knowing how much to highlight. The more you highlight, the harder it will be to find a quote again later; but highlighting short sentence fragments can make it hard to recall what they meant in context.
  • Across Kindle and Preview, I use highlight colours fairly consistently. On Kindle, yellow is a possible quotation, blue is for citations of other literature, red is something I might criticise, and orange is a possible hook for argument. I never use red for Foucault.

Searching annotations

Unfortunately, the Kindle app does not let you search within your highlights and annotations, or indeed for text fragments across multiple books.

  • To search notes and annotations within a single book, which is to visit the Kindle Notebook website, open your notes for that book and use Find in your browser.
  • Unfortunately, if you have highlighted a lot of text, the website will truncate quotes for copyright reasons.
  • There is a Search box on the Kindle Notebook website, which in theory should allow you to search across books, but my testing suggests it currently isn’t functional.
  • You could use Evernote Capture or Zotero to save your quotes into a more searchable database, so long as they haven’t been truncated on the Kindle Notebook website.

Writing with quotes from Kindle

  • If you use a PDF, you can use Zotfile to export your annotations into separate notes in Zotero, and it will even insert pre-formatted citations with the page number. Currently, Kindle does nothing of the sort — so remember, when you copy a quotation into your working document, add the author-year and page number to save yourself pain later.

About the series

‘Sensible Tools for Scholars’ will be an occasional post series that profiles alternatives to established choices like Endnote and Nvivo, which have well-known and long-standing problems with reliability, functionality and interface usability and consistency. I’m a Mac user and a qualitative researcher doing both fieldwork and discourse analysis, and that will no doubt influence my choice of tools to profile — I don’t want to recommend anything I haven’t spent a good chunk of time using myself, but I would welcome guest posts from researchers in other traditions.


This post is copyright Daniel Reeders 2017. Posts in this series, including images and text, must not be copied in full without permission and attribution.


What’s next?

Fans of the West Wing and the really great West Wing Weekly podcast will recognise the title — it’s the question Pres Bartlet asks when he’s done with a topic and wants to move on. I’m guessing that’s how queer people are feeling about the postal survey on marriage for consenting adults regardless of gender.

1/ Prepare for the results announcement

ACON has done a really great job of producing resources encouraging self-care and help-seeking among people doing it tough during the debate. The latest one encourages queer people to make a decision ahead of time about where you’ll be on results day, and who you’ll be with. You might want to be at one of the public events planned; equally valid, you might want solitude — you know yourself best. Be prepared for some unexpected emotions, even if the result is what we’re all hoping for.

2/ Prepare for some shitty hot-takes

Mark Kenny at The Age has jumped the gun on this one, with this frankly confused opinion piece, even as he was writing another piece about how conservatives are already planning to delay marriage equality even further.

Screenshot 2017-11-11 11.46.02

3/ Prepare for ‘disaggregated’ results

The headline result will be an aggregate — a single number that sums up all the votes. I am expecting a majority ‘Yes’ vote, but then, I was wrong about Trump and Brexit. Most opinion polls only survey about 1,500 people, and then use a mathematical model to project (guess) how the whole of Australia will vote. So we could get a surprise.

But one thing that’s guaranteed: conservative MPs will demand the results for their own electorates, in addition to the national figure. This ‘disaggregates’ (splits apart) the result by electorate. They want this so they can say, ‘well, my electorate voted No, so I can’t support the marriage equality bill,’ regardless of what party leaders commit to.

4/ Prepare for last minute objections

Conservatives are already preparing to demand ‘religious freedoms’ on top of the extensive exemptions religious bodies already have. Waleed Aly has a terrific analysis of the problem with this stance: if the Yes votes gets up, it means these demands have been tested in a public vote and failed. So it’s illegitimate to say the marriage legislation must accede to these demands. However, we can also view these demands as yet another delaying tactic — and viewed as such, they are likely to succeed.


Whatever the result next Wednesday, there is a way still to go — this is a marathon, not a sprint. We need to take this opportunity to take a breath, engage our rituals and practices for self-care, touch base with each other, take time to ourselves. One day this will pass.

Catholic ethics and moral leadership on marriage

It’s an odd quirk of my upbringing that one of my babysitters as a young child was the future Archbishop of Sydney, Dr Anthony Fisher OP, back when he was a Dominican brother at our local parish. He was a great babysitter — a very gentle man. My mother studied with him at the local theological college. She jokingly relates that when they met in their first week of classes, she thought he was alright, because he was the only Dominican brother not wearing robes; of course, it turned out they just hadn’t arrived yet.

Fisher later completed his PhD in bioethics at Oxford, looking at IVF issues. I read the book published from his thesis when I was studying undergraduate bioethics and wondered if, perhaps, wanting to reach a wider audience, he had omitted key aspects of his argument. In hindsight I recognise it had Catholic belief as a hidden premise. As a gay kid I grew up in constant exposure to the hypocrisy of the Church’s teachings on love, and thus I cannot supply the hidden premise that makes Fisher’s analysis work.

This problem affects the Catholic doctrine on same-sex marriage as well. It poses a question: why should the Catholic position on marriage apply to all people in Australian society, including those who don’t believe in Catholicism? (Or who believe in different faiths, or don’t believe at all?) The church would claim it has a special expertise on marriage and child-rearing, and that it plays a role of moral leadership on behalf of the nation. But here, the way its arguments are premised on faith becomes a huge problem, because they cannot be reasonably accepted by people who don’t accept that premise. And so we see two things happening.

One is an appeal to the harm that will be suffered by children if same-sex marriage is permitted — an argument tailored for liberal democracy, which uses the harm principle to mediate between incommensurable systems of belief. But again, particular aspects of Catholic teaching strongly inflect the harm perceived in same-sex relationships, such as the role the complementarity of gender plays in Catholic ideas of ‘natural law’. If you don’t hold with those ideas, you probably don’t perceive that harm, except as a vestige of a more generalised homophobia which descends from those teachings.

The other is just the naked use of power — what Foucault calls ‘non-discursive relations’. (You read that correctly: Foucault never held that there is nothing outside of discourse; that’s an invention of film and cultural studies.) We see this in the threat to sack anyone who marries a same-sex partner or even expresses support for same-sex marriage — and that’s no idle threat, given that Catholic agencies are, all-up, one of Australia’s largest non-government employers. We see it as well in the Catholic Archdiocese of Sydney threatening to breach its contracts with any corporation that comes out in support of same-sex marriage. This approach exposes the weakness of its teachings, if it can’t persuade rational observers to its position and must instead threaten their ability to put bread on the table.

But even if we concede, for a moment, that there is something to Catholic ethics, it isn’t at all clear that its position on marriage is justified. The one thing Catholicism is known for is a principled objection to utilitarian ethics — which suggests that the good is whatever brings the greatest happiness to the largest number of people. A criticism of utilitarianism, from its earliest days, is that it can be used to justify majoritarian abuse of minorities: for instance, experimentation on a small number of people if it benefits a much larger number, or torture of people accused of terrorism if it might ensure the security of the population. Utilitarians have developed different forms of their approach that don’t suffer from these problems. But there’s something quite valuable in the Catholic insistence on human dignity — that even the most benighted human life has inherent dignity and, as a consequence, nobody’s wellbeing should be sacrificed, even if it leads to the benefit of the majority.

This focus on human dignity is the basis of the Catholic claim to moral leadership in modern society. And it’s what gets the Catholic church into trouble on marriage. Their position is that a small minority — queer people — should be denied marriage rights, because society as a whole is better off if marriage is restricted to male-female couples for the purposes of reproduction. This is a plainly utilitarian argument. It is no different from saying torture is acceptable if it leads to national security.

If you think the analogy there is inflammatory, you are probably not exposed to the kind of suffering the plebiscite is causing queer people. (Either not exposed, or aware and not taking it seriously.) This distress is an acute form of the chronic fear and insecurity that families with same-sex parents experience in the absence of marriage rights. For example, my friend who rides home from work knowing that if she gets hit by a car and killed, her biological family have presumed custody over her adopted son, rather than her de facto wife.

And the Catholic church position on marriage reflects an acute theological error: It protects a particular image of what a dignified life looks like, rather than protecting the dignity of actually-existing humans in all their diversity, notwithstanding the beliefs or the interests of the majority.