Negotiating HIV Prevention: the Talk, Test, Trust Story and Beyond

Negotiating HIV Prevention: The Talk, Test, Trust Story and Beyond.

Justin W. McNab

A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy University of New South Wales, 2009

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School: National Centre in HIV Social Research Faculty: Arts and Social Sciences

Title: Negotiating HIV Prevention: The Talk, Test, Trust Story and Beyond.

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In May 1996 the AIDS Council of NSW launched Talk Test Test Trust …Together (TTTT), an HIV prevention campaign aimed at decreasing risk of infection within gay men’s relationships. The rationale behind TTTT was ‘negotiated safety’: that it was safe not to use condoms for anal sex in primary relationships if specific steps were followed. TTTT generated contestation within AIDS Councils in Australia and New Zealand, but also amongst researchers, policy makers and gay communities. Arguments about TTTT and negotiated safety appeared logical and reasonable and did not fall neatly along an Australia/New Zealand divide. This study used a qualitative approach to interview key HIV educators in New South Wales who were involved in the development of TTTT and New Zealand educators who did not promote negotiated safety. This thesis argues that in order to understand the contestation around negotiated safety and TTTT it is necessary to understand the broader social and historical factors that shape HIV prevention contexts and practice. These include factors arising from the epidemic itself (which, to some extent, were responsible for the difference between Australia and New Zealand) such as the increasing complexity of gay men’s risk reduction strategies, the rise of a positive voice, and impact of treatments and factors associated with and the broader context such as the rise and continuing history of a gay political and social movement and associated identity and community formation, and later, fragmentation, changing concepts of love, intimacy and relationships and of risk and the uncertainty, anxiety and fear from living in a complex individualised detraditionalised world. This approach will show that a focus on a dynamic epidemic, and the broader social and historical context can shed light on arguments made about negotiated safety and TTTT. Further, applying Bourdieu’s formulation of the complex interaction of habitus, fields and practice (1977) makes sense not only of the arguments made about negotiated safety and TTTT, but of educator practice and of HIV prevention, of the broader HIV and AIDS sector, and of how societies continue to learn to live with and adapt to the epidemic.

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To Dr. Nancy Bowers (1928 – 2006), a friend and mentor. Abstract

This study used a qualitative approach to interview key HIV educators in New South Wales who were involved in the development of TTTT and New Zealand educators who did not promote negotiated safety.

This thesis argues that in order to understand the contestation around negotiated safety and TTTT it is necessary to understand the broader social and historical factors that shape HIV prevention contexts and practice. These include factors arising from the epidemic itself (which, to some extent, were responsible for the difference between Australia and New Zealand) such as the increasing complexity of gay men’s risk reduction strategies, the rise of a positive voice, and impact of treatments and factors associated with and the broader context such as the rise and continuing history of a gay political and social movement and associated identity and community formation, and later, fragmentation, changing concepts of love, intimacy and relationships and of risk and the uncertainty, anxiety and fear from living in a complex individualised detraditionalised world.

This approach will show that a focus on a dynamic epidemic, and the broader social and historical context can shed light on arguments made about negotiated safety and TTTT. Further, applying Bourdieu’s formulation of the complex interaction of habitus, fields and practice (1977) makes sense not only of the arguments made about negotiated safety and TTTT, but of educator practice and of HIV prevention, of the broader HIV and AIDS sector, and of how societies continue to learn to live with and adapt to the epidemic.

5 Acknowledgements

First, I would like to thank my research participants for freely giving their time and insight, without which this project would not have been possible.

I would also like to thank my supervisor Associate Professor Heather Worth and co- supervisor Dr Robert Reynolds for their comments and support through the writing of drafts and through the production of the final document.

The Consortium for Social and Policy Research on HIV, Hepatitis C and Related Diseases provided support in the form of a three-year scholarship. I am grateful for this financial assistance. Likewise, the National Centre in HIV Social Research provided post-graduate support and accommodation, and also library and computer resources. I would like to thank the National Centre for making this project possible.

Finally, I thank Brendon Gembitsky and Sarah Oxenbridge for proof reading the manuscript, and thanks also to my friends and family who supported me through all phases of this research.

6 Abbreviations

ACON AIDS Council of New South Wales AFAO Australian Federation of AIDS Organisations AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy ASO AIDS Service Organisation GMHC Gay Men’s Health Centre GP General Practitioner (general practice physician) HAART Highly Active Antiretroviral Therapy HBM Health Belief Model HIV Human Immunodeficiency Virus NCHSR National Centre for HIV Social Research NGO Non Government Organisation NSW New South Wales NZAF New Zealand AIDS Foundation SAPA Social Aspects of the Prevention of AIDS SMASH Sydney Men and Sexual Health SSS Sustaining Safe Sex STI Sexually Transmitted Infection TTTT Talk Test Test Trust … Together UNSW University of New South Wales VAAC Victorian AIDS Action Committee VAC Victorian AIDS Council

7 Contents

1. Introduction ...... 10

Argument and Aim ...... 15 Method...... 17 Theoretical Perspective ...... 18 Contents...... 22

2. Methodology, Method and Theory...... 34

Sampling and Recruitment...... 37 Interviews and Analysis ...... 38 Participants ...... 39 Use of Pseudonyms...... 43 Theoretical and Methodological Background ...... 43 Theory in Social Anthropology...... 44 Action or Practice Based Approaches...... 46 Debates about Structure and Agency ...... 47 Further Theoretical Developments...... 48 Debates about Modernity and Post-Modernity in Sociology ...... 50

3. The Advent of HIV and AIDS and the Rise of AIDS Organisations in Australasia ...... 55

From ‘Homosexual’ to ‘Gay’: The Rise of a Social and Political Movement ...... 56 The Nineteenth Century Category of ‘The Homosexual’ ...... 56 Gay Liberation: A Social and Political Movement ...... 59 A Response to the Epidemic in Australasia ...... 62 Australia...... 63 New Zealand...... 70 Governmental Responses – Partnerships with AIDS Organisations ...... 74 Early Behaviour Change ...... 81

4. Early Stirrings of the Negotiated Safety Debate in Australia ...... 85

Feeling Our Way (1990)...... 87 The Victorian AIDS Council’s ‘Safe Relationships’ Campaign (1994)...... 93 Formation of the Victorian AIDS Council...... 93 ‘Because We Want To Be Together’ (The Safe Relationships Campaign) ...... 93 Campaign Materials...... 96 Launch, Dissemination and Reaction...... 101 ACON’s Fucking Without Condoms (1994) ...... 104

5. ACON’s Talk, Test, Test, Trust … Together (1996)...... 113 Planning, Campaign Materials, Launch and Dissemination ...... 122 Initial Reaction...... 127 Talk Test Test Trust … Together Created Space for a Dialogue about Sex Without Condoms...... 132 Complexity of Negotiated Safety and TTTT...... 134

6. Intimacy, Love, and Relationships ...... 141

8 Transforming Intimacy ...... 142 Love and Risk of HIV Infection in Relationships ...... 151

7. Risk ...... 163

A Sociology of Risk ...... 164 Harm Minimisation...... 168 To Trust or Not to Trust...... 172 Social Aspects of AIDS Conference, Melbourne (1997)...... 175 Fear, Anxiety, Uncertainty...... 183

8. Resistance and Agency ...... 190

Agency and Habitus...... 196 Prevention Now and into the Future...... 203 The Practice of HIV Prevention...... 203 Beyond a ‘Social Public Health’...... 207 AIDS Organisations and Information Provision ...... 211 The Continuing History of Negotiated Safety and HIV Prevention...... 216

9. Conclusion ...... 225

References ...... 236

Appendix One: Interview Guide ...... 249

Appendix Two: Campaign Details ...... 251

VAC’s Because We Want To Be Together ...... 251 Launch and Dissemination...... 251 Reaction ...... 252 ACON’s Fucking Without Condoms ...... 255 ACON’s Talk Test Test Trust … Together ...... 257 Planning ...... 257 Launch and Dissemination...... 258 Initial Reaction...... 260

Appendix Three: Fucking Without Condoms (ACON Lift-out) ...... 263

Tables

Table 1: Age of Participants by Country...... 39

Figures

Figure 1: Because We Want To Be Together (VAC Flyer)...... 97 Figure 2: Because We Want to Be Together (Reverse Side) ...... 98 Figure 3: Talk Test Test Trust … Together (ACON Pamphlet - outside)...... 124 Figure 4: Talk Test Test Trust … Together (ACON Pamphlet - inside)...... 125

9 1. Introduction

As the first cases of AIDS came to light in western metropolitan societies in the early nineteen eighties, so grew a public awareness about the epidemic. The resulting resurgence of homophobia, and of older ideas of homosexuality-as-a-moral-and/or- physical sickness1, led to some severe “contain and control” sentiments being expressed about those unfortunate enough to be infected with HIV (see for example Sendziuk 2003: 82; Patton 20022, Bowtell 1992; Gilaman 19893; Watney 1987; Parkinson 1985). These statements came not just from members of the public but also from government officials and some members of the medical profession. This situation produced a potent political and social brew within which HIV prevention had to be defined, appropriate approaches negotiated, and safe sex campaigns and messages implemented.

By the mid eighties in amongst the lauding of the heroes of ‘big’ science who would save humanity from this latest disease threat, and the very public search for a casual agent – its naming and the characterisation of its mechanism of operation – came early pronouncements about prevention. Because of the dominance of the medico- scientific model, these were often from a behaviourist perspective (Bowtell 1992; Kippax et. al 1993b: 4) and also often value laden and socially conservative. The epidemiological “contain and control” view continued to dominate, which led to the inevitable admonitions about “gay lifestyle” and pleas for monogamy and even

1 In The History of Sexuality: Volume One, An Introduction (1978) Michel Foucault identified “four strategic unities” which from the eighteenth century “formed specific mechanisms of knowledge and power … ” around which discourses and institutions controlling talk and use of sex and sexuality arose. One of these four strategic unities was a psychiatrization of perverse pleasure (1978: 103 – 105). Homosexuality was one of the key areas in which this pyschiatrization occurred, and, along with ideas from the religious and legal spheres, became a source for the stigma and discrimination around homosexual and gay identities and communities that continued into the twentieth and twenty-first centuries.

2 Patton described the epidemiological view in the following way, “An epicentre is, by definition, unstable and uncontained. Epidemic disease must be confined and policed” and “For AIDS, epidemiology tends to understand curative drugs and condoms as a means of containment, of keeping HIV in the infected cell or infected body rather than highlighting their positive capacity of keeping HIV out of the uninfected cell or body.” (2002: 42, 43).

3 As Gilman wrote “[t]he construction of various boundaries of disease, of images of the patient as the container and transmitter of disease, depends on our own sense of our own mortality and our consequent desire to distance and isolate those we designate as ill” (1989: 107).

10 abstinence, or at the very least reduction in numbers of partners (Race 2004: 215, Watney 1987).

However, as the input from affected groups and educators in community-based organisations grew, encouraged by supportive governments and health policy, an alternative approach emerged. This non-epidemiological approach to HIV prevention was apparent mainly in the gay and associated media, but also came from social researchers, some health professionals (including gay physicians) and government officials, and from AIDS Councils and the educators within them. In stark contrast to the views expressed by some doctors and politicians, these messages embraced a communitarian approach, namely that by standing together and working as a collective to educate and inform, with members of gay communities4 working as educators, these communities might have a chance of protecting themselves from the worst ravages of the epidemic (see chapter three for further detail). Initially, when a casual agent for AIDS was still unknown, prevention messages focussed on protection from bodily fluids but this approach quickly evolved to an emphasis on the condom as the primary barrier to infection when HIV was identified as the cause of AIDS in 1984.

As the epidemic rolled on through the nineties, and people began to learn to live with and adapt to its exigencies, the possibility of treatments also appeared on the horizon and debates around prevention became more nuanced and sophisticated. At the same time HIV social research was developing a deeper understanding of broader social and cultural factors affecting gay men’s lives and their connection to risk of HIV infection. Research coming mainly out of the SIGMA group in the U.K. (see for example Davies 1993) and the National Centre for HIV Social Research (NSHSR) in Australia (Kippax et. al. 1993b) illustrated that there were a set of broad socio-cultural factors affecting the lives of gay men at the time they were infected. However, it was

4 The plural gay ‘communities’ in this thesis designates not only gay communities that may exist in different physical locations, but also indicates groups, gatherings, networks and collectives of people who recognise or label themselves as part of a ‘gay community’ within or across physical locations. This is not to imply that there is a linear relationship between same sex attraction, a ‘gay’ sexuality and a political or social gay identity that grants automatic membership to a gay community. Perhaps it is most useful to think of these links as varied and idiosyncratic although broadly encompassed by a social and political movement. These concepts underpin the discussion of negotiated safety and TTTT in this thesis.

11 equally clear from this and other research that there was a complex set of contextual factors – biographical, psychological and interpersonal – that intersected with the broader socio-cultural context to produce a complicated interaction with prevention messages and perceived risk.

While this research went a considerable way in unpicking the factors influencing the complex milieu surrounding risk perception and behaviour, the question as to how AIDS organisations should interpret this information, or how they should act on it in formulating prevention campaigns or messages, remained largely unanswered. Nonetheless, charged with the responsibility of putting prevention into practice (in Australia and New Zealand at least) AIDS organisations forged ahead and learnt through trial and error what worked and what did not.

It was into this environment that the AIDS Council of NSW (ACON) launched a campaign in May 1996. Talk Test Test Trust …Together (TTTT) aimed at decreasing the risk of HIV infection within gay men’s relationships.5 On the surface, there was nothing unusual or exceptional about this. However, there was something very different about this campaign from those that preceded it, as the TTTT message was that it was safe not to use condoms for anal sex in primary relationships if a number of very specific steps were followed. These steps included discussing and establishing an agreement about anal sex and condom use both within and outside the relationship, discussing the ramifications of HIV testing, each partner then having a test, waiting three months (the period required after infection for HIV antibodies to be present in sufficient quantities to be tested for in an individual’s blood) and then testing again, and if both partners had remained HIV negative during this time only then not using condoms for anal sex in the relationship (AIDS Council of New South Wales Pamphlet, Talk Test Test Trust …Together, 1996). Condom use for anal sex in casual

5 In this thesis “relationship” is defined as meaning any regular sexual arrangement with a particular partner, the duration of which can be weeks to many years. It can cover a wide range of contexts for having sex, and does not necessarily mean the partners are cohabiting. The use of the word is always going to be somewhat arbitrary and will not capture the full complexity or diversity of human sexual and emotional relations. However, it is necessary to use some kind of shorthand to describe an arrangement that is not ‘casual.’ A casual partner is any sexual partner who is not purposefully seen again for sex, or not seen again for sex on a planned or regular basis.

12 encounters continued to be advocated whether or not individuals were following the TTTT framework.

This was a significant change in both HIV prevention policy and practice in Australia, which up until this time, like most other HIV prevention efforts across the western world, had consistently promoted the ‘condom-every-time’ mantra, regardless of context (Mackie 1996: 39). TTTT generated considerable debate within ACON during its development, and over the next few years, when the concepts behind the new campaign began circulating on the international stage (in particular the XI International AIDS Conference held in Vancouver in 1996). The controversial campaign precipitated much discussion and aroused some emotion and reaction in many within the prevention community (see for example Ridge 1996).

Across the Tasman in New Zealand, where the New Zealand AIDS Foundation (NZAF) continued to implement campaigns that promoted the ‘condom-every-time’ message, a rift centred around TTTT began to grow between the usually closely aligned Australasian prevention organisations. Divergent views came to a head in Melbourne at the Social Aspects of AIDS conference in 1997 where opposing and strongly held opinions clashed head on (see chapter seven for further detail). Debates about the ideas behind TTTT, though much muted, linger to this day and continue to have relevance for contemporary prevention issues (see chapter eight).

Arguments articulated for and against TTTT and negotiated safety6 (the prevention concept behind TTTT) appeared, on the surface at least, logical and reasonable. Proponents on both sides of the debate drew on a mix of medical, epidemiological and social research findings – as well as broader concepts from public health, health promotion, social marketing and views from affected communities themselves – to argue their cases.

The main bone of contention was whether TTTT (and the Victoria AIDS Council’s campaign before it Because We Want To Be Together) would undermine the condom- every-time message in relationships and also in other prevention contexts, and so have

6 Kippax et al. coined the phrase “negotiated safety” in 1993 (Kippax S., Crawford J., Davis M., Rodden P. and Dowsett G., ‘Sustaining Safe Sex: A Longitudinal Study of a Sample of Homosexual Men’, AIDS 7 (2), 1993b: 257 – 263).

13 the opposite effect to that intended, to increase the risk of HIV infection not only in gay men’s primary relationships, but also more generally throughout gay communities. The main argument used in defence of the new strategy was that there was evidence to demonstrate that condoms were often not used in gay men’s primary relationships, and so a harm minimisation approach that addressed the dynamics of this and disseminated a framework that, if followed, would reduce risk was necessary and appropriate. A further argument, that such an approach acknowledged gay men’s agency7, resistance and sexual freedom, developed later and continues to be used in debates within prevention today (Kippax and Race 2003). A counter argument to the ‘pro’ negotiated safety position was that the steps involved in negotiating an agreement about safe sex without condoms within a relationship and safe sex outside the relationship – most notably trust and communication – were known to be fraught in gay men’s relationships (Worth et. al. 2002, Ridge 1996) and indeed in any intimate sexual relationship. Other arguments from those opposed to TTTT as a prevention campaign included that the message was too complicated for large scale mass media dissemination and that the strategy itself was too complex for individuals to follow and negotiate in a relationship (see chapters five and seven).

A striking feature of the controversy was that although there was support for TTTT and negotiated safety at the organisational level from most Australian AIDS organisations there was much more contestation and debate behind the scenes. This occurred not only during the development and implementation of TTTT but also during the earlier Because We Want to Be Together campaign of the Victoria AIDS Council (VAC) which had also addressed the issue of infection in relationships and anal sex without condoms. Indeed, it had been the forerunner to the TTTT campaign. Further clouding the issue, the main advocate of the development of TTTT in ACON was a New Zealander and former NZAF employee.

7 Inden defines human agency as “the realized capacity of people to act upon their world and not only to know about or give personal or intersubjective significance to it. That capacity is the power to act purposively and reflectively, in more or less complex interrelationships with one another, to reiterate and remake the world in which they live, under circumstances where they may consider different courses of action possible and desirable, though not necessarily from the same point of view” (1990: 23).

14 Meanwhile, in New Zealand, a similar phenomenon was occurring. Publicly, AIDS organisations were registering their scepticism for negotiated safety and their adherence to the condom-every-time approach. Privately, AIDS educators and members of affected communities were much more divided in their views. In part this was not only due to the fact that negotiated safety was a new and controversial development in prevention policy and practice, but also because of the inherent difficulties and politicisation of HIV prevention in general. In this way TTTT and negotiated safety can be seen also as a focal point for many of the wider issues and difficulties associated with HIV prevention work.

Argument and Aim

This thesis argues that in order to better understand the negotiated safety debates, TTTT and HIV prevention and what shapes, moulds and drives it, it is also necessary to understand the broader social, cultural and historical context that influences HIV educator practice (and negotiated safety and TTTT within it), as well as the dynamics of the epidemic itself and gay communities and wider societies’ responses to it. This context can also be thought of as a number of factors, some related to the epidemic itself and others related to the wider historical context of life in the late twentieth to early twenty-first centuries, the late or post-modern period. These factors are closely related and exert influence on and interact with each other as well as the broader context. Negotiated safety and TTTT are used as a case study, a particularly dense transfer point, a nexus of prevention issues, to illustrate the contestations that occur around the practice of HIV prevention and to uncover or expose these factors or these deeper levels of influence (Stake 2005: 447). Social theory from social anthropology and sociology is used to provide a theoretical framework to undertake this project (see Theoretical Perspective below for further discussion).

The aim of this thesis is to elucidate and analyse these historical and socio-cultural factors and their relationship to and interaction with each other and their influence on negotiated safety and TTTT, HIV prevention and gay men’s lives, as well as the dynamics of the epidemic itself and gay communities and wider societies’ responses to it. These factors will be identified and analysed and then applied to a number of areas within the history of the negotiated safety debates and TTTT and in so doing shed further light on:

15 why there was a marked change in prevention policy and practice in Australia and not in New Zealand, given that both AIDS Councils had been remarkably similar in prevention strategies and approach up until the introduction of negotiated safety and associated campaigns;

the contestation around negotiated safety and TTTT on both sides of the Tasman, both within AIDS organisations themselves and more broadly amongst researchers, policy makers, academics and within gay communities;

the machinations around arguments about negotiated safety and TTTT, in particular the communitarian agency friendly approach to prevention that negotiated safety and TTTT exemplified versus a more rational behaviourist condom-every-time approach based on the health belief model (Becker 1974; Davies 1993: 46; Bowtell 1992);

how arguments on opposing sides of the debate seemed logical and reasonable, in many instances drawing from the same evidence, albeit making different interpretations and arriving at very different conclusions.

This thesis will attempt to find a theoretically informed way through this impasse and to reconcile these seemingly irreconcilable positions by seeing past the particulars of the arguments. It will be argued Bourdieu’s (1977) conceptualisation of the complex relationship between habitus, fields, and practice can better encompass, account for, and explain these seeming contradictions, inconsistencies and complexities (see also chapters two and eight). Bourdieu’s conceptualisation of habitus, capital and fields spans across and integrates all social life, both at the individual and collective level, as well as through history and time, and indeed through the social, bureaucratic and political institutions of society. A discussion of fields and the various capitals set in motion against each other can shed a lot of light on the concepts of gender, sexuality, sexual identity, and ‘gay’ in western societies, and indeed on the interaction of the various players in the HIV sector and finally on HIV education and prevention. The variations in educators’ practices resulting from their various views, arguments and strategies about prevention can be see as different ways of “playing the game” (Bourdieu and Wacquant 1992; Bourdieu 1993), different ways of engaging various available capitals, different ways of interpreting the factors affecting the epidemic,

16 different ways of negotiating the intersecting fields that make up HIV prevention and education, academic and policy maker discourse and of course the practices, sexual and otherwise, of gay men.

Bourdieu has been and remains a popular theorist in the social sciences, but application of his ideas to the field of HIV prevention and health promotion is innovative. By applying Bourdieu’s concepts to these areas this thesis makes a significant contribution to the ongoing debates about new approaches in HIV prevention and education.

Method

A method was required that would allow the collection of rich, contextualised, detailed qualitative data – “thick description” as Geertz (1973) famously coined it – on both the specific details and arguments for and against TTTT and negotiated safety, but also on context of HIV prevention in which the campaigns were implemented. However, the method employed would also have to be able to facilitate the identification and analysis of broader historical and socio-cultural factors, their relationship to and interaction with each other, and their influence on negotiated safety and TTTT, HIV prevention and gay men’s lives, as well as the dynamics of the epidemic itself and gay communities and wider societies’ responses to it.

In-depth qualitative interviewing of HIV prevention workers and educators in both Australia and New Zealand was considered the method best suited to gathering rich, contextualised data on arguments about TTTT, debates on negotiated safety and on the context of HIV prevention in which the campaigns of interest developed. Seventeen interviews were carried out between February and October 2006. Seven of these interviews were with New Zealand workers while ten were with Australians. It is this substantial body of qualitative data (220 pages of transcribed text, over 135,000 words) that forms the basis of the case study for negotiated safety and TTTT. Further detail on sampling, recruitment and analysis of interviews is provided in chapter two.

The method employed in identifying factors associated with the broader historical and socio-cultural context initially arose from analysis of the interview material. Some obvious themes began to emerge early in the analysis. Perhaps some of the most obvious of these themes were issues of intimacy, trust, as well as communication and

17 negotiation of sex and safe sex practices within and outside the primary relationship. This immediately suggested the broader context of gay men’s relationships, and for that matter, relationships in general in the late or post modern period would be of some importance. Clearly, perception of risk of HIV infection within relationships is also pertinent here, and is an example of the interconnectedness of the various factors. As discussed earlier, the idea that TTTT was a harm minimisation strategy that acknowledged and addressed the fact that gay men made their own assessments about risk in relationships led to a later argument about negotiated safety as an expression of gay men’s agency, resistance and/or sexual freedom. This was another area that needed to be explored further. A “ground up” approach is an inductive method that explores and analyses the data in tandem with the academic literature as the study proceeds (Ezzy, 2002: 12). It was clear that an exploration of theory relating to these areas was required if the various factors influencing the broader context were to be understood in the context of TTTT and negotiated safety. An “insider” or “emic” perspective (Harris (1976: 331) was also central in connecting interview material with theoretical and other literature. Chapter two discusses the background to these methods in greater detail.

Theoretical Perspective

The term ‘socio-cultural factors’ has been used on a number of occasions in this introduction and immediately implies that ‘culture’ and ‘the social’ or broader ‘society’ are in some way implicated in the deeper influences that shape HIV prevention. Similarly, some sense of history, of changes in these factors over time, is also necessary in order to understand the ongoing effects of this broader context. Taking first the question of what exactly is ‘culture’ and/or ‘society’? The discipline of social anthropology is where the systematic study and theorisation of ‘culture’8 has, in the main, occurred – although there is an argument that cultural studies has taken over this field in the more recent past (Kuper, 1999: 229) – while the study of what constitutes ‘society’, usually western society, is found in sociology.

8 When posing the question ‘what do anthropological theories theorize about?’ Moore suggested a wide range of possible responses including: culture, other cultures, cultural difference, ways of life, social systems and world views. ‘More abstract formulations’ included power, difference, diversity, agency and representation while family forms, political structures, livelihoods and forms of faith were ‘more concrete examples’ (1999: 2).

18 The legacy of thought in both anthropology and sociology has shaped the theoretical framework of this thesis in a number of important ways. This thesis embraces the ‘composite, partial and eclectic’ approach to contemporary theory in anthropology as described by Moore (1999: 4 – 5) hence the use of both anthropological and sociological theorists writing in diverse areas to expand the discussion of key areas of interest as described in the preceding section. In particular, sociologist Anthony Giddens’ work The Transformation of Intimacy: Sexuality, Love and Eroticism in Modern Societies (1992) is used to provide further theory and context to the discussion of relationships and intimacy while Ulrich Beck’s Risk Society: Towards A New Modernity (1992) provides insight into the conceptualisation of risk in the late modern period. These authors, along with a number of works from Zygmunt Bauman (2001, 2003, 2006, 2007), also provide a theoretical framework to assist in understanding a complex detraditionalised individualised late modern world. As previously discussed, anthropologist Pierre Bourdieu and his notion of habitus (1977) is used to explore the concept of resistance and agency in the context of HIV prevention, and to further discussion about how people interact with medical information and health promotion messages.

The theoretical framework of this thesis has also been strongly influenced by action or practice approaches that focus on social practices and processes, ‘doing’ generated through culture and at the same time generating new and changing culture. The elaboration of action or practice theory through ‘the power shift’ and ‘the historic turn’, as Ortner describes them (2006: 4, 8) has also led to an interest in history in the context of structure and power, its organisation and discourses, drawing from Foucault’s characterisation of the complex nature of power and how it is played out in shifting coalitions and resistances (1978: 92 – 93). The ongoing history of institutions and their discourses are central to culture also. A focus on structure, power and history sheds light on the phenomenon under study, in this case negotiated safety and TTTT within the broader context of HIV prevention. It is from this perspective that the relationship between history and culture is viewed in this thesis.

This thesis is not intended to be a detailed history of prevention in Australia and New Zealand, but rather focuses on the advent of the epidemic and early gay community

19 responses, and negotiated safety and the Australia New Zealand divide.9 An historical perspective allows the illustration of recurring themes in prevention campaigns, research and policy, and related debates in social science and HIV prevention and education over time, and allows these themes to be linked to a wider context – such as the influence of overseas movements and related HIV and AIDS prevention and education, changes in gay communities and society generally, and more specifically changes in a consciousness about HIV and AIDS as well as its prevention and relative risk, and the factors that influence this complex milieu. This history, and the factors that influence it, has not been documented.10 A strength of this thesis is that it documents, tracks, discusses and analyses the dynamic between the lived experience of gay men, sex and risk, specifically negotiated safety, and how education and prevention in general, and campaigns in particular have responded to this dynamic (and factors that change it). Is it just a policy choice of condoms all the time, emphasising epidemiological constructions of risk of infection (linear rational interpretations) or an agency friendly negotiated safety type interpretation of information with all its contextual socio-cultural implications?

In 1993, Kippax et. al. made the following comments on the weaknesses of an individualistic medico-psychological approach in understanding the role of a collective agency in responding to HIV and AIDS.

The philosophical individualism that underpins much of mainstream medicine and psychology makes ‘the individual’ or the piece of ‘behaviour’ the basic unit of analysis. Combined with abstracted research methods, this produces an elision of history and social

9 This historical account has also been limited in its scope to allow a focus on negotiated safety and TTTT as a case study and the elucidation of the broader factors that affect HIV prevention. For example, this thesis is not intended to be a process evaluation although the development and implementation of the campaigns of interest are described, and to a certain extent assessed for their effectiveness and impact, in chapters four and five. Similarly, this is not a comprehensive study of community politics but on occasion the thesis does focus on this area in as far as it impacts on the history of gay communities’ and AIDS Councils’ response to the epidemic.

10 However, there are more general historical accounts of HIV and AIDS prevention in Australasia, and responses of affected groups, available. For example, Sendziuck’s book Learning to Trust: Australian Responses to AIDS (2003) and the edited volumes AIDS in Australia (1992) and Intimate Details and Vital Statistics: AIDS, Sexuality and the Social Order in New Zealand (1996).

20 processes … In policy discourse the process of elision results in categories such as ‘behaviour change as an outcome of intervention programs’, which effectively deny the agency, and especially the collective agency, of groups who are responding to the epidemic among them” (Kippax et. al. 1993b: 4).

The theoretical perspective of this thesis takes account of a history of collective agency, in fact tracks changes over time and records in detail meanings and action of this collective agency through many social processes around the formation and content of prevention campaigns, research and policy, and related debates in social science and HIV prevention and education. However, interpretation of facts and events, and therefore interpretation of “history” is often contested. As stated earlier, aspects of TTTT and negotiated safety were interpreted very differently and sometimes hotly contested between various parties, not only between Australia and New Zealand, but also within interested groups in the two countries, and resulted in a change in HIV prevention policy in Australia and not New Zealand (countries that were otherwise very similar in their prevention approaches).

This thesis will explore ways to conceptualise this contestation and explain how such different outcomes could result from otherwise very similar prevention environments. The theoretical perspective of this thesis has been influenced by the ‘deconstructive turn’ in anthropology and the associated move away from viewing cultural and social phenomena as homogenous, bounded and unchanging and instead seeing them as hybrids, where cultural or group boundaries are ‘punctured and contested’ (Rosaldo 1989) or “temporal, and emergent”; fragmented, internally contested, its boundaries porous (Kuper 1999: 239, 209).

One way to theorise this contestation, Weeks suggested in his influential work Sexuality and Its Discontents, is to view history as politics (1985: 10). As Ortner put it “... the most significant forms of practice are those with intentional or unintentional political implications.” (1984: 149). In the case of negotiated safety this requires seeing the TTTT campaign as the product of a collective history of variously competing and allied interests within concentric circles of political action, some of it within gay communities, some of it within academic and policy debates, and some of it encompassed by broader societal or cultural views on sex and (homo)sexuality,

21 health and disease. Bourdieu’s concept of habitus will be applied to this formulation to further elucidate the interactions of these various interests and groups.

Again referring to the work of Bourdieu, there is an emphasis on structure and agency in the theoretical content of this thesis. Structure can be thought of, in the context of this discussion, as wider historical and socio-cultural factors or what Ortner describes as ‘the system’ while agency can be thought of as the actions, thoughts, doings or practices of an actor, person, self, individual, or subject (Ortner 1984: 144, 2006: 2), or as the collective action of an organisation such as an AIDS Council, or a group of individuals as in the case of HIV educators, or indeed the activities of a gay political and/or social movement. The problem that most often rears its head in theoretical discussions about structure and agency is that either too much emphasis is placed on the all encompassing and determinant nature of structure, with little or no room left for agency or resistance to impact on these structures (exemplified by structural Marxists such as Althusser, 1971), or, conversely, that too much emphasis is placed on human agency, resistance, identity, subjectivity or reflexivity compared to powerful and determining social structures, institutions, ideologies and discourses. A central argument of this thesis is that Bourdieu’s concept of habitus (1977) gets around this impasse by proposing that structure and agency, and all the corollary and/or dichotomising subject (agency)/object (structure) arguments that attempt to define and describe them separately, are essentially part of the same much wider and all encompassing social processes. As Ortner succinctly summed it up, modern practice theory sees society as a system, that the system is ‘powerfully constraining’ and that “… the system can be made and unmade through human action and interaction.” (1984: 159). Connecting this back to the importance of history in this conceptualisation she continues, “an emphasis on history allows people to be seen not simply as passive reactors to and enactors of some ‘system’, but as active agents and subjects of their own history” (1984: 143), as she puts it, “history makes people, but people make history” (2006: 2).

Contents

Chapter Two

Chapter two provides further theoretical and methodological detail including background in anthropology to the theory used, debates about structure and agency

22 and post-modernity for the former and sampling, recruitment and analysis of interviews for the latter.

Chapter Three

Chapter three begins the discussion of the various social, cultural and historical factors that influence HIV prevention and practice. Building on Giddens’ characterisation of expert discourses as also having an agency friendly dimension, that they also constitute “resources for the creation of reflexively ordered narratives of self” (Heaphy 2007: 123), the chapter starts with a brief historical sketch of the formation of a category of ‘the homosexual’ from the discourse of the sexologists in the nineteenth century and then continues with an outline of the rise of a self defining and identifying gay social and political movement. The emergence of AIDS and gay communities response in the form of HIV prevention will then be detailed through an examination of the early history of AIDS organisations in Australasia. The discussion will illustrate emerging themes and approaches in HIV prevention and link them to this wider context – the influence of international communities, the rise of a social and political movement, and the emergence of a consciousness about HIV and AIDS. This also illustrates the interaction of the various factors influencing HIV prevention and practice.

As the epidemic progressed and its impact intensified, the response of gay communities and other interested parties also changed and evolved. Interlaced with the response to HIV and AIDS is the impact of debates generated by academics, HIV and AIDS educators and health professionals. Chapter three introduces material from fieldwork carried out by including the views of some of the initial members of AIDS organisations in Australia and New Zealand, their reactions and insights, as the organisations they worked for evolved with the epidemic, and as they also reacted to and used information generated from a developing HIV and AIDS medicine and soon after a social science response. The links between a strong communitarian approach, a ‘sex positive’ stance (Altman 1993: 10), an earlier experience with STIs and the connection to a growing understanding of the new strategies required to address AIDS are explored in this context. This will be important for a later discussion of negotiated safety, its continuities and discontinuities with this ongoing history, the arguments that were framed for and against it, and how and why these arguments arose. The

23 chapter continues with a discussion of the formation of AIDS policy at the national level in both Australia and New Zealand and concludes with a brief discussion of early behaviour change, again illustrating the interaction of various factors influencing HIV prevention.

Another theme introduced in chapter three that is continued throughout the thesis, drawing on Giddens (1991, 1992), Bauman (2001, 2003, 2006, 2007) and Beck (1992), is that of the uncertainty, contingency and ambiguity associated with the late or post modern period. This uncertainty can that manifest itself, among other things, as conflict, contestation, confusion, fear and anxiety as according to Beck there are no experts on risk in the late modern period (1992: 29). Chapter three illustrates the conflict and contestation within gay communities and AIDS Councils about approaches to prevention. The contradictions between medical and social/communitarian models in government, AIDS Council and other responses is also explored in this context.

Chapter Four

Chapter four details AIDS Councils in Australia disseminating negotiated safety information as a prevention strategy in the early nineties in the form of the Victorian AIDS Councils’ Because We Want To Be Together flyer and the AIDS Council of New South Wales’ Fucking Without Condoms insert in the gay newspaper Sydney Star Observer. The chapter discusses the ambivalence and ambiguity of negotiated safety as a prevention message, and the conflict and contestation within AIDS Councils implementing such messages, and so continues the exploration of the theme as introduced in the previous chapter.

Chapter four illustrates that ambiguity was present in both VAC’s Because We Want To Be Together and ACON’s Fucking Without Condoms where the difficulty and pitfalls of negotiating an agreement with a regular partner was emphasised at the same time as outlining the steps to negotiate such an agreement. The chapter outlines how this ambiguity reflected AIDS Councils’ collective ambivalence in promoting messages of not using a condom for anal sex at a time when using condoms had been established as a standard prevention message and a community norm, and perhaps also reflects a wider culture of doubt (Heaphy 2007: 76) where knowledge of HIV prevention was continually changing, subject to some contestation both within and

24 outside AIDS councils, and only valid until a different or more compelling interpretation of the situation was forwarded, or another concern reared its head, or a new prevention issue or different target group was considered a priority. The chapter illustrates that the wider historical and societal context of uncertainty and ambivalence that accompanies reflexive modernity (Heaphy 2007: 64) was impacting on and shaping not only prevention practice, but particular campaigns. It also elucidates another factor important in the shaping of prevention campaigns and practice, that gay men’s and Australian AIDS Council’s responses to risk where becoming more complex, and more sophisticated prevention strategies were developing as a result.

Referring back to debates about structure and agency, the chapter suggests the negotiated safety materials produced in the early nineties by VAC and ACON are examples of gay men’s active involvement in engaging with HIV prevention messages, rather than passively enacting them (as posited by a psychologically oriented behaviourist model). Gay men were pragmatically accessing meanings around a condom-every-time message in a relationship or love context to circumvent the rigidity of the message without ignoring risks (but not necessarily accurately accessing risk either).

Chapter Five

Chapter five details the behind-the-scenes contestations within ACON that led to the policy change of which negotiated safety and TTTT were a part. It then uses material from the interviews and other related documents to describe the development and implantation of TTTT, reaction to it, arguments for and against it, and evaluation of its effectiveness. Using TTTT as an example, the chapter continues to extend the discussion about factors that were important in shaping prevention practice introduced in previous chapters but also elucidates a number of new factors related to the epidemic itself.

‘Positive in prevention’, consultation with and, when appropriate, inclusion of positive men’s perspectives in the wider practice of HIV prevention is illustrated in the chapter with a discussion about ACON’s Fucking Without Condoms, which had clearly taken a positive perspective into account in formulating its content. In terms of

25 approaches to negotiated safety, a positive status meant a very different set of considerations (for example, to disclose one’s HIV status or not) and subsequent negotiations both with a negative or a positive partner.

Related to a positive voice in prevention was the rise of an HIV/positive ‘identity’ and ‘community’ (Dowsett 1992; Duffin 1990) which is another factor influencing HIV prevention practice identified in chapter four. Extending the discussion about structure and agency the chapter argues that contradictory elements exist within the formation of HIV identities and communities. The chapter discusses that in the previous history of struggle against and resistance to dominant discourses about homosexuality a reasonably coherent group identifying as gay or homosexual had been united in their collective action. Now, with the development of ideas about a positive identity or community (whether or not one is persuaded there is sufficient enough difference between positive and negative men to signify an emerging new identity) came competing and at times conflicting interests.

Chapter five also begins to detail arguments both for and against TTTT from interview material, such as supporting arguments like TTTT creating a ‘space’ for dialogue about negotiated safety amongst gay men, counsellors, and prevention and education workers; and arguments against including that TTTT relies on trust, open and communication and the complexity of the TTTT message. The chapter returns to the theme of contradiction when discussing TTTT and arguments about it, including the dichotomy between a condom-every-time approach versus a more holistic communitarian, agency friend approach that negotiated safety and TTTT exemplify. A condom-every-time approach provides a straightforward unambiguous health promotion message that can be easily and consistently repeated, but at the same that this ‘one size fits all’ approach does not allow for any flexibility or taking account of contexts where condom use may be unnecessary – for example in gay relationships where each partner is known to be HIV negative and where a negotiated safety agreement based on trust and open, honest communication is in place.

The chapter concludes by connecting earlier discussion of gay men’s and HIV prevention’s increasingly sophisticated risk reduction strategies and the rise of a positive voice to Dowsett et. al.’s concept of ‘post-AIDS’ which they characterise as “… a fragmentation and multiplication of gay community responses to HIV/AIDS, a

26 differentiation in both experiences and consequences that warranted a new, multifaceted approach to health education among gay men, whether HIV-positive or negative” (2001: 209). Kippax and Race further added to the definition by observing that the success of combination antiviral therapies was also implicated in ‘post- AIDS’. (2003: 6). The fracturing of the unity of safe sex in the post-AIDS period is relevant to discussions about increasing complexity in this and previous chapters and will be built on in following chapters in connection to the structure/agency debates and the complex interplay of factors acting on HIV prevention.

Chapter Six

Chapter six explores the wider context of relationships, love, rationality and sexual health behaviour in the late or post modern period as a factor influencing HIV prevention and practice, with particular reference to intimate relationships drawing on the work of Giddens (1992, 1991, 1990). The discussion in chapter six will centre on his suite of theoretical musings focussed around the concept of ‘reflexive modernisation’ (1990: 36 – 38) and its impact on intimacy, relationships, trust and negotiation. The chapter will then go onto examine the complex dynamics of gay relationships within this wider historical and social context, and consider negotiated safety and TTTT in this light.

The chapter discusses that there is also relevance in Giddens’ concepts to the sphere of HIV prevention and TTTT specifically. The description of mutual trust, openness, communication and discussion characteristic of Giddens’ pure relationship (1992: 2) sounds surprisingly similar to the steps advocated for the safe implementation of a negotiated safety agreement, except that it is in the broader sphere of relationships, not the specific context of sexual health and avoidance of HIV infection. The chapter also discusses whether it is possible that part of the wider context of the negotiated safety debate is this drive, this transformative shift, towards a new kind of intimacy encapsulated within the pure relationship? However, there are complications and criticisms to both Giddens’ argument itself, and the application of aspects of it in the area of gay men’s relationships, intimacy, love and HIV prevention. The work of two authors, Jamieson (1998) and Worth (2002), are chosen to highlight some of the difficulties in Giddens’ arguments in this context.

27 Using interview material, chapter six examines the complex dynamics of gay relationships within this wider historical and social context, with reference to HIV prevention and to arguments about negotiated safety and TTTT. Love – drawing on the work of Bauman (2001) – intimacy, communication (or lack thereof), symbolism of semen exchange and condom use (or not), risk and rationality are discussed. The chapter concludes that for both Bauman and Giddens the potential for angst, uncertainty, ambivalence and risk in the context of relationships and love is most certainly an aspect of the late or post modern period, and so contributes to the backdrop of relationships more generally and also constitutes one of the wider forces impacting on HIV prevention

Chapter Seven

Chapter seven situates HIV social research focussed on the concept of risk in a broader characterisation of risk as discussed by Beck in his defining work in the area Risk Society: Towards A New Modernity (1992) and Bauman in his more recent works (2007, 2006, 2003). As in previous chapters, this chapter will continue to argue that negotiated safety and TTTT are particular expressions within a much broader post or late modern conceptualisation of risk, as is HIV prevention more generally, where the certainty of truth and knowledge is undermined creating “ … a culture of radical doubt where all kinds of knowledge, including expert knowledge “are only valid until further notice” (Heaphy 2007: 76). The chapter also discusses the perception of risk of HIV infection within relationships, an example of the interconnectedness of these arguments with those made about intimacy, which were discussed in chapter six.

Of particular relevance to this chapter, Beck asserted conceptualisations of modern risk were based on causal interpretations and so initially existed only in terms of the scientific or lay knowledge about them. For Beck, science’s monopoly on rationality is broken in the area of risk as “[t]here are always competing and conflicting claims, interests and viewpoints of the various agents of modernity and affected groups … There is no expert on risk” (1992: 29). Consequently conceptualisations of risk could be “changed, magnified, dramatized or minimized within knowledge, and to that extent they [were] particularly open to social definition and construction” (1992: 23). This description of the social construction of risk, and the knowledge that is constructed concomitantly with it, seems a particularly apt description of the various

28 definitions, redefinitions, negotiations and contradictions that accompany the TTTT story and the negotiated safety debates. Applying this to one of the areas the thesis hoped to shed further light on, the chapter also suggests that seemingly contradictory arguments begin to make more sense when wider social, cultural and historical factors are taken into account, in this instance the social construction of risk in late modern societies.

The chapter argues that the different perspectives of the various players – epidemiologists and assorted other medicos and health promoters, academics of various persuasions, and HIV educators – and the debates about risk of HIV infection in gay relationships and whether or not health promotion negotiated safety messages should be aimed at gay men in relationships were to be expected. The construction of risk from various players’ sometimes complementary sometimes contradictory scientific and/or social knowledge also explains how the same ‘evidence’ was used to construct rational and logical arguments for or against negotiated safety. Using interview material, examples of this are illustrated in two sections of the chapter, Harm Minimisation and To Trust or Not to Trust.

The chapter also discusses the contestation in Melbourne in 1997 at the Social Aspects of AIDS Conference. The question of whether gay men had the required negotiation skills and levels of trust and honest communication in their relationships to strike negotiated safety agreements came to something of a head at the conference. Travel between Australia and New Zealand was another area of contestation within the negotiated safety debates. The chapter discusses arguments about consistency of prevention messages in the context of travel, the differing assumptions and socio- cultural norms that may be operating around those messages. It argues that this is an issue that perhaps remains unresolved or unanswerable in the context of general HIV prevention, including negotiated safety and TTTT.

The chapter moves on to suggest that although the social construction of risk explains a lot of the contestation around issues of negotiated safety and TTTT, other factors to do with the epidemic must also be taken into account to explain the difference between Australian and New Zealand prevention policy. The chapter suggests most relevant to the divergence of opinion over TTTT between Australia and New Zealand are the larger gay populations in Australia (most particularly Sydney where TTTT

29 originated) and so higher HIV incidence, and connected to this the varying impact of AIDS related deaths11 and the relative strength of a positive voice in prevention.

Chapter seven ends with a discussion of some of the more theoretical aspects of risk, that assessing risk is a means of assuaging fear and giving the illusion that those things that seem beyond control can in fact be understood, planned for, avoided, or prevented. The chapter argues that uncertainty, fear and anxiety are key components of late modern or risk societies, using the work of Bauman (2007), Weeks (1995) and Lupton (1991) to illustrate the point. This argument is extended to the sphere of relationships, HIV and AIDS. For Weeks, uncertainty is a particular quality of living with HIV and AIDS (1995: 17).

Chapter Eight

Previous chapters illustrate that TTTT was developed and implemented as a harm minimisation strategy that acknowledged and addressed the fact that gay men made their own assessments about risk in relationships. This was part of a wider debate in prevention about the ongoing interaction of gay men’s knowledge and practices with medical and epidemiological constructions of risk and technological advances in the field such as HIV antibody and viral load testing (see for example Race 2001 and 2003; Kippax and Race 2003). The chapter outlines Kippax and Race’s (2003) concept of a “social public health” – an argument about negotiated safety as a collective practice, and as an expression of gay men’s agency, resistance and sexual freedom. It then goes on to discuss limitations of the concept; that it does not get beyond the dichotomy between the agency friendly communitarian approach and the more restrictive dictatorial behaviourist approach. The chapter argues Bourdieu’s concept of habitus (1977) may provide a way past this difficulty.

Chapter eight discusses the complex interplay of positive and negative elements in both structure and agency. Referring to Race’s comments about the challenges associated with the use of medicine within gay sexual repertoires, as he puts it, involving more than simply supplying people with information about risks of various

11 This is not to suggest that deaths as a result of AIDS in New Zealand were any less devastating and traumatising to the friends and families involved, just that a much larger number of deaths as a consequence of higher HIV incidence and a much larger gay population had a much greater effect cumulatively in Australia, particularly Sydney.

30 practices and also “more than a celebration of agency” (2004: 219) the chapter discusses the examples of interplay of positive and negative elements in structure and agency presented in the thesis. The chapter discusses how the descriptions of gay men’s proactive response to the earlier epidemic, and their engagement with medicine and prevention to enact more sophisticated risk reduction strategies (and indeed the earlier appropriation of the nineteenth century category of the homosexual into the empowering and self defining gay liberation and wider social and political movement) does sound like a celebration of agency, that gay men’s lived cultures are inherently resistant, subversive, communal, sophisticated, and safe. However, the chapter continues that an important theoretical difference in the argument presented in this thesis is the inclusion of an analysis of these empowering and unifying forces also being at times fragmenting and dissociative, spawning complexity and a diversity and a multiplicity of identities.

The contradictory nature of these forces is commented on in earlier chapters, and seems to be present in both factors particular to the epidemic itself and in wider historical, social and cultural forces acting on and shaping HIV prevention practice. This thesis argues the complex interplay of elements of structure and agency have both unifying or positive effects and fragmenting or negative aspects that are not always predictable and that do not necessarily equate to the structural aspects having only negative impacts and the agency aspects having only positive effects on people’s lives. A number of examples illustrating this point, both of factors relating to the epidemic and those relating to the broader socio-historical context, are discussed in chapter eight. Chapter eight argues that Bourdieu’s concept of habitus (1977) provides a way to conceive of these unifying and fragmenting elements of both structure and agency differently, by moving away from the structure/agency, subject/object dichotomies that plague some theory in the area, instead suggesting that each is constitutive of, and generated by, the other (1977: 72).

As has been discussed at length, other inconsistencies, contradictions and subtleties were apparent in the interview data. Chapter eight argues Bourdieu’s conceptualisation of the complex relationship between habitus, fields, and practice can better encompass, account for, and explain these seeming contradictions, inconsistencies and complexities. The variations in educators’ practices sometimes

31 expressed as practical prevention actions (including developing and implementing particular campaigns about particular prevention issues such as TTTT, or for that matter, opposing them or not wishing to implement them) resulting from their various views, arguments and strategies about prevention can be see as different ways of “playing the game” ((Bourdieu and Wacquant 1992; Bourdieu 1993), different ways of engaging various available capitals, different ways of interpreting the factors affecting the epidemic (which themselves can be different in different locations as the New Zealand/Australia divide over TTTT in part illustrated) and the broader social and cultural context, different ways of negotiating the intersecting fields that make up HIV prevention and education, academic and policy maker discourse and of course the practices, sexual and otherwise, of gay men. Similarly, the chapter argues, academics, medicos and scientists, policy makers, health workers and gay men themselves (and members of other affected groups) are also subject to the same processes as they participate in the ongoing practices that collectively constitute HIV prevention.

Chapter eight continues by presenting interview material on AIDS organisations and information provision and the continuing history of negotiated safety and HIV prevention and concludes with a discussion of factors affecting the epidemic and prevention now, and into the future – incorporating views from participants for a final time.

Concluding remarks are made in the ninth and final chapter, drawing together the discussion and arguments made in the various chapters about the case study of negotiated safety and TTTT within HIV prevention practice, and how they have been influenced and shaped by a range of factors, some related to the epidemic itself, some relating to broader historical and socio-cultural context of the late or post modern period. It is concluded Bourdieu’s (1977) conceptualisation of the complex relationship between habitus, fields, dud better encompass, account for, and explain contradictions, inconsistencies and complexities of the negotiated safety and TTTT story.

32 Applying Bourdieu’s concepts to these areas has moved forward debates about new approaches in HIV prevention and education and has provided a new way to think about how people interact with medical information and health promotion messages in the broader sphere of public health.

33 2. Methodology, Method and Theory

The method chosen for the collection of rich, contextualised, detailed data (Geertz’s (1973) “thick description”) on negotiated safety, TTTT and broader HIV prevention and education practice was in-depth qualitative interviewing. However, the method employed also had to identify and analyse the broader historical and socio-cultural factors influencing negotiated safety and TTTT, HIV prevention and gay men’s lives, as well as the dynamics of the epidemic itself and gay communities and wider societies’ responses to it. A theoretically informed “ground up” inductive method that explored and analysed the interview data along with the academic literature (Ezzy, 2002: 12) was used to provide this analysis. Data are analysed as they are collected and then fed back into the researcher’s understanding as further interviews are conducted. This iterative process continues as the study moves into the writing phase. In this way, a theoretically informed picture begins to form as the study progresses. This method is sometimes criticised for its tendency to become too broad, too amorphous and unfocussed. However, it is precisely this method’s ability to encompass and incorporate the broader context that made it particularly well suited to this study. Connections between arguments and theories about TTTT and negotiated safety and happenings at a broader socio-cultural or societal level were able to be described and analysed using this method.

This inductive approach was paired with an “emic” or insider perspective that allowed the researcher to draw on previous experience not only with HIV prevention, but with broader debates about sex, sexuality, health and community service evaluation and policy to identify key areas of theoretical and other interest in the interview material. There is a long history of the use of the emic or insider perspective in anthropology (and its opposite “etic” or outsider perspective). Harris (1976: 331) outlines this history and traces the use of the term emic back to the work of linguist Kenneth Pike (1967). Phonemic accounts of the sounds of a language are based on the ‘implicit or unconscious system of sound contrasts’ speakers hold within their minds which they use to make sounds meaningful (Harris 1976: 332) hence the use of emic to indicate the interior or insider perspective. As Feleppa put it, “[a]dvocates of “emic” analysis seek a form of understanding that is, to some extent, like that which subjects have of themselves and their world” (1986: 243). Recently, Young commented on the use of

34 emic (insider) and etic (outsider) perspectives in participatory action research (2005: 151).

The research for this thesis also incorporated a participatory aspect (Kemmis and McTaggart 2005: 562 – 568; see also Action or Practice Based Approaches next section). In recent years there has been a growing interest, in the health and medical fields, in incorporating the views of health workers, as well as client and consumer groups, into health research methodologies, partly because of the growing acceptance of qualitative methods in the sector, but also because of the acknowledgement of the importance of consultation with all interested parties and stakeholders in the development of sound policy and best practice in service delivery (Dockrell 1995; Miller and Crabtree 2005; Opie 1998). The metaphor of a conversation in which the HIV prevention workers and educators could participate in the research by adding their voices to those of academics and policy makers is a useful way to conceive of the input of HIV prevention workers in this study. The views and perceptions of educators appear in the text as material transcribed from the interviews. Written material and academic works from the HIV and AIDS social science and social research debates, and the policy debates around HIV prevention and education, are also integrated throughout the body of the thesis.

Sometimes such participatory research methodologies are referred to as “participatory action research” (Kemmis and McTaggart, 2005: 559 – 603) or “community based participatory research” (Israel et. al. 2005, Israel et. al. 1998). Kemmis and McTaggart identify several different ‘phases’ of action research with its origins in community action programs in the United States during the 1940s, a strong and continuing presence in education, and its most recent libratory expression as ‘critical emancipatory action research’ through association with social movements in the developing world (2005: 560). They list action research’s particular attributes, which distinguishes it from conventional research, as: “…shared ownership of research projects, community-based analysis of social problems, and an orientation toward community action.” (2005: 560). Such a research methodology can lead to the community or group, along with the researcher(s), acting on the information gathered through the research process and lobbying local authorities or state or federal governments for community or social change. Clearly this is a methodology at the

35 more politically active end of the research continuum.12 Dowsett specifically called for more action research in the field of HIV and AIDS (1995: 249).

Some might think a close involvement and a previous personal history with HIV prevention is an indication of ‘bias’, but from a perspective of participatory research at least, this embeddedness leads to greater understanding and increased objectivity rather than decreased understanding and bias (Kemmis and McTaggart 2005: 566 –7). To be sure, the researcher must guard against the collection of skewed data by not asking leading questions and not putting words into interview participants’ mouths, and also by ensuring analysis of the issues and arguments involved are not obscured as a result of the researcher being overly wed to a particular theoretical perspective or point of view. The way to overcome these limitations is to be explicit about point of view, theoretical perspective and the context of the research, thus allowing the reader to judge for themselves the validity of assertions made and whether the arguments being advanced are reasonable or not. This is often referred to as “reflexivity” in the research process (see for example Heaphy, 2007: 44; Kemmis and McTaggart, 2005: 567). Kippax and Kinder describe the importance of reflexivity and its relationship to objectivity in social research and in HIV education in the following way:

From the positions of researcher and health promotion professional, a commitment to reflexivity cuts across a desire for certainty. Acknowledgement of reflexivity is a disturbing one for many social researchers because it acknowledges the subjective nature of research. Research does require a kind of objectivity which can be thought of as ‘an intelligent learned use of our subjectivity … not an escape from it’ (2002: 101).

Adding a further dimension to this view of reflexivity in HIV social research, Dowsett, an advocate for ‘working in one’s own epidemic’ for many years (see for example Dowsett 1996a: 22; Dowsett and McInnes 1996: 32), explains the importance of conducting research that seeks to understand the specific context in which educators work, and its relationship to the wider context, what he describes as “the many other forces at work in shaping the practices of HIV/AIDS health education.”

12 This is not to suggest that ‘objective’ research, thought to be politically neutral at the time it is carried out, cannot have unintended political or other unforseen consequences when it is

36 To help educators, it is vital to undertake research into HIV/AIDS health education that understands the conditions under which educators work and the resources on which they draw. It means working within what Connell (1983) called the ‘black box’ of social reproduction, not just looking at what goes in or what comes out and leaving un-interrogated the mechanisms of the educational process. Developing new models without that interrogation as a way to transform educational practice misunderstands educators’ relation to theory and practice. Throwing social or behavioural research findings at the ‘black box’ in an attempt to redirect health educators’ efforts fails to engage the many other forces at work in shaping the practices of HIV/AIDS health education. Working within the ‘black box’ of HIV health education gives us a better chance of understanding what works, why it works, and what else is workable. (Dowsett et. al. 2001: 220)

The research carried out for this thesis is a good example not only of working in one’s own epidemic, as Dowsett suggests, but also of research that focuses on the ‘black box’ of HIV health education that will allow a better understanding of “what works”, “why it works”, and equally important, “what else is workable.” However, this does not mean that there will be a list of policy recommendations (common in policy research) at the conclusion of this thesis with accompanying claims that if followed these recommendations will ‘fix’ policy deficiencies in the area and improve practice. Rather, this research should be seen as providing greater understanding to the context in which prevention policy and practice operates, and in which TTTT and other campaigns were developed. This increased understanding has the potential to improve future HIV prevention efforts if considered by education workers, managers and volunteers.

Sampling and Recruitment

Purposive sampling is a technique in which potential research participants are identified because of their relevance to, and involvement with, the proposed area of study (Stake, 2005: 451). In this case it was clear that those people involved in the conception, development and implementation of TTTT, as well as the managers of the gay men’s education units in Australia that developed campaigns at the time of TTTT and negotiated safety, were obvious potential interviewees for this project. Also, for comparative purposes, HIV education workers and managers working in New

disseminated to a wider audience.

37 Zealand at the time of the negotiated safety controversy were also targeted as potential participants. While some of these people had moved on to other work or fields of study and so were not able to be contacted, the majority were known to me and thus, after appropriate ethics approval was sought and gained from the UNSW Human Research Ethics Committee (HREC), approached for participation in the study. Interviewing would proceed until ‘saturation’ (Bertaux, 1981: 37) was reached, that point where interviews were not producing any new information, and not adding any further understanding to the issues and arguments under examination (see the Participants section following for further discussion). While this sounds somewhat vague in theory it is usually clear to the qualitative researcher, particularly the experienced researcher, when this point is reached. Using previous experience as a qualitative researcher in a wide range of diverse contexts, I estimated that approximately twenty interviews would be required before saturation was reached. Roughly equal numbers of Australians and New Zealanders would be recruited.

Interviews and Analysis

An unstructured qualitative interview technique was used (Fontana and Frey, 2005: 705 – 708). A rough guide to broad interview subject areas was split into five sections: a brief introductory/biographical section; a section focussing specifically on TTTT and other relevant campaigns; a section exploring the organisational context in which the interviewee had worked at the time of TTTT; a section on rationality and safe sex campaigns; and a final section on the more general issues and history of HIV prevention and education (see Appendix One). While participants were guided to these areas of conversation, there was plenty of opportunity for them to discuss other issues and arguments they felt were relevant during the interview.

Interviews were taped and lasted between forty-five minutes to an hour and a half. Those interviews with participants directly involved in the development and implementation of TTTT and other relevant campaigns tended to be longer while interviews with managers and workers with more limited involvement tended to be shorter and more focussed on broader prevention issues and history.

38 Interviews were transcribed in full and software for qualitative data analysis, QSR NUD*IST 413, was used to index and organise the transcribed text thematically. In- depth analysis without the benefit of assisting software then proceeded from this initial categorisation. Content areas generated from further in-depth analysis included: the early history of AIDS Councils and HIV prevention in Australia and New Zealand; the history of the idea of negotiated safety in HIV prevention in Australia (and the campaigns developed from it); the reaction to these campaigns; specific arguments about negotiated safety and their relationship with the broader context of education and prevention, as well as gay communities’ responses to the epidemic; and finally HIV prevention today and insights about its continuation into the future. In the writing of the manuscript, interview material from these categories was integrated with material that related to relevant theory and debates in the literature to form the chapters of this thesis.

Participants

Seventeen interviews were carried out between February and October 2006. Seven of these interviews were with New Zealand workers while ten were with Australians. Nine of these men were in their fifties, seven in their forties, and one in his thirties (see Table 1). This age distribution reflects the purposive sampling used, in which potential participants involved in the TTTT and negotiated safety controversy were targeted. Necessarily, this resulted in a group of mainly older workers being interviewed as they were employed in AIDS Councils at the time of the controversy in the mid nineties.

Table 1: Age of Participants by Country

Age Australia New Zealand Total 50s 5 4 9 40s 5 2 7 30s 1 1 10 7 17

13 Qualitative Solutions and Research (QSR) Pty. Ltd. Non-numerical Unstructured Data Indexing Searching and Theorizing (NUD*IST) Version 4.

39 An examination of the biographical material collected in the interviews revealed that the majority of participants had worked for AIDS organisations in the area of HIV education and prevention for at least ten years at the time of interviews. Four interviewees, two Australians and two New Zealanders, had worked for AIDS Councils for over twenty years, had held senior management positions, and had been instrumental in forming approaches to prevention from the beginning of the epidemic. Their comments provided invaluable insights into prevention from its inception in both countries. These men were in their fifties, and along with another four of their contemporaries who came to the area a little later (two Australians and two New Zealanders), had been influenced to varying degrees by the gay liberation movement. The influence of ideas about human sexuality, sexual liberation, human rights, equality and community development were very important to the evolution of HIV prevention in both Australia and New Zealand, as chapters three and four will illustrate. However, there was great divergence of views concerning a wide range of issues, including what may or may not constitute ‘gay community’, what relevance and importance it may or may not have as a site of intervention in HIV prevention. Some of these men could even be described as gay dissidents, having views that would not be considered orthodox within the context of HIV prevention or gay community.

Another group of men in their forties had worked in prevention and education units, the earliest from the late eighties with another significant group from the early to mid nineties. Four of these men had been central to the development and implementation of TTTT and other closely related campaigns as they had been the primary workers on the projects. These men were also influenced by ideas from the gay liberation movement but being one generation removed perhaps not quite so embedded in or unswervingly dedicated to the concepts promoted by the movement.

Four Australian educators identified themselves as HIV positive, as did one of the New Zealand interviewees. Four of these five people worked for organisations that represented and advocated for people living with HIV and AIDS at the time of the interview.

Interviewees came from a diverse range of backgrounds. Of the five Australian men in their fifties, one had trained as a physician but almost immediately began working

40 for an AIDS Council. He continued to work for AIDS organisations for over twenty years and has recently retired. Another has worked within the international union movement on HIV and AIDS after working in local prevention and education until the early nineties. One participant worked in community development and health promotion before working in the HIV and AIDS policy area for a health department from the early nineties. Two more men in this age group have worked for organisations that represent the interests of people living with HIV and AIDS for many years. Of the four New Zealanders in this age category, one had been a teacher, another had been an environmentalist and lobbyist before both took up senior positions within an AIDS Council. Both worked for this AIDS Council since the mid eighties where one continues to work, while the other now works in a health bureaucracy. Another had been a journalist before taking up a position with an AIDS Council in the mid nineties.

Of the five Australian men in their forties, two continue to work for AIDS organisations, one starting his career from the late eighties, the other from the early nineties. Two more no longer work in AIDS Councils although one continues to work in the field for a health department policy unit. The other works in the legal field on human rights and anti-discrimination issues. Another participant had worked as an adult educator before taking up a position in the early 2000s with an organisation representing people living with HIV and AIDS. Of the New Zealand men in the forties and thirties age cohort, one had a background in the performing arts before starting work for an AIDS Council in the mid nineties. He now works in health promotion for a health organisation as does another in this group. A third man has worked for an AIDS Council since the mid nineties, all of his working career.

It is an indication of the dedication and commitment of the participants in this study that they have remained working in the area of HIV and AIDS or health promotion and education, or closely related fields, over the two decades of the epidemic.

The seventeen interviews conducted resulted in a substantial body of qualitative data (220 pages of transcribed text, over 135,000 words) that formed the basis of the case study for negotiated safety and TTTT. The volume of data in itself indicates the depth and breadth of coverage of issues explored (as listed above). However, it does not necessarily indicate whether saturation was reached in the data. In his key work

41 Bertaux explains the concept with reference to his study of French bakers, using a life history approach:

The first life story taught us a great deal; so did the second and the third. By the fifteenth we had begun to understand the pattern of sociostructural relations which makes up the life of a bakery worker. By the twenty-fifth, adding the knowledge we had from life stories of bakers, we knew we had it: a clear picture of this structural pattern and its recent transformations. New life stories only confirmed what we had understood, adding slight individual variations. We stopped at thirty: there was no point in going further (1981: 37).

Similarly in this study, the people most intimately involved in the planning, development and implementation of TTTT and other earlier negotiated safety campaigns were targeted first. After maybe four or five interviews with these key people it was clear a detailed picture of the machinations, arguments (both for and against TTTT and negotiated safety) and contestations around the change in prevention policy, dissemination of the message and reaction to it had been reached. Interviews continued with people who had been involved in the evolution of HIV prevention approaches on both side of the Tasman, and been HIV educators at the time of TTTT, filling out the historical context and further detail of arguments gathered in the earlier interviews. It was clear that saturation had been reached by the time all key people had been interviewed who had been involved in early prevention efforts in Australasia and later debates about TTTT and negotiated safety as no new arguments or detail about either the campaigns or the wider Australasian prevention context was emerging from the interviews, just reiteration of points at this stage well understood.

While a sample of seventeen HIV educators in Australasia may sound somewhat limited to some (particularly those from quantitative backgrounds), their diversity of opinion not only on negotiated safety and TTTT but on a wide range of prevention, health promotion, public health and other political and social issues (the breadth of issues covered in the interviews), the volume of material gathered, and a method that uses this material as a case study to connect it to the broader historical and socio- cultural context ensures this sample was sufficient and appropriate for the stated aims of this study.

42 Use of Pseudonyms

This thesis takes an historical perspective in much of its approach and analysis. It may seem unusual to readers more familiar with the conventions of historical writing that persons involved in events and policies described are referred to by pseudonyms. It is a requirement of the UNSW HREC that research undertaken for this thesis protect the anonymity of participants. In some instances the views and opinions of the people interviewed are available on the public record because of their high profile in the area, but this is not the case for several of the interviewees. For these reasons, and for consistency, pseudonyms are used for all participants and any information that could easily identity interviewees has been removed from quoted interview material.

Theoretical and Methodological Background

As noted in the Introduction, the discipline of social anthropology is where the systematic study and theorisation of ‘culture’ has, in the main, occurred while the study of what constitutes ‘society’, usually western society, is found in sociology. However, there is considerable overlap between the two disciplines, as the following discussion will illustrate. It is not possible to summarise here the history of thought and theorising about ‘culture’ and ‘society’ in social anthropology and sociology (after all, these have long been and continue to be some of the central questions of both disciplines) but it is possible to very briefly describe my own perspective on these questions with specific reference to the theoretical issues pertinent to this thesis. This discussion begins, then, with an outline of a history of ideas and associated theoretical developments in social anthropology as this tradition informs the qualitative interviewing method chosen for the data collection, and also underpins the theoretical framework used to elucidate those socio-cultural factors shaping the context and practice of HIV prevention. Theoretical debates from sociology – particularly those relating to the current context of western society, often referred to as post, late or high modernity (Heaphy 2007), reflexive modernity (Beck 1992; Giddens 1992, 1991, 1990), or more recently ‘liquid’ modernity (Bauman 2007, 2006, 2003) – were also pivotal in shaping the theoretical framework of this thesis. These debates will be outlined later in this discussion.

43 Theory in Social Anthropology

In an influential essay Ortner sketched the various theoretical developments in social anthropology from the 1960s. She described three dominant schools of thought prevalent at the end of the 1950s. The British structural functionalism of pioneering anthropologists like Radcliffe-Brown and Malinowski, the American cultural anthropology of Margaret Mead and Ruth Benedict with its psychological influence, and American evolutionary anthropology (1984: 128). By the beginning of the 1960s these ‘somewhat exhausted paradigms’, as Ortner described them, had given rise to three highly influential schools of thought in social/cultural anthropology with ‘new aggressive advocates’: interpretive or symbolic anthropology; cultural ecology; and structuralism (1984: 128). She has since argued that while these were very different enterprises, they were theories of ‘constraint’, the view that “[h]uman behaviour was shaped, molded, ordered, and defined by external social and cultural forces and formations …” (2006: 1). The most relevant of these three influential schools to the theoretical framework of this thesis, interpretive/symbolic anthropology, will now be examined in greater detail.

There were two main schools of thought within symbolic anthropology: the British tradition with its focus on ‘society’ championed by Victor Turner, and the American interpretive approach stemming from the work of Clifford Geertz, with his emphasis on ‘culture’. Geertz’s intellectual interest was primarily in “ … how symbols operate as vehicles of ‘culture’” (Ortner, 1984: 129). Geertz’s foundational chapter ‘Deep Play: Notes on the Balinese Cockfight’ in The Interpretation of Cultures (1973) illustrated this view by conveying the idea that culture can be read over the shoulder of participants as something like a text, modifying the structural functionalist metaphor of data collection as an objective scientific endeavour to a more interactive interpretative notion. Turner was more influenced by British structural-functionalism and Marxism, hence his emphasis on how solidarity and harmony were maintained in the face of conflicts and contradictions (1984: 130). For Turner symbols were operators in the social process that when put together in certain arrangements in certain contexts (e.g. rituals) were socially transformative (1984: 131). Here it is apparent that the arbitrary divide between the study of culture in anthropology and society in sociology is in fact not the case, with anthropology also integrating the concept of society and ‘the social’ in its theorising. Ortner described symbolic

44 anthropology in both its guises as lacking ‘a systematic sociology’ and having ‘an underdeveloped sense of the politics of culture’ (1984: 132). However, this situation would soon be addressed with the rediscovery of Marx and also the influence of new social movements in the 1970s. Rosaldo noted that at this time the New Left “stimulated groups to organize … around forms of oppression based on gender, sexual preference, and race” (1989: 35). According to Ortner first the counterculture and antiwar movements, and soon after the women’s movement, not only affected the academic world but largely originated within it (1984: 138, 2006: 17). In anthropology early critiques based on this new theoretical synergy exposed the historical links between anthropology, colonialism and imperialism, what Kuper described as the ‘guilty liaison’ between anthropology and colonialism (1999: 202). This caused theoretical shifts to occur, and new theories to arise. As Kuper put it, “[t]his project of emancipation required new theories, and the most cherished ideas of anthropology were discarded … The notion of culture itself was called into question” (1999: 204). Rosaldo has argued that the “received notion of culture as unchanging and homogenous” arising from the structural-functionalist tradition in anthropology “was not only mistaken but irrelevant” (1989: 36).

As a consequence of this theoretical turmoil the new breed of radical young anthropologists “ … quickly moved to the deeper question of the nature of our theoretical frameworks, and especially the degree to which they embody and carry forward the assumptions of bourgeois Western culture” (Ortner, 1984: 138). The influence of Marx led to the rise of structural Marxism in Britain and the closely related political economy school in America. Structural Marxism was one of the biggest influences on anthropology in the 1970s, although as Ortner points out, not through any direct influence of the major writers in the field (for example Althusser, Godelier, Sahlins or Freidman) but rather that structural Marxism was “the original force within anthropology for promulgating and legitimating ‘Marx’…” (1984: 139). Structural Marxism moved away from the centrality of the concept of culture focussing rather on “determinative forces ... within certain structures of social relations … [the] social, and especially political, organization of production.” Within this theoretical framework culture was seen as ‘ideology’ and analysed for its role in social reproduction “… legitimising the existing order, mediating contradictions in the base, and mystifying the sources of exploitation and inequality in the system.” (1984:

45 139). Structural Marxism’s American cousin, political economy, most apparent in the work of Wallerstein, Gunder Frank (1984: 141) and Eric Wolf (2006: 8), was more focussed on large-scale regional political/economic systems and stressed the importance of history and the broader context. While political economy was sometimes criticised for being too economic, too strictly materialist, and too capitalist-centric (1984: 142), it was a welcome antidote to the ‘denial of the relevance of history and the intentional subject in the social and cultural process’ (1984: 137) apparent in much anthropological theorizing up to this point, perhaps most obvious in structuralism and structural functionalism. According to Ortner, structural Marxism “ … put a relatively powerful sociology back in the picture” even if its “… narrowing of the culture concept to ideology…” and “its tendency to focus on relatively discreet societies or cultures” could sometimes be problematic (1984: 140 - 1). The theoretical framework of this thesis is strongly influenced by these developments and embraces the relevance of ‘the social’ and history in understanding the ongoing effects of broader socio-cultural factors on the practice and context of HIV prevention.

Action or Practice Based Approaches

By the early 1980s these various theoretical ructions had caused fragmentation, segmentation and specialisation in anthropology. Ortner described the field at the time as “ … a thing of shreds and patches, of individuals and small coteries pursuing disjunctive investigations and talking mainly to themselves.” (1984: 126). However, within this fragmentation Ortner also saw an emerging trend, “a new … theoretical orientation is emerging, which may be labelled “practice” (or “action” or “praxis”). As she put it, “this was neither a theory nor a method in itself, but … a symbol, in the name of which a variety of theories and methods [we]re being developed.” (1984: 127). This new focus was a response to calls in the late 1970s for a more action or practice-based approach from ‘big hitters’ in anthropology such as Geertz, Barnes, Collier and Rosaldo, and Ortner (1984: 145). It was also a reaction to the more psychologically orientated structuralism. Highly influential in the development of these new action/practice-based methods and theories was Bourdieu and his landmark work Outline of a Theory of Practice (first translated into English in 1977) and English Sociologist Anthony Giddens’ Central Problems in Social Theory: Action, Structure and Contradiction in Social Analysis (1979) (Ortner 2006: 2).

46 An action or practice-based approach forms the basis of this thesis’s data collection as well as contributing to its theoretical framework. This approach allows for the collection of detailed contextualised qualitative data ‘on the ground’ that at the same time is used to elucidate the wider socio-cultural context. As Ortner explained it, “[t]he analyst takes [a group of] people and their doings as the reference point for understanding the processes involved in the reproduction or change of some set of structural features”; “the genesis, reproduction, and change in form and meaning of a given social/cultural whole …” (1984: 149). An action-based approach also shifts the focus to the people themselves who are acting, doing, and being, and the relationship between them and the broader societal or cultural context. Action or practice theory is interested in how ‘the system’ impacts on action and vice versa.

Debates about Structure and Agency

This brings the discussion to one of the central theoretical themes of this thesis, known in anthropology and sociology as debates about structure and agency. Structure can be thought of, in the context of this discussion, as wider historical and socio-cultural factors or what Ortner describes as ‘the system’ while agency can be thought of as the actions, thoughts, doings or practices of an actor, person, self, individual, or subject (Ortner 1984: 144, 2006: 2). As discussed in the Introduction, in theoretical discussions about structure and agency the emphasis is placed on either the determinant nature of structure with no focus on agency or too much emphasis is placed on human agency and resistance compared to powerful and determining social structures. A central argument of this thesis is that Bourdieu’s concept of habitus (1977) gets around this impasse by proposing that structure and agency are part of wider social processes – Ortner’s system that can be ‘made and unmade through human action and interaction’ (1984: 159) and bringing history back into the equation, “history makes people, but people make history” (2006: 2).

This is a marked shift from the view of traditional structural functional anthropology that saw societies, and their associated ‘cultures’, as bounded entities – ahistoric, homogenous and unchanging. More recently Ortner has expanded on her earlier view and, with the benefit of hindsight, added to it. She argues that the work of Bourdieu and Giddens, and also anthropologist Marshall Sahlins, were enormously important as they conceptualised, albeit in different ways, the articulations between the practices of

47 social actors ‘on the ground’ and the structural constraints of society and culture as dialectical rather than oppositional (2006: 2) hence the system is made and unmade by people, and people are made and unmade by the system.

Giddens’ continuing interest in this issue can be seen in his theorising of reflexive modernisation, the self and intimacy and the rise of the ‘pure relationship’ as discussed in The Transformation of Intimacy: Sexuality, Love and Eroticism in Modern Societies (1992). This work is used in this thesis to put intimacy in gay relationships into the wider context of love, intimacy, and relationships more generally in the post or late modern period and will be discussed further shortly.

Further Theoretical Developments

The next development in theory in social anthropology relevant to this thesis was the ‘deconstructive turn’ of the mid 1980s, coming from the influence of post-modern thought and theorising and exemplified by two key American works: Writing Culture: The Poetics and Politics of Ethnography edited by James Clifford and George Marcus (1986) with eleven contributors from anthropology and literature departments, and Anthropology as Cultural Critique: An Experimental Moment in the Human Sciences authored by George Marcus and Michael Fischer (1986). According to Kuper, Geertz’s advocacy of literary theory as evidenced in The Interpretation of Cultures (1973) “ … formed the new generation of anthropologists, just as much as their flirtations with the New Left …” and offered “an opening toward a radical reorientation” (1999: 206). He continues: “…exciting new theories now appeared, as “deconstruction” … the next turn in American anthropology was toward an extreme relativism and culturalism, the program of Geertz, but stripped of all reservations” (1999: 206).

Marcus’s view was this ‘postmodernist anthropology’, as Kuper described it, introduced a literary consciousness to ethnographic practice by showing different ways in which ethnographies14 can be read and written (1999: 206). As with an action-based approach, the scientific objectivity of the classical ethnography was rejected and “… no privileged perspectives, no neutral voice-over was to be tolerated”

14 Ethnographies are the texts by which anthropologists describe the various cultures, societies or groups under their study.

48 (1999: 208). According to Clifford (1986), these new ethnographies were to present a variety of discordant voices, undermining the anthropologist’s own assumptions and assertions and presenting culture as “contested, temporal, and emergent” (Kuper, 1999: 209). For Clifford, cultural boundaries were uncertain and subject to negotiation, and all cultural fabrications were contested from within. Both “native” and ethnographer struggle “…to make themselves up, to find an identity in the chaos of the changing, converging world” (Kuper, 1999: 212). Similarly, Rosaldo (1989) wrote that in a post-colonial or post-modern world all cultures were hybrids and all cultural boundaries were ‘punctured and contested.’ This view of culture strongly influenced the growing field of cultural studies. Kuper was of the rather pessimistic view that anthropologists were sidelined in debates about the nature of culture as the new field of cultural studies grew (1999: 228).

Referring to the effects of these and other influences on ongoing debates about the ‘purposes and pretexts of anthropological knowledge’ Moore wrote that “… many anthropologists in the last ten years repudiated theory …” resulting not only in a retreat from theory but from “…the project of anthropology itself” (1999: 1).15 However, Moore was more optimistic about the future than Kuper noting, with caution, the emergence of ‘new theories and new forms of theorising’ at the turn of the century (1999: 2). Referring to Ortner’s 1984 article she wrote that while it was no longer possible to speak of coherent theoretical approaches that were neatly delineated from others, and that theory in contemporary anthropology had become ‘more composite, partial and eclectic’, still it was possible to identify larger theoretical trends. Indicating the continuing relevance and currency of the method and theoretical framework of this thesis in the field of anthropology she commented that “[p]ractice theories continue to inform many theoretical projects across the range of anthropological endeavours, and much of this work draws implicitly and explicitly on the work of Bourdieu … and Giddens …” (1999: 4 – 5). Ortner has reprised her 1984 take on practice theory and argued that it continues to be highly influential and inform today’s anthropology (2006: 1 – 18). However, she also points out its limitations commenting that while the early practice theorists (Bourdieu, Giddens) did not ignore

15 This phenomenon is not new. Ortner notes that “ … over the past several decades many anthropologists have argued for dropping the culture concept altogether” (2006: 12).

49 power, neither did they position it centrally in their analyses. She claims the work of Foucault (1978) did do this, as did others (2006: 4). Foucault will be returned to shortly, when the impacts of this broader theoretical background are discussed with reference to following chapters and particular discussion pertaining to the wider context of sex, sexuality and homosexuality contained within them.

Debates about Modernity and Post-Modernity in Sociology

So now it is time to leave the discussion of theory in anthropology and to turn to theoretical debates in sociology relevant to this thesis, most particularly the work of Giddens (1992) and Beck (1992). As previously noted, Giddens’ work is used to contextualise and theorise intimacy and relationships in the post or late modern period while Beck is used to theorise risk, a central theme in HIV prevention practice, in this period. To understand the specifics of Giddens’ and Beck’s arguments and their relevance to the theoretical themes of this thesis it is first necessary to gain a sense of these theorists’ views on the changes in western societies as they transformed through the modern to the post or late modern period. According to Heaphy, Giddens and Beck were ‘especially influential’ in shaping the new interest in ‘reflexive, late, advanced, second or global modernity’ which is “ … distinguished by the reconfiguration of modernity’s institutions and its social, cultural and political forms through processes associated with globalization, detraditionalization and individualization” (2007: 69 – 70). For Giddens late modernity was characterised by broad and sweeping transformations in a wide range of social, cultural and political forms including developments in: electronic and communication media, world economic order especially mobility of capital, changing global and local patterns of political action, changes in the relationship between work and domestic sphere, change in public and personal life (Heaphy 2007: 75). A key concept for many engaged in debates about the nature of post or late modernity was that of ‘disembeddedness’. Giddens defined disembedding as “… the ‘lifting out’ of social relations from local contexts of interaction and their restructuring across indefinite spans of time-space” (1990: 21) As Clarke interpreted Giddens, “… modernity is inherently globalising, and this is evident in the characteristics of modern institutions, in particular their disembeddedness and reflexivity.” (2006: 137, emphasis in original).

50 Giddens was also concerned with developing an integrated frame of reference to understand these changes and how these institutional changes connected to and affected day-to-day life (Heaphy 2007: 75). These interests were links to practice theory and its focus on actors or agents as well as structure/agency debates and the concern with how structure articulated with, and was influenced by, agency and vice versa. Another key concept for Giddens in pursuing these theoretical interests was ‘reflexive modernisation’. Giddens explained the evolution of the concept, pointing out that “… reflexivity is a defining characteristic of all human action” and that “[a]ll human beings routinely ‘keep in touch’ with the grounds of what they do as an integral element of doing it” (1990: 36). He goes on to argue that in traditional societies the past was honoured and symbols were valued because they ‘contained and perpetrated the experience of generations’ (1990: 37) while in modern societies reflexivity took on a different character – thought and action were ‘constantly refracted back upon one another’ (1990: 38). As he put it, social practices were “ … constantly examined and reformed in the light of incoming information about those very practices, thus constitutively altering their character” (1990: 38); where social life fed back into social life itself influencing change and transformation (1991: 20). This is not dissimilar to Bourdieu’s concept of habitus (1977) as discussed previously. Clarke described Giddens’ reflexive modernisation, as “… reflection on the nature of reflection itself” (2006: 139).16

But this reflexivity and in particular its connection to rational thought undermined the certainty of truth and knowledge. According to Giddens, when claims of reason replaced those of tradition in the late twentieth century they appeared to offer greater

16 As in anthropology, post-modern or poststructuralist thought had considerable impact in sociology. Heaphy noted the influence of the ‘deconstructive turn’ on debates about modernity and the shift to post-modernity. Modernity sought order, commitment, universality and homogeneity and viewed difference, contingency, ambivalence and uncertainty with suspicion. Post- modernity was the recognition or institutionalisation of diversity, uncertainty and ambivalence (Heaphy 2007: 64). For Heaphy, theorists such as Giddens, Bourdieu, and Beck are ‘reconstructivist modernists’ or, following Lemert, ‘radical modernists’ – those who acknowledge the changes apparent in the late modern period but ‘refuse to see the end of modernity’. According to Lemert, there are also radical postmodernists, such as Lyotard and Baudrillard, who believe that modernity, both concept and society, is exhausted; and strategic postmodernists such as Bauman who are open to seeing the (post-modern) world as transformed (Heaphy 2007: 8 – 9, 59). According to Bauman, post modernity is modernity aware of itself (1992: 187 – 88).

51 certainty but in fact the reflexivity of modernity subverted reason because “ … we can never be sure that any given element of that knowledge will not be revised” (1990: 39). As Clarke described it “… we believe in the certainty of our knowledge, in particular the scientific world view. But we can never be certain that knowledge will remain constant, it could be wrong, it could change, it could be reinterpreted” (2006: 139 – 40). Heaphy goes further discussing the ‘double reflexivity’ of late modernity (2007: 76). He notes that on the one hand science and expert knowledge has provided the basis for understanding and manipulating the material and social world but on the other hand rational thought has failed to provide the control, certainty and order that it was first thought it would. So the simple reflexivity of early modernity allowed for the demystification of pre-modern bases of authority and legitimation such as myth, religion, monarchy and aristocratic privilege. But in the double reflexivity of late modernity rational thought turns in on itself, interrogating and questioning itself and in the process, undermining the certainty of truth and knowledge and creating “ … a culture of radical doubt where all kinds of knowledge, including expert knowledge are only valid until further notice” (Heaphy 2007: 76).

Beck (1992) was also concerned with reflexive modernisation. As with Heaphy’s argument, Beck made a distinction between the modernisation of tradition and the modernisation of industrial society, the former being classical modernisation and the latter being reflexive modernisation (1992: 11). For Beck, reflexive modernization and risk were intimately connected with changes that occurred in western metropolitan societies through the shift from industrial societies in the modern period to risk societies in the late or post modern period. As Beck argued, “[i]n advanced modernity the social production of wealth is systematically accompanied by the social production of risks” (1992: 19, emphasis in original). Beck defined risk as “ … a systematic way of dealing with hazards and insecurities induced and introduced by modernization itself” (1992: 21, emphasis in original). For Beck there were two kinds of risks, those that were part of industrialisation and modernity, and a second type that dominated public, political and personal life (Heaphy, 2007: 79 – 80). Another key point for Beck was that in the area of risk “[t]here are always competing and conflicting claims, interests and viewpoints … There is no expert on risk” (1992: 29).

52 Both Beck and Giddens theorised about the insecurity and doubt, or ‘uncertainty and contingency’ of living in the late or post-modern period (Heaphy, 2007: 69). Giddens wrote about ‘ontological security’ in this context (Giddens 1990: 92, 131). For Giddens ontological security was “…the confidence that most human beings [had] in the continuity of their self-identity and in the constancy of the surrounding social and material environments of action” that generated a largely unconscious sense of ‘being-in-the world’ (1990: 92). This sense of self-identity or subjectivity developed in childhood through relationships with others. For Giddens, trust was also key in this process (1991: 51). Developing a sense of trust was an essential part of early life experience and trust established in early life formed the basis for ontological security. However, self-identity and personal life were undermined because of threats and dangers and personal meaningless associated with reflexive modernity (Giddens 1990: 102) that in turn led to “a heightened sense of personal or existential insecurity” further heightened when people encountered existentially troubled issues like mortality, the start or end of a relationship or serious illness (Heaphy 2007: 85). HIV and AIDS are implicated in all these aspects.

According to Giddens, ontological security allowed people to deal with or keep at bay existential insecurities and anxieties arising from moral problems or dilemmas that threatened to overwhelm at times of personal crisis. This occurred through ‘sequestration of experience’, which Giddens described as “… processes of concealment which set apart the routines of ordinary life from the following phenomena: madness; criminality; sickness and death; sexuality and nature …” (1991: 156). However, moral dilemmas arising from these types of life experiences are not easily held at bay with the heightened sense of personal meaninglessness and risk and the ‘dissembling dynamics of the post-modern’ (Heaphy 2007: 97 – 99). Unlike theorists who focussed on the destabilisation, disembeddedness and detraditionalisation of the post-modern era, such as Bauman and his concept of liquid modernity (2007, 2006, 2003), Giddens’ was a theory of agency that emphasised how individuals had the potential to respond constructively and meaningfully to life’s existential challenges, what he termed life’s ‘fateful moments’. For Giddens, fateful moments were when individuals were faced with a changed ‘set of risks and possibilities’ (1991: 131). Fateful moments could be destabilising and threatening but

53 also had the potential to be empowering and to “ … explicate new and emerging forms of politics in late modernity” (Heaphy 2007: 101). As Heaphy put it,

Life political questions stem from personal life because they concern the politics of life decisions. They mark the return of those moral and existential issues that were institutionally sequestered in modernity such as madness, illness, sexuality, mortality, criminality … life political questions stem from personal life and life choices but globalizing influences also penetrate deep into personal life and prompt life political questions … (2007: 162)

Heaphy saw AIDS as “… a life-political issue par excellence … [as] the syndrome is often drawn on in discussions of mortality in late modernity to illuminate new risks and contingencies that threaten the reflexive self” (2007: 163). And more generally, in the sphere of intimate personal and sexual relationships, following Giddens, Heaphy argued that “ … in the insecure and risky world of late modernity, intimate life is identified as the place where security is most intensely sought and cherished, but is also where radical insecurities and contingencies can be encountered in powerful ways.” (2007: 120). The contradiction apparent in this statement will be explored in chapters dealing with intimacy in gay relationships and the HIV prevention campaigns developed to address these issues. Giddens’ analysis of the influence of reflexive modernisation and a transformation of intimate relationships based on mutual respect, trust and negotiation will also be explored in this context.

54 3. The Advent of HIV and AIDS and the Rise of AIDS Organisations in Australasia

Before it is possible to begin a detailed discussion of HIV prevention campaigns designed to address HIV infection in gay relationships it is first necessary to understand the wider historical, social and cultural context within which these campaigns developed. This is essential as it provides an important background to the impact of HIV and AIDS on gay communities and their response to it. In this way the specific events that took place and prevention initiatives that were undertaken are understood as part of a broader history in which “history makes people, but people make history” (Ortner 2006: 2) and in which expert discourses while on the one hand may be dominant, hegemonic and impenetrable, on the other hand may have an agency friendly dimension and function in Giddens’ view as ‘resources for the creation of reflexively ordered narratives of self’ (Heaphy 2007: 123).

These themes will be explored in this chapter first through a brief historical sketch of the formation of a category of ‘the homosexual’ from the discourse of the sexologists in the nineteenth century and then in the rise of a self defining and identifying gay social and political movement in the mid twentieth century. The discussion will continue with an examination of the early history of AIDS organisations in Australasia. It will illustrate emerging themes and approaches in HIV prevention and link them to this wider context – the influence of international communities and the emergence of a consciousness about HIV and AIDS. Gay communities’ response to AIDS began almost as soon as the disease was known (although it would be some time before it was named). This response changed and evolved as the epidemic progressed and its impact on gay communities intensified. Interlaced with this story is the impact of debates generated by academics, HIV and AIDS educators and health professionals. This chapter will include the views of some of the initial members of AIDS organisations in Australia and New Zealand, their reactions and insights, as the organisations they worked for evolved with the epidemic, and as they also reacted to and used information generated from a developing HIV and AIDS medicine and soon after a social science response.

55 The chapter continues with a discussion of the formation of AIDS policy at the national level in both Australia and New Zealand and concludes with a brief discussion of early behaviour change.

From ‘Homosexual’ to ‘Gay’: The Rise of a Social and Political Movement

The Nineteenth Century Category of ‘The Homosexual’

In The History of Sexuality: Volume 1 An Introduction (1978) Michel Foucault theorised that in the last three centuries in Western European societies matters of sex, sexuality and associated morality were not being repressed or censored, but rather talked about, analysed, and categorised incessantly. In particular, Foucault identified “four strategic unities” which from the eighteenth century “formed specific mechanisms of knowledge and power … ” around which discourses and institutions controlling talk and use of sex and sexuality arose. These four strategic unities were: – a hysterization of women’s bodies, a pedagogization of children’s sex, a socialization of procreative behaviour and a psychiatrization of perverse pleasure (1978: 103 – 105). Homosexuality was one of the key areas in which this pyschiatrization was concentrated, and, along with ideas from the religious and legal spheres, became a source for the stigma and discrimination that has persisted around homosexual and gay identities and communities. So by the late nineteenth century the new science of medicine (with its roots in the Enlightenment) was setting about defining, describing and conceptualising, among a great many other things, homosexuality.

So began the capturing of homosexuality in the rationality of science, and the beginning of a societal consciousness about homosexuality.17 According to most sources the word ‘homosexual’ was coined in 1869 by a Swiss doctor Karoly Maria Benkart who described “a sexual fixation among men irresistibly under the spell of their own sex” (Weeks 1977: 3).18 A German doctor, Karl Westphal, while never using the term homosexual described in 1870 “contrary sexual feeling” and asserted that it was the product of moral insanity resulting from “congenital reversal of sexual

17 Earlier same sex activities, groups and cultural categories had preceded the nineteenth century category of the homosexual. See for example Bloch and his discussion of ‘the molly’ in seventeenth century England, 1996: 394.

18 Altman (1986: 40) refers to the individual concerned as Hungarian.

56 feeling” (Weeks 1990: 27; 1981: 104; Foucault 1978: 43; Thompson 1985: 84). German writer and lawyer Karl Ulrichs, himself homosexual (Weeks 1990: 26), in 1862 began writing books and articles on homosexuals calling them ‘urnings’ and Uranians after the character Uranos who, in Plato’s Symposium, advocated love between men. An urning was an individual who was the product of anomalous development of an embryo – the result of which was a female mind and/or soul in a male body or vice versa (Thompson 1985: 85, Weeks 1981: 104). Foucault described this idea as a “kind of interior androgeny, a hermaphrodism of the soul” (1978: 43). Another German, Magnus Hirshfield, theorised the existence of a third sex based on biological discoveries concerning the role of sex hormones in sex differentiation (Weeks 1981: 104 – 105). Showing the power and endurance of these early ideas, Hirshfield’s work proved to be influential in the study of transexuality as recently as the 1970s.

The theme of internal gender/sex inversion was also common amongst nineteenth century English sexologists such as J. A. Symonds and Edward Carpenter. Both men, themselves homosexual, picked up on the idea of homosexuals as an intermediate or third sex in their works. Carpenter published a book entitled The Intermediate Sex based on these ideas in 1908 (Weeks 1990: 29 – 30). Other influential sexologists of the time were Havelock Ellis and Richard von Krafft-Ebbing. Krafft-Ebbing’s book Psycopathia Sexualis was first published in 1887 and listed in Latin (so only scholarly types could read and understand such delicate information) a raft of sexual categories and ‘minor perversions’ including homosexuality (Weeks 1990: 26). Krafft-Ebbing received hundreds of letters and inquiries after the first edition of Psycopathia Sexualis resulting in the publication of twelve subsequent editions to incorporate the additional information. Similarly Havelock Ellis, Symonds and Carpenter were also swamped with correspondence. Illustrating Giddens’ point that expert discourses can also be used as “resources for the creation of reflexively ordered narratives of self” (Heaphy 2007: 123) it would seem that to be defined at all was empowering, even if those definitions were based in hegemonic discourses and overwhelmingly negative, or at best ambiguous, by today’s standards. It also raises the question that the beginnings of the mechanisms of reflexive self-definition and narratives of self may have begun much earlier than the late or post-modern period. Weeks makes a similar point to Giddens but with specific reference to sexuality. As Weeks put it, “…

57 sexuality… embodies the imprint of a vast range of social meanings… the value systems built around it have to be understood as both historical and contingent…. They are … arbitrary social arrangements, products of innumerable social and ideological struggles, and hence of shifting power relations, of patterns of domination and subordination, of historical settlements and individual and collective resistances” (1995: 48 – 49).

But perhaps the most influential of all authors of the nineteenth century concerning homosexuality was Sigmund Freud. In The Psychoanalytic Theory of Male Homosexuality Lewes (1988) analyses the influence and impact of Freud’s ideas about homosexuality on the psychoanalytic tradition. Contrary to received wisdom, and according to Lewes, Freud was extremely ambiguous about whether or not homosexuality was a pathology or an illness. At different times in his career and in no particular intellectual progression, Freud implied a range of positions on the subject. Lewes maintains that it was the twentieth century psychoanalytic tradition that interpreted this ambiguity in a negative way, although he also adds that “Freud himself did not articulate these implications but they are reasonable inferences to be drawn from his theory (1988: 29).

But it was not just sexologists and related medical/scientific disciplines and spheres of knowledge-power discourse that contributed to the formation of the category of a homosexual person in the late nineteenth century. The appearance of ‘the homosexual’ as a particular scientific and /or medical category was also related to the historical continuity of religious laws and beliefs concerning ‘sodomy.’ In the Judeo- Christian tradition homosexual acts were condemned along with all forms of non- procreative sex. There was no perception that a particular sort of person, a homosexual, performed these acts (Weeks 1990: 11 - 12). ‘Buggery’, ‘sodomy’ and other ‘unnatural acts’ could refer to a wide range of activities that did not, or could not, result in conception. However, as this category of person emerged from a complex intertwining of many discourses in the late nineteenth century, so the religious view of sodomy as a sin and a crime was narrowed down to apply more particularly to a category of person.

Further contributing to this process, and reinforcing the idea of homosexuality as a crime, and increasingly, homosexuals as criminals, was the influence of the law, the

58 legal sphere of knowledge-power discourse. The Labouchere Amendment of the 1885 English Criminal Law Amendment Act was enacted to control child prostitution, but it also had the unintended and unforseen consequence of creating the category of ‘the homosexual’ in law, with legal sanctions applying against this person (Weeks 1990: 18). Drawing on the religious tradition as previously mentioned, English law concerning buggery dates from a 1533 Act of Henry the VIII – in which the penalty for what was referred to as the ‘abominable vice of buggery’ was death (Weeks 1990: 12).

There were many strands of knowledge-power discourse to this complex and non- linear interaction. By the late nineteenth and early twentieth centuries in western societies, a category of person labelled ‘the homosexual’ had been defined, described and simultaneously controlled by strong legal and increasingly, social sanctions (the structural side of the structure/agency equation, but to be defined at all, even if negatively, also had an agency friendly aspect). This formed the basis of ongoing stigma and discrimination against both individuals and communities identified as homosexual well into the mid to late twentieth century. The elements of the various discourses that contributed to the category of the homosexual (and sexuality more generally) changed as the twentieth century progressed, with the religious sphere’s influence lessening, the influence of governmentality growing, and the influence of medicine continuing. As Weeks wrote “… formal demarcations of what is right and proper, appropriate or inappropriate, have become increasingly the province of non- religious experts – in sexology, psychology, welfare services and social policy, as well as medicine itself” (2003: 95).

Gay Liberation: A Social and Political Movement

As Ortner states, an emphasis on history allows people to be seen not simply as passive reactors to and enactors of some ‘system’, but as active agents and subjects of their own history” (1984: 143), as she puts it, “history makes people, but people make history” (2006: 2). A striking example of this is the rise of the gay liberation movement that sought to take the dominant hegemonic discourses of homosexuality as a moral and physical disease (that also made a group of like individuals visible at least), and remould them into a self defining, identifying and empowering international social and political movement. By the mid twentieth century societal

59 consciousness of male homosexuality as a sin, crime and sexual/social deviancy derived from the medical, legal and religious spheres had impacted on the lives of individuals and wider society to the point where isolation and ostracism were the norms for those appearing to be homosexual, whether or not such individuals identified themselves as sexually and/or socially different. The rare individual who could forge an identity over and above these powerful structural determinants did so without the help of a surrounding community of like minded individuals although small groups and social networks did, no doubt, exist, just as they had prior to the formation of the category homosexual in the nineteenth century. In the 1960s homosexual law reform societies organised by liberal academics, lobbyists, and sympathetic Christians continued to accept the dominant view of homosexuality as a moral and/or physical sickness, arguing for law reform on the basis of compassion – to help lonely, isolated and suicidal individuals better cope with their lives (Weeks 1990: 168 – 182). Weeks described the English Homosexual Law Reform Society as “a classical middle-class single-issue pressure group ... its membership was overwhelmingly professional middle class, with … a preponderance of lawyers, clergymen and medical men” (1990: 171). However, by the 1970s the thought and action of the gay liberation movement was to catalyse a new ‘gay’ consciousness that advocated self-definition and self-acceptance, hence firmly rejecting the sickness model.

Weeks identified three elements that had come together in the modern gay consciousness: a struggle for identity: a development of sexual communities, and the growth of political movements (1985: 195). These elements were to be more tightly integrated in the new gay liberation movement than previous liberal movements that still accepted the sickness model to some degree or other. Gay liberation had its roots within the counterculture movement of the late sixties in North America (Weeks 1977: 186). However, its birth is often traced back to the now mythologised Stonewall Riots. In June 1969, police raided a popular gay bar, The Stonewall, in New York’s Greenwich Village. As a result of the police action the patrons rioted, precipitating ongoing street battles that lasted several days. It is generally agreed that what was new about this situation was that ‘the homosexuals’ fought back – in this case in the form of physical resistance, but this resistance was to be taken up symbolically by gay liberation movements as part of their rhetoric. By the early seventies gay liberation

60 ideas and organisation had spread to other western industrial nations such as Britain, France, Italy, Germany, Belgium, Holland, Canada, Australia and New Zealand (Weeks 1977: 189). In the 1970s as the immediate influence of gay liberation faded, a wide range of self help gay friendly organisations sprang up in its wake. The balance had shifted, within burgeoning gay communities throughout the west at least, from dominant views of homosexuality as moral or physical sickness to an agency driven self-defining acceptance. As Weeks put it “[w]hat all these disparate organisations had in common was an allegiance to the belief that homosexuals themselves could best respond to specific problems and special needs” (1977: 209). This would be pivotal in the coming crisis of AIDS and gay communities’ response to it.

Any discussion of these political and social developments must also take into account the effect of AIDS. In the 1970s a developing gay consciousness was very much a part of an increasingly public gay sexuality (Shernoff 2005: 7; Altman 1986: 7). The advent of AIDS, with all its attendant baggage, had the net effect of causing gay communities to examine their own sexual practices in more depth than had ever been necessary before. Furthermore, because of the fear and homophobia generated in wider society worldwide, from the linking of AIDS with older ideas of homosexuality as a sickness or disease, gay communities were forced to examine their collective sexualities in very public and largely disapproving forums. This, and the death of large numbers of previously young healthy people had a deep and profound effect. Nothing in the previous history of homosexuality had prepared anyone for such a circumstance. However, once again the ability of agents to act creatively and proactively within dominant and at times overwhelming forces is illustrated as gay communities responded to the epidemic. Resonating with Giddens and his idea of fateful moments, times of existential crisis that provide individuals with the potential to respond proactively and empower themselves in face of changing sets of opportunities and risks (1991: 131, 156), Weeks discusses a similar concept suggesting that the impact of AIDS acted “… as a ‘developer’ in a new and uniquely painful social and cultural conjuncture. Crisis moments force their participants to see a coherence in their sense of the world which ordinary circumstances would not have produced” (1995: 113). This will be an ongoing theme in the theoretical discussion of this thesis. The formation of the category ‘homosexual’ in the nineteenth century brought with it both risks and opportunities: the opportunity to identify with a group

61 of like minded people even if the categories were negative, and the somewhat overwhelming risk of jail and even death if one was to be identified publicly as homosexual. So too the transformation to a self empowering ‘gay’ in the twentieth century brought with it opportunities and risks: the opportunity to identify with and become part of a supportive, empowering and sexually active community, yet the ongoing risk of being subject to stigma and discrimination if one was ‘out and proud.’ AIDS heightened the risks and highlighted the contradiction between the ambiguity, uncertainty, contingency and unpredictability of HIV infection yet at the same time illustrated the defining and empowering nature of the AIDS crisis through fateful moments and resistance against dominant discourses and structures.

The following section will now detail the early history of AIDS organisations in Australasia. It will illustrate emerging themes and approaches in prevention and link them to the wider historical context as just discussed – the influence of international communities and the emergence of a consciousness about HIV and AIDS. This will be important for a later discussion of negotiated safety, its continuities and discontinuities with this ongoing history, the arguments that were framed for and against it, and how and why these arguments arose. It also illustrates the importance of an historical approach that allows sense to be made of the impact of broader social and cultural factors on the specific practice of HIV prevention.

A Response to the Epidemic in Australasia

In 1993 Kippax, Connell, Dowsett and Crawford felt there was sufficient evidence from their Social Aspects of AIDS (SAPA) and Sustaining Safe Sex (SSS) studies to proclaim, in the Australian context, that gay communities’ response to HIV and subsequent behaviour change was “one of the most profound changes of practice ever found in the social science and public health literature” (Kippax et. al. 1993a: 157)19. Illustrating the continuity with the earlier self-empowering social and political gay liberation movement, the origin of this remarkable response in gay communities began before the first cases of AIDS were reported in Australia. A similar situation

19 Becker and Joseph 1988; Winklestein et. al. 1987 noted a similar phenomenon in the U.S context.

62 occurred in New Zealand. In both Australia and New Zealand, San Francisco20 proved to be the most influential international link for HIV prevention information dissemination. The first community orientated AIDS organisations grew out of this context. Parnell summed up the situation when he wrote: “In the early 1980s, as gay men learnt about the AIDS epidemic in the United States, they started to use existing communication networks, such as the gay press and gay political and social organisations, to disseminate accurate information about both the epidemic and strategies for prevention” (1992: 185). A closer examination of this ongoing history will illustrate these points.

Australia

In a report describing the early years of a response to AIDS in Australia, written by ex-federal Minister for Health Dr Neal Blewett, Dr Ron Penny stated the first case of AIDS was identified in 1982 and reported in The Medical Journal of Australia in 1983 (2003: 21). In the same report long time HIV activist Lou McCallum described a meeting at the Paddington Town Hall in Sydney calling for volunteers to be trained as community carers. He commented that this occurred before the first person had been diagnosed in Australia. He noted that Sydney activists were in close contact with San Francisco and “it seemed inevitable that we would be affected” (2003: 28). Kippax et. al. also commented on this connection, “Australia’s gay communities were well connected to their North American counterparts and had for a long time been influenced by the politics and culture of the emergent modern gay communities in San Francisco and New York in particular” (1993a: 9). One of my research participants, Kevin, who was closely involved in the early response to AIDS in Sydney, described the all-important connection to San Francisco.

[I was] very involved in gay activist stuff … And as I was in the Sisters of Perpetual Indulgence I visited San Francisco in 83 and brought back, and other people had visited just before me, and we’d brought back material which was sort of not clearly about AIDS because AIDS wasn’t

20 Shilts characterised the importance of San Francisco on the growth of the gay movement in the following way, “[t]here are times, rare times, when the forces of social change collide with a series of dramatic events to produce moments which are later called historic. Just such a time fell on San Francisco during the late 1970s … San Francisco became the national vortex for the aspirations of a new movement which was only then coming of age – the gay movement (1982: xiii).

63 named so people were concerned about hepatitis and about Kaposi’s and ah, like Giardia and Amoebiasis and all sorts of things, and there was a sudden consciousness of quite a serious threat in terms of sexual health, like fatal, semi-fatal type stuff. [Kevin]

The Sisters of Perpetual Indulgence were an irreverent collective of gay men who dressed in nuns’ habits and whose public appearances were an impromptu mix of theatre, parody, and humour. A public manifestation of The Sisters provided important commentary and critical insight into human rights, health and social issues relevant to gay communities. The Sydney chapter of The Sisters was modelled on the original San Francisco chapter, founded in the late seventies. In 1982 members of the San Francisco chapter of The Sisters and a group of sympathetic medical professionals21 produced ‘Play Fair’, a pamphlet that is now considered to be the first harm minimisation information disseminated to gay communities about AIDS that talked about ‘safer sex’ and used “plain … language, practical advice and humor” (http://thesisters.org/playfair.html). These were the first inklings of what would much later be coined a ‘sex positive’ approach to prevention (see for example Altman 1993: 10), the conscious choice to promote condom use and other risk reduction strategies while avoiding a morally negative stance on sex and desire.

The material brought back from San Francisco by the Sydney chapter of The Sisters was used to put together an Australian pamphlet. As Kevin described it, “The first thing that goes out is thousands of copies of The Sisters’ concertina thing about … sexual health, and with the concept of safe sex.” Sendziuk also remarked on the involvement of “the cheeky gay group Sisters of Perpetual Indulgence” who distributed leaflets on safe sex in Sydney in the early eighties (2003: 106). As Kevin explained, the San Franciscan approach appealed because it “had a sense of humour about it and it was more generally about responsibility and health.” The Sisters’ involvements in these early information dissemination activities were the beginning of a continuing tradition in gay communities where drag and other performers promote prevention messages.

21 Treichler points out that “ambiguity and uncertainty are features of scientific inquiry” (1989: 36) illustrating that powerful medical discourse is not hegemonic and monolithic but rather is fragmented and subject to interpretation and reinterpretation just as with other discourses and institutions of the post or late modern period.

64 So with the growing realisation of the existence of a serious sexual health threat it was clear to activists and gay health educators that information and practical advice to avoid infection needed to be disseminated rapidly to those most affected. The Sisters’ safer sex pamphlet was the first example of this in Australia. The link to other communities overseas that were already beginning to deal with the situation was drawn upon, as was previous experience with sexually transmitted infections (STIs). Gay communities began responding to the epidemic in North America, Australia, and as will be discussed shortly, New Zealand, before the medical profession had come to fully appreciate or understand the potentially devastating impacts of the new disease, let alone formulate effective strategies for its prevention. Patton made the point in the American context, “[o]verly individualistic in their approach, the traditional professionals never realized gay men and IV drug users had coped with the fear and reality of AIDS long before the traditional professionals began en masse to confront this “new” phenomenon of AIDS” (1990: 41). Again illustrating a proactive and agency driven response, and a connection with an earlier history of dealing with STIs and using condoms, she also pointed out that gay communities in America had a jump on ideas about prevention, because they had advocated the use of condoms for STIs in the 1970s, preceding the advent of the AIDS epidemic in the 1980s. As Patton puts it “[m]any gay-health educators actually viewed STD-reducing behavior change as an easy task. In the late 1970s, before anyone had even imagined AIDS, some gay periodicals were already promoting condom use …” (2002: 66).

The links between a strong communitarian approach, an earlier experience with STIs, and the connection to a growing understanding of the new strategies required to address AIDS was also commented on by Russell, another interviewee who was involved in conceptualising and operationalising the very earliest prevention efforts in Australia.

… these early efforts were spontaneous self-funded and basically done by people who were already attached to the gay community. Who else was in the position to do that, health education, because basically in your early career as a gay man, if you had come out in the late 70s and early 80s you had to learn about STDs because they were everywhere. The STD clinic was part of what you did. And so you had to teach people … about how you got tested and what you did … HIV of course was a completely different beast, needing different strategies. But I

65 think people recognised that really quickly after, once the initial brouhaha was over. [Russell]

So even though previous experience with STIs was useful to this budding field of AIDS education, a continuing information flow outlining new strategies to prevent the spread of an as yet still unidentified sexually transmitted infection was essential in these early years. Patton commented on the very influential ‘How to Have Sex in an Epidemic’ pamphlet in the U.S in this context, which in 1983 followed the very successful San Franciscan Sisters’ pamphlet. Again illustrating agentic involvement from the very beginning of the epidemic, in opposition to dominant disempowering medical discourses (with their roots in the formation of the nineteenth century category of ‘the homosexual’ as previously discussed) she also noted that men who were already symptomatic were involved in the pamphlet’s production.

The first safe sex advice was put into circulation by gay men, and was constructed in opposition to the insulting dictates of doctors. By 1983 enough safe sex information was available for a group of gay men, including men with AIDS, to write a forty page booklet called “How to Have Sex in an Epidemic”. It stands as the single most comprehensive guide to safe sex, including explanations of theories of transmission, sexual techniques, and the psycho/social problems of coping with the change to safe sex and with the fear of AIDS. It is important to realize that this booklet was written before a retrovirus was associated with AIDS: men understood and made major, effective changes without the benefit of HIV antibody testing … (Patton 1990: 42)

Russell described the influence of North America on the first debates about numbers of partners and condom use and the first campaigns resulting from these discussions, once again, before a specific agent of infection had been conclusively identified. It is important to note that with this early harm minimisation approach – which would become a cornerstone of prevention among gay communities in western countries – a critical distinction had already been drawn between the risks associated with particular sexual practices as opposed to the more morally laden arguments about numbers of partners and gay ‘lifestyles’ (abounding in some medical literature at the time and again illustrating continuity with earlier ideas of homosexuality as a moral or physical illness).

The first debate was about, like it was a long debate about what our goals were, whether it was just use a condom every time and learn how to do that, and about, you know, what our motivation was. So we went for the easiest achievable behaviour change that would cause the least

66 disruption. So we didn’t recommend reduction in numbers of partners because we didn’t think that a) that it was appropriate or b) that it was necessary. We thought use a condom every time was enough … There was a campaign ... almost a carbon copy of a San Francisco campaign … It was very simple put out information sort of stuff. What it was designed to be was to just provide the information that we knew … And it was meant to say, you know, about how you have sex not about how many people you have sex with … There was also a campaign done by some people in Melbourne. It was also used in Sydney and it was the first safe sex guidelines. It was much more detailed than use a condom, basically went through every activity and made a few mistakes. But it was, you know, looking back with the benefit of over twenty years hindsight, it’s still a remarkably accurate pamphlet according to current knowledge … [Russell]

It is clear that from these earliest efforts the individualised approach favoured by some in the medical and health professions was rejected in favour of a collective communitarian approach that was consciously embraced and thoughtfully applied to galvanise and mobilise “a community” into action.22 Illustrating the power of the concept of a collective agency, Kevin observed,

… it wasn’t actually about individual change, it was about the community. The community was the subject and the community would have to move, as a community, to deal with a threat and the threat was affecting the whole community. And I think that’s where we started and therefore we wanted something that was achievable with the community as subject rather than individuals or individual couples. [Kevin]

Kevin continued this line of thought and commented once again on the influence of gay communities on the west coast of America, explaining that a health belief model developed there that encouraged individuals to identify risk at both the individual and collective level was adapted and applied in the Australian context.

And then from San Francisco I think it was [a] model of health belief which was … about recognising the risk might affect you, recognising something can be done about it, recognising you can do it, recognising that your community will support you doing it. It was about how you get from a situation of denial to a situation of people being empowered to carry out a behaviour change that is achievable, like using condoms. [Kevin]

22 Watney wrote that a sense of belonging to some kind of community '”will always determine the development of a resilient sense of self esteem which is demonstrably the sine qua non of safer sex education” (1991: 13).

67 Russell also commented on the concept and use of community in HIV and AIDS prevention and education. He pointed out that although the advent of the epidemic was devastating and traumatising, it also had the paradoxical effect of becoming the “glue” that held a gay social and political movement together as it progressed from the 1970s and the influence of gay liberation, and its struggle for anti discrimination legislation23, into the 1980s and the profound and complex influence of AIDS.

Our whole belief was that … the motivation to, like our motivation for being involved in the first place was because we perceived HIV as a threat to community. And we’d just come through law reform and we were at the point in the development in community where our ties were very unified. So after law reform AIDS became, if you like, the glue. Even though it was a completely devastating thing it became the thing that we were working together against. And so a large part of people’s collective motivation was not just I will survive but we will survive. It was absolutely integral to the whole way we did our work. [Russell]

Weeks made a similar observation, identifying both the destructive and community building aspects of the early epidemic. He wrote “I see in the AIDS crisis a redefiner of the social, a whirlwind which devours, but also a storm which illuminates and reshapes” (1995: 13). This links back to earlier discussion of AIDS acting as a ‘developer’ to force people to see a coherence in their sense of the world which ordinary circumstances would not have produced” (Weeks 1995: 113). AIDS heightened the risks of a new and developing sexual freedom in gay communities yet at the same time illustrated the defining and empowering nature of the AIDS crisis through resistance against dominant discourses and structures and also through Giddens’ concept of ‘fateful moments’ – times of existential crisis that provide the potential for individuals and communities to respond proactively and empower themselves in face of changing sets of opportunities and risks (1991: 131, 156).

23 In the Commonwealth policy discussion paper forming part of the First National AIDS Strategy entitled AIDS: A Time to Care, A Time to Act (1988) it is pointed out that, at the time of writing, homosexual activity between adult males was illegal in Queensland, Tasmania and Western Australia and that “[t]his appears likely to act as an impediment to education programs or to [homosexual or bisexual men] seeking information or advice on unsafe sex” (1988: 129). Parkinson and Hughes made a similar comment in the New Zealand context pointing out the proactive response of the gay community “despite the problems created by the legal situation of gay men” (1987: 77). Homosexual law reform was enacted in NSW in 1984 and in New Zealand in 1986.

68 The growing awareness of a serious, possibly fatal, sexual health issue amongst the gay population in Australia sparked off state and federal level organisation around the perceived threat. Edwards noted that the first community based organisation, the AIDS Action Committee, emerged in mid 1983 in NSW in response to the first reported cases of AIDS in Australia (1997: 44). This nascent volunteer based organisation led to the formation of the AIDS Council of New South Wales (ACON) in 1985 (Kippax et. al. 1993a: 13). As discussed in the Introduction, a recurring theme in this thesis is the contestation around many aspects of HIV and AIDS organisation, from definitions of community to differing views around appropriate priorities and action concerning prevention, treatment, support and care, to varying prevention theory, policy and methods. Inevitably, within the broad bounds of “gay community”, different groups with different motivations and perspectives were involved. Two of my participants, Kevin and Russell, described the contestation around the formation of the committee.

I went to the first, the formation meeting and I was elected to their first committee, so the formation meeting was an amalgamation of six organisations. So basically in New South Wales what had happened was that Blewett through pressure from other people, had decided he was going to seed funding to set up organisations directly in most States and Territories to get things going. So one organisation had formed in Victoria. There were a couple but mutually they decided to become one. There had been six organisations that had already formed in Sydney, like 84. All sort of different. So there was the Green Monkeys which was an education organisation. There was the AIDS Counselling organisation which was an offshoot of the Gay and Lesbian Counselling Service but more designed to do one on one. There was the Community Support Network to do practical home care. There was the Bobby Goldsmith Foundation which was about money. There was the, what was it called, AIDS Action I guess … All completely different and the sorts of people who would never usually have something to do with each other. Anyway, what Blewett said was he wasn’t funding six organisations. He was funding one … [There was] this meeting in the upstairs of the Midnight Shift – it was about bringing, getting six organisations to agree to be one which was just torture … So the initial committee was not elected, it was just two people from each organisation and the charge was drawing up a united constitution. And they did that and then one organisation was formed. Three organisations decided to fold themselves into the organisation. The other organisations remained separate or tried to keep a separate identity. [Russell]

I think … our gay leaderships were very conflicted. I remember an early AIDS council annual meeting where there was an election and there

69 were five voting blocks with approximately 20 per cent each. One was catholic, like acceptance, one was counselling service, one was gay solidarity and the left, one was sort of communist party, and I’ve forgotten what the other one was. And so stuff was negotiated between these different ideologies really … [Kevin]

Organisation was also occurring at the national level at this time. By August 1984 members attending the 9th National Conference for Lesbians and Homosexual Men formed the first national organisation, the Australian AIDS Action Committee, which later became the Australian Federation of AIDS Organisations (AFAO), once again illustrating ongoing links and historical continuity with a broader social and political movement (with its origins in gay liberation). This committee met with Neal Blewett, the then Federal Health Minister and a national response to AIDS was underway. The section Government Responses – Partnerships with AIDS Organisations later in this chapter takes up this story as it examines the development of an Australian federal response to AIDS in more detail.

New Zealand

In New Zealand, as in Australia, the influence of a broader international movement was pivotal to the development of a gay community response, which began before AIDS had arrived in the country. Worth described the situation in the following way, “[e]arly safe-sex information came almost solely from the gay community itself. A striking example of community action to prevent the spread of disease, it preceded any mass HIV prevention and health promotion campaigns” (1996: 89). Parkinson and Hughes provided more detail of early gay community activities in New Zealand noting that “[a]lerted to the crisis, early gay community leaders in New Zealand were able to start work before AIDS arrived …” (1987: 77). They described several gay community led information initiatives including the first story on AIDS in September 1981 in the national lesbian gay community news magazine Pink Triangle entitled ‘Gay Pneumonia? Not Really Says Researcher’ “before the syndrome was even named” (1987: 77).

Several other initiatives ensued over the next few years including meetings with health officials in regional areas, publishing a “factual information pamphlet for gays about what AIDS was … keeping gay community as informed as possible of new developments” and “seeking to extend special STD clinics at gay venues so as to help

70 detect cases of AIDS …” (Parkinson and Hughes 1987: 77). The pamphlet Choices and Chances was published in December 1983 and gave two possible explanations for AIDS, viral infection, considered a more likely explanation at the time, and overload to the immune system (Worth 1996: 88 – 9). Lindberg and McMorland noted that the New Zealand Department of Health was not prepared to contribute to publication costs of this pamphlet (1996: 105).

As in Australia, the formation of community based organisations in response to AIDS had continuity with an earlier history of gay liberation influenced organisations. Parkinson and Hughes outline the connection to the National Gay Rights Coalition, which they comment had been dormant since 1981 but “was revived in the spring of 1983 specifically to deal with the AIDS crisis” (1987: 77). Formed in July 1977 the National Gay Rights Coalition had it roots in the New Zealand homosexual law reform debates and was also strongly influenced by ideas from the gay liberation movement. As in early Australian prevention efforts, the Coalition consciously used the concept of responsibility to a community to guide its early prevention information and activities. Emphasising this collective agentic approach, in 1983 Hugh Gaw, the general secretary of the Coalition, wrote in a Pink Triangle article entitled ‘Crisis – What Crisis? A Healthy Gay Community’, “What is to be stressed is that we have a responsibility to ourselves, our friends and other gay people to make sure our community is a healthy one” (Gaw 1982/3: 1).

Coalition efforts continued and led a seminar on AIDS in June 1984, agreed upon at the National Lesbian and Gay conference in Christchurch at Easter that year. The seminar was the catalyst for the formation of the AIDS Support Network (Parkinson and Hughes 1987: 78), which soon after became a Trust. In August 1985 the Trust became the New Zealand AIDS Foundation (NZAF) (1987: 79). Bruce Burnett had returned to New Zealand with an AIDS-related condition in late 1983 and in May 1985 received a formal diagnosis of AIDS. He died shortly after. He was pivotal in early AIDS awareness and prevention in New Zealand and was the first paid worker of the NZAF (Parkinson and Hughes 1987: 79). Indeed, Lindberg and McMorland described him as “the driving force behind the establishment of the NZAF” (1996: 103).

71 As in the Australian context, there were specific links to AIDS prevention efforts of gay communities in North America. Burnett had taken his very influential ‘AIDS Roadshow’ around New Zealand in August 1984 talking about his experience with the Shanti Project24 based in San Francisco. One of my New Zealand participants, Walter, spoke of the San Francisco connection and its importance to early prevention and awareness raising work in New Zealand.

We had got some money … which we used to bring two people from San Francisco, Sam Puckett and Tom Coates. Tom was a Professor of Internal Medicine … and Sam worked with a community based organisation … we had the money to bring them across to help us develop our approach to prevention for the gay community. We had no theoretical framework. We did have the STOP AIDS model which had [been] introduced into New Zealand … Bruce Burnett … worked with the Shanti project in San Francisco … which was a peer support model [Walter]

As Walter noted, another influential North American response to the epidemic was the STOP AIDS Project, established in San Francisco in 1985 by Sam Puckett and Larry Bye, also volunteer-based and continuing prevention and education work to the present day. The STOP AIDS model advocated ‘grassroots prevention and support’ by recognising that prevention needed to move beyond simple information provision to include close personal contact between individuals in relaxed informal settings. As the STOP AIDS website still states, “Our work extends beyond education – we help change behavior, create personal commitment to safer sex, build community support for each individual, and live these compelling beliefs” (www.stopaids.org/about_us/). This was a community-based model of HIV and AIDS peer education that proved highly influential for prevention in New Zealand in the mid eighties. As Lindberg and McMorland noted, the STOP AIDS model “was being investigated as a model for peer education” by the NZAF in 1985 (1996: 107).

Another of my New Zealand participants, Tim, also talked of the influence of the STOP AIDS and Shanti models on the formulation of early prevention campaigns in

24 According to the shanti.org website Shanti (sanskrit for inner peace or tranquillity) was founded by Dr Charles Garfield in 1974. In the early eighties Shanti volunteers began support operations in San Francisco and this work continues today, some thirty years later, with the stated aim to “enhance quality of life for persons living with life threatening or chronic illness by providing volunteer based emotional and practical support” for people living with HIV and AIDS and breast cancer (www.shanti.org/model.html).

72 New Zealand, noting that in the absence of local research, the experiences and information of overseas communities already dealing with the epidemic were instrumental in forming approaches. He also spoke of the influence of groups of doctors on both the west and east coasts of North America who had previously worked in sexual health and who had begun specialising in the new and emerging field of HIV and AIDS medicine. It is obvious here that, as in Australia, pragmatic risk minimisation strategies were established very early in gay communities’ response to the epidemic. He also mentioned the connection between specialist STI doctors working in gay communities in late 1970s and early eighties with the idea of condoms for AIDS prevention.

And of course we didn’t know very much at that stage but the best work had been done, the best work on working out what the scientific parameters around prevention were had been done, in my view, by the two gay physicians groups in the United States, the one in, Bay Area Physicians for Human Rights and the New York equivalent. And they’d been working on the STI explosion in the late 70s and the early 80s and coming up with recommendations which were generally tailored around STIs including condom promotion but, you know, there were other things as well. So the issue for us was how do we, we decided quite early on that we were going to treat HIV differently, not just treat it as an STI. So what we needed to know was which particular activities were safe and which weren’t, as much as you could know this. And of course as time’s gone by it’s all become much more clear … There were certainly some things that were highly risky for the transmission of certain STIs like the warts virus which is, you know, mutual masturbation and things like that, hand to hand contact, which we already knew were not risky for HIV so we were able to discard some of those.

And those first recommendations came together in the campaign, August or September of 1985. And by, I guess, by the middle of 1987 it was then clear to everybody that the risk activity was overwhelmingly unprotected anal intercourse. And at that point the Foundation’s focus on that was put in place … [Tim]

What is clear from Tim’s comments is that by 1987 the NZAF had developed an understanding that unprotected anal intercourse was the most risky practice in terms of HIV transmission. Accordingly, a clear prevention policy of a condom every time regardless of context was implemented by this time.

73 Governmental Responses – Partnerships with AIDS Organisations

However quick, insightful, proactive and agency friendly, early gay community responses were, the lack of funding from the state for prevention (as well as support and care) was a problem that needed to be addressed in both Australia and New Zealand. As more people fell ill, some seriously, the matter became urgent. After an initial tardiness politicians began planning and responding.

Events unfolded quickly in 1983 and 1984 in Australia. Fears of the electorate were heightened at this time by the highly publicised cases of the haemophilic babies in Queensland, who contracted AIDS through infected blood products (Sendzuick 2003: 56 – 80). In the highly charged atmosphere that resulted, arguments about how best to protect blood supplies became entangled with older ideas, previously discussed, of homosexuality as a sickness and homosexuals as the vectors of disease – physical, psychological, and societal. Discriminating against homosexuals to stop the spread of infection was considered acceptable by many, particularly those that subscribed to the contain and control approach. This highlighted society’s greatest fear, the spread of the disease from what were thought to be relatively discrete sub-populations into the general population.

The seriousness of the situation, and escalation of fear and misunderstanding around AIDS, gave the federal government the final push to act. Federal Health Minister (of a Labor government) Neal Blewett relied heavily on his openly gay senior policy advisor Bill Bowtell to provide him with the link to affected gay, drug using and sex worker communities. In the Australian Broadcasting Corporation television documentary Rampant: How A City Stopped A Plague outlining the early history of the epidemic in Sydney (aired in early 2008), the central question was posed, “could the ratbags and deviants stop it [AIDS] themselves.” Perhaps encouraged by the early prevention and information dissemination efforts of groups within these communities, and risking considerable voter backlash from a fearful electorate, made more uncomfortable with public discussions about anal sex and illicit drug use, Blewett trusted his instincts and agreed to meet with affected groups. Blewett was also politically savvy enough to know that voter dissatisfaction could be minimised if gay organisations themselves were seen by the general public to be responsible for the much needed sexually explicit prevention campaigns. In this way prevention, and

74 AIDS organisations, could be kept at arms length from the government (Altman, 1992: 63). This approach also had the advantage of the gay movement itself continuing what it had started in responding to AIDS, largely in its own way, with minimal constraint from funding arrangements.

Illustrating the tangled web of converging events at this time, Russell described the unpreparedness and inexperience of the newly formed Australian AIDS Action Committee when negotiating with the then Commonwealth Department of Health. He also pointed out the lack of knowledge and denial about AIDS within gay communities themselves, citing the importance of the gay media in disseminating information in the charged atmosphere of the eighties, particularly a series of articles written by Adam Carr in the gay magazine OutRage in 1984. Perhaps the most influential of these was entitled ‘AIDS: the Coming Crisis.’ The article was written when HIV was yet to be widely understood as the virus that caused AIDS25 and when there was still much speculation about potential numbers of people who would be infected. However, despite the lack of certainty of ‘the facts’, the article had an impact that is still clearly remembered by several of my Australian participants.

So we were all juniors at this stuff. We didn’t ask for any money which really shocked [Blewett] apparently cos he expected us to come cheque books in hand. It was sort of interesting cos we were still in denial. Everyone knew. It was all round the conference [9th National Conference for Lesbians and Homosexual Men (1984)] … It took Adam Carr to write a really significant article in OutRage or whatever it was called at the time which basically said yes the blood bank matters and yes all these others things can happen but this is real. This is about how we behave in relation to each other and what sort of sex we have. And really that article changed, completely changed the landscape in Australia in a fortnight. And so from a situation where people were still hot on - you know, law reform in New South Wales had just happened - people were still hot under the collar about discrimination by the blood bank, all sorts of stuff like that … it was also about a sexual disease that related to the type of sexual activity you actually had. Within a fortnight the whole thing had changed. I mean HIV was still a virtual activity in

25 HIV was named and identified as the virus that caused AIDS by Robert Gallo and his U.S. team in 1984. Years later, this would prove to be controversial when it became apparent a French team did much of the hard grind laboratory work that resulted in the identification of the offending virus. Following on from the identification of the virus that caused AIDS a test for HIV antibodies was soon developed and became available in Australia and New Zealand in late 1984 and early 1985.

75 people’s heads. No one had actually experienced the full horror of it then. People knew that it was real, that something was coming. [Russell]

And it was not only gay communities that were unprepared for the coming epidemic. Federal government was caught equally unaware. Blewett described the development of HIV and AIDS policy in what he called the “primitive years” in Australia, pointing out that the federal government was not prepared for the public health handling of epidemics in the early 1980s, as previous experience with epidemics dated back to the 1940s and 1950s with poliomyelitis (2003: 11). A reluctance to deal with AIDS at the national level in the earliest years of the epidemic led to a situation Blewett described in the following way, “rarely has policy been made with so thin and contested an information base and with societal mechanisms so inadequately prepared and reluctant to take on the task as in the early years of AIDS policy making” (2003: 4).

Davies took a somewhat different view when describing the New Zealand context commenting that public health approaches to epidemics were pragmatic, shaped by “a willingness to use the State and to learn from mistakes” and “a history of egalitarianism and progressive legislation in health and social policy” (1996: 3). But he also noted that the early response to AIDS in New Zealand went through “a period of latency in the first half of the 1980s in which gay activists took the lead” (1996: 3), as was clearly illustrated in the previous section. Also commenting on the initially tardy response of the New Zealand Labour government, Parkinson and Hughes stated “a major community health campaign was implemented long before the official health authorities began a serious response to the crisis” (1987: 77).

However, despite initially tardy responses that one could guess may have been in part a reluctance to deal with a difficult issue with links to a difficult history (as previous sections have discussed), governmental responses to AIDS did soon occur in partnership with newly formed AIDS organisations, health departments and officials, in both countries by the mid to late 1980s. Kippax et. al. characterised the situation in the following way “[b]y 1984 it was clear that Australia was going to experience a significant epidemic, and government public health machinery, after a faltering start in 1983, moved into top gear, establishing the institutional arrangements and policies which have guided the country since” (1993a: 9). They described the development of a partnership involving “the Commonwealth, state and territory governments, and

76 their public health officials; the non-government sector, initially and predominantly the gay communities’ AIDS organisations; health professionals and research academics” (1993a: 9). Davies noted a similar situation in New Zealand describing “a three-way partnership between the government and the medical and community health sectors” also commenting that “[p]ivotal to the partnership approach to AIDS was the establishment of grassroots agencies to provide HIV information, support and outreach to members of ‘risk’ communities” (1996: 5). Tim also described this relationship as vital to the early success of HIV prevention and education in New Zealand,

I mean there are two things probably that were critical. The community connection and the fact that the Ministry of Health here, enormously to their credit, understood that the only people that were actually going to be able to manage this epidemic were the communities that were affected. [Tim]

It is worth noting that unlike Australia, there was no significant research component in the New Zealand partnership.

It is not the intention here to discuss in detail the political and ideological machinations that accompanied the development of national AIDS policy in Australia and New Zealand. Such a discussion lies outside the scope of this thesis, which focuses primarily on educators and gay communities’ responses to the epidemic. However, it should be noted that both countries soon initiated national AIDS policy bodies and advisory boards, in New Zealand most notably the AIDS Taskforce within the Department of Health with the primary role to “jump-start community participation by providing grassroots organisers with support and funding for interventions and outreach” disbanded in 1991, and the National Council on AIDS (NCA), created in 1988 but disbanded in 1993 with its role as “autonomous critic, watchdog and advisor on HIV and AIDS policy” (Davies 1996: 6 – 7). Illustrating the political dimensions of such advisory bodies, Davies also noted that while physicians involved in HIV and AIDS medicine saw the NCA as securing community participation gay activists saw it as a governmental strategy to gather information and contain protest (1996: 7).

In Australia a National Health and Medical Research Council working party became the AIDS Task Force, chaired by the Dean of Medicine at Melbourne University

77 David Pennington. The function of the Task Force was to provide scientific advice to health ministers (Edwards 1997: 45) while the National Advisory Committee on AIDS (NACAIDS) chaired by Ita Buttrose was to facilitate dialogue between the Commonwealth and affected communities and guide the development of public and targeted community based education programs (cited in Blewett 2003: 23). Commenting on the Task Force, and demonstrating the politically charged aspects of AIDS policy formulation in Australia, long time HIV physician Dr Ron Penny noted establishing the Task Force without gay community representation was “an unfortunate and flawed policy” (cited in Blewett 2003: 23). The stormy and controversial relationship between the Task Force and NACAIDS illustrated the wider clash between medico-scientific and community-based models of public health (Edwards 1997: 45). In 1986 Pennington favoured testing of all “high-risk” groups – the test, contain and control approach – while AIDS Councils supported an approach emphasising confidentiality and preventative education. NACAIDS also supported the latter more community friendly position, as did Health Minister Blewett (Altman 1992: 57). Consequently, the federal government continued to fund AIDS Councils to carry out prevention and education activities (Sendziuk 2003: 110 – 111). In 1988, after the resignations of both Pennington and Buttrose, the Task Force and NACAIDS were abolished and replaced by the Australian National Council on AIDS (ANCA). ANCA was made up of seven medical and eight non-medical members in an attempt to overcome the divergent approaches apparent in the Task Force/NACAIDS split. Further discussion of the political machinations of the formation, membership and disbandment of these advisory groups in Australia, and the involvement and interaction of federal and state governments, can be found in Blewett (2003), Sendziuk (2003) and Altman (1992).

Ideological and theoretical divisions are often apparent in debates about public health approaches to HIV and AIDS, including the negotiated safety debate as subsequent chapters will illustrate. The reasons for this are complex and connected to the broader history of the medical and social sciences as well as governmental responses, what is considered ‘evidence’ in different theoretical, paradigmatic and bureaucratic contexts, and the degree to which consultation and participation of affected groups is facilitated in policy processes. Plummer described the clash between biomedical and social explanations in the early days of the epidemic in the following way:

78 … debate became polarised between those who seemed to have ultimate faith that biotechnology would solve the AIDS problem (underpinning that perspective was the fact that AIDS was a medical complaint caused by a viral infection) and those who believed that the key to the AIDS epidemic lay in behaviour change (because the spread of AIDS was determined by human rather than viral factors)” (1992: 73 – 4).

It was these underlying assumptions that precipitated the differences in the analysis of ‘the problem’ and proposed solutions between the Task Force and NACAIDS. However, this situation was not particular to Australia. Similar debates and disagreements occurred throughout western metropolitan societies. In the U.K and Canada, like Australia and New Zealand, the communitarian approach to behaviour change and prevention eventually prevailed after an initial dominance of the medical model, while in the U.S.A the medico-scientific perspective continued to dominate prevention strategies. Conflicts and contestations around definitions of risky practice and risk groups as well as appropriate prevention strategies and policies to address risk of HIV infection brings to mind comments made by Beck and Heaphy. For Heaphy, following Beck and Giddens, the late modern period is characterised by “ … a culture of radical doubt where all kinds of knowledge, including expert knowledge “are only valid until further notice” (Heaphy 2007: 76). For Beck, science’s monopoly on rationality is broken in the area of risk as “[t]here are always competing and conflicting claims, interests and viewpoints of the various agents of modernity and affected groups … There is no expert on risk” (1992: 29). That AIDS is ‘a life political issue par excellence’ (Heaphy 2007: 163), heightening moral and existential anxiety around issues of sexuality, relationships and morality, is also relevant here as this would serve to further intensify divergent views and competing interests and interpretations.

Leaving aside the controversies of the formation and implementation of AIDS policy at the national level, it is generally accepted by most commentators that the partnerships between government, non-government agencies and affected communities in Australia and New Zealand was a major component to the early success of HIV and AIDS prevention and so limiting the spread of infection in both countries. Perhaps the best early example of effective partnership between federal government and community in the early years of the epidemic in Australia was the work of Elizabeth Reid in consulting with affected communities for the first national

79 AIDS strategy. Altman described this as “possibly involving more consultation than any similar policy document in the history of Australia” (1992: 58) while Sendziuk commented that it was an example of Labor’s “long-standing commitment to promoting community participation in health policy” (2003: 128). McCallum also described the situation, “… I remember being struck at the time by the fact that those front-line workers could actually have a voice in national policy development. I had never seen this kind of access to policy-making as an oncology nurse. I suspect that many people in the health system still do not see this kind of direct access to the formulation of national policy” (cited in Blewett 2003: 32). McCallum went on to outline the value and practical meaning of the partnership, and its importance to a community response.

The notion of partnership, combined with the existence of a national strategy that not only clearly set out roles and policy, but also allocated funds, was the core of the response. Defining a clear role for the community sector at national and at state and territory level, with guaranteed funding, meant that we in the community sector could get on with the tasks we were allocated. It meant that, even though we were working in partnership with other sectors, we had some distinct turf and legitimacy as distinct partners at the decision making table. It also meant that we could speak with some authority on issues relating to the communities at risk…” (cited in Blewett 2003: 33).

In their article reflecting on twenty years of HIV prevention, Kippax and Race also commented on partnership, broadening the description to include the importance of a ‘liberal’ or left wing political climate (Labour governments were in power in both Australia and New Zealand in the mid to late 1980s) and the contributions of social research to prevention debates.

What was learnt in the early ‘prevention only’ days of the epidemic (up to 1996) was that successful strategies depend upon the following: partnerships between government, non-government organisations and affected communities, reflexive relationships between researchers, educators and communities, and the necessity of acknowledging the changing and disparate patterning of practice and its social and cultural production … Rosenbrock et. al. (2000:1610) speak of the importance of an “exceptionalist alliance” which, depending on the particular country, included gay community, liberal and left-wing parties, and/or large sections of the health care and psychosocial professions. (2003: 8)

By the mid eighties, partnerships with government had given AIDS organisations in Australia and New Zealand the mandate and funding to carry out prevention and

80 education activities. Illustrating that historical continuity with a gay political and social movement was not always necessarily an asset, a point that will be returned to in detail in the following chapters, the conceptualisation and implementation of prevention and education strategies was an enormous challenge for organisations that had previously been oriented towards liberation goals and rights based discourses. Edwards described it as a move “from an anarchistic revolutionary politics in the 1970s to a professional, bureaucratised politics in the 1980s” (1993: 46). Lindberg and McMorland characterised the situation in the following way,

Historically, the organising tradition of these gay communities was collectivist and informal, but the epidemic has challenged gay men to mobilise resources towards specific and clearly articulated outcomes that had not hitherto been part of their communal purpose or their organising tradition” (1996: 103).

Being one of the main groups affected by HIV and AIDS, and taking a proactive role in early prevention and policy initiatives, did not necessarily prepare AIDS organisations (and educators within them) for the complexities of thought and action required to keep pace with a dynamic epidemic and an equally dynamic and politically charged societal context. In order to plan, develop and implement the necessary prevention campaigns and education strategies, AIDS organisations throughout the west, including in Australia and New Zealand, began to employ increasing numbers of professional staff, to expand in size, and to become more ‘bureaucratised’ (Altman 1993: 8 – 9; Aggleton 1993: 132; Weeks 1994: 3; Lindberg and McMorland 1996: 108). However, a strong reliance on volunteers remained for support and care (McCallum 1992), and to a lesser extent community based prevention activities and outreach.

Early Behaviour Change

While it is generally accepted that gay community led HIV and AIDS education and prevention was a success in both Australia and New Zealand by the late 1980s to early 90s (see for example Dowsett 1996b: 5; 1995: 246), some commentators, including some of my participants, were of the view that significant behaviour change had already occurred in many gay communities by 1985. Patton commented on this phenomenon in the U.S. context: “[m]ajor sexual risk reduction among gay men had occurred by 1985, well before professional educators exerted influence in the

81 burgeoning AIDS industry. These shifts in mores … were the result of efforts by activists who had little knowledge of traditional health education theory or strategy” (1990: 41). Russell observed this in the Australian context, drawing on his experience of working in prevention in Sydney in the early to mid eighties.

Well, a temporary, a huge behaviour change happened in response to media panic. Adam Carr saying we have to own this, it’s real. Media information, you know, small scale information campaigns … We don’t have data but I think what happened is lots of gay men stopped having large amounts of sex and started using condoms and it was sufficient to stop both STIs and HIV in its tracks … So, you know, it doesn’t prove that people were good for, you know, that all of sudden permanent behaviour changed. The change that happened was only probably temporary. It was enough to basically stop the epidemic in its tracks… [Russell]

What can only be described as ‘the fear factor’ – the very real possibility that if one was infected then one may not have long to live – was not only important as a driver of behaviour change (both decreased sexual activity, particularly anal sex, and increased condom use) in these early years of the epidemic, albeit temporary as Russell suggested, but now is no longer important as a factor in prevention, ironically now because of its absence (which does continue to be a factor). This is largely due to the advent of effective treatments in 1996 that meant HIV infection was no longer perceived as fatal amongst vulnerable populations. Walter and Tim also discussed the impact of the fear factor and their perception that it resulted in early behaviour change in gay communities in New Zealand.

Well the epidemic peaked in New Zealand in about 1989, well plateau- ed at 1989 I should say, and the epidemiologists in New Zealand could find no other explanation than that there had been very effective behaviour change amongst a significant number of gay men in those early years of the epidemic. I mean we need to be quite clear that we were all very afraid. [Walter]

So my sense was that even if we wanted to, and I didn’t, the chances of getting gay men not to have anal sex was very very remote. Because if in fact what people experienced through 1983 to 1987 was not enough to make them stop having [unprotected] anal sex well then nothing was. [Tim]

While there is no comprehensive information available for the very first years of the epidemic, observations about early behaviour change are supported by evidence from the mid to late 1980s in both Australia and New Zealand. Parkinson and Hughes

82 noted that in New Zealand by 1987 “… safe-sex practices have been widely adopted and relatively small numbers of openly gay men seem to be still at risk. Condoms are being used, and the dramatic fall in the incidence of rectal gonorrhoea, which has been noticed in both Wellington and Auckland, is an encouraging sign that unprotected anal sex is out of favour” (1987: 79). Worth pinpointed the shift in behaviour more precisely noting that in a 1983 study in Christchurch by Pepperell “many of those interviewed were not on the whole worried about AIDS” with some commenting “that the ‘AIDS scare’ would have to become much worse … to have any effect on their behaviour” (1996: 92–3). By 1985 “most men in [Parkinson’s] … sets of studies said that they had changed their sexual behaviour” (1996: 93). However, Worth pointed out the main component of this shift was change in relationship type, towards increased monogamy. She also commented on evidence from studies indicating diverse sexual practice in New Zealand gay communities, including that according to these studies anal sex was not the main sexual practice even before the advent of AIDS. This is perhaps a timely reminder that HIV and AIDS prevention cannot be thought of as a simple strategy to increase condom use for anal sex but rather needs to understand and embrace a wide range of social, cultural and contextual factors to be successful. The importance of these elements of prevention will be illustrated in following chapters.

Kippax et. al. also illustrated the complexity of early behaviour change within the gay social and sexual landscape in the Australian context. Commenting on 1986/87 data from the SAPA study they stated that the men surveyed had reported that since the advent of AIDS they had adopted a wide range of strategies to avoid HIV transmission and infection including “the use of condoms for anal intercourse, the exclusion of anal intercourse from men’s sexual repertoires, the foregoing of anal intercourse with casual partners, care in selection of partners, and moves to monogamy and even celibacy” (1993a: 89).

This chapter has illustrated the influence of an international gay movement, particularly the west coast of America where the impact of AIDS was greatest in the early years of the epidemic, on the initial response to the disease in gay communities in both Australia and New Zealand. In these early prevention efforts the seeds of a harm minimisation approach and a morally neutral stance on sexual practice were

83 already apparent. As AIDS organisations grew out of this early collective communitarian response, increased governmental participation and accompanying funding brought increased bureaucratisation and professionalisation, and pressure for more rational outcome-based and measurable interventions. This, combined with a trend towards more individualised targeted interventions, set the scene for the need to develop more sophisticated prevention approaches and campaigns in the face of an evolving epidemic and a dynamic political and social environment of both affected groups and wider society. A previous history of struggle against and resistance to dominant constructions of homosexuality, and a proactive and empowering response to the early advances of the epidemic, did not necessarily prepare AIDS organisations and HIV educators for the complex debates around risk of HIV infection within the so-called safe haven of love and long-term relationships. The following chapters will explore the interaction between a developing HIV prevention discourse around risk reduction and harm minimisation in the context of gay relationships, the dynamics of gay relationships themselves as well as the broader context of love, intimacy and relationships in the late modern period, drawing on the work of Giddens (1992).

84 4. Early Stirrings of the Negotiated Safety Debate in Australia

The following chapters will explore three closely related themes: the interaction between a developing HIV prevention discourse around risk reduction and harm minimisation in the context of gay relationships; the dynamics of gay relationships themselves; and the broader context of love, intimacy and relationships in the late modern period, using the work of Giddens (1992). As was noted in the previous chapter, a previous history of struggle against and resistance to dominant constructions of homosexuality, and a proactive and empowering response to the early advances of the epidemic, did not necessarily prepare AIDS organisations and HIV educators for the complex debates about HIV prevention within the so-called safe haven of love and long-term relationships. Indeed, HIV prevention itself was still somewhat in its infancy in the late eighties to early nineties.

Along with harm minimisation, community empowerment and a sex positive attitude, (see previous chapter), HIV prevention was also strongly influenced by the Health Belief Model (HBM) in the late eighties to early nineties. The HBM deriving from Becker (1974) was a psychologically based model of decision-making that attempted to predict whether or not people would accept medical intervention and treatment, and whether they would follow prevention recommendations ‘such as engaging in safe sex’ (Davies 1993: 46). One version of the HBM, the AIDS Risk Reduction Model (Catania et. al. 1990), proposed three stages of change, “(1) recognition and labelling of one’s sexual behaviours as high risk for contracting HIV, (2) making a commitment to reduce high risk sexual contacts and increase low risk activities and (s) seeking and enacting strategies to obtain these goals” (1990: 54). Central to the model was a relationship between knowledge and attitudes towards and beliefs about AIDS, HIV and the uptake of safer sex practices. As Davies et. al. put it “ … the model states the desired outcome, safer sex practices, will occur only if the practitioners know about and have positive attitudes towards safe sex and also believe that safe sex will have the desired effect” (1993: 46, emphases in original). This ‘information giving’ model of health education (Aggleton 1989: 223) was popular in HIV eduction at the time because it was relatively easy to implement: information was provided; positive attitudes to safe sex and negative attitudes to unsafe sex were

85 fostered and the simple message that safe sex works was disseminated and intuitively understood” (Davies et. al. 1993: 46 – 47).

Early prevention efforts in Australasia, while driven by a proactive community response, were also becoming increasingly informed by the HBM. As increased governmental participation and accompanying funding brought increased bureaucratisation and professionalisation in AIDS councils, the rational HBM lent itself well to alleviating the pressure for more rational outcome-based and measurable interventions. The influence of this model can be seen in the development of campaigns to address the issue of risk of HIV infection in gay relationships, namely VAC’s Because We Want To Be Together, and ACON’s Fucking Without Condoms and Talk Test Test … Trust. The following chapters will now chart the development of these campaigns and the accompanying dynamics of gay relationships themselves; and the broader context of love, intimacy and relationships in the late modern period. As apparent in debates about policy formation and prevention approaches in advisory committees at the national level, and debate about prevention approaches at the state and local levels, conflicts and contestations around definitions of risky practice and risk groups as well as appropriate prevention strategies and policies to address risk of HIV infection are apparent. This again brings to mind Beck’s assertion that there no experts on risk in the late or post modern period (1992: 29), and comments by Heaphy that HIV and AIDS are ‘life political issues par excellence’ (2007: 163), heightening moral and existential anxiety around issues of sexuality, relationships and mortality – Giddens’ ‘fateful moments’ (1991: 131, 156).

By the late 1980s to early 1990s there was a growing awareness among HIV educators internationally that while gay men were using condoms for anal sex in casual encounters, there were problems with continued condom use within gay relationships and so higher risk of HIV infection (Doll et al., 1991; Hunt et. al., 1992; McLean et. al., 1994). This was also observed in New Zealand (Worth et. al. 1997) and by workers in AIDS organisations and confirmed by social research in Australia. In 1989 an ACON document, Future Directions for the AIDS Council of NSW: A Strategic Planning Document, commented that “a significant number of men have not moved towards safer sexual conduct within a regular relationship” (1989: 15). In 1992 Dowsett et. al. wrote, in discussing survey data from the SAPA study, “that in NSW,

86 as elsewhere, unprotected anal sex was more common within regular relationships than in casual encounters” (1992: 4). An NCHSR qualitative study begun in 1993, in which in-depth interviews were conducted with men who had recently become HIV positive, was also providing evidence that infection within relationships was occurring (Kippax et. al. 1994).

Feeling Our Way (1990)

AFAO gathered information about inconsistent condom use in gay relationships in Australia through a federally funded project that resulted in the book Feeling Our Way: Gay Men Talk About Relationships (1990). Funded by the then Commonwealth Department of Health and carried out through AFAO by Blue Stone Media in 1989, social researchers interviewed 50 gay couples, 100 men, about many aspects of their lives and relationships. The volume consisted of five chapters containing edited excerpts from the interviews. Perhaps indicating that HIV prevention discourse was a work in progress, and the undeveloped nature of theory and practice in the area (Dowsett 1996b: 6), there was no explanatory or analytical text linking themes or content in the main body of the publication. Overall, the book provided a broad and holistic view of gay relationships – ranging from relationship formation to the many facets of sex and sexuality within the relationship and in the broader context of society, family and friends.

While the initial impetus for the research had been concern about increased risk of HIV infection in gay relationships, it would appear that as the project progressed the focus shifted to a broad view of the relationships themselves. The authors and editors Vadasz and Lipp confirmed this. As they explained in their introduction they had set out to write about “common patterns in gay relationships” (1990: xiii). The absence of analysis in the book is also explained. The authors had questioned their position as experts as “the interviews made it clear that the capacity of people to make the right decisions for their own circumstances was more impressive than any advice we could give” (1990: xiv). While an admirable position to take in terms of representing the lives of participants unobtrusively, and in acknowledging the active role of gay men in prevention knowledge uptake (an enduring theme in the negotiated safety debate and prevention more generally, as subsequent chapters will illustrate), this still leaves

87 the question of how effective such texts are in HIV and AIDS prevention and health promotion.

While not focussing on the dynamics of risk of HIV infection in gay relationships specifically, the book did address the subject in a number of places (under a variety of sub headings including: safe by inclination, to test or not, using protection, risks and slip-ups, casual sex and HIV, and contracts and trust). These sections illustrate where there is a comprehensive coverage of the issues and problems relating to HIV infection in gay relationships that are now well understood and researched throughout the sector. These issues included: the difficulty of behaviour change (primarily condom use for anal sex) for those who were sexually active before the epidemic; the difficulties (both physical and emotional) required to use condoms consistently for anal sex either for regular and/or casual partners; the difficulties in communicating and negotiating agreements about sex, safe sex and HIV and AIDS within and outside primary relationships (and the associated issues of trust and honesty); monogamy versus polygamy; and difficulties around disclosure of HIV antibody positive status. But these sections constituted a small part of the publication as a whole, and the main body of the book did not discuss HIV and AIDS in the context of prevention and education.

However, perhaps curiously given the original reason for the research, there was such a discussion entitled “Relationships and HIV” hidden away in an afterword at the end of the volume. Here the authors state that the motivation for the research was indeed “…. the evidence that gay men in apparently stable relationships were conspicuous among new cases of HIV infection” and that the researchers had set out to “investigate possible reasons why this was happening” (1990: 173). Possible explanations are suggested: that such men were not in contact with an organised gay community and had missed prevention campaigns of the previous five years; that this group may be resistant to behaviour change and; that “some gay men believed that a relationship gave them a special kind of protection that made safe sex precautions unnecessary” (1990: 173). The authors continue that they decided these questions could not be answered without a better understanding of gay relationships and that when the researchers had some answers “a book on gay relationships would provide an ideal vehicle in which to canvass possible solutions” (1990: 173). No discussion of

88 possible solutions is evident in the volume itself and no further book was forthcoming.

Vadasz and Lipp also observed that there was no simple answer to HIV in relationships as they had found gay men adopted “a range of strategies in dealing with HIV, some appropriate and some highly risky” (1990: 173). They continued that this posed an interesting problem for AIDS organisations who promote one simple, unambiguous message of condom use for anal sex for all gay men in relationships “regardless of their relationship or antibody status” (1990: 173). It was concluded that “[t]he clear evidence from our research suggests that a large proportion of gay couples have chosen not to follow this advice” (1990: 173).

This is perhaps a first glimpse of the situation that AIDS organisations faced. They had not only to decide on policies and campaigns that addressed the complexity around the lived experience of gay men, the sex they had, and the risk associated with their sexual practice, but also how education and prevention in general and campaigns in particular should respond. Commenting on the figures from their own study, that only two couples practiced protected anal sex within their relationship and that this was alarming in light of official HIV prevention policy, Vadasz and Lipp pre-empted later debate about negotiated safety when they wrote, “[v]iewed in a broader social context … an entirely different picture emerges. Not one of rejection of safe sex, but of the development of an alternative safe sex strategy” (1990: 174). A description of what would later come to be known as negotiated safety, but minus the all-important HIV testing element, is also furnished “[m]ost of our couples have adopted the strategy of practising unprotected sex within their relationship in conjunction with an agreement to have a monogamous relationship, or outside sex that is either protected or non-penetrative” (1990: 174).

The authors continued that given this situation educators had the option of making more intensive efforts in encouraging “gay men to adopt universal protection during anal sex” or validate the alternative strategy by focussing efforts on making it viable. However, this statement is qualified with a warning that the strategy was “fraught with risk and potential vulnerability” (1990: 175) and that individuals needed to know their antibody status for the strategy to be effective. The difficulty gay men had in negotiating monogamy or sex outside the relationship and the trust and honesty such

89 discussions required was also stressed, as well as the dangers of overly rigid agreements which might inadvertently discourage honesty and perhaps even end the relationship. The afterword concluded that the book was not meant to endorse or encourage “dangerous practices” but that it was also “pointless and dangerous to ignore the fact that a great many gay men have opted for an alternative strategy to stay uninfected” (1990: 176). It is also stated that “consistent with principles of education through empowerment, AIDS education policies must reflect a commitment to supporting gay men who decide to have unprotected sex within their relationship”; that “[a]s with all effective education, this book can do no more than provide information, options and support” and finally that “[i]n the end we must put our faith in individuals as learners rather than our expertise as teachers” (1990: 176).

These comments are also interesting as they illustrate that prevention in Australia was beginning to shift from the crisis era of AIDS in the 1980s, in which providing information about risky practice and condom use for anal sex was paramount, to the more individualised targeted approach of HIV prevention in the 1990s. Feeling Our Way is also one of the first discussions about some of the more sophisticated questions around prevention and the role of educators and AIDS organisations within it. These questions include: should AIDS organisations be supporting a strategy that the authors have described as “fraught with risk and potential vulnerability” even if it is a practice that is occurring in gay communities? What would the reasons be for supporting a strategy so described? And more generally, can AIDS organisations only provide information, or do they also provide recommendations and/or advice? Clearly the authors are of the view that it is the former, information is provided and it is up to gay men to decide how to interpret and act on it, or not. If it is the latter case, that AIDS organisations should also provide guidance on how to interpret information, how should various risk reduction strategies or options be presented, or even, should such options be presented? Should certain sexual practices be supported over others, and what evidence is there to support one view or course of action over another? These are all thorny, difficult questions that seem to be thrown into even sharper relief when put in the context of risk of HIV infection in relationships (and it is these questions that form the crux of later negotiated safety debates). Many of these questions remain unresolved or not discussed in Feeling Our Way, and perhaps

90 through the course of this thesis will be revealed as remaining unresolved, or at best only partially resolved.

Also, it should be remembered that this was still the first decade of the epidemic. Should we expect a sophisticated analysis of education and prevention at this early point? It is surprising that this kind of discussion is taking place at all given the continuing influence of the medical model and the accompanying ‘all-or-nothing’ position on condom use of AIDS organisations at the time. And perhaps we should not be too harsh on AIDS organisations and expect them to be able to enter, debate and resolve these vexing questions within the organisation given their limited resources, and, coming from voluntary roots, their lack of expertise as researchers and health promoters. It is probably an effect of close engagement with gay communities that these ideas can be expressed at all at this time and so a valuable contribution for this reason.

Russell, one of my Sydney participants, commented on Feeling Our Way pointing out that many of the interviewees were employees of AIDS Councils. He went on to suggest this raised interesting questions about the official ‘condom-every-time’ stance of AIDS organisations considering many employees were not following this in their private lives. Rather, they were using their antibody status to negotiate not using condoms for anal sex in their primary relationships. The previous chapter illustrated a long history of resisting dominant discourses about homosexuality. This history continues but in this case in the more specific field of HIV prevention. This is an example of gay men’s active involvement in engaging with HIV prevention messages, rather than passively enacting them (as posited by a psychologically oriented behaviourist model), and perhaps also an example of Giddens’ idea of people actively using “resources for the creation of reflexively ordered narratives of self” (Heaphy 2007: 123) – in this case gay men pragmatically accessing meanings around a condom-every-time message in a relationship or love context to circumvent the rigidity of the message without ignoring risks (but not necessarily accurately accessing risk either). Russell mentioned more careful decision-making because of the transgressive nature of going against newly established gay community safe sex

91 norms (a ‘safe sex culture’)26, a factor that again becomes important later in the epidemic, but this time because it has lost its transgressive quality.

… It was interviews with couples. A lot of the couples were actually employees of AIDS Councils and what was revealed in the book was the actual, the actual stories of unprotected sex in relationships. Most, one half of each relationship was an educator in an AIDS Council who were talking about their negotiated unprotected sex so Ooooohhhh sister, what’s goin’ on here … [the] story was told by Danny Vadasz where if you read the story it was really clearly that people were using their antibody status to negotiate unprotected sex in regular relationships. You know, I think as a practice, I think the first lots of people who decided to break what was probably much more stronger rules than they are now about using a condom every time probably did use the antibody test to make that negotiation whereas I think people are far less likely to now. But anyway, in the early times because unprotected sex was a much more transgressive act then probably people were more careful about this, the decisions. That’s what it seems like in reading the book. [Russell]

Another one of my participants remembers Feeling Our Way well. For him, it was not questions of the role of educators and AIDS organisations in providing relevant information to communities that he was interested in, rather it was a simple and pragmatic need for practical advice. As he explained:

At any rate I was looking forward to some forthright practical guide for how me and my partner could throw away the condoms safely, even if it was only to check that what we had already agreed was going to work. And instead we got lots of interesting short stories. My focus was I wanted a practical guide and particularly when things went awry … [Carl]

Such sentiments built to a critical mass in the prevention community in Victoria in the early 1990s and this led to the first campaign in Australasia to address the issues around infection in gay relationships.

26 In 1993 Kippax et. al. wrote “A ‘safe sex’ culture has developed: it is now largely taken for granted that condoms will be used for anal intercourse; it is intercourse without condoms that needs to be negotiated, not intercourse with condoms” (1993a: 161). Dowsett also expressed the idea of safe sex being fully integrated into gay communities’ sexual practice when he wrote that “for gay communities safe sex culture and gay culture are inextricably entwined” (1995: 247).

92 The Victorian AIDS Council’s ‘Safe Relationships’ Campaign (1994)

Formation of the Victorian AIDS Council

In a potted history Ten Years of the Victorian AIDS Council, 1983 – 93 Adam Carr wrote that when the first gay man in Australia died of AIDS in Melbourne in July 1983 reporting of the case caused “a wave of alarm among gay men in Melbourne.” Much like NSW, a public meeting was called that was attended by over 300 people. Calls for an organisation to be formed to deal with the new threat were made. A subsequent meeting established the Victorian AIDS Action Committee (VAAC). According to Carr VAAC had advantages over other newly formed AIDS organisations as it had a clear mandate to represent the organised “fairly small” gay community of Melbourne where “most people knew each other”, and so to organise AIDS services without the contestation Sydney experienced. However, Carr also noted the committee was confronted with a “paradox” in 1983 and 1984. The committee had little work to occupy it as “there were no people with AIDS in Victoria, so far as the committee knew, and when they did appear, as they began to do during the following year, they went straight into hospital.”

Although this did not remain the case, numbers of those infected never reached the numbers that they did in Sydney so the Victorian AIDS Council (VAC)27 had the breathing space to plan campaigns in a way that the pressure of numbers and the climate of fear and contestation in Sydney did not allow. As one of my Sydney participants, Kevin, put it, “I do think Melbourne was ahead of us. So often they initiated stuff and we followed.” This would be the case with campaigns addressing HIV infection in relationships as the next chapter will illustrate (when NSW launched its own negotiated safety campaign - Talk Test Test Trust … Together).

‘Because We Want To Be Together’ (The Safe Relationships Campaign)

In the Summary Report “Safe Relationships” Campaign August – December 1994 the objective given by VAC for embarking on the campaign was “to raise the level of gay community awareness of the issues, dangers and opportunities involved in the

27 The VAAC transformed from an unincorporated volunteer committee to the membership based organisation VAC at a large public meeting in December 1984. This change allowed it to receive government funding for prevention, treatment and care activities like its sister organisation ACON in NSW.

93 practice of unsafe sex inside gay relationships” (1995: 2). The report noted strategies to meet this objective included generating “… debate and discussion among homosexually active men, and especially men in gay relationships, of the dangers of seroconversion inside such relationships” and designing and distributing “print materials and/or advertising on the topic…” (1995: 2). The idea of stimulating debate and discussion about risk of HIV infection in relationships amongst the community at which the message is aimed is an ongoing theme in the story of negotiated safety. ACON’s Fucking Without Condoms and Talk Test Test Trust …. Together also had this stated aim. A more detailed discussion of this will be returned to after these campaigns have been described.

The report goes on to state that the need for a campaign was informed by published research including Feeling Our Way (1990) and Parnell’s Because It’s Warm, It’s Moist, and It’s Intensely Human: A Report of an International Study Tour Investigating Perceptions About Why Some Homosexual Men Are Still Practising Unsafe Sex (1993). Parnell conducted open-ended interviews with behavioural and other researchers, AIDS educators, gay community leaders and psychotherapists in San Francisco, Boston, London, Amsterdam and Copenhagen in mid 1992 (1993: 7 – 8). Because It’s Warm, It’s Moist, and It’s Intensely Human stands out in my memory as one of the first reports in the Australasian prevention context to acknowledge what could broadly be described as the “human nature” side of risk assessment in the prevention equation, namely that risky or unsafe sex within established gay relationships may be motivated by a wide range of reasons and contexts, some of them justifiable and “safe” in an HIV prevention context, others highly risky.

In the context of this thesis, the report also stands out now for its critical stance on the concept of ‘relapse’ – describing individuals ‘relapsing’ to what was defined as ‘unsafe sex’ after practising ‘safe sex’ (1993: 16 – 18) – which was popular in the American literature at the time. As Parnell noted, the arbitrary use of these rigid categories was sometimes problematic, particularly when the practice of anal sex without condoms negotiated in relationships where both partners were seronegative was arbitrarily defined as ‘unsafe.’28 He also noted that researchers in the UK,

28 Ekstrand et. al.(1993) represented an extreme of this position going so far as to say “negotiated danger” rather than negotiated safety was inherently flawed and risky because it relied on

94 particularly the SIGMA group (see for example Davies 1992 and Hart et. al. 1992), and Australian researchers (Kippax et. al. 1993b), had also critiqued the relapse concept. The document contained a detailed discussion of the complexities of arguments around negotiated safety, and prevention more generally, outlining both the advantages and disadvantages of promoting negotiated safety as a prevention strategy (1993: 39 – 48).

The Summary Report also cited discussions with gay specialist GPs and HIV testing counsellors about gay men using testing as part of a strategy to avoid routine condom use in the context of an ongoing primary sexual relationship” as another factor informing the campaign. Through discussions with the GPs and counsellors the campaign project officer stated it was possible to “clarify key strategies to recommend in the campaign” and hence design an appropriate message to be delivered in relation to “common points of breakdown in negotiated safety arrangements” (1995: 3). VAC approved a plan and work commenced in May 1993 on the minimal budget of $11,000 (1995: 2). These drafts were reworked, informed by the discussions with GPs, “other education personnel” and “attendance at peer education and support groups for gay men talking about relationships” and so formed the basis of images used in the 1994 campaign (1995: 5).

The project officer also mentioned he had originally drafted advertisements in late 1990 “after reflection on a close personal experience of a failed negotiated safety strategy.” Perhaps here is a hint of Giddens’ fateful moments when individuals are faced with a changed ‘set of risks and possibilities’ (1991: 131). In the sphere of intimate personal and sexual relationships, following Giddens, Heaphy argues that “ … in the insecure and risky world of late modernity, intimate life is identified as the place where security is most intensely sought and cherished, but it also where radical insecurities and contingencies can be encountered in powerful ways.” (2007: 120). Failed negotiated safety agreements where a trusting partner is exposed to the possibility of HIV infection may lead to anxiety about the viability of the relationship.

accurate knowledge and truthful communication. The authors also commented on the implications of negotiated safety for prevention stating that while ‘relapse’ to unsafe behaviour was part of the ‘human learning process’ it should not be excused by HIV prevention that aims for risk minimisation. They continued that while risk elimination may be impossible it is the only acceptable goal.

95 Issues of fidelity (or lack of it) might be highlighted and the possibility of sickness or death may further heighten anxiety and insecurity. The security of intimacy in a long- term relationship is replaced by uncertainty, doubt and fear. This serves to make debates about negotiated safety more charged and contested because of the anxieties and moral dilemmas aroused through this fear and insecurity.

Campaign Materials

Development of the campaign progressed with a survey29 and focus testing of campaign materials with a small sample of gay men. Forty-two men were involved in this phase of the consultation, 16 from ‘cruisey’ gay nightclubs, 18 in long-term relationships, and 12 HIV positive men from peer support groups (1995: 6). Campaign images and text were refined from feedback from this process. The final version of the campaign was a two-sided A4 flyer. (see Figures 1 and 2).

29 Although the sample was very small and so caution should be exercised in generalising findings, the survey seemed to confirm the need for a campaign addressing HIV infection in relationships with a third of men reporting not using condoms for anal sex with a regular partner. The survey also gave some guidance as to the effectiveness of the message and potential audience indicating that men in relationships were more likely to read the materials, with the majority of participants interpreting the message as ‘safe sex every time’ or ‘condom use even with your partner is simpler/easier/better/safer’ and a minority interpreting ‘the message as a neutral comparison of routine condom use to negotiated safety’ (1995: 7).

96 Figure 1: Because We Want To Be Together (VAC Flyer)

Reproduced with permission.

97 Figure 2: Because We Want to Be Together (Reverse Side)

Reproduced with permission.

98 The image used for the front of the flyer (Figure 1), the bedside table of a gay couple covered with assorted homely items, deliberately elicited the sense of security and cosy domesticity of the ‘ideal’ long term relationship. The text accompanying the image succinctly encapsulated many of the complexities and negotiations required to make negotiated safety work – from the practical steps required to accompanying emotional and communication commitments – to pointing out some of the main contexts and reasons risk might occur, such as ‘slip-ups’ and unsafe casual sex. Reflecting the wider ambivalence of the prevention community in promoting negotiated safety as a prevention strategy, the text was informative about what negotiated safety was, but ultimately struck a discouraging tone with statements like “At first we thought about fucking without condoms. But it’s so complicated!” and “A few of our friends are in relationships without condoms and they seem happy despite having such a big responsibility. But we are special to each other already. We don’t need to throw away the condoms to prove it.”

The photograph of the two men with their arms around each other on the reverse side of the flyer (see Figure 2) was chosen by the project officer “to fit a predicted viewer response loosely in the grey area between admiration and identification; i.e. ‘I want to have sex with them’ – ‘I want to be like them’ and ‘They are like me’” (1995: 8). According to the project officer, the crossed fingers behind the back of one man was used to convey a double meaning; “‘luck, faith and hope in the future’ as any agreement, including a negotiated safety agreement, relied to some extent on luck and good fortune to be successful versus the worst case scenario, ‘dishonesty and deceit’, the fingers crossed also meaning hoping not to get caught out” (1995: 7). The two columns underneath the photograph entitled ‘without condoms’ and ‘with condoms’ again reflect the overall discouraging tone of the flyer by visually portraying the complexity and multiple steps involved in negotiating safety as opposed to the simple message “Use condoms when you fuck with your partner or anyone else”, the standard official prevention policy of AIDS organisations in both Australia and New Zealand at the time.

Illustrating Beck’s assertion that there are no experts on risk (1992: 29), and the continuing theme of contestation around approaches to prevention, in the Summary Report the project officer described the internal debate about the aims of the

99 campaign. This contestation began from the early stages of planning, with the project officer pointing out that there was ‘substantial concern’ among VAC/GMHC (Gay Men’s Health Centre) members that campaign materials “would de facto fall into the category of either ‘endorsing’ UAI (unprotected anal intercourse) in gay relationships or ‘forbidding’ it” (1995: 4). The report continues that “positions were energetically argued from both perspectives” to determine what was the organisation’s “party line” on negotiated safety. There was an organisational shift, through the course of campaign development, from initially wanting to warn of the dangers of negotiated safety and a concern not to disseminate a message that could be interpreted as “permission to have unsafe sex” to confidence that “sophisticated materials which acknowledged that safe UAI with a trusted long-term partner was possible but more complicated psychologically and emotionally than routine condom use” had been produced (1995: 4).

Paralleling the organisation’s shift in perspective was the project officer’s personal and intellectual journey with the issues involved. As previously mentioned, one of the factors that had informed the campaign was the project officer’s personal experience with a failed negotiated safety agreement. In an interview conducted for this thesis he described how he integrated his personal experience with research and other analysis connected with campaign development. Perhaps the project officer’s mixed views on the subject, and the wider late or post-modern context of “ … a culture of radical doubt where all kinds of knowledge, including expert knowledge are only valid until further notice” (Heaphy 2007: 76), also to some extent explains why ambiguity remained in the campaign message.

… there was a period where I thought ‘well it’ll [negotiated safety] never work. You can’t trust [men], all men are bastards.’ No one tells the truth, even in long-term relationships. You should never throw the condoms away even with your partner.’ But fortunately the research we did, the consultation we did, and the education campaign methodology that we adopted including consultation with medical doctors and focus testing of the message, meant that my personal [issues] ultimately got put well and truly second to effective communications technique and on reflection I am glad I was prepared to listen and look at the data I was getting from the reports from the doctors, from the focus groups, cos if I’d gone ahead and done an ideologically motivated campaign saying never try negotiated safety, all men are bastards, then it would have set back honesty in community education… [VAC project officer]

100 However, what was not in doubt was why VAC eventually decided to go ahead with a campaign that addressed negotiated safety and not using condoms for anal sex in relationships – the practice was occurring in the gay community so a harm minimisation approach to address it would be applied. As the campaign Summary Report states, “[t]he ‘party line debate’ became, instead, a debate about how best to apply a harm reduction approach to the issue, that is to acknowledge the reality of negotiated safety and equip men in gay relationships with some of the information and skills needed to avoid HIV infection of themselves or their partner” (1995: 4). As was noted in the previous chapter, harm minimisation was apparent from the earliest prevention efforts, with educators reluctant to impose what they considered as unrealistic limitations on sexual practices if they were thought not to constitute significant risk of HIV infection (based on the information available at the time). Not recommending cessation of oral sex, even though it was known it carried a small risk of HIV infection, was a good example of this harm minimisation approach, one that was agreed upon on both sides of the Tasman. It is of course much more contentious to suggest negotiated safety carried minimal risk in the same way as oral sex. Harm minimisation arguments played a significant role in later debates about negotiated safety with various participants claiming negotiated safety both was, and was not, an example of effective harm reduction (see chapter seven). In the instance of Because We Want To Be Together it was considered by VAC that a harm minimisation message about negotiated safety was necessary and appropriate.

Launch, Dissemination and Reaction

The launch and dissemination proceeded with the printing of the A4 flyer. The flyer was distributed in Victoria through mail to gay and HIV specialist services, 250 GPs attending an HIV/AIDS medicine training course at the time, VAC’s regular newsletter mailing list, to gay and lesbian and AIDS telephone counselling services and as a series of advertisements in the gay press. The bulk of this activity occurred from July to September 1994. A formal campaign launch was held on August 12th 1994 (1995: 9). The campaign materials were sent to all the Australian AIDS Councils as well as the NZAF, and to other international HIV and AIDS education organizations. Reaction to the campaign was mixed. Early feedback about the campaign included that from GPs and HIV testing counsellors in Victoria who

101 reported that the materials were ‘long overdue’ and had prompted them and their clients to discuss issues around ‘trust, honesty, disclosure and negotiation’ (1995: 10).

In NSW ACON’s managers of the Education and Community Development Programs initially gave positive feedback and expressed an interest in distributing the flyers but concerns over the content and message of the materials and the relevance to Sydney tempered ACON’s response. ACON was itself planning a four page lift-out supplement in the gay newspaper, the Sydney Star Observer, addressing the issues of ‘fucking without condoms’ (which the next section will discuss in detail) so it was decided to wait for this “before distributing any message to their community on negotiated safety” (1995: 11 - 12). According to the Summary Report, feedback from other interstate AIDS Councils and gay HIV and AIDS educators was “very mixed” with most suggesting that while the campaign might be appropriate for Melbourne it was “culturally inappropriate” for their particular State. (1995: 12). Perhaps what was not being articulated (except for ACON) was that there were significant concerns about the aims and objectives of the campaign itself, and that breaking the now well established safe sex norms of a condom every time, even if to address a potentially risky practice that was understood to be already occurring within gay relationships, was more challenging to AIDS Councils than arguments about cultural appropriateness of campaign materials would suggest.

According to the Summary Report, local academics responded favourably saying a campaign addressing seroconversion in relationships was “long overdue” although some pointed out the complexity of the issues involved and suggested “further exploration of those class and cultural obstacles to gay men successfully negotiating such agreements” (1995: 13). There was also some positive international reaction about the campaign, most particularly, and perhaps surprisingly given its reputation for morally conservative prevention approaches, from the U.S.A. (for further detail on the launch and dissemination of Because We Want To Be Together, and reaction to it, see Appendix Two).

Looking back at Because We Want To Be Together, the VAC project officer summed up the effect of the campaign in the following way,

Everyone knew there was a lot of seroconversion inside long-term gay relationships. No one was prepared to – or able to, and I’m not sure how

102 much of which, being prepared to or able to – do a print campaign which said ‘you can throw away the condoms with your long term partner if you do it this way, these are the steps you need to follow’ … We needed to move beyond denial and break this log jam and actually acknowledge that gay men were like other monogamous couples who deal without condoms in the context of a long term relationship. [VAC project officer]

VAC/GMHC has continued its commitment to providing information to Victorian gay men in relationships who want to have anal sex without using condoms. ‘Sex Without Condoms (In Relationships)’ has appeared in some form on the VAC/GMHC website for some years and remains on the current version, which states “Some People, who know that they share the same HIV status, choose to fuck without condoms. This can only be ‘safe’ if you know for certain that you are both HIV- or both HIV+.” The page goes on to outline a ‘Talk, Test: Test, Trust’ strategy that is based on the framework outlined in the Because We Want to Be Together flyer. It would not be until 1996 after ACON’s Fucking Without Condoms 1994 insert in the Sydney Star Observer and the 1996 Talk Test Test Trust …Together campaign that further local and international reaction to negotiated safety campaigns would occur.

By the mid 1990s discussion about gay couples not using condoms for anal sex in relationships, and what to do about it, if anything, was also building within the prevention community in NSW. This resulted in the ACON initiative Fucking Without Condoms in November of 1994, an insert in the Sydney Star Observer, and in 1996 the ACON Talk Test Test Trust …Together campaign. The following section will continue the discussion of initiatives and campaigns developed to address HIV infection within gay relationships, and once again will include the views and recollections of the workers of the AIDS organisations involved.

103 ACON’s Fucking Without Condoms (1994)

At an AFAO National Gay Men’s Education Strategies Workshop held in April of 1994 negotiated safety, among many other prevention matters, was discussed. The report recorded the comments in general discussion: “Negotiated safety isn’t new. The first thing we have to do in strategising around negotiated safety is to be able to talk about unsafe sex, to be comfortable about it.” A session devoted to negotiated safety followed the general discussion with groups brainstorming the advantages and disadvantages of negotiated safety. Advantages included spontaneity and intimacy in sex, valuing monogamy and acknowledging the ‘realities of desire’ while disadvantages were listed as it depended on trust, testing and quality of relationship, worry about constant negotiation, and complexity of the issue (van Reyk 1994: 16 – 18).

Discussion generated by the VAC Because We Want To Be Together campaign had also added to debate already occurring within AIDS organisations about anal sex without condoms. Bryce, an ACON worker at the time, described the situation, “negotiated safety was on everyone’s agenda.” He continued,

… [VAC] had come up with one major flyer … and it was quite anti not using a condom in relationships, but it did address it … And we were all discussing it at the national level and [ACON Deputy Director] wanted to produce, he was adamant that, yeah, he always wanted to do it, like open letters and big ads and big things to the gay community and demand responses. We used to say Evita from the balcony (laughs). [Bryce]

An insight to ACON’s rationale can be glimpsed in a story in the Sydney Star Observer printed on the same day the insert was published, “[t]he safe sex culture which has developed in the gay community, based on a message of ‘use a condom every time’, may have over stigmatised unsafe sex” an ACON educator was quoted as saying. Partly prompted by the VAC campaign, the ACON prevention team had also formed a view that any campaign they developed would be around “negotiated sex” rather than “negotiated safety” hence broadening the message to ‘fucking without condoms’ and ‘calculation of risk’ in a wide range of contexts, not just that of negotiated safety within relationships (Gill, Report on Visit to ACON September 15 and 16 (1994), 1995). And it is clear that this view was implemented in the four page

104 lift-out Fucking Without Condoms published in the Sydney Star Observer on the 17th of November 1994 (see Appendix Three).

Printed on green paper to separate it from the rest of the newspaper, and addressed as ‘An open letter to the gay community from the AIDS Council of NSW’, the Fucking Without Condoms insert began by declaring “It’s time to talk about the fucking without condoms that’s happening in our community.” Immediately following was a statement about the risks involved in not using condoms for anal sex, acknowledging that while it was often high risk it may also be low risk “in some cases.” Then came one of the key objectives of the insert, that whatever the risk may be, non- judgemental clear discussion about what was safe and what was not was essential. These opening passages emphasised the ‘negotiated sex’ inclusive approach, talking about anal sex without condoms in the context of regular and casual partners for positive and negative men. Like VAC’s Because We Want To Be Together, this approach was a clear move away from the previous approach of AIDS Councils to prevention, acknowledging that anal sex without condoms occurred and attempting to open dialogue about it, rather than stressing the condom-every-time message regardless of context. The insert went on to state that “[d]ifferent people take different risks in sex” and “there are lots of reasons why.” Over pages one and two the lift-out then outlined eleven reasons (with accompanying explanatory passages) for taking risks that were by now well known to prevention and well described in social research. Unlike VAC’s Because We Want To Be Together that only mentioned sex between positive men in the context of negative health effects around reinfection, Fucking Without Condoms addressed issues around sex between and with HIV positive men more extensively (for further detail of Fucking Without Condoms see Appendix Two).

The insert included an advertisement for ACON’s ‘Lovers’, a series of three free workshops “for gay men on the relationships we form.” Brian, an interviewee who worked for ACON at the time and who helped facilitate the workshops, described the evolution of these workshops, explaining they had been developed to complement the publication of Fucking Without Condoms, “… it was kind of the basis for the Relationships workshops we continue to have. So it was kind of the very first one. It was done in a bit of a hurry I think, to reinforce that [referring to Fucking Without

105 Condoms].” Brian went on to outline the structure of the workshops and the areas they covered,

The workshops were three nights, three night workshops, and looked at finding a relationship, being in a relationship, and the last night was, yeah, how to end a relationship, that sort of stuff which, the structure we don’t use any more cos a lot of guys didn’t come to the last one [laughs] … So we had like 40 or 50 people at the first night and maybe 10 or 15 at the last. I remember that. But anyway there were a lot of guys that didn’t, they came with their boyfriends and they didn’t want to talk about breaking up. [Brian]

In the ‘Lovers’ workshops there was emphasis not only on negotiation and communication skills in relationships generally, but more specifically negotiation around not using condoms, what was by then starting to be called ‘negotiated safety.’

… so what we were talking about was negotiated safety. We were talking about a whole lot of stuff, communication skills and negotiating not using condoms … When you look at the workshop structure, a large part of it was actually negotiation, or communication skills, basic communication, all that sort of stuff, so that was always recognised. [Brian]

Pages three and four of the lift-out addressed negotiated safety in detail. The large inset box titled ‘Fucking Without Condoms’ made three points: that some gay men in relationships, both positive and negative men, were choosing to have anal sex without condoms; that there were “potential health issues” for positive men doing this covering what is described as the “theoretical possibility” of reinfection; and finally that “if you are both HIV-negative, then choosing to fuck without condoms is a choice that can go wrong unless you get the rules right.”

Repeating the ambivalence about negotiated safety of the VAC flyer, but also raising the theme of complexity, which will be discussed shortly, there was also a brief story about ‘Michael’ who speculated about whether he could cope with the complications around negotiated safety, even though he knew some of his friends were doing it and “they seemed happy despite such a big responsibility.” Finally ‘Michael’ concluded that “… we are special to each other already. We don’t need to throw away the condoms to prove it.” Brian commented on the ambivalence of the message in Fucking Without Condoms,

106 I think what we kind of tried to do was kind of convince people not to do it. That was almost the sub text, you know, you can do it if you want but it might go wrong and… I think there are three personal stories. I think two of them are situations that go wrong and one’s where it works. [Brian]

The lift-out ended with a section ‘So, to finish up’ which reiterated points made throughout. Joint responsibility was emphasised with the proviso not to assume someone else will protect you from HIV. Echoing the earlier years of prevention, where a sense of protecting each other as part of a community was invoked, the section continued “Maybe he’s got a lot of his own dramas to deal with.... Talking to “people you like and respect and who are not judgemental” or, failing that, trained ACON counsellors was advised for those who were having anal sex without condoms to “try and be clear about why and what is going on.” The difficulties involved in implementing and maintaining a negotiated safety agreement were again outlined, followed by “if all this sounds too much – and it is for a lot of us – then stick to condoms every time.”. Returning to the original impetus of the project, to generate discussion and reaction within the gay community about anal sex without condoms, the lift-out finished by advising talking to friends about the content, distributing the insert to anyone who had not seen it, or going to an ACON workshop, group or meeting to talk to others about the issues involved, “This is one case when talking about it does help” the lift-out concluded.

The ambiguity around the overall message of this lift-out has to be commented on here. The lift-out explained negotiated safety and the steps required to implement it in great detail but at the same time carried several statements about the difficulty of such a process and consistent condom use for anal sex, for example the myth advertisements touted the standard condom-every-time line. This inconsistency of message in the one lift-out is potentially a problem, whereas two different resources addressing the prevention concerns covered separately would not cause confusion of message, even if not addressing the wider issue of AIDS Councils disseminating negotiated safety information as a prevention strategy. Ambiguity was also present in VAC’s Because We Want To Be Together campaign where the difficulty and pitfalls of negotiating an agreement with a regular partner was emphasised at the same time as outlining the steps to negotiate such an agreement. This ambiguity reflected AIDS councils’ collective ambivalence in promoting messages of not using a condom for

107 anal sex at a time when using condoms had been established as a standard prevention message and a community norm, and like the VAC flyer perhaps also reflects a wider culture of doubt (Heaphy 2007: 76) where knowledge of HIV prevention was continually changing, subject to some contestation both within and outside AIDS councils, and only valid until a different or more compelling interpretation of the situation was forwarded, or another concern reared its head, or a new prevention issue or different target group was considered a priority. It would appear the wider historical and societal context of uncertainty and ambivalence that accompanies reflexive modernity (Heaphy 2007: 64) was impacting on and shaping not only prevention practice, but a particular campaign.

A notable difference between VAC’s Because We Want To Be Together and ACON’s Fucking Without Condoms was the latter’s inclusion of an HIV positive men’s perspective (ACON had criticised the VAC campaign for lacking such a perspective and focussing on negative men). While this approach was integrated throughout the insert, it was most notable in discussions about disclosure that explained how a positive man may feel less inclined to disclose his status if he were repeatedly rejected, and how this situation, plus assumptions about a person’s status, may lead to unsafe sex. Another example was the blurb of the “When one of you is HIV negative and the other positive” section where a sympathetic view towards positivity was expressed through an explanation of a negative man wanting to take risks with his positive partner “… so he can show his acceptance of his positive lover or totally share his experience.” Many of my participants who were HIV positive spoke of the importance of ‘positive in prevention’ – consultation with and, when appropriate, inclusion of positive men’s perspectives in the wider practice of HIV prevention. Fucking Without Condoms had clearly taken a positive perspective into account in formulating its content. As was commented on by participant Russell in the previous section, and evidenced in Feeling Our Way, HIV antibody status was a big factor in how people were interpreting prevention messages. A positive status would mean a very different set of considerations (for example, to disclose one’s HIV status or not) and subsequent negotiations both with a negative or a positive partner.

This growing visibility and voice of positive people in several different spheres of the HIV sector, most notably treatment, support and care and, to a lesser extent,

108 prevention, is evidence of the formation of what is sometimes referred to as an ‘HIV identity’ (Dowsett 1992) or an ‘HIV community’ (Duffin 1990). Present from the earliest debates about priorities of, and representation on, AIDS councils issues around the inclusion of a positive perspective in the HIV sector had been gathering pace from the eighties and continued into the nineties. In the previous history of struggle against and resistance to dominant discourses about homosexuality a reasonably coherent group identifying as gay or homosexual had been united in their collective action. Now, with the development of ideas about a positive identity or community (whether or not one is persuaded there is sufficient enough difference between positive and negative men to signify an emerging new identity) came competing and at times conflicting interests. Again illustrating the theme of contestation, debates about the allocation of resources to treatment, support and care as opposed to prevention at times became heated. Some of my participants even went so far as to refer to such debates as ‘sero-wars.’ Heaphy argues that there is an emphasis on diversity in the late or post-modern period (2007: 64) as evidenced by the influence of social movements of identity politics or ‘radical difference’ such as feminist, queer, or postcolonial movements (2007: 39, 44). In the case of a ‘positive community’ the biological fact of HIV positive antibody status is being used “for the creation of reflexively ordered narratives of self” (2007: 123) rather than social categories and discourses of homosexuality as was previously the case in the rise of a gay political and social movement (although social and political considerations and actions also rapidly built up around HIV positive status). While the sphere of HIV prevention in gay relationships and the dynamics of these relationships themselves were already complex, the contestation and difference brought to HIV prevention and debates about negotiated safety by an HIV positive voice further added to the complexity, contestation and diversity of opinion and interpretation. Identity politics, a notable feature of the late or post-modern period, which had previously acted as a unifying force, was now acting as a force of diversification, contestation and added complexity and in so doing demonstrating itself to be another of the many forces at work in shaping the practices of HIV education and prevention.

Another example of an initially unifying force later becoming a more fragmentary or diversifying force was the use of the concept of ‘gay community attachment’ in HIV prevention. At the beginning of the epidemic gay communities’ initial prevention

109 responses were from a collective communitarian perspective. By the early nineties social science was providing evidence that this approach was successful. The NCHSR’s large scale SAPA study illustrated a positive correlation between a gay ‘community attachment’ index and the adoption of safer sex practices (Kippax et. al. 1993a). By the mid nineties even the most reputable of medical journals, The Lancet, published an article extolling the virtues of a community-based approach in HIV prevention (Coates et. al., 1996). However, by the late nineties Ridge, Minichiello and Plummer (1997) posited that, in the Australian context at least, there were further complexities to this argument, demonstrating the more ambiguous and contradictory nature of gay social networks that could not be characterised simply as ‘community’, which also raised questions about community as a site of HIV prevention.

The Report and Process Evaluation of ACON’s later negotiated safety campaign Talk Test Test Trust … Together, while not commenting specifically on the impact of a positive perspective, did note that Fucking Without Condoms “for the first time responded to the issue of unprotected [anal sex] within regular relationships … by emphasising its complexity” and that the insert was “well received by HIV/AIDS educators, although no formal evaluation … was completed” (Mackie 1996: 8). The Report continued that the insert was also the first time an AIDS Council had “talked about the possibility of how not [emphasis in original] to use condoms, but do so safely” and that this represented “a marked shift from the message of always use a condom.” The Report stated that criticism of the insert “generally centred on its length, being text dense” (probably reflecting the complexities involved as discussed) and that although it was considered “a fine policy statement for an AIDS Council” it “fell well short as an education strategy” (1996: 9). This is an important point. While the discussion of anal sex without condoms within gay communities may have been welcome at a time when the condom-every-time was the dominant prevention paradigm, the fact that the insert was not a successful education strategy has to also be taken into consideration when assessing the overall effectiveness of the intervention.

It is unclear from the report who made these criticisms. As with VAC’s Because We Want to Be Together the report noted that counsellors and educators had reported “people using the insert to describe their own issues, bringing it into a discussion and

110 using it by stating ‘this describes me”’ (1996: 9). ACON’s goal was to generate discussion within gay communities about issues around anal sex without condoms in relationships, negotiated safety, and unsafe sex more generally. The Report’s comments would suggest this goal had, at least in counselling and education contexts, been achieved. Comments made by ACON worker Bryce suggest that reaction to Fucking Without Condoms also went further than the immediate sphere of HIV counselling and education,

So [ACON Deputy Director] wanted to do a full-page lift-out in The Star [Sydney Star Observer] which we did do ... And it was an open discussion about fucking without condoms to the community. It was huge. It was like lots of stories and lots of stuff … and that really ignited a lot of debate in the community. With this strategy we also had a series of consultations with the community. There were a couple in the city and regional areas and people were openly discussing it as well. I think we may have even organised a community discussion on fucking without condoms at the same time. [Bryce]

ACON’s goal of generating discussion about anal sex without condoms was occurring within the inner city Sydney gay community at least, but this also had a downside, as ACON worker Francis explained,

Well I think in terms of ACON’s first thing in the Star Observer, we knew that that was a mostly inner city Sydney readership. I remember one criticism one night a little bit after the campaign had come out. I was chatting to a doctor in the Oxford Hotel who worked at Albion Street who gave me a little serve about how he thought a lot of people, a lot of gay men or homosexually active men, had over-interpreted the message and he’d heard you don’t have to use condoms any more, which I think was not what the campaign was about. It was only saying that under, in relation to quite specific circumstances. But anyway, what he was saying was that the message was too complex and that he was particularly making the point that um, people from non English speaking backgrounds who he worked with a lot didn’t understand the subtleties and complexities of that message and that what they’d taken away from it instead was, I guess, a message that condoms weren’t important any more. [Francis]

While some considered the complexity of Fucking Without Condoms an advantage others thought the complex text dense campaign was confusing, liable to misinterpretation and so not appropriate for the negotiated safety message. Carl, a VAC worker, said of Fucking Without Condoms “ACON did that lift-out ... It was widely unread by those who needed it most and not in a format that could be readily

111 transmitted.” These criticisms would again be expressed with the launch of ACON’s next negotiated safety campaign, Talk, Test, Test, Trust … Together, which the next chapter describes.

112 5. ACON’s Talk, Test, Test, Trust … Together (1996)

After an initial and very rapid community led response to the AIDS crisis in the early 1980s, there had been a slowing of production in prevention campaigns within ACON from the late eighties into the early nineties. The general discussion around future directions of prevention in Australia, Fucking Without Condoms, and the community and organisational response to it, had been catalysts for ACON to be more explicit about their prevention policies, as had the need for greater accountability and accompanying increasing bureaucratisation and professionalisation of AIDS Councils generally. In 1995, the Sydney Gay Men’s Education Unit (renamed from the Community Development Unit) – the unit within ACON responsible for gay men’s prevention and education campaigns, strategy and policies – developed a strategic document on prevention and education and initiated four new campaigns, including Talk, Test, Test, Trust … Together (TTTT). Bryce, an education worker for ACON at the time, outlined the discussion-taking place within ACON.

ACON had gone through a period of not, had struggled with campaigns. I think they’d done just one in three years or something, and there was a lot of anger and so forth about what was being done. But a lot of it had been wound back as I recall … [We] sat down and devised a strategy, a strategic plan for ACON ... And in the strategy we developed, we said we were going to do four campaigns that year. The first one was on withdrawal, the next one was Talk Test Test Trust, then we were going to one on …. yeah, withdrawal before cumming in inserting anal sex um… and the third one was going to be about anal sex and the fourth one was going to be about community. [Bryce]

The principles set out in ACON’s Gay Men’s Eduction Strategy 1995 – 1997 were to guide this new negotiated safety campaign. The strategy was developed through an extensive consultation with key stakeholders, including ACON staff and clients, the wider gay community, health professionals, social researchers, staff of the AIDS and Infectious Diseases Branch of the NSW Health Department, other AIDS Council educators, and representatives from AFAO. The strategy noted that ACON’s 1994 – 1998 Strategic Plan had stated the need to “continuously clarify, review and where appropriate refocus educational strategies”, and that ACON should have “cyclical review of education programs for gay men to ensure optimum effectiveness.” The new strategy was the first of such reviews.

113 Also listed were a number of other reasons for the strategy’s development including: “recent criticism of gay men’s education which received widespread media coverage; increasing reports of ‘AIDS fatigue’ having an effect on risk taking by gay men; and “new research information regarding gay men’s sexual behaviour” (Gay Men’s Eduction Strategy 1995 – 1997: 5). Odets, among others, discussed the concept of ‘AIDS fatigue’ in his book In the Shadow of the Epidemic: Being HIV-Negative in the Age of AIDS (1995a). AIDS fatigue was the idea that gay men were tiring of safe sex messages and switching off from them and that this was part of a broader psychological response to the grief and loss associated with death and the AIDS epidemic. Suggesting this was not just an American phenomenon, HIV Prevention Among Inner Sydney Gay Males: Attitudes to Risk and Safe Sex Messages, a consultative research project commissioned by ACON, noted that in Sydney some participants switched off when they saw the ACON logo and that prevention and education messages needed “freshening up” (1995: A1 - 4). The continuing impact of the epidemic, in this case the idea that gay men were tiring of safe sex messages and switching off from them, is another of the factors acting on and shaping the practices of HIV education and prevention.

ACON’s comment about the influence of new research on the strategy and future campaigns indicated its close collaboration with the National Centre in HIV Social Research (NCHSR). This had a strong influence on the development of Talk, Test, Test, Trust … Together. This collaboration had begun with individual researchers as early as 1985 (Kippax and Kinder 2002: 96) but became more formalised in 1987 when the NCHSR was one of three research centres established through the Commonwealth AIDS Research Grant Scheme (Altman 1992: 63). Continuing the collaborative relationships formed in the 1980s, regular meetings between NCHSR and ACON staff (and other interested parties in the HIV and AIDS sector) allowed for new research findings to be discussed and for educators to take this information into account when planning future projects. Of particular relevance to campaigns addressing negotiated safety was the NCHSR SAPA study and the qualitative ‘recent sero-converters study’ in which in-depth interviews were conducted with men who had recently become HIV positive (Kippax et. al. 1994). This study had reported that up to fifty per cent of new HIV infections were occurring within relationships. Similarly the large scale Sydney Men and Sexual Health (SMASH) survey, also

114 carried out by the NCHSR, indicated 42 per cent of men in that study had reported at least some unprotected anal sex with regular partners.

Kippax and her colleagues were also examining and writing about ‘sexual negotiation’ and ‘negotiated safety’ at the time. The SAPA team had reinterviewed and surveyed men in 1991 (the earlier SAPA data being gathered in 1986/87) focussing on “the stability of men’s sexual responses to HIV/AIDS” (1993a: 141). This study, the Safe Sex Study (SSS), found that the “majority of men in the sample negotiated their sexual activity” with 79 per cent having a “clear agreement” on sexual practice within their relationship – either to have unrestricted sex (42 per cent) or safe sex (54 per cent). Eighty per cent claimed to have never broken the agreement. Seventy-four per cent of men in the sample had a clear agreement about sex outside the relationship – either no sex outside the relationship (39 per cent), safe sex all the time (36 per cent) or safe sex with casual partners only (23 per cent). Eighty-one per cent of men in this group said they never broke the agreement (1993a: 153). In conclusion Kippax et. al. wrote “it is important to distinguish the negotiated and agreed practice of unprotected anal intercourse between two partners of HIV negative serostatus from the practice of unprotected anal intercourse between partners where there has been no negotiation and no agreement” (1993a: 155), having coined the term ‘negotiated safety’ for the former arrangement in a landmark paper that same year.

The men surveyed in the SAPA study in 1986/1987 reported that since the advent of AIDS they had adopted a wide range of strategies, which they believed enabled them to avoid transmitting HIV and HIV infection .… the findings of this study demonstrate that many men use their concordant serostatus as a means of preventing the transmission of HIV. A new term is needed, therefore, for unprotected anal intercourse (or any other sexual practice) that is safe in a particular context, even though the same activity is deemed ‘unsafe’ in the abstract. We suggest ‘negotiated safety’ (1993b: 257 - 258).

It was this paper that disseminated the idea of negotiated safety to a wider international academic and prevention audience. It is also worth noting the comment made by Kippax et. al. about the men in the studies using a range of strategies to avoid HIV infection and transmission. This is perhaps a precursor for an argument about gay men’s active engagement with prevention messages and medical knowledge that would later develop and find expression in Kippax and Race’s

115 concept of a ‘social public health’ (2003). As previous chapters have illustrated, this idea had a long history both in theory and action, not only in the development of a gay political and social movement out of a previously restrictive and negative category of ‘the homosexual,’ but also in the proactive, community empowering and agency friendly response of newly formed gay communities to the onset of the HIV epidemic. However, in the area of risk of HIV infection in gay relationships, and a prevention response to this complex area, these previously unifying forces began to precipitate diversity, complexity and ambiguity.

Research findings of NCHSR were discussed in regular ACON/NCHSR forums to assist in the development of Talk, Test, Test, Trust … Together. Such a close collaboration between researchers and educators to specifically inform a prevention initiative was, and still is, rare in the HIV and AIDS sector. Two ACON workers, Brian and Bryce, discussed the connection between TTTT and the research of the NCHSR.

Oh ok, well the Board had been saying that we needed a strategic plan. Well we said to the Board that we were going to have a strategic plan so we drew on as much data as we could … Kippax’s paper had come out. We were quite, we used have regular meetings with the National Centre every three months so we were talking a lot about papers that were being produced. There was data from, I think, the Periodic Survey had been run by that time. [Bryce]

So, you know, the negotiated safety term had been coined by… Kippax from my recollection cos we were talking about it [negotiated safety] in Fun and Esteem [ACON group] as well. We talked about it in the groups … It had come up in social research and I think pretty much the research had been saying it had been happening for about two years by this stage. [Brian]

Desmond, a worker at the NSW Department of Health’s AIDS and Infectious Diseases Bureau recalled the influence of the Centre’s research on the development of TTTT.

So, you know, in terms of my involvement in Talk Talk Test Trust I was familiar with the research, you know, showing that most guys in relationships don’t have protective sex and was familiar with research coming out of [the National Centre] sort of indicating that there was sometimes negotiation around that, agreements around that … Yeah, so my recollection of things were that ACON really were the ones that took the research and said well, what’s an appropriate response to this. And

116 while the concept of negotiated safety was coined by the Centre [NCHSR] as a description of what was happening, its translation into an education strategy was largely the work of ACON. [Desmond]

Desmond also mentioned the importance of a sympathetic bureaucracy in ensuring the initiative was developed and implemented. However, he is also clear that convincing arguments based on rigorous research data needed to be made for the department to accept the change in prevention policy that TTTT represented.

… the way things worked at that time was the department funded everything basically, just about, that ACON did so the department had to be convinced that this was a right strategic move to make cos it was very clearly a significant change in strategy and there was resistance. I mean, there was a debate … because people were very concerned that it undermined the whole condom message, that it complicated the message, that it would create confusion … We had good chief health officers, you know, who were very sort of driven by an evidenced based approach to things so it was an environment, bureaucratically, where good arguments, generally, won out. [Desmond]

Again the theme of contestation is apparent as another ACON worker, Francis, also recalls the discussion with social researchers and controversy around the policy change that TTTT demonstrated, but he traces the debates back to VAC’S Because We Want To Be Together and ACON’s Fucking Without Condoms.

… it was so fraught. There were certainly mixed views, I think, within ACON and the sector. And I thought that was something that should be contemplated and at the end of the day I think people like [ACON Deputy Director] and others at ACON of us believed that we needed to not stand in the way of such a overwhelming change in gay men’s practice and work out how to support that rather than try to turn it around … [There] were a few meetings with social researchers talking about data and talking about the Victorian campaign and then I have a fairly clear recollection of the process of working on that inset. Yeah, so maybe I wasn’t as involved in the forum at ACON that decided on the policy shift but I certainly supported it and was involved in working on the campaign response. [Francis]

Brian also recalled what he describes as “the angst” around the policy change,

I remember the angst that we had about it. And I remember we [ACON] went on, we went to the quarantine station for a retreat or we went to the quarantine station for an advance [retreat]. We didn’t want to call it a retreat [laughter]. And one of the main things we talked about there was the Talk Test Test Trust thing and whether we were doing the right thing and I remember like every person at ACON was sitting around, I think,

117 sitting around in a big circle and they had to talk about whether they thought it was a good idea. So that was quite interesting because it was all the subtle reflection. Overwhelmingly people thought it was the right way to go. But there was some concern obviously. [Brian]

The Gay Men’s Eduction Strategy 1995 – 1997 acknowledged the controversy and debate around this policy change. It emphasised a number of what it described as “important new directions and developments” in ACON’s prevention and education policy. The first of these “[a] move away from broad targets and general messages to focussing on a few high priority targets and issues” was of particular relevance to campaigns developed by ACON to address negotiated safety. The strategy went on to list “relationships” as a priority issue, more particularly “HIV transmission within relationships … not about relationships in general but specifically about the current large degree of transmission of HIV in relationships”, “men in relationships” as a priority target and “[g]ay men’s need for more detailed information to assist in more complex sexual decision making” as a “primary process principle” (Gay Men’s Eduction Strategy 1995 – 1997: 11 – 12). ACON’s focus on HIV infection in gay men’s relationships and the identified need for more information for gay men to more safely make negotiations and agreements led to the development of TTTT, the campaign developed to address and respond to these high priority issues. It also illustrates the drive towards more sophisticated, targeted campaigns – in this case a specific intervention aimed at gay men in relationships who may have been at risk of HIV infection.

Two other new directions listed by the strategy, “[a] shift from principles of ‘individual responsibility’ in sexual activity, to principles of ‘shared responsibility’”; and “the adoption of risk reduction principles throughout ACON’s education program” (Gay Men’s Eduction Strategy 1995 – 1997 : 3) were also key to the development of TTTT. As has been described in chapter three, risk reduction or harm minimisation had long been an ingredient in prevention efforts, but here it is explicitly stated as an important prevention principle. Bryce pinpointed the relevance of the harm minimisation approach to the negotiated safety debate.

… a range of other people who were involved, I can’t remember all of them, saying that ‘look, if we say use a condom every time, and they’re not, what value is that message’. You know, we’re not talking to all those people who are in relationships who are not using a condom every

118 time. We’re just letting them loose out into the world and saying ‘we don’t have a message to give to you, we don’t have anything worthwhile to say to you’. We’ve got to be able to say something to these people that is worthwhile … As an organisation we just can’t ignore that, we can’t quite let that pass. We need to have a meaningful dialogue with these people, and we need to find what is the safest message to say to these people. What is the safest thing we can say … I remember this was a long conversation, I remember arguing with [ACON Deputy Director] saying ‘well what is the safest thing we can say’. He always asked that question. What can we say to these people that usefully, represents ... the minimum we could say that is the safest. [Bryce]

The Fucking Without Condoms lift-out had also demonstrated the shared responsibility and inclusive approach to positive and negative men in ACON education projects (as the previous section noted) but it is being explicitly stated as a new direction in Gay Men’s Eduction Strategy 1995 – 1997.

In their discussion of gay men’s strategies to avoid HIV infection Schiltz and Adam made a direct connection between shared responsibility and negotiated safety, “ … over years, a strategy based on ‘shared responsibility’ has developed. Under this rubric we place both those men who have a monogamous relationship and those who have decided to have unprotected sex with their stable partner following an agreement systemically to protect themselves during ‘extra-conjugal’ relations” (1995: 7). However, observations made by Murphy and Ellard in a 2006 conference poster cast the concept of responsibility in a more complex light. The authors examined HIV educational materials and campaigns produced in Sydney from 1988 to 2006. They also analysed interviews conducted by the NCHSR between 1993 and 2006 with Sydney gay men who had recently become infected with HIV (N = 140). They noted that the intended audience for these educational materials and campaign messages could be conceptualised in three different ways: the communitarian, the strategist and the citizen. These characterisations coincided with the changing historical and social context of HIV prevention, the pre Highly Active Anti-Retroviral Therapy (HAART) period 1988 to 1996, the post-HAART period, and the 2000s where rising HIV infections had again become an issue for educators and social researchers.

The authors argue that in the communitarian period HIV was conceptualised as a “shared and community responsibility” but that in the post HAART period there was a shift to education messages that focussed on risk management and individual choice

119 where “material were less directive giving readers information and expecting them to make the appropriate decision.” While ACON’s Fucking without Condoms and Talk Test Test Trust … Together were good examples of this less directive approach, Fucking without Condoms falls at the end of the shared responsibility period while TTTT was at the beginning of the shift towards individual responsibility, perhaps a difficulty for a campaign message that was attempting to appeal to ideas of shared responsibility both within a sexual partnership and a sense of collective responsibility about not spreading HIV infection in the broader gay ‘community’. While campaign material and commentary stated that negotiated safety was all about shared responsibility, and dialogue about anal sex without condoms at a community level, it is still difficult to classify TTTT and it antecedents as leaning towards a shared responsibility. Even though negotiations and agreements around condom use, or not, and sex outside the relationship, or not, can be seen in a limited sense as collective (involving two people at least) such discussions still largely occurred within the private sphere of the relationship itself, and as Altman emphasises, more in keeping with “ … the swing to extreme individualism of the 1980s, with its insistence on the individual autonomous actor untrammelled by social allegiances or obligation …” (1993: 6). The broader societal context of AIDS and HIV prevention coinciding with this shift towards the idea of a rational actor and accompanying individualism is again one of the wider forces acting on HIV prevention in general, and on TTTT and preceding campaigns addressing negotiated safety in particular. As a consequence of the detraditionalisation, individualisation and reflexive modernity of the late modern era, Giddens posits the formation of a new and democratising “pure relationship” (1992: 2) This relationship is based on negotiation and trust: an opening up of self occurring within a reciprocal bond of mutual trust and disclosure, a “transactional negotiation of personal ties by equals” (1992: 3). This sounds very similar to the concept of negotiated safety except that it is in the broader sphere of relationships more generally, not the specific context of sexual health and avoidance of HIV infection. Possibly, this is another wider force operating on the conceptualisation of relationships themselves. This will be discussed in greater detail in the following chapter.

As Murphy and Ellard’s analysis suggests, another complicating factor in the social and medical landscape surrounding the discourses of HIV prevention at this time was

120 the development of antiretroviral therapy known at the time as Highly Active Anti- Retroviral Therapy (HAART). Nineteen ninety six was the year that the world became aware of what were known then as protease inhibitors, antiviral drugs that significantly reduced viral replication in HIV infected individuals. Later this treatment would become known as antiretroviral therapy (ART). Many commentators would herald protease inhibitors as a ‘cure’ for AIDS and although time, unpleasant side effects and increasing resistance to the drugs in some individuals would temper this enthusiastic view, 1996 and the arrival of an effective treatment for HIV and AIDS infection (and the reconceptualisation of the disease from fatal to a ‘chronic manageable illness’) is seen by many as a watershed in the changing nature of the epidemic and another major factor to be considered in the wider context of HIV prevention and education.

It was clear that by the mid-nineties the focus of prevention was shifting from a response to crisis, as was the case in the first decade of AIDS, to issues around maintenance of safe sex practice, and targeting and relevance of prevention messages. It was also clear from social research describing risk reduction strategies that many gay men were responding to the epidemic and in learning to live with it (and developing a collective consciousness about it), becoming more sophisticated in their risk assessments (Dowsett 1995: 248). The increasing complexity of gay men’s risk reduction strategies was also being used by educators to guide new policy directions and assist in targeting more particular interventions, including negotiated safety.

Gay men are seeking and needing more detailed information to assist with negotiating “safe behaviour” decisions. The utility of blanket statements like “Safe Sex Always” is generally limited in the experience of gay men living within the context of being exposed to twelve years of HIV educational messages. We need to follow the example of “Fucking Without Condoms” and provide gay men with up to date, relevant, specific information on issues such as: withdrawal, negotiated safety, viral load and oral sex” (Gay Men’s Eduction Strategy 1995 – 1997: 15).

The process evaluation report of TTTT would later state ACON’s policy position on prevention even more clearly.

Through social research and the anecdotal experience of AIDS educators, it has become clear that the reality of gay men’s lives is not as black and white as the “Condoms always” slogans of HIV/AIDS education campaigns. While gay men for the most part understand the

121 fundamental facts of safe sex, they apply these facts in far more sophisticated ways to their sex lives and within their relationships, than HIV/AIDS educators were giving them credit for (Mackie 1996: 7).

Again, this illustrates the point that gay men were proactively engaging with prevention messages, part of a long history of actively engaging with discourses about, first, homosexuality and the shift to a self defining gay social and political movement, and then drawing on this empowering experience, an early response to the epidemic in the form of a communitarian and sex positive approach, and finally a sophisticated and nuanced response to the complexities of risk of HIV infection in relationships and in their wider sex lives. Clearly, this is a story of people acting as “active agents and subjects of their own history” (Ortner 1984: 143), people making history yet at the same time being made by it (Ortner 2006: 2). However, the balance between powerful structural forces such as the dominant discourses arising from the nineteenth century category of the homosexual (and their continuing influence through the medical sphere and so in some aspects of HIV prevention) and people’s agency and resistance to them is a subtle, shifting and ongoing phenomenon. The complex interplay of these various elements of structure and agency will be discussed in detail in chapters six and eight, drawing on Giddens (1992) and Bourdieu (1977).

Planning, Campaign Materials, Launch and Dissemination

And so the organisational and policy scene was set within ACON for the development and implementation of the Talk, Test, Test, Trust … Together campaign. In January 1996 the ACON Eduction Management Team developed a campaign creative brief and action plan which stated that the objectives of the campaign were to: “provide clear direction to couples considering negotiating to practice unprotected anal intercourse; send a clear message that giving up condoms in a relationship is not just something couples can ‘slip into’, and; provide direction for educators to use as a starting point to talking through issues with clients” (Mackie 1996: 10). Initially it had been planned that TTTT be launched in January 1996 to coincide with ACON peer eduction workshops but the launching of AFAO’s nationwide ‘One Community’ campaign in that same month resulted in the decision to defer the launch until May (Mackie 1996:12). This allowed more time to develop the brief and plan and negotiate new and innovative dissemination outlets for the campaign, including large street banners and a television community service announcement (1996: 12). Consultation

122 with ACON staff occurred in April 1996. According to the TTTT evaluation report “for the most part feedback from staff, especially from education staff, was highly complementary” (Mackie 1996: 13). Approval of the campaign materials was gained from the ACON Education Unit manager, the Education Strategy Team convenor, the ACON executive and the NSW Department of Health, AIDS and Infectious Diseases Branch – who were responsible for funding the campaign.

While the development of the campaign sounds reasonably straight-forward and unproblematic, the views and opinions of one of my research participants gives a glimpse of a more dynamic ‘behind-the scenes’ story where the campaign, and more generally prevention policy and approaches, are once again contested both within and outside ACON. As with the earlier discussions around the policy change, controversy reared its head towards the end of campaign development. Bryce recounted events within ACON immediately before the launch of TTTT.

Well even in production, like the posters, the pamphlets, things like that, there was certainly a lot of issues with the campaign before we even got it out. Even within ACON, even to the point where the head of counselling … he was very anti the campaign. And as you can imagine, you know, counsellors, I mean this is how we rationalised it and still do pretty much. Counsellors do see a lot of individuals and a lot of those individuals are people in need and of course they’re going to be seeing people whose relationships have fallen apart and they’re not going to be seeing the people who are having the successful relationships. So we had a special staff meeting to discuss the campaign about two days before it was launched and really go through it and it did end up in a bit of a yelling match with him saying ‘look, we think it is the worst thing you could possibly do in the circumstance, don’t go ahead.’ [Bryce]

Bryce continued that such a situation was not unique to TTTT and had occurred with other campaigns. He attributed this to the passion and commitment of ACON staff to the cause (study participants were described as such in the Participants section of chapter two).

But that wasn’t unusual for a campaign of ACON as well. The next campaign we ran was positive or minus one community, negative one community, which seemingly on the surface would be a wholesome good message to get across. That caused enormous controversy. There were huge fights about that [laughs]. So it’s not unusual. And ACON is a sort of very passionate place. [Bryce]

123 Despite this controversy on the eve of the campaign launch, ACON decided that TTTT would go ahead.

Printing of the campaign materials was completed by late April 1996 and included 20,000 pamphlets, 500 venue posters, 500 street posters and 10,000 wallet-sized cards. Three large plastic banners, two ten by one metre and one five by four metre, were produced with the Talk Test Test Trust … Together slogan and the ACON logo on them (Mackie 1996: 15). The pamphlet was double sided, A4 sized (folded into thirds), coloured, largely consisting of text but also including background images and three small photographs (see figure 3).

Figure 3: Talk Test Test Trust … Together (ACON Pamphlet - outside)

Reproduced with permission.

124

Figure 4: Talk Test Test Trust … Together (ACON Pamphlet - inside)

Reproduced with permission.

When it was folded shut the front of the pamphlet displayed the words ‘talk test test trust … together’ interlaced with the text “essential information for gay men who want to consider not using condoms in their relationship.” When unfolded, the first third of the inside of the pamphlet informed readers “[u]sing condoms remains the safest way of having anal sex, but … if you are in gay relationship and you want to fuck without condoms, then there are 4 steps to take together.” The other two thirds of the inside of the pamphlet show the four steps of negotiated safety: “talk about it; both get tested; get tested again; and, trust each other.” Accompanying each step was the now familiar blurbs about the importance of communicating honestly, what to do if one or both partners tested positive, that counselling support was available for support through the talking and testing process, the importance of a clear agreement about sex inside and outside the relationship, and what to do about ‘slip-ups’ or if the agreement was broken.

125 The back of the pamphlet shows photographs of gay couples. Accompanying the photographs is the text “but remember unless you follow these four steps use a condom everytime.” The final third of the back of the pamphlet has the text “ACON acknowledges that there are gay men in relationships who are fucking without condoms.

The inclusion of two statements about condoms remaining the safest way of having anal sex, additions from consultation with ACON staff, demonstrates the same ambiguity of message present in ACON’s Fucking Without Condoms and VAC’s Because We Want To Be Together. Bryce and Brian discussed the ambiguity of message in TTTT,

There was a lot of talk about condom every time. And the opening line in the campaign is ‘condoms every time is the safest way of having sex’ or something like that and then it says ‘but if you want to have sex in your regular relationship without a condom this is what you have to do’. And we were quite keen, everything, posters, everything, to always say ‘a condom every time’ as the opening line. But we did talk about it. I mean we talked about it at length until we were blue in the face... [Bryce]

When we did Talk Test Test Trust, what we ended up with was a positive series of steps that you could take, well at least what I’m trying to say is, you know, it’s best not to do it … it was kind of recognising people doing it but trying to convince them not to. [Brian]

So even though clear policy decisions had been made by ACON’s Education Unit and executive to launch a campaign addressing the issue of negotiated safety there was still wider organisational ambivalence about the appropriateness of the message.

The campaign was launched on May the 7th 1996 at the Australian National Museum in central Sydney, just a few blocks away from Oxford Street (the main gay precinct of the city since the late seventies). Over eighty people attended. The campaign’s distribution was broad and innovative, surpassing previous ACON prevention initiatives in both breadth and scope. Eight full page and eight horizontal strip advertisements of the Talk Test Test Trust … Together slogan appeared in the gay newspapers Sydney Star Observer and Capital Q over a two-month period from the campaign launch. The campaign pamphlets and posters were distributed to “gay community bars, clubs, saunas, backrooms, shops, bookshops and gyms” in the inner city and inner west areas of Sydney (Mackie 1996: 17). Campaign materials were also

126 distributed to a wide range of ACON eduction projects and branches. Five hundred street posters, which carried the Talk Test Test Trust … Together slogan, were pasted around building sites in eastern, central and inner western Sydney suburbs during the course of the campaign. The three large banners displaying the Talk Test Test Trust … Together slogan were hung on buildings and on freeway overpasses during the campaign. The two larger ten metre banners were hung from freeway overpasses in the inner city and east for periods of up to five days at a time (Mackie 1996: 19). A thirty-second television advertisement featuring Australian pop princess Kylie Minogue’s “What Do I Have to Do (To Get the Message Through)” was run over thirty times (after 8.30 pm) on a Sydney commercial channel from the 8th of May to the 28th of June 1996. This ‘community service announcement’ was a first for an ACON campaign (Mackie 1996: 19). Overall, the total campaign budget, reported in the process evaluation, was $22, 71530 (1996: 20 – 21). See Appendix Two for further details of the planning, launch and dissemination of TTTT.

Initial Reaction

30 This figure did not include staff salaries or estimates of costs saved by the use of volunteers (Mackie 1996: 21).

31 Along with the Health Belief Model, principles from social marketing (Talk Test Test Trust itself was described as a “social marketing campaign” in the process evaluation (1996: 11), as well as the Ottawa Charter and health promotion were strongly influencing and informing HIV prevention and education initiatives in Australasia by the mid 1990s, and continue to do so today. Social marketing in the HIV prevention context borrows from a broad advertising approach to determine who would be motivated to take notice of a particular prevention message (known in the jargon as ‘predisposing factors’), either generally as a member of the gay community, or more specifically as the message becomes relevant to an individual’s social network, their friends and lovers, and eventually the ‘immediate’, how relevant the message is to the individual’s own life. Social marketing also takes account of the wider social network and societal context, what is referred to as ‘enabling and reinforcing factors.’ In the case of negotiated safety this would be whether friends and acquaintances were practicing negotiated safety in their relationships, and workshops, conversations with GPs, public forums etcetera discussing negotiated safety. The World Health Organisation’s definition of health promotion, the Ottawa Charter (1986), outlined a holistic view of health within a wider framework of community empowerment. It proposed five main areas of action to improve a population’s health – public policy, social environments, community action, personal skills and health services (Lindberg and McMorland 1996: 110). The NZAF was strongly influenced by the Ottawa Charter from the early 1990s (1996: 110) as was Australian HIV/AIDS health

127 and articles in the gay community press discussing the campaign favourably. The campaign was also commended by “community leaders, academics and fellow educators” at the AFAO National Educators conference held in mid May 1996 (1996: 23).

Two surveys about TTTT were administered by ACON volunteers at Oxford Street and Newtown gay clubs and bars in April and late June of 1996 with 63 and 107 people responding respectively. Surveys were also filled in at the Gay Leather Pride Fair Day. Results were collated and, while the sample was small, gave some interesting insights. Questions asked about recognition of campaign message and materials produced favourable results. Forty eight per cent of post campaign respondents could name TTTT without prompting when asked about recent ACON campaigns, with 80 per cent responding that they had seen the slogan when prompted. When asked what they thought the main message of the campaign was sixty-nine per cent of respondents reported it was to “talk, get tested, get tested again and form an agreement if you are not going to use condoms within a relationship.” From the results of this survey no-one thought the message was not to use condoms in a relationship although almost a quarter, 23 per cent, thought it was either to use condoms always (12 per cent) or to get tested regularly when in a relationship (11 per cent). The process evaluation report commented that this was an encouraging result as it meant no-one had mistaken the message in a highly risky way, to not use condoms in a relationship and not know partners’ HIV status (1996: 29) The process evaluation commented the responses to the questions about the impact and importance emphasised “the relevance of the message in the campaign to gay men’s lives” while also remarking that the survey had limited capacity in “measuring the objectives of the campaign” (1996: 30).

The ACON Beats Outreach Team had distributed campaign materials to about forty men during the course of the campaign. They had attempted to target men who had regular partners. The process evaluation reported that the feedback from beat users was that the campaign was ‘good and clearly visible around town’ and that it was

policy (Edwards 1997: 47). The academic discipline of Health Promotion takes the principles of holism and community reinforcement expressed in the Ottawa charter, as well as drawing on medical and epidemiological data, to inform public health messages.

128 ‘about time ACON released a campaign in which the reality of what’s going on for gay men was addressed.’ However, according to the report some men commented that the issues involved would be difficult to communicate, too complex to talk about in a relationship or that they felt they did not have the skills to negotiate the four steps and were afraid of the conflict such negotiations might bring to their relationships (1996: 31). While the objectives TTTT had been quite specific, to arm men with the skills to talk about and negotiate sex without condoms in their relationships, an objective of the earlier Fucking Without Condoms lift-out had been to encourage an open general dialogue on the subject within gay communities. It would appear from the beat users’ comments that perhaps this is much easier said than done, and harks back to the complex dynamics of relationships more generally, as well as negotiating matters of sex and sexual practice within them. These themes will be discussed further in following chapters.

The campaign materials were also distributed to approximately 600 participants of the Mature Aged Gay Men’s Project (MAG) through their project newsletter. The campaign was discussed at various project forums and meetings. According to the process evaluation report, men participating in the discussions commented that while the campaign message ‘was considered to be very relevant to older men’ the references to trust and slip-ups were unrealistic. As with men in the Beats Project, they also questioned whether people were ‘equipped to communicate at the level required for the negotiation’ (Mackie 1996: 33). The report also noted that the MAG project officer believed the campaign message ‘could lead to more seroconversions rather than less, as the campaign almost condones the act of not using condoms during anal sex’ and that as the focal point of HIV/AIDS education ACON should ‘take a hardline and deliver stronger messages’ (1996: 33). Once again this illustrates the divided views on the campaign and whether or not a negotiated safety message was an appropriate prevention strategy (see Appendix Two for further detail of the initial reaction to TTTT).

As previously noted, the ACON counselling team had had concerns about the complexities of the campaign message. According to the report, while the counsellors thought the content of the campaign was relevant to the target group, they felt the text did not address the ‘psycho-social issues around communication’ – that the

129 information was clear but the processes of negotiating and trusting were very difficult for people to carry out. The group felt step four should have covered “all of the risks associated with contracting HIV’ and the text generally should have included ‘a broad discussion of the issues raised in the campaign” (Mackie 1996: 32). It is difficult to imagine how such a discussion could have been included in the limited space of a pamphlet, and also bearing in mind that Fucking Without Condoms, which to some extent had attempted to include a broad discussion of the wider issues and contexts involved, had been criticised for being too wordy and too complex. This raises an argument about negotiated safety that would gather momentum in the months and years after TTTT, both in Australia and overseas, namely, were campaigns the appropriate vehicles for discussions around the complexities involved in negotiated safety and sex without condoms in relationships. This will be discussed further in the following section. The group also thought that given the shift in prevention policy that TTTT represented, more internal consultation was needed (1996: 32). Brian, an ACON worker at the time of TTTT, also supports this view. As he said,

I think it was a surprise the vitriol that we experienced from some people … from, you know, just some of the doctors and some of the counsellors, that sort of stuff. I think we were quite taken aback by that. To some extent though that’s probably because we didn’t involve them in the process earlier on. So what they ended up seeing was a campaign that said if you are in a relationship you can do these things, da da da, which would contradict what they were saying and they wouldn’t have had any chance to contribute to it beforehand. [Brian]

The views of Albion Street clinic counsellors were also varied with some thinking the campaign message was clear and understandable while others thought ‘it failed to fully explain the risks’ particularly in reference to condom breakage or leakage, ‘the possibility of low risk transmission’ (risks that were not particular to negotiated safety but existed for all safe sex messages that advocated condom use), and again, as with Beats and MAG participants, and ACON counsellors, ‘the difficulties of negotiating trust’ (1996: 33). The process evaluation commented on the diversity of opinion on the campaign within ACON and although pointing out “disagreement over the campaign content … was not universal” nonetheless suggesting, as with Brian above, “a more coordinated approach to discussion of education issues ... and informing ACON staff generally about developments in education” (1996: 34).

130 In summing up early reaction to Talk Test Test Trust … Together within ACON and allied health services and service providers, the process evaluation concluded that the campaign was a “success in initially achieving the development objectives ...” and that “in terms of market reach, acceptability of message and mix of components [the campaign had] succeeded in getting the desired message to the Sydney gay community” (Mackie 1996:39). It also acknowledged the campaign was a new direction in ACON’s education policy that reflected a new “realism and appropriateness” and also “a move from the restrictive messages of ‘safe sex or unsafe sex, yes or no’ that have characterised HIV and AIDS education to an attempt to provide gay men with explicit, clear and specific information to particular sexual acts and circumstances, so as they can accurately assess risk and decide for themselves when and whether or not to use condoms” (1996: 39). Harking back to the communitarian approach to prevention apparent in early campaigns and information dissemination, the report continued the campaign was “an important, practical personal strategy to further strengthen the gay community’s commitment and ability to practice safe sex” (1996: 39).

Finally, the process evaluation acknowledged that there had been “some genuine criticism of the campaign largely centring on the ability of gay men to communicate the complexities involved in negotiating unprotected sex within a relationship safely” but that it was “clear from both social research and anecdotal evidence that whether or not gay men [were] capable of that level of communication or trust, they [were] already and [had] been for some time, employing strategies to negotiate unprotected sex within regular relationships” (1996: 39). Indeed, there had been indications that this was the case as early as 1990 and the publication of Feeling Our Way. However, the debates around issues of trust, communication and the ability of gay men to negotiate agreements – as evidenced by comments by some counsellors, ACON workers and gay men involved in some ACON projects – were only just beginning. These debates would broaden to include the international prevention and academic stage, but most particularly the Australia/New Zealand divide, as chapter seven will illustrate.

No formal evaluation of TTTT was carried out. However, a number of my participants commented on the effectiveness or otherwise of the campaign, advancing

131 arguments to support their views. The following sections outline the most common arguments advanced about TTTT, namely one in favour of it arguing that it created dialogue about sex without condoms within gay communities and a number, both supporting and opposed, addressing the complexity of both TTTT and the wider environment of gay relationships within which it was trying to operate. Arguments concerning whether or not TTTT was an effective harm minimisation message and its connection with issues of trust, and honest open communication within a primary relationship are addressed in chapter seven.

Talk Test Test Trust … Together Created Space for a Dialogue about Sex Without Condoms

As the previous sections have indicated in a number of places, an argument in favour of the effectiveness of TTTT that was articulated by some of my interviewees was that it created forums in which to discuss issues connected to negotiated safety. It will be remembered that the stated objectives of Fucking Without Condoms and Because We Want To Be Together were also to generate discussion about anal sex without condoms in counselling and education settings and within gay men’s relationships. There was some evidence to suggest that this had occurred in both instances. ACON worker Brian commented that TTTT was a similar kind of ‘hook’, as he called it, to initiate dialogue – the structure from which counsellors, GPs, educators and gay men could discuss anal sex without condoms and agreements about sex outside the relationship, HIV testing and negotiated safety. These discussions were important even if people did not follow the TTTT steps precisely. As Brian said,

[TTTT] gave counsellors in particular but also GPs I think something that they could actually refer to so they had it on paper, they could refer to it, they could talk to the individual or couples and so you look at things now and talk about actually getting tested together, getting results together, so two people come in to get results … even though people didn’t get the order, they actually referred to it, they knew about it ... The reason why I say I think it worked well is it gave men a kind of hook on which to, you know, hang their discussions about sex within their relationship that they didn’t have before … I don’t know about you but when I talk about these [negotiated safety and TTTT] I talk about them as if they’re somewhat different. So negotiated safety is one thing, and Talk Test Test Trust is just the structure we created to help people talk about it. [Brian]

132 For men who were used to discussing matters of sex both within and outside their relationships the limited evidence available (no formal evaluation of TTTT was carried out) suggests TTTT did create a space for more open dialogue about anal sex without condoms in this context. And perhaps another group who were not so practiced in discussing such matters benefited the most from TTTT by being able to discuss negotiated safety and related matters within the various professional and social spaces TTTT created. However, as comments from men attending ACON forums also attest, some men found communicating about issues concerning negotiated safety difficult. It is perhaps unlikely that such men would take advantage of the spaces created by TTTT to discuss negotiated safety, and it is these men who are most at risk of HIV infection in their relationships precisely because they found discussing such matters difficult. As Schoofs succinctly put it, “[t]he complex dynamics of negotiated safety may be most difficult for those most at risk” (1995: 38 – 39).

The idea that TTTT created space for discussion about anal sex without condoms was not limited to Australian educators involved with the campaign. Race (2003) takes the concept of a dialogue around negotiated safety and extends it by incorporating the idea of a ‘public’ created from this. As he writes, “‘[n]egotiated safety’ could be understood as an example in which a “public” was conceived, whereby the existence of the technique was made known, debated, brought into articulation with practical and medical knowledge, and acknowledged as viable by authorities and many members of the public it constituted” (2003: 377). He continues by pointing out that TTTT allowed gay men to interact with a public health message in a proactive way, in a way that took account of the complexities and specific circumstances of their lives, “[w]hat was important here was … the extension of a scene of circulation in which reflexive consideration of currently existing health directives could occur and be brought into articulation with the practicalities and characteristic habits of gay men’s lives (2003: 377). As been discussed in previous chapters, proactive interactions with public health messages are an important and ongoing theme in this thesis. However, what Race is adding here, along with the idea of a created ‘public’, is that this interaction occurs reflexively within the practicalities of how gay men are already living their lives, in other words, within the existing social and cultural context of gay men’s relationships and sex lives. Referring to Kippax and Race’s ‘social public

133 health’ (2003) this argument will be extended in subsequent chapters using the work of Bourdieu (1977).

Complexity of Negotiated Safety and TTTT

While the fact that TTTT (and Because We Want to Be Together before it) was not a black and white (right or wrong) type public health message allowed a space in which dialogue about negotiated safety could occur, it was this same ‘greyness’ or complexity of message that was seen by some as a reason not to promote it. Some of my participants from both Australia and New Zealand were also of the view that negotiated safety was too complex a concept to disseminate as a health promotion message, or at least too complex a message for a print or mass media campaign using a social marketing approach.

Kevin, who was involved in prevention and education in Sydney in the 1980s and early 1990s, took the view that the dynamics within many gay relationships were often not such that fair and equal discussion in general, including negotiation of use of condoms, could occur. For these reasons he was opposed to the dissemination of a public health message addressing negotiated safety.32 He summed up the situation in the following way, outlining that the problems of unequal power and associated social disadvantage in gay relationships led to a situation too complex to address in a public health or social marketing mass media campaign.

… what we were being told, sort of unofficially, cos there wasn’t enough ability to research it, was that all these people had problems.... That, that one way or another you could summarise it in terms of lack of power within short term or serious long term relationships, and that we could have followed up is what were the vulnerabilities. And they were really complex and it was about, it was about power, it was about gender, race, it was about age, it was about class, it was about psychiatric illness, it was about drug and alcohol. A lot of the people

32 Part of Kevin’s objection was also about whether or not a harm minimimisation message could be sent to one section of the community, gay men in relationships, while not to other men who did not fall into this group. This was a concern expressed by many of my participants, both Australians and New Zealanders. There were some who were of the view that some form of targeting occurred with just about every HIV prevention campaign while others felt that a condom every time approach was unambiguous and should be promoted consistently regardless of which particular sub-group the campaign in question was focussing on. New Zealanders were more likely to hold this view. Some of my participants felt that while some campaigns could be targeted, others could be broadly applicable to most of the gay male population.

134 that were getting infected had a lot of problems and their relationships were not relationships of equal power where they had good access to education and that education was going to help them negotiate safety properly cos their relationship wasn’t about that. Now you can handle that sort of stuff by more research and you handle that sort of stuff, I think you handle… education strategies around negotiated safety well at a certain register of education. That is you can do it in outreach, you can do it in counselling, you can do it in group work but its hard not to misfire with mass media messages … So the negotiated safety stuff as a mass campaign doesn’t deal with… actually doesn’t help any of that stuff … we couldn’t broach that level of complexity in mass campaigns. Like, if you think you’re a middle class well educated 30 year old man this message is for you. If you’re secretly out of control, if you’re drunk every second night, the message isn’t for you. [Kevin]

Unlike Kevin, Australian health bureaucrat Desmond supported TTTT. However, he also made the point that effective social marketing should involve more than just the mass media message. The previous chapter detailing the implementation of TTTT provided evidence that some of this activity did occur in other ACON groups and workshops.

I think it is very difficult in social marketing to get complex messages across and um, you know, the social marketers will always argue that social marketing is something that has depth to it, it’s not just the media messages. It should be complimented by other strategies, in a sense, doing peer education, doing more one on one contact is part of a bigger social marketing strategy in any case. So, but, I think it’s not unreasonable to say this is a complex message and it is difficult to get a complex message across in mass media. [Desmond]

TTTT campaign organisers also acknowledged this point in the process evaluation, “ACON staff … saw the need for a range of resources, including some that discuss the issue in more depth. Resources dealing with the complexity of the social and emotional issues that are involved in negotiating sex in relationships (Mackie 1996: 34),

Carl, from Victoria, discussed the ambivalence of co-workers in implementing Because We Want to Be Together, not just around whether or not a negotiated safety message should be promoted, but also whether it was too complex a concept to address in print media.

I thought now’s my chance to get this on the agenda, [it] has been put in the too hard basket forever … For those who acknowledged the need to address the subject, and not everyone did, some acknowledged the need

135 to do something about it but some people said, no we can’t endorse it. We can’t tell gay men they can have safe sex without condoms because they can’t. And you know, it’s condoms every time with everyone. And there was a kind of grey area or a continuum where other people would say, yes of course people who are in long term relationships won’t use condoms with each other but you can’t talk about that in print because it’s too complicated to deal with it in a print campaign. [Carl]

For Patrick, one of my Australian participants who works for an organisation representing HIV positive people, the issue was not the complexity of negotiation in relationships, it was the complexity of the steps required to navigate TTTT successfully.

I had trouble remembering Talk Test Test Trust and whether it was Talk Talk Test Trust. I thought it was stupid. I thought it was hard to get your head around … I thought it was too clever. It was trying to be too clever. The message was too clever … Well, complicated I spose is the way to say it cos there were all those steps that you had to take. But clever in the way that it was trying to package them into the four ‘T’s. As I’ve said, I could never unpack what was what so that’s why I say clever, but I think it was too complicated. I can see that it was a good thing to try and help people negotiate agreements and that was really important given that lots of seroconversions were happening, you know, through people not discussing and through contracts being broken, whatever they were, or that people were just not forming contracts, were just discussing in order to form them, and because of the viral pool out in the community it was important that people had an agreement about their practices that they did in and out of relationship and try to form some way of doing that. But I don’t think it happened. I think there were, I think I’ve heard that there were people who misinterpreted it in some way and that it didn’t work. [Patrick]

While Patrick was opposed to TTTT as a message on the grounds of its complexity, he still thought the concept of negotiating agreements about not using condoms in relationships was worthwhile even if TTTT ‘didn’t work’ because people misinterpreted it. New Zealander Tim was also of the view that TTTT was too complex a process, but for him there was no room for manoeuvre when it came to not using condoms for anal sex. For Tim the health promotion message was condoms should always be used for anal sex. Another advantage to this approach for Tim was the lack of any ambiguity in the message and that a condom being worn was clear and easily ‘verifiable.’

The only STI that condoms work to prevent really really really effectively is HIV. But they do work really well and it’s because HIV is

136 difficult to transmit, you know, and it’s essentially only transmitted in the context, to any significant extent, of anal sex. And the best to leave gay men’s sexual behaviour intact with minimum interference is condom use. Now there are some people who say oh condom use is a terrible imposition. And I say, excuse me, you must go and test, you must then use condoms for three months, you must test again, you must talk to your partner, you must disclose every event that happens outside your relationship. You know, this is not an imposition? Give me a break. And the other thing that I would say is, if you just actually want to use the term verifiability, one thing that’s very good about condoms is that they’re verifiable. You know if someone’s fucking you with a condom on and they know if they are or not. And it’s very difficult, unless there’s some mental health difficulties, to pretend that you are fucking with a condom when you’re not. [Tim]

However, condom use is not without its problems. Difficulties with consistent condom use are well known to HIV educators and include lessened sensitivity, erectile dysfunction, that condoms ‘kill the moment’, and condom failure in the form of breakage and leakage. Furthermore, while condom use is not as complex as TTTT and other negotiated safety arrangements, it still requires, to a certain point, negotiation and communication skills. As Kevin pointed out in the context of TTTT, there will always be the vulnerable and socially disadvantaged who are not able to negotiate in their relationships. This applies equally to condom use in relationships, although clearly the level of negotiation and communication required for consistent condom use is not as great as that required for negotiated safety. Perhaps more significantly, condom use only requires these skills in the moments or hours leading up to sex as opposed to the ongoing trust, communication and honesty that is required over weeks, months and even years in the case of TTTT and negotiated safety. New Zealander Andrew discussed his personal journey through initial acceptance of a condom-every-time regardless of context policy to doubt about the inflexible ‘one size fits all’ aspects of this approach, along with lack of acknowledgement about the difficulties and negotiation required for consistent condom use. As he explained,

They [condoms] require a level of social sophistication and personal confidence to bargain for in the first place, that they’re not particularly comfortable, that they lessen the enjoyment and other issues as well I guess, but those were the kind of fundamentals that people just didn’t want to deal with because it complicated what was a very straight forward ‘just use a condom every time’ kind of deal. And I found that increasingly worrisome but I was never able to come up with a viable alternative to it from a, I guess, from a epidemiological point of view, looking at it as a population, a gay men’s population point of view....

137 Sure there were people who didn’t need necessarily to be doing that because their circumstances were in fact such that – there were people who had all things in place that needed to be in place for you to be absolutely sure that there was no question of infection therefore it’s not an issue.

I think it would be true to say that for quite a long time in the early years I thought that it [consistent condom use] made a great deal of sense. It made sense because from a purely mechanistic point of view and from a rational point of view it was in fact the best answer short of not having penetrative sex, you know, anal sex ... So in terms of it being I guess common sense based in some kind of science, in terms of knowing that this was a way of, a barrier to infection and so forth, it did make a lot of sense.... and what seemed at the time radical challenges in thinking from overseas [campaigns addressing negotiated safety], but it started to occur to me that it wasn’t as easy for people as it seemed and that it was a one size fits all answer. It probably wasn’t fits all as you wanted it to be, but there didn’t seem to be any other alternative … The organisation’s policy was, in practice, that you set up what it is that you’re going to say and you keep saying it because consistency is part of it, over time, and keeping it simple and there being a line in the sand that people could constantly refer to, was actually better practice in the long term than chopping and changing your mind. [Andrew]

The various – sometimes contradictory – elements of negotiated safety debates are clear here. Andrew is aware that condoms-every-time provides a straightforward unambiguous health promotion message that can be easily and consistently repeated, but at the same time he realises that this ‘one size fits all’ approach does not allow for any flexibility or taking account of contexts where condom use may be unnecessary – for example in gay relationships where each partner is known to be HIV negative and where a negotiated safety agreement based on trust and open, honest communication is in place. Patton also comments on the rigidity of the condom every time approach, connecting it to the rapid expansion of AIDS organisations and the associated need to find broad-based cost effective health promotion messages. As she writes, “[a]lthough ASOs [AIDS service organizations] have been highly flexible and evolved quickly in many areas, their sheer size now produces inertia: mistakes are costly and it seems better to fit different types of people to the existing model, rather than changing the model to accommodate new needs” (1990: 23).

Some of my participants also pointed out ramifications and complexities around negotiated safety that were less well known or discussed. Duncan, long time NZAF employee, pointed out the connection between anal sex without condoms and

138 increased risk of sexually transmitted infections (STIs) other than HIV – a negative aspect of negotiated safety that is seldom mentioned.

I mean we haven’t even mentioned other STIs. Well I mean that makes it much more complicated because although the primary focus for a long time now has been HIV there are other STIs obviously involved and they’ve become increasingly present because of barebacking33, because of people taking risks without condoms. We’ve gone back to pre-HIV issues around STIs which disappeared, and particularly for positive men who have huge issues and they actually increase HIV transmission so you’re just making it more complicated. [Duncan]

While it is probable that HIV negative couples who were concerned about their sexual health would also test for STIs it is not necessarily the case they would do so, and there was a notable absence of any information alerting couples to this possibility in any of the Australian negotiated safety prevention messages. Because We Want to Be Together, Fucking Without Condoms and TTTT do not make any mention of this added complication. In contrast to this all three do mention the possibility of increased risk of STIs for couples who are both HIV positive and are not using condoms (as it was well known at the time that the presence of other STIs can increase the likelihood of HIV transmission, as Duncan also mentions).

However, proving once again that contradictory arguments about negotiated safety are often drawn from the same context, Race (2003) argues that negotiated safety reduced the likelihood of barebacking in Australia because it minimised “resonance’ with the transgressive nature of unprotected anal intercourse. As he writes,

Like other sexual practices, anal intercourse without condoms has variant, context-specific meanings and affects, shaped by historically variable systems of value. In this regard, it is possible that the sociopolitical context produced by the endorsement of gay men’s risk minimization has had the effect of making barebacking less resonant in Australia … On this argument, negotiated safety made reflection on the circumstances in which UAI occurs possible and proper, thus depleting the transgressive appeal of UAI produced as ‘barebacking.’ (2003:373).

33 ‘Barebacking’ is a term that arose in the 1990s, first in America but then elsewhere throughout the western world. Essentially it means (possibly highly risky) anal sex without condoms with participants not knowing or not caring about their partner’s HIV status. Extreme versions of this came to be known as ‘bug-chasing’ where people actively sought to become HIV positive.

139 In the inaugural address to The Consortium for Social and Policy Research on HIV, Hepatitis C and Related Diseases held in Sydney on March of 2004 Dowsett described a further complexity to negotiated safety by suggesting VAC’s Because We Want to Be Together and ACON’s Talk Test Test Trust … Together broke the unity of safe sex by allowing the possibility of safe unprotected sex to be integrated into HIV prevention practice. In other work, he dubbed the period beginning 1996 as ‘post- AIDS’ to distinguish it from the preceding ‘sustaining safe sex’ phase in Australia. He also described an initial period in prevention (as chapter three detailed) as a first phase that offered “… a message about HIV and safe sex for the first time – and prevention, which recognised the ongoing nature of the struggle to stay safe,” (Dowsett 1996a: 22). As Dowsett explained, “Post-AIDS tries to leap over artificially created or sustained uniformity and seeks a firmer ground for solidarity than crisis, than fear of infection” (1996a: 22).

Later Dowsett et. al. had refined the concept of ‘post-AIDS’ and described it as “… a fragmentation and multiplication of gay community responses to HIV/AIDS, a differentiation in both experiences and consequences that warranted a new, multifaceted approach to health education among gay men, whether HIV-positive or negative” (Dowsett el. at 2001: 209). Kippax and Race further added to the complexity of the definition by observing that the success of combination antiviral therapies was also implicated in ‘post-AIDS’. (Kippax and Race 2003: 6). The fracturing of the unity of safe sex in the post-AIDS period has been discussed in other contexts in previous chapters and will be returned to later in connection to the structure/agency debates and the complex interplay of factors acting on HIV prevention.

By far the most common arguments mounted for or against negotiated safety by my participants also centred around trust, honesty and communication (or the lack of it) in gay relationships, as well as the complex nature of human relationships more generally. Using the work of Giddens (1992) the next chapter will explore the broader social and historical context of human relationships and sexuality in greater depth. It will then examine the complex dynamics of gay relationships within this wider conceptualisation, and apply the findings to arguments about negotiated safety and TTTT.

140 6. Intimacy, Love, and Relationships

The impact on HIV prevention of the broader social and historical context of the late or post-modern period, and of factors relating to the epidemic itself, has been commented on a number of times in the previous chapters in reference to the complexity and ambiguity of messages formulated specifically to address risk of HIV infection in gay relationships, and the contestation and controversy around development of campaigns (VAC’s Because We Want to Be Together and ACON’s Fucking Without Condoms and TTTT). This chapter will explore the broader social and historical context of the late or post-modern period with particular reference to intimate relationships and sexuality, drawing on the work of Giddens (1992, 1991, 1990). The discussion will centre on his suite of theoretical musings focussed around the concept of ‘reflexive modernisation’ and its impact on intimacy, relationships, trust and negotiation. The chapter will then go onto examine the complex dynamics of gay relationships within this wider historical and social context, and apply the findings to arguments about negotiated safety and TTTT.

Factors arising from the dynamic nature of the epidemic (Patton 2002: xxv) have been identified in relation to campaigns addressing negotiated safety and identified as affecting not only the campaigns in question but also the broader field of HIV prevention. A number of factors have been noted in the preceding chapters. The focus of prevention shifting from a response to crisis where the message of condom-everytime was appropriate and indeed life saving for a great number of gay men in the western world to more targeted prevention messages where the previously established norm of condom use was questioned. Gay men were responding to the epidemic and in learning to live with it (and developing a collective consciousness about it), and in so doing becoming more sophisticated in their risk assessments (Dowsett 1995: 248). The increasing complexity of gay men’s risk reduction strategies was also being used by educators to guide new policy directions and assist in targeting more particular interventions, including negotiated safety.

Another factor identified as affecting prevention was the continuing impact of the epidemic itself, the idea that gay men were tiring of safe sex messages and switching off from them and that this was part of a broader psychological response to the grief and loss associated with death (Odets 1995a). The arrival of an effective treatment for

141 HIV and AIDS infection in 1996 (and the reconceptualisation of the disease from fatal to a ‘chronic manageable illness’) is another important factor identified as affecting the wider context of HIV prevention and education.

Those factors that could be described as more generally connected to the broader social and historical context of late or post-modernity have also been commented on in previous chapters, most particularly in reference to the complexity of issues surrounding the campaigns in question and also the dynamics of love, intimacy and relationships with regard to risk of HIV infection. Best and Kellner describe four thematic similarities across many disciplines in academia as a response to the post- modern turn, “difference plurality, fragmentation, and complexity … uncertainty or ambiguity … “ (1997: 255 – 258). And it is these same themes that are often discussed as characterising the late or post-modern period itself. For example, Bauman is of the view post-modernity is the recognition or institutionalisation of diversity, uncertainty, ambivalence (quoted in Heaphy 2007: 64). Similarly, Heaphy argues that there is an emphasis on diversity in the late or post-modern period (2007: 64) as evidenced by the influence of social movements of identity politics or ‘radical difference’ such as feminist, queer, or postcolonial movements (2007: 39, 44). As chapter three detailed, identity politics played a central role in the formation of gay liberation and the resulting broader social and political movement was instrumental in a rapid community led prevention response to the onset of HIV and AIDS. Later identity politics played a more fragmentary role with the rise of HIV positive identities.

Transforming Intimacy

For Giddens’ late modernity is characterised by the reconfiguration of modernity’s institutions and its social, cultural and political forms through processes associated with globalization, detraditionalization and individualization (Heaphy 2007: 69 – 70). A key concept for Giddens in understanding these processes is ‘reflexive modernisation’. Giddens explains the evolution of the concept, “… reflexivity is a defining characteristic of all human action” as “[a]ll human beings routinely ‘keep in touch’ with the grounds of what they do as an integral element of doing it” (1990: 36). He goes on to argue that in traditional societies the past was honoured and symbols were valued because they ‘contained and perpetrated the experience of generations’

142 (1990: 37) while in modern societies reflexivity took on a different character – thought and action were ‘constantly refracted back upon one another’ (1990: 38). As he put it, social practices were “ … constantly examined and reformed in the light of incoming information about those very practices, thus constitutively altering their character” (1990: 38); where social life fed back into social life itself influencing change and transformation (1991: 20).

Giddens applied this concept of reflexive modernity to the area of love, intimacy and relationships and in 1992 published the thought provoking Transformation of Intimacy: Sexuality, Love and Eroticism in Modern Societies. Giddens’ argument was detailed and multifaceted and focussed, along with other authors in the field (see for example Foucault 1978; Weeks 1985, 1995), on historical shifts in societal structures, practices, ideology and institutions around sex, sexuality, sexual identity and gender in western metropolitan societies. A central idea of Foucault’s thesis was that rather than being repressed and/or censored (not to be confused with controlled, however) the use of sex and sexuality, and the discourses around them, had multiplied exponentially over the past three centuries in western societies. Foucault identified “four strategic unities” – a hysterization of women’s bodies, a pedagogization of children’s sex, a socialization of procreative behaviour and a psychiatrization of perverse pleasure34 – which from the eighteenth century “formed specific mechanisms of knowledge and power … ” around which discourses and institutions controlling talk and use of sex and sexuality arose (1978: 103 – 105). For Foucault this was associated with the ‘public interest’ in talking about and regulating the sexuality of populations for newly emerging capitalist states (1978: 25 – 26).

Weeks also discussed the ‘use’ of sex and sexuality to population management for the state arguing the “grappling for control” connected with rapidly changing social, economic and gender relations associated with industrial capitalism led to “[s]exuality being a symbolic battleground both because it was the focus of many of these changes” but also because it became “the surrogate medium through which other

34 Homosexuality was one of the key areas in which this pyschiatrization was concentrated, and, along with ideas from the religious and legal spheres, became a source for the stigma and discrimination that persisted around homosexual and gay identities and communities that this thesis has commented on elsewhere.

143 intractable battles could be fought” (1985: 74). Weeks also argued the rise of identity politics and the discovery of personal and social ‘truth’ through sexual identity was a feature of late modern societies. He expanded on his theory of the importance of identity in later work suggesting “…questions of identity, personal and collective, are flashpoints for some of the most poisoned and violent disputes across the world” but that “[s]imultaneously, new political and cultural identities have proliferated, around race and ethnicity, gender and sexuality, HIV and AIDS…” (1995: 86). For Weeks, while having the tendency to draw arbitrary boundaries around self and community, sexual identities also “multiply points of resistance and challenge, and expand the potentialities for change” (1995: 99). Again, this is the concept of identity acting as both a unifying and fragmenting force. Pertinent to and consistent with Giddens’ argument, Weeks listed changes in concepts of self and identity and the ‘democratisation of everyday life’ (changes in love and intimacy as equals) as transforming personal relationships in late modern societies.

Like Foucault and Weeks, Giddens’ argument was situated in a theoretical framework of historically constituted and changing gender and sexuality relations. Unlike them, he focussed specifically on the couple relationship and argued that in late modern (western) societies sex and sexuality, love and intimacy bound within a democratising “pure relationship” (1992: 2) were sites of a new and transformative change. Unlike its forerunner formalised and institutionalised by marriage, Giddens saw the pure relationship as a durable bond having “qualities intrinsic to that tie” (1992: 2), as Worth et. al. put it “a primary site of meaning in, and of, itself” (2002: 238). As for Weeks and sexual identity, Giddens also saw the pure relationship as a defining trait of self. Further, beyond the sphere of the individual, this new form of democratic relationship had the potential to bring about a structural and democratising change to the institutions of western societies (1992: 184 – 203). Integral to this new and transformative bond was also a change in human sexuality, what Giddens’ coined as “plastic sexuality”, a flexible sexuality freed from kinship obligations and the considerations and/or restrictions of reproduction (1992: 2). Accompanying this shift in sexuality was a change in love. Within the realms of plastic sexuality and the pure relationship now lurked a new “[o]pening oneself out to the other …” described as “confluent love” (1992: 61). This opening up of self occurred within a reciprocal bond of mutual trust and disclosure, a “transactional negotiation of personal ties by

144 equals” (1992: 3). Giddens described this negotiated agreement in some detail, for example:

Trust entails trustworthiness of the other – according ‘credit’ that does not require continual auditing, but which can be made open to inspection periodically if necessary. Being regarded as trustworthy by a partner is a recognition of personal integrity, but in an equalitarian setting such integrity means also revealing reasons for actions if called upon to do so – and in fact having good reasons for any actions which affect the life of the other (1992: 191).

Another key concept for Giddens in this suite of theorising is the impact of reflexive modernisation on self-identity, what he termed ‘reflexive projects of self.’ For Giddens, in late modern societies “[s]exuality becomes a property of the individual the more the life-span becomes internally referential and the more self identity is grasped as a reflexively organised endeavour” (1992: 175). Consequently “the reflexive project of self involves an emotional reconstruction of the past in order to project a coherent narrative towards the future” (1992: 60). Bauman made a similar observation about identity in a ‘globalizing world’. For Bauman “… ‘individualization’ consists in transforming human ‘identity’ from a ‘given’ into a ‘task’ – and charging the actors with the responsibility for performing that task and for the consequences (and also side-effects) of their performance …” (2001: 144). These processes of individualisation led to an increasing emphasis on autonomy and what Giddens called ‘reflexive identity’. As he put it, “[a]utonomy means the capacity of individuals to be self-reflective and self determining: to deliberate, judge, choose and act upon different possible courses of action (1992: 185).

Giddens also theorised about the insecurity and doubt, or ‘uncertainty and contingency’ of living in the late or post-modern period (Heaphy, 2007: 69). Giddens wrote about ‘ontological security’ in this context (Giddens 1990: 92, 131). For Giddens ontological security was “…the confidence that most human beings [had] in the continuity of their self-identity and in the constancy of the surrounding social and material environments of action” that generated a largely unconscious sense of ‘being-in-the world’ (1990: 92). This sense of self-identity or subjectivity developed in childhood through relationships with others. For Giddens, trust was also key in this process (1991: 51). Developing a sense of trust was an essential part of early life experience and trust established in early life formed the basis for ontological security.

145 However, self-identity and personal life were undermined because of threats and dangers and personal meaninglessness associated with reflexive modernity (Giddens 1990: 102) that in turn led to “a heightened sense of personal or existential insecurity” further heightened when people encountered existentially troubled issues like mortality, the start or end of a relationship or serious illness (Heaphy 2007: 85). Giddens’ referred to these life situations as ‘fateful moments.’ For Giddens, fateful moments were when individuals were faced with a changed ‘set of risks and possibilities’ (1991: 131). Fateful moments could be destabilising and threatening but also had the potential to be empowering. They could be unifying or they could be fragmenting. Here it is clear that Giddens’ was a theory of agency that emphasised how individuals had the potential to respond constructively and meaningfully to life’s existential challenges, or alternatively to respond with fear and anxiety and retreat into doubt, uncertainty and insecurity. In the sphere of intimate personal and sexual relationships, following Giddens, Heaphy argued that “ … in the insecure and risky world of late modernity, intimate life is identified as the place where security is most intensely sought and cherished, but it also where radical insecurities and contingencies can be encountered in powerful ways.” (2007: 120).

And here is the relevance to a discussion of negotiated safety. The description of mutual trust, openness, communication and discussion characteristic of Giddens’ pure relationship sounds surprisingly similar to the steps advocated for the safe implementation of a negotiated safety agreement, except that it is in the broader sphere of relationships, not the specific context of sexual health and avoidance of HIV infection. Is it possible that part of the wider context of the negotiated safety debate is this drive, this transformative shift, towards a new kind of intimacy encapsulated within the pure relationship? Caution must be exercised when making such an assertion. There are complications and criticisms to both Giddens’ argument itself, and the application of aspects of it in the area of gay men’s relationships, intimacy, love and HIV prevention.

In her 1998 book Intimacy Jamieson examined Giddens’ argument in detail and used empirical evidence to support or refute his assertions. She used a wide range of both quantitative and qualitative research, mainly from gender and sexuality studies, to assess the validity of Giddens’ claims and found his argument wanting in a number of

146 ways. It is immediately noticeable that, rather than pure relationship, Jamieson preferred to use the expression ‘disclosing intimacy’ which she defined as “… mutual disclosure, constantly revealing your inner thoughts and feelings to each other” (1998: 1) in her project to deconstruct and nuance Gidden’s idea of transformative intimacy. Following Gidden’s argument she accepted that “ … greater individualism means more opportunities to value people for themselves, for the unique qualities that they possess, and more opportunities for self expression, including expression of emotion. Each of these aspects of individualism opens up possibilities for greater intimacy and particularly ‘disclosing intimacy’” (1998: 36). However, for Jamieson there were many different forms of intimacy that occurred within primary or personal relationships, of which disclosing intimacy was but one (1998: 8). Further contributing to this multiplicity, she asserted that sex, love and intimacy could be connected or separated depending on context or social milieux (1998: 106), and that trust, knowing understanding, communication, loving, caring, and sharing were all socially and culturally constructed (1998: 9 – 10). Adding still to the diversity of intimacy, Jamieson pointed out it could extend beyond sexual relationships. For Jamieson intimacy of varying types, rather than disclosing intimacy exclusively, could be found in primary kinship and friendship relations. As she put it “ … relationships with both kin and friends generally contain a mix of dimensions of intimacy, rather than simply disclosing intimacy and mutual appreciation of each other’s unique qualities” (1998: 173).

Taking into account this much greater diversity and multiplicity of intimacy, Jamieson concluded that at best evidence to support Giddens’ argument was equivocal, as she put it “… there is no clear evidence that disclosing intimacy is increasingly the key organizing principle of personal lives” (1998: 2). However she conceded that disclosing intimacy had some influence on the everyday lives of people living in late modern societies, “[i]t is impossible that a new emphasis on ‘disclosing intimacy’ in public stories does not have some resonance with the everyday ways in which people live their lives” (1998: 159). Still Jamieson was wary of giving this trend too much weight suggesting that overemphasising its influence on personal life in the late modern period would be to “overdramatise a selected aspect of the variety of ways in which people can create intimacy” (1998: 160). Perhaps she put it best when she said “ … this book suggests that the story of a shift to ‘disclosing intimacy’

147 is too selective a story to be anything other than a very partial picture of an emerging story (1998: 159).

While Jamieson’s nuancing and downgrading of the pure relationship to disclosing intimacy in all its diversity is a valuable insight and important modifier to the concepts of intimacy and love in late modern relationships, it does not impact on my argument that it was an important influence on debates about negotiated safety. This is because the question of degree is not central to my assertion. It is enough for me that disclosing intimacy exists as a strong contemporary influence, as “a key dimension of personal life” (1992: 75) as Jamieson herself describes it. This is sufficient for this trend to strongly influence (either as a relationship ideal or as an established practice) negotiation of sex outside the relationship and the disclosure of this and HIV serostatus in gay men’s relationships as evident in the negotiated safety campaigns TTTT and Because We Want to Be Together, and some passages in the newspaper inset Fucking Without Condoms.

However, while Jamieson’s argument illustrated that Giddens’ may have been overstating the transformative nature – both on the personal and institutional or societal levels – of this new form of intimacy in relationships, it did not address another claim made by some theorists in the field. Both Giddens (1992) and Weeks (1995) have suggested gay relationships are at the forefront of the democratisation of intimacy. In their qualitative study of twenty New Zealand gay men (eleven couples) Worth et. al. (2002) specifically set out to investigate whether there was evidence in these relationships to support this view. In their discussions of monogamy, trust, and sexual behaviour negotiations in the study interviews Worth et. al. found that “[o]verall, they [the interviewees] had conventional notions of relationships, romantic love and monogamy that prompted decisions to discard condoms for anal sex was proof of their love for each other” and that “the relationships were marked by ‘infidelity’ anxieties and a reluctance to disclose sexual encounters outside the relationship and to discuss or negotiate their possibility” (2002: 237).35 Worth et. al.

35 Melbourne based researcher Ridge made a similar observation when discussing the SHRG project ‘Sexual and social pathways and HIV’ in which in-depth interviews with 24 gay men carried out. As he wrote “Open verbal communication, i.e., honest two-way discussion based on equal relations, around sexual issues is a prerequisite for negotiated safety: however, such communication was not common in these men’s partnerships” (1996: 98).

148 go on to warn readers “ … not to assume that gay relationships are necessarily as democratic and open as Giddens suggests” (2002: 237). However, the authors do concede the relationships in their study also demonstrated “a certain ostensible accordance with Giddens’ notions of plastic sexuality and confluent love” but also point out “the effects of class, ethnicity and age divisions” (2002: 239) that ran counter to these egalitarian aspects.36 Jamieson made similar comments in the context of heterosexual relationships, pointing out that Giddens was too optimistic of the pure relationship and its potential to overcome structural gender inequality (1998: 40, 134).37

Worth et al. concluded these observations are all “pertinent when regarding the development of programmes aimed at reducing HIV transmission within relationships” (2002: 237). And so they are. Many of the interviewees in this study have made similar observations, and many of these issues were interrogated at length not only during the development of TTTT and Because We Want to Be Together but for some considerable time after their implementation. Some of the debates continue today. However, I am still left with the question, as were supporters of TTTT and other negotiated safety initiatives, even if the majority of gay men were not able to discuss sex outside the relationship and/or negotiate safe agreements, is this necessarily an argument not to provide them with information and support to better do this if they wish to discard condoms for anal sex in their relationships? Worth et. al. suggested intimacy for gay men in the late modern period was not simply a question

36 In literature on risk the connection between increased risk and structural inequality is well know. Beck observed that wealth accumulated at the top of the class structure and risks at the bottom among “the poor and the weak” (1992: 35). Pertinent to a discussion of negotiated safety, and who may be at greater or lesser risk of HIV infection, Beck went on to characterise the situation in some detail, pointing out that those less affected by structural inequality were more able to access and interpret relevant information and so avoid risk. “The possibilities and abilities to deal with risks, avoid them or compensate for them are probably unequally divided among the various occupational and educational strata. Whoever has the necessary long-term financial cushion at hand can attempt to avoid risk … The same is true for nutrition, education and the related behaviour patterns in eating and informing oneself. … Education and attentiveness to information open up new possibilities of dealing with and avoiding risks” (1992: 35).

37 Heaphy has also argued, referring to Jamiesons’ work, that Giddens’ overplays agency and undermines structure (2007: 131) and goes on to point out that some feminist thinkers have also claimed Giddens ignores power (2007: 138 - 147). This argument will be addressed in chapter seven when Bourdieu’s habitus (1977) is discussed as a way of moving past these arguments.

149 of a free wheeling sexual pleasure (reminiscent of the heyday of gay liberation) but rather a fraught negotiation of a complex and diverse range of sexual and social factors. As they put it,

… in an environment of increased tolerance, gay romantic couple relationships seem to be burgeoning. Yet this increasingly pluralistic environment constitutes a situation within which gay couples’ approaches to and engagement in intimate relationships, far from being simply subject to the pursuit of highly individual pleasures, demand the negotiation of socially, ethically and sexually complex hazards. Not only is the fin de siecle a period of diversity, but also one of anxiety (2002: 238).

This anxiety springs not only from the difficulty involved in negotiating relationships, intimacy, love, pleasure, desire and sex in a post AIDS era, but also factoring this complexity into strategies to allow gay men to live their lives meaningfully while also navigating the troubled waters of risk of HIV infection. The following chapter focuses on broader conceptualisations, theories and constructions of risk and draws on the work of theorists in the field of the sociology of risk, most particularly Ulrich Beck’s Risk Society: Towards A New Modernity (1992), Deborah Lupton’s Risk (1999) and Zygmunt Bauman’s recent work Liquid Fear (2006) to shed further light on this complex and difficult area.

So in summing up then, while perhaps gay relationships are not at the forefront of a democratising pure relationship, and following Jamieson (1998) and others, confluent love and the negotiation of an ongoing democratic romantic narrative, while not an all pervasive practice in late or post-modernity, is still none-the-less a powerful romantic ideal. This in itself is sufficient for transforming intimacy to be one of the broader social and cultural factors influencing relationships in late or post-modernity – as the similarity of negotiation of anal sex without condoms to Giddens’ negotiation within a pure relationship attests.

Using interview material, the next section will examine the complex dynamics of gay relationships within this wider historical and social context, with reference to HIV prevention and to arguments about negotiated safety and TTTT.

150 Love and Risk of HIV Infection in Relationships

In the international literature a variety of factors have been found to contribute to the complex dynamics of gay men’s relationships – their sexual decision-making and risk-taking – and whether or not a condom is used with a regular partner. These include: knowledge of the partner’s sexual history (McLean et. al. 1994; Boulton, McLean, Fitzpatrick and Hart 1995; Misovich, Fischer, and Coates 1997); familiarity with the partner in general (Boulton et. al. 1995; McNeal 1997); monogamy (Misovich et. al. 1997; Hays et. al. 1997; Worth et. al. 2002); trust (Remien, Carballo- Dieguez and Wagner 1995; Boulton et. al. 1995; Misovich et. al. 1997; Appleby, Miller and Rothspan 1999; Worth et. al. 2002); love (McLean et. al., 1994; Boulton et. al., 1995; Carballo-Dieguez and Dolezal 1996; Appleby, Miller and Rothspan 1999); intimacy (Remien, Carballo-Dieguez and Wagner 1995; Boulton et. al, 1995; McNeal 1997; Appleby, Miller and Rothspan 1999) and HIV status (Kippax et. al. 1993b; Hays et. al. 1997; Hoff. et al., 1997; Crawford, Rodden, Kippax, and Van de Ven 2001; Halkitis, Wilton, Parsons and Hoff 2004).

In Australia HIV prevention had been grappling with the same issues. As early as 1990 Feeling Our Way had illustrated the difficulties in communicating and negotiating agreements about sex, safe sex and HIV and AIDS within and outside gay relationships, and the communication, trust and honesty required for such arrangements to be struck (Vadasz and Lipp 1990: 41 – 64). Kippax et. al. wrote in 1993 that “… [t]he success of the ‘negotiated safety’ strategy does, however, rely on having accurate knowledge of one’s own and partner’s serostatus, as well as honesty and trust.” (1993b: 263). More recently Shernoff has described the situation, “[n]egotiations about condom use have the potential to be highly fraught. After all, men are talking about whether or not, how often, under what circumstances, and when they would be willing to trust38 their partner with their health and ultimately their life…” (2005: 189).

38 Shernoff notes a possible further development in the practice of negotiated safety in America. In a personal communication with psychologist Michael Ross who has worked in the field for some years, Ross commented that “ … [f]or some couples negotiated safety has evolved into ‘let’s agree not to have unsafe sex outside the relationship.’ Ross suggested that this has shifted the paradigm of negotiated safety from something that was safe to ‘something that relies on trust and a belief that one is negative [due to an outdated test result]. This is in fact a

151 The evaluation of TTTT also acknowledged – as evidenced by comments by some counsellors, ACON workers and gay men involved in some ACON projects – that there had been “some genuine criticism of the campaign largely centring on the ability of gay men to communicate the complexities involved in negotiating unprotected sex within a relationship safely” (Mackie, 1996: 39). Some men involved in the Beats Project told ACON workers the issues involved would be difficult to communicate, too complex to talk about in a relationship or that they felt they did not have the skills to negotiate the four steps and were afraid of the conflict such negotiations might bring to their relationships (1996: 31).

Another of the confounding factors arising from the wider context of gay relationships that would not be able to be separated out from the specific effects of the TTTT message could loosely be described as ‘love’ (one of the factors identified as intimately connected to sexual risk taking and decision making in gay men’s relationships as noted in international research, see above). HIV educators had been aware of the connection between ‘love’, unprotected sex in gay relationships, and the implications for prevention for some time. In Feeling Our Way one of the reasons proposed for men having unsafe sex was that the relationship gave them some kind of protection from HIV (1990: 173). Sydney participant Russell laughingly commented educators thought “love was the problem” when discussing a 1991 ACON prevention campaign ‘Keep It Up’ formulated to enforce ‘the notion of love not protecting you from HIV’ (Mackie 1996: 7). The theory was that some people were more likely to not use condoms for anal sex in relationships because it made them feel physically and/or emotionally closer to their partner. As early as 1990 Prieur had written that “[i]n a closer relationship, sex is a way of communicating with the other, and a means of expressing tenderness and compassion. In this communication, a condom is a negative message …” (1990: 113). Harking back to the history of struggle against dominant discourses about homosexuality, and the stigma and discrimination that arose from them, Parnell commented that “influence of relationships may be particularly intense with gay men, a group who have for much of their lives been denied the type of love they want, and who consequently have a great need for

move from ‘negotiated safety’ to ‘negotiated trust,’ which is not the same thing’ (Ross quoted in Shernoff 2005: 204).

152 closeness. This need may be so intense that it outweighs fear of risk” (1993: 41). Shernoff commented on the same phenomenon, “[m]any people, across the spectrum of mental and emotional health, find that romantic love is the organizing principle of their personality and self-concept. For these people, sex and this kind of love become inextricably linked, and rather than risk losing love they may have unprotected sex …” (Shernoff 2005: 190). In their survey of 46 long-term couples Appleby, Miller and Rothspan (1999) found that love, trust and commitment were used more often by their respondents to explain riskier sex rather than safer sex. Those more dependent on their relationships who wanted a lasting and stable union practiced riskier sex. McLean et. al. also discussed the link between feelings of love, unprotected sex, and risk, “[s]ome studies have found an association between unprotected sex and ‘being in love’ … This suggests that men’s desire to express their deep emotional involvement in their regular partners through unprotected intercourse may be a more important factor in shaping behaviour than assessments of risk of HIV infection” (1994: 332). On the subject of risk taking in relationships and its connection to ‘love’ United Kingdom AIDS researcher Green wrote,

Taking risks within relationships is part of a long cultural tradition in a society in which we are all potentially ‘fools for love’. Risk-taking is a common feature of sexual relationships: the risk of being emotionally or economically dependent, the risk of falling pregnant or contracting an STD, the risk of domestic violence, etc. The risk of HIV-transmission occurs within this cultural context; and has to be balanced against other risks within relationships or the risk of not having a relationship at all (1995: 156).

Andrew also commented on the possibility of not having a relationship at all if the subject of sex outside the relationship was broached, as he put it “fear of loss of a partner was probably far more acute than the fear of infection.”

… we actually ran a national campaign around … men’s perception of monogamy and the reality that Male Call39 threw up, you know, that 50 per cent of couples were not monogamous and 50 per cent of those men were not using condoms and not telling their partners that they were having unprotected sex outside of the relationship. And when you think

39 Worth H., Reid A., Saxton P., Hughes T., Segedin R. Male Call/Waea Mai Tane Ma: Report Two: Men in Relationships With Men, A Research Project of the New Zealand AIDS Foundation funded by the Health Research Council of New Zealand, Auckland, 1997.

153 about it from a human point of view … fear of loss of a partner was probably far more acute than the fear of infection. [Andrew]

He goes on to connect unsafe sexual behaviour to a heady and sometimes irrational mix of ‘love, denial, and desire.’ He also points out that both the condom-every-time approach and negotiated safety agreements rely on an assumption that individuals’ personal health decisions are based in rational decision-making processes. This theme will be taken up in the following section and discussed in greater detail.

… I think that what the condom every time thing missed was, and the negotiated safety campaign in Australia I think, what it missed was the essentially human aspect of the equation. That we were not automatons, that we just didn’t sit down and blithely negotiate a rational agreement about sexual practice … Love was involved, and denial, and desire and wanting and all the rest of it, all in the mix. [Andrew]

For Kevin ‘love’ interacting with ideas of negotiated safety early in relationship formation was a particular problem. It had been known for some time from large scale longitudinal survey data that risk of HIV infection was greater in newly formed relationships (see for example Davidovich et. al 2004; Kippax et. al. 1993a).40 For Kevin, while there were a group of people who were able to deal with the negotiation and testing required to implement TTTT safely, there was another group, particularly younger people, who were engaging in serial monogamy and “half doing negotiated safety because they were in love” and so putting themselves at greater risk of HIV infection.

We knew that for a whole range of people that we were dealing with in mainstream education, that they were handling it ok and had enough understanding from the press or from their doctors or whatever about how to test, how to talk about stuff, how to strategise about having unsafe sex in long term relationships and have safe sex in casual relationships. And we knew that right from the start. What was not being handled was that the people who appeared to be getting infected at the time where the issues were much more complex. But it’s also about serial monogamy, and particularly with young people, that we had all

40 In their survey of 324 gay men Davidovich et. al. (2004) found that of the men who had unprotected anal sex with their steady partners, 55 per cent did so within the first three months of the relationship. Research on unprotected sex between gay men in “boyfriend” relationships carried out by Hays et al. (1997) found that gay men’s sexual behaviours also became increasingly risky as the relationships progressed.

154 this clear information that what was happening was people were half doing negotiated safety because they were in love, but they were in love with different people every four weeks [laughter] and that it was a real experience for them. And the people who were infecting them were their partners and that the negotiated safety strategy wasn’t able to be applied in those situations for a whole lot of reasons. [Kevin]

In newly formed relationships, the rules of communication are yet to be defined, and what is able to be said or not said about HIV antibody status and/or sex outside the coupling, or perhaps other information relevant to the risk of HIV infection in the relationship, are yet to be negotiated (or not negotiated or discussed at all as the case may be). Russell discussed the history and development of TTTT as a prevention strategy, suggesting that disclosure of HIV status may be more problematic early in relationships and that this particular issue goes way beyond TTTT, that it is part of a much more complicated dialogue about HIV antibody status and the broader context of communication and intimacy in gay relationships.

… initially people were happy with sex in relationships, it wasn’t defined as a problem, then it became seroconversions are happening in the early stage of relationships, so it’s a problem with people not doing negotiated safety properly. Right. So let’s fix up the rules and get it right. But if you really look closely at the problems that people were having in relationships and what was leading to them, it was much more complicated than simply Talk Test Test Trust, it was why didn’t he tell me he was HIV positive, or why didn’t he know he might be HIV positive, and why can’t men communicate with each other and those sorts of things. They’ve got a really much more complicated dialogue about the complexities of communication … early relationship formation and rigours of risk appropriate to take or not to take and the meanings that they take on is actually really complicated. Reducing it all to Talk Test Test Trust … It is the issue of intimacy between two people and communication … [Russell]

Duncan pointed out that the traditional male gender stereotype hindered gay men in effectively communicating their feelings about intimacy and sex.

… I mean gender, I mean if you think about, cos my training is in sociology, the sociology of gender and the construction of masculinity involves not very good communication because people, male stereotypes involve, um, often having words taken away from people so that people … so they’re punished for things that their gender stereotype has taken off them. And gay men are socialised as straight men. I don’t think they are any better at communicating than anybody else, particularly about intimacy and about sex because it’s easier to do it than talk about it. And it’s an area fraught with difficulty. [Duncan]

155 Recent research into intimacy and men has reinforced this view. In their qualitative study of male perception of intimacy Patrick and Beckenbach comment that among their participants intimacy was “described as an experience or emotion that is difficult to put into words” (2009: 49).

Another consideration in the complex interplay of factors around negotiated safety, intimacy and love in relationships may be the symbolism perceived or interpreted by some of not using a condom or receiving semen into the body unimpeded. In short, negotiated safety and not using a condom was functioning as a deeper or more symbolic communication, an unsaid statement about ‘love’, intimacy and/or commitment. Perhaps Patton described this phenomenon best when she observed “ … most couples, regardless of sexuality or age, perceive a magic point in a relationship when to stop using condoms represents a deepening of mutual trust and commitment.” (1990: 100). In her oft-quoted paper about intimacy and gay men Prieur wrote “ … sex is a way of communicating with the other ... In this communication, a condom is a negative message, and refusing the semen is a rejection” (1990: 113). Drawing on Prieur’s work, Worth also examined the issues around anal sex without condoms in a paper ‘The Authenticity of Semen’ given at the Institute for Research on Gender at the University of Auckland in 1998. In this paper Worth proposed that “anal sex without a condom [was] the authentic expression of not just gay sex but also of gay selfhood.” She argued that in this context “semen is warm and good, life and self affirming, that bodily fluid is fundamental to both selfhood and a oneness with, or incorporation into, the other.” For Worth, the condom was a paradoxical symbol as it simultaneously represented life (and was quite literally a life saver in terms of HIV infection before treatments) and “the very signifier of death” not only in its association with HIV but also in its role as destroyer of full selfhood as it prevented the gift of semen as a symbol of intimacy and love in sex.41 However, Worth goes on to argue that the nostalgic longing of some gay men for the condom-free sex of the gay liberation pre-AIDS era, of anal sex without a condom as the authentic expression of gay selfhood, was never an “authentic or pure experience.” There are implications

41 In a qualitative study of young gay Norwegian men Middlethon (2001) also picked up on the idea of the condom – in this case its use or non-use – as paradoxical, as simultaneously symbolic of both trust and mistrust.

156 for arguments about negotiated safety in this line of thought, and also echoes of Schoofs and his argument about the contradiction between the ideology of gay liberation and the supposed/assumed intimacy and security of long-term relationships. Is it possible that campaigns promoting negotiated safety were appealing to this nostalgic idea of condom-less sex in the pre-AIDS era? As Schoofs put it, an attempt to have it all, “ ... eros and agape, hot sex and intimacy” (1995: 38). The contradictions apparent in the condom as representing both life and death, and its use or non-use in long-term gay relationships as a symbol of both trust and mistrust (when a partner asks to use condoms it may raise the suspicion, whether accurate or not, that he has been having undisclosed and possibly risky sex outside the relationship) will be explored further in the following chapter.

New Zealander Duncan also discussed the symbolic significance of semen exchange arguing it was an aspect of early HIV prevention that was often underestimated or not discussed at all and, importantly for arguments about negotiated safety, that it could be addressed in a prevention context without making a case for unprotected anal sex.

… earlier on in prevention I think people underestimated the significance of semen exchange between men and it’s symbolic significance. Now I’m not saying that as an argument for unprotected anal sex. I’m just saying that, there was a point where it was like sometimes you’ve got to be careful to not say ‘oh this is sex between men so it’s not as significant as the same thing between a man and a woman or other groups, it’s just like a commodity’ because it actually has greater significance than that and if you minimise the symbolic significance of some male male sexual things then you’re actually going too far the other way. [Why do you think it’s so significant?] Um, semen exchange, um, well it depends, not just semen exchange but other things. It’s probably because, it’s obviously proving symbolic, animalistically symbolic of commitment and desire to have part of the other person in you, or part of your body, whether it’s done orally or anally or whatever. There are other ways of doing it than anally. And they’ve never been promoted but they could be. [What are some of those then?] Orally cos it’s low risk. You could legitimately do a campaign about oral hygiene and safety. Make sure your mouth is intact, how to look after your mouth. And then encourage semen exchange orally, so that it wasn’t held in the mouth but spat out or swallowed, in an intimacy situation. [Duncan]

For Carl the ongoing debate about gay marriage is a contemporary expression of the need for symbolic commitment in gay relationships, just as negotiated safety was in the 1990s.

157 What’s more interesting I think is where gay marriage is now on the social agenda. Um, and the question, would it have been on the social agenda, or at least on the social agenda in the same way, were it not for HIV. For me, for example, two gay men deciding to do without condoms is a kind of, because they are in a long term relationship or intend to be in a long term relationship, that decision to do without condoms for the first time is a symbolic step similar to heterosexuals statement of intimacy [marriage] in monogamous relationships or long term relationships. Is it [negotiated safety] like marriage, is it more like attempting to become parents together, maybe have some elements of both in terms of meaning for gay couples. Well that might be reframing it. At the very least it’s asking for an important question to be asked before you look at the effect of symbolic meaning of negotiated safety, cos we need to also answer that in the context of the effect of symbolic meaning of heterosexual marriage or heterosexual long terms relationships. [Carl]

So for two of my participants the symbolic nature of anal sex without a condom – be it the significance of semen exchange, or that negotiated safety itself was a symbol of commitment, love and intimacy in a long term relationship – was underestimated, or not sufficiently discussed in the debate about TTTT, and whether negotiated safety messages were appropriate for mass media prevention campaigns. This factor, along with others previously discussed, will now be examined further using relevant social theory to shed light on the broader societal and relationship context in which arguments about negotiated safety and TTTT were made.

In presenting material from the literature and from interviews, a number of themes relating to gay coupledom have become apparent including: monogamy, sex outside the relationship, love, communication and intimacy. Closely connected to these themes are a broader historical context of gay liberation, as well as relationships, sex and sexuality in late modern societies. A number of works will now be drawn on to discuss these issues in greater detail.

First, on the theme of love and how it may outweigh rational evaluations of risk of HIV infection and so by extension, perhaps even the possibility of death. As is clear throughout this thesis, rationality and reason are the assumed basis for behaviour change through the vehicle of health promotion, whether based on an epidemiological construction of risk, a sociologically informed socio-cultural construction, or a communitarian model (or indeed a mix of these). Many have commented on the assumed rationality of the human actor in the health belief model. Both Kippax and

158 Lupton, for example, commented on its linear nature assuming that knowledge shapes or determines attitudes that, in turn, shape behaviour (Lupton 1999: 21; Kippax 1993a: 5). In their in-depth interviews examining ‘risk discourses’ with 92 men who had recently become HIV positive Slavin, Richters and Kippax found the men had two overarching discourses about risk: a rational approach to public health that saw risk as “objectively knowable through the application of scientific method or reasoned thinking” and a second more agent friendly approach that saw risk as “culturally embedded ... itself a cultural category.” As the authors point out “[t]he fact that all men in this study became infected demonstrates the potential fallibility of both approaches ( 2004: 39).

Davies et. al. castigate those who “use ‘rational’ to refer to … an unrealistically complex version of the decision-making process” and who “… regard individuals as making rational decisions on the basis of detailed epistemological data and sophisticated models of contagion and infection which are simply outside the scope of the ordinary person in the street or the bedroom” (1993: 50). This immediately raises the question of how ordinary people in the street or in the bedroom do make such decisions. The previous section exploring the dynamics of gay relationships suggested a wide range of sometimes conflicting elements were in play. But as interviewee Andrew noted in the previous section, people did not “ … just sit down and blithely negotiate a rational agreement about sexual practice … love was involved, and denial, and desire and wanting and all the rest of it, all in the mix.” I will now again turn to social theory to provide an insight into the wider context of love. Harking back to Giddens’ idea of the reciprocal pure relationship, Bourdieu describes an “ … enchanted island of love … [which] can be snatched from the icy waters of calculation, violence and self interest. This is a world of non-violence, made possible by the establishment of relations based on full reciprocity and authorizing the abandonment of self; a world of mutual recognition …” (2001: 110). Bauman makes a distinction between love which he argues is about “value” and reason which he argues is about “use” (2001: 164). As he explains,

To use is to annihilate the other for the sake of the self. To love, on the contrary, means to value the other for its otherness, to wish to reinforce it in its otherness, to protect that otherness and make it bloom and thrive, and to be ready to sacrifice one’s own comfort, including one’s own

159 mortal existence, if this is what is needed to fulfil that intention (2001: 165 – 166).

So there is a contradiction between useful reason in which matters pertaining to the self are privileged (such as the sexual health of the individual) and valuable love in which a relationship to an ‘other’ is paramount and matters of self are downplayed or, as Bauman suggests, “sacrificed.” This is at least one explanation as to why, in the context of HIV infection, some people are prepared to sacrifice their lives for the sake of the other. This is a difficulty for HIV prevention which is squarely situated in the realms of love and desire, yet presumes such matters can be rationally communicated through health promotion and so logically evaluated and negotiated under the more restricted categories of health beliefs, behaviour change, and sexual practice weighed against risk of HIV infection. It is perhaps a particular problem for negotiated safety, the supposed pinnacle of rational and reasonable talk and negotiation about sex, trust, and honesty all in the context of emotionally charged and (at times at least) highly irrational relationship formation, continuation and cessation. As Bauman says “[r]eason and love speak different languages which do not easily translate …” (2001: 163). Furthermore, Bauman goes on to argue that reason is much more able to articulate itself, to communicate, than love. As he puts it, “[r]eason is a better talker than love, and so love finds it excruciatingly difficult, nay impossible, to redeem itself in discourse… Argument is not love’s forte” (2001: 163). It would seem highly unlikely then that love could argue its point of view, its wants and needs, its concerns, in the face of a rational negotiated safety. However, the suggestion that negotiated safety agreements, condom free anal sex and even semen exchange can function as a symbol of commitment may be one non-verbal way that tongue tied love can express itself.

In discussing Bauman’s argument, I do not mean to suggest that love is without its own kind of reason or logic. Bauman does not hold this view either. As he says “the heart has its reasons” (2001: 164) and specifically on HIV infection weighed against other considerations “ … using a condom protects partners against HIV infection. But such an infection is but one of a great number of unanticipated and certainly unbargained-for consequences of sexual encounters …” (2003: 51). I am reminded here of Green’s characterisation of risk in relationships. The risk of contracting an STI is weighed against other more important or potentially devastating events, as he

160 puts it “the risk of being emotionally or economically dependent, the risk of falling pregnant … or the risk of not having a relationship at all (1995: 156). So in relationships there can be different types of rationality: a rationality of the heart; a rationality based on wider relationship, economic, social or cultural imperatives; or indeed a rationality aimed at protecting the sexual health of the individual or the couple. Davies et. al. argue that a decision not to have safe sex after an earlier decision to remain safe is not necessarily a failure of rationality but rather the ‘logic of the sexual conversation dominating over the logic of safety’ (1993: 53). They go on that “... in the midst of a particularly steamy session we may decide the immediate rewards of a decision are far more important than the long-tern potential costs” (Davies et. al. 1993: 53). I would add to this that such considerations may be weighed up one against the other in an entirely logical manner, they may be sporadically, periodically or partially evaluated in a rational manner, or indeed the irrationality of love, desire and sex may be thrown into the mix at any time in combination with these more rational considerations.

And if this sounds complex then this is only the tip of the relationship complexity iceberg according to Bauman. As he comments, when discussing the rise of counsellors and their presumed necessary interventions in the realms of human romantic relations, “… the complexity [of relationships] is too dense, too stubborn and too difficult to unpack or unravel for individuals to do the job unassisted …” (2003: xi). His work Liquid Love: On the Frailty of Human Bonds gives a full account of what he describes as “ ... the risks and anxieties of living together, and apart, in our liquid modern world” (2003: xiii). As he puts it, “[i]n our world of rampant ‘individualization’ relationships are mixed blessings. They vacillate between sweet dream and a nightmare, and there is no telling when one turns into the other.” (2003: viii). Elsewhere Bauman discusses this ambiguity, the unpredictably of being in a relationship with another. To love, he says, is to be in a state of “perpetual uncertainty” (2001: 171), or, poetically, “[i]n every love, there are at least two beings, each of them the great unknown in the equations of the other” (2003: 6).

For Bauman then relationships and love can be the source of a great adventure, a poetic journey into discovering the other, but equally within this journey lurks the possibility of uncertainty, of dissolution, of failure of the relationship. Bauman has a

161 tendency to emphasis the more negative side of this equation, the anxiety, uncertainty and ambivalence, because he tends to also emphasis the disembedding nature of these forces in his conceptualisation of late or post-modernity (Heaphy 2007: 72 -73). In contrast, Giddens’ with his emphasis on agency and his concept of fateful moments in the context of sexuality and relationship formation and dissolution, where changed circumstances bring possibilities but also risks and anxieties, tends to emphasis the re- embedding rather than the fragmentation or disassociation potential in these moments of existential and moral angst. As Giddens puts it “the unifying features of modern institutions are just as central to modernity – especially in the phase of high modernity – as the disaggregating ones” (1991: 27). Heaphy extends Giddens’ argument, pointing out that because of the ‘radical doubt’ of the high, late or post-modern period “ … people and agencies are nowadays connected by the uncertainties they face. They are potentially brought together by common concerns – such as risks posed to the environment, health crisis such as HIV/AIDS, or the threatened collapse of the financial markets – that all have global implications. They are brought together by risks and crises, but also potentially by the opportunities for responding to these” (Heaphy 2007: 77).

So for both Bauman and Giddens the potential for angst, uncertainty, ambivalence and risk in the context of relationships and love is most certainly an aspect of the late or post modern period, and so contributes to the backdrop of relationships more generally.

The following chapter focuses on broader conceptualisations, theories and constructions of risk and draws on the work of theorists in the field of the sociology of risk, most particularly Ulrich Beck’s Risk Society: Towards A New Modernity (1992), Deborah Lupton’s Risk (1999) and Zygmunt Bauman’s recent work Liquid Fear (2006) to shed further light on this complex and difficult area. The chapter then moves on to a discussion of agency, resistance, Kippax and Race’s social public health (2003) and finally Bourdieu’s concept of habitus (1997) to start to bring the various theoretical themes so far discussed together.

162 7. Risk

Understanding, assessing or even perceiving risk of HIV infection in any given context is a difficult business. The interactions and negotiations between human motivations and consciousness, individual biographies, human relationship factors, trajectories through the epidemic, gay community and other socio-cultural factors, and wider societal context are complex. Attempting to address these factors in different cultural settings further adds to this complexity. In the last two decades, HIV social science research has dedicated much time and effort, and directed considerable resources, into characterising and separating out the various and varied influences of these interactions in a wide range of different social and cultural settings. Focussing attention only on papers dealing specifically with ‘risk’ in HIV social research literature quickly compiles a list over two decades. Taking first the 1990s the literature has specifically addressed risk in a wide range of biographical, psychological, interpersonal socio-cultural contexts (see for example Catania, Kegeles and Coates 1990; Doll et. al. 1991; Watney 1991; Lowry and Ross 1994; McLean et. al. 1994; Bosga et. al 1995; Green 1995; Hart and Boulton 1995; Heckman et. al. 1995; Hospers and Kok 1995; Remien, Carballo-Dieguez and Wagner 1995; Schiltz and Adam 1995: Hays, Kegeles and Coates 1997; Misovich et. al. 1997; Quirk, Rhodes and Stimson 1998; Appleby, Miller and Rothspan 1999). This focus on risk continued into the 2000s (see for example Davidovich, de Wit and Stroebe 2000; Rhodes and Cusick 2000; Crawford et. al. 2001; Race 2001; Crawford et. al. 2003; Race 2003; Halkitis, Wilton, Parsons and Hoff 2004; Korner, Hendry and Kippax 2004; Slavin, Richters and Kippax 2004; Van de Ven et. al. 2004; Brown and Maycock 2005; Korner, Hendry and Kippax 2005; Crawford et. al 2006; Volk et. al. 2006).

It is not my intention to reiterate this scholarship in this thesis, but rather to situate this research in a broader characterisation of risk as discussed by Beck in his defining work in the area Risk Society: Towards A New Modernity (1992) and Bauman in his more recent works (2007, 2006, 2003). As in previous chapters, I will continue to argue that negotiated safety and TTTT are particular expressions within a much broader post or late modern conceptualisation of risk, as is HIV prevention more generally, where the certainty of truth and knowledge is undermined creating “ … a

163 culture of radical doubt where all kinds of knowledge, including expert knowledge “are only valid until further notice” (Heaphy 2007: 76). Clearly, perception of risk of HIV infection within relationships is also pertinent here, and is an example of the interconnectedness of these arguments with those made about intimacy, which has been discussed in the previous chapter.

Central to the negotiated safety story is risk and the question as to whether prevention campaigns promoting negotiated safety such as TTTT increased the risk of HIV infection in gay relationships and consequently throughout gay communities. Many of the arguments and trains of thought presented so far can be tied together with an examination of the conceptualisation of risk in late modern societies. In order to do this it is first necessary to briefly outline Beck’s conceptualisation of risk and its connection to the continuing modernisation of western metropolitan societies.

A Sociology of Risk

Like Giddens, the grandfather of risk sociology, Ulrich Beck was ‘especially influential’ in shaping the new interest in ‘reflexive, late, advanced, second or global modernity’ (2007: 69 – 70). In his watershed work Risk Society: Towards A New Modernity (1992) Beck was writing about two closely related themes. The rise of what he described, again like Giddens, as “reflexive modernization” (1992: 10 – 11) and its intimate relationship to risk and changes that occurred in western metropolitan societies through the shift from industrial societies in the modern period to risk societies in the late or post modern period. As Beck succinctly described it, “[i]n advanced modernity the social production of wealth is systematically accompanied by the social production of risks” (1992: 19, emphasis in original). Beck defined risk as “ … a systematic way of dealing with hazards and insecurities induced and introduced by modernization itself” (1992: 21, emphasis in original). For Beck, these risks and hazards were fundamentally different from those of earlier historical periods in that no individual, government, institution or corporation could be held accountable for them and that they would affect future generations and cross national boundaries (1992: 22 – 23). As Lash and Wynne explained in the Introduction to the book “[f]or Beck, the consequences of scientific and industrial development are a set of risks and hazards, the likes of which we have never previously faced” (1992: 2). However, in the context of the HIV epidemic this raises a problem as HIV is like disease hazards

164 western societies have faced before, the 1918 influenza epidemic immediately springs to mind as does the plague before it. And as chapter three outlined Australia’s experience with epidemics dated back to 1940s and 1950s with poliomyelitis before AIDS made itself apparent (Blewett 2003: 11). As this thesis attests, epidemics and pandemics are powerful forces that shape history and the social world. However, as Weeks observed in the case of HIV and AIDS, it was both a whirlwind that devoured but also a storm that illuminated and reshaped (1995: 13). AIDS heightened the risks of a new and developing sexual freedom in gay communities yet at the same time illustrated the defining and empowering nature of the AIDS crisis through resistance against dominant discourses and structures and also through Giddens’ concept of ‘fateful moments’ – times of existential crisis that provide the potential for individuals and communities to respond proactively and empower themselves in face of changing sets of opportunities and risks (1991: 131, 156). Again this raises the theme of the complex interplay between powerful structural forces and agents’ active resistance to them. This theme will be discussed again shortly in the context of Bourdieu’s habitus (1977).

Beck was also focussed mainly on environmental risks and hazards brought on by the unrestrained exploitation of global resources through industrial capitalism such as deforestation, chemical and radiological pollution, as well as the ‘nuclear threat.’ This view led him to describe such risks as constituting a “… threat of self-destruction of all life on Earth” (1992: 21). Another important aspect of these risks was that they were on the whole invisible. As he put it they ‘escape perception’ (1992: 21), and have the potential to cause systematic and irreversible harm. Further, for Beck the unknown and unintended consequences of these risks had become “a dominant force in history and politics” (1992: 22) of risk societies in the late modern era. It is not difficult to conceptualise HIV as ‘on the whole invisible’, or to readily accept that it and AIDS have caused systematic and irreversible harm. Following on from this point, and of particular relevance to this thesis, Beck asserted conceptualisations of modern risk were based on causal interpretations and so initially existed only in terms of the scientific or lay knowledge about them. Consequently conceptualisations of risk could be “changed, magnified, dramatized or minimized within knowledge, and to that extent they [were] particularly open to social definition and construction” (1992: 23). This description of the social construction of risk and the knowledge that

165 is constructed concomitantly with it seems a particularly apt description of the various machinations, definitions, redefinitions and contradictions that accompany the TTTT story and the negotiated safety debates more generally. This will be illustrated in the following two sections using interview material.

Beck continued that those experts central to defining risk – mass media and the scientific and legal professions – became “key social and political positions” (1992: 23). Obviously, in the arena of HIV and AIDS – and the characterisation and continuing description and hence ongoing construction of risk of HIV infection – science and the medical professions have played a key role, particularly in the early crisis period of the epidemic. However, as the history of TTTT and negotiated safety has demonstrated, social science and HIV educators operating from various more agency friendly or communitarian models have contributed equally, perhaps even dominated the process in more recent years. Beck also commented on the rationality and objectivity of science and its relationship to risk, as well as what he described as “social rationality” (1992: 29), the knowledge and perception of risk from the sphere of the general public and various groups affected by or concerned about the risks in question. For Beck, science’s monopoly on rationality is broken in the area of risk as “[t]here are always competing and conflicting claims, interests and viewpoints of the various agents of modernity and affected groups … There is no expert on risk” (1992: 29). He also commented on the interaction of the various competing interests of groups and experts involved in identifying and defining risk. While there was not a harmonious relationship between these various interests, indeed they frequently failed to appreciate each other’s point of view, at the same time they were interdependent and ultimately needed each other. As Beck rather poetically put it,

The two sides talk past each other … Social movements raise questions that are not answered by the risk technicians at all, and the technicians answer questions which miss the point of what was really asked and what feeds public anxiety. Scientific and social rationality do indeed break apart, but they remain at the same time interwoven and interdependent … scientific rationality without social rationality remains empty, but social rationality without scientific rationality remains blind.” (1992: 30, emphasis in original).

Contemplating this in the context of this thesis then, perhaps the various players – epidemiologists and assorted other medicos and health promoters, academics of

166 various persuasions, and HIV educators – and the debates about risk of HIV infection in gay relationships and whether or not health promotion negotiated safety messages should be aimed at gay men in relationships were to be expected. As the following interview material will illustrate, the construction of risk from various players’ sometimes complementary sometimes contradictory scientific and/or social knowledge also explains how the same ‘evidence’ was used to construct rational and logical arguments for or against negotiated safety. The view of history as politics (Weeks 1985: 10) is in the case of TTTT and negotiated safety a collective history of defining, redefining and negotiating views of the construction of risk of HIV infection in gay relationships, and in gay communities. Some of this process occurred within gay communities, some of it within academic and policy debates, and some of it encompassed by broader societal or cultural views on sex and (homo)sexuality, health and disease. Some of the debate was framed within rational scientific (medical or epidemiological) terms, some if it from equally rational health promoting community empowerment social models, but much of it from mixtures of these and other individual and experiential prevention knowledges. People and organisations supporting various positions in the debate did not fall neatly into an Australia/New Zealand divide, or an academic/educator or policy maker/community member split, or indeed a scientific versus social model divide. Perhaps Beck summed it up best when he wrote, “[t]he growing awareness of risks must be reconstructed as a struggle among rationality claims, some competing and some overlapping. One cannot impute a hierarchy of credibility and rationality, but must ask how, in the example of risk perception, ‘rationality’ arises socially, that is how it is believed, becomes dubious, is defined, redefined, acquired and frittered away” (1992: 59, emphasis in original). The various machinations, arguments, claims and counterclaims around the development and implementation of TTTT and other negotiated safety campaigns as outlined in the early chapters of this thesis, and as outlined below, illustrate this process very clearly. Heaphy’s comments that in late modernity rational thought turns in on itself, interrogating and questioning itself and in the process, undermining the certainty of truth and knowledge and creating “ … a culture of radical doubt where all kinds of knowledge, including expert knowledge are only valid until further notice” (2007: 76) are also pertinent.

167 Harm Minimisation

Taking Beck’s point then, this section on the various interpretations and reinterpretations around the concept of harm minimisation and its relevance (or not) to TTTT will illustrate that: conceptualisations of risk could be “changed, magnified, dramatized or minimized within knowledge, and to that extent they [were] particularly open to social definition and construction” (1992: 23); and that science’s monopoly on rationality is broken in the area of risk as “[t]here are always competing and conflicting claims, interests and viewpoints of the various agents of modernity and affected groups … There is no expert on risk” (1992: 29).

As previous chapters have outlined, a harm minimisation approach was employed at the conception and development stages of TTTT. This approach was informed by social research, most particularly Kippax et. al. (1993b), which had demonstrated that the practice was already occurring in gay relationships, and had been for some time. Educators were also of the view that anal sex without condoms had been occurring for some time, as AFAO’s Feeling Our Way had illustrated as early as 1990. As Russell put it “ … we knew about negotiated safety, although we hadn’t coined the phrase, several years before the campaign, like we had explicit discussions about what it meant and what we should do about it.”

Given the acceptance that anal sex without condoms was already happening in gay relationships, the question for educators moved from ‘should we address this situation?’ to ‘how do we address this situation?’ One answer, harm minimisation in the form of TTTT, gave men in relationships a message on how to be safest when abandoning condoms, but questions remained for many who supported this approach. Would this campaign undermine consistent condom-every-time messages? In answering this question there was a strong emphasis amongst educators supportive of TTTT on reflecting where gay men were at, meshing with what they are already doing in terms of sexual practice in their lives so not only the negotiated safety message, but all prevention messages and approaches, remained credible and effective. Brian and Desmond discussed this,

… that was the angst people felt, would us doing this for people in relationships [promoting TTTT and negotiated safety] undermine everybody else, you know who aren’t in relationships, that sort of stuff. Absolutely yeah, we talked about that … I think you’ve got to look at it

168 overall. So what we try to do with our education is to, you know, keep people as safe as possible. If it works, if it’s done properly, this is as safe as any other method and so we kind of accepted that. For all of our other messages to be relevant we need to be talking to people about things that they’re doing and the way that they’re doing it and, you know, their understandings of stuff and we would have to address this issue for our other stuff to remain relevant [Brian]

I spose the reasons, the arguments about why it was a good idea were all the things that we would probably argue about … now, which is people are already doing it. If you want to stay relevant to people you need to, you know, at least be talking the same language or reflecting it. [Brian]

… so the men that don’t take it on, well, they are no worse off and no better off. They’re not using condoms anyway so if they don’t get this message it doesn’t change anything. They’re still not using condoms. So it may be some part of that group will get the message, it will influence their behaviour, the people who it doesn’t influence it’s just not going to make any difference to the overall risk that is occurring. [Desmond]

Jeremy, who works for an organisation representing HIV positive people in Australia, also talked about addressing people’s existing practices in a health promotion setting and the importance of recognising and working with existing practices.

I think at the time it [TTTT] was an important thing to happen because it …. recognised the actual practices that people were doing and tried to accommodate those, yeah, yeah. So people were negotiating things. People do negotiate things so I guess it was a matter of trying to capture that and make use of it to prevent transmissions, yeah. [Jeremy]

Another participant George, who has been involved in HIV prevention in both Australia and New Zealand, acknowledged that TTTT was by no means a perfect prevention message, but also agreed that some kind of harm reduction message aimed at men in relationships was better than no response at all, as it “lowered the risk parameter” in the ongoing process of living with the epidemic and learning to more accurately assess risk of HIV infection.

Did the Foundation [NZAF] have a point, maybe, about negotiated safety. And I think the conclusion at the end of that exercise was that it’s, you know, it’s not perfect. It’s flawed but this plays into that whole basic ethos about being where gay men are. And knowing that gay men will be where gay men are, and about creating that safety parameter, or the lower risk parameter on the frontier as we move forward. So it’s about being there and a form of harm reduction or harm minimisation I guess as opposed to, you know, anything else. [George]

169 Francis commented on the pitfalls of embracing a harm minimisation approach to negotiated safety in the form of TTTT. In particular he pointed out the responsibility AIDS organisations felt when disseminating prevention information and campaign messages, knowing that there was always the risk of people misinterpreting the message and so increasing their risk of infection, the opposite effect to that desired by planners and educators.

I think that ….. Well I think a number of people were pointing to the potential flaws in negotiated safety as a strategy and were worried that if ACON and other HIV organisations came out with a policy around, you know, effectively risk reduction and if people got it wrong that ACON would be responsible in some ways for those people getting HIV, if that was the result … those sort of people took a lot of comfort in the position that if you just told people to use condoms every time then that is a safer strategy than risk reduction. It’s not without some risk … So yeah I think people were struggling with that notion of embracing a strategy which had, which was more complex, which relied on people having personal skills around negotiation, communication, and um, trust in relationships. There were debates about whether people weren’t going to stick to those sort of negotiated agreements and introduce HIV infection into relationships you know, and just try and work out what proportion of people might do that as opposed to what we thought was another imperative, which was for guys who wanted to establish negotiated safety agreements and we probably sort of understood from the social research that that was a lot of gay men who wanted to do that, that we also felt an imperative to assist those men in striking those agreements in what we thought would be the safest and most effective sort of way. [Francis]

Perhaps Odets summed up the ‘pro’ negotiated safety position best, making a more nuanced argument emphasising that guidance in the specifics of how to go about discarding the condoms in relationships is the crux of the matter. As he wrote “[t]he issue is not whether people will contract HIV through negotiated safety … The question is whether fewer people will contract HIV through clarified negotiation.” (quoted in Schoofs 1995: 39, emphasis in original).

It would seem from these comments that a harm minimisation approach to negotiated safety, in the form of TTTT, was logical and reasonable. The practice of not using condoms in relationships was acknowledged as occurring so the prevention decision was how to frame a message that would minimise risk amongst this group of men. However, illustrating the point that arguments against negotiated safety and TTTT can sound equally reasonable and rational, and of course Beck’s point that “[t]here are

170 always competing and conflicting claims, interests and viewpoints” (1992: 29), I turn now to some of the comments of my New Zealand participants. Duncan put it bluntly and succinctly, “Well it sounds more like risk maximisation … in terms of theory its all fine and dandy but you’re dealing with human beings who are fallible.” Another of my New Zealand interviewees, Walter, acknowledged that some people will not use condoms but takes the opposing view to the Australians quoted above when it comes to applying that knowledge to a public health message,

… anything that made it, that provided people with another excuse not to use condoms was a mistake. Doesn’t matter how hard we work at normalising condom use, people are still not going to use them if they don’t want to. But to provide them with a public health excuse was, um, I think in terms of public health positioning, a mistake … using a condom is sufficiently onerous and negotiating the use of condoms are sufficiently sophisticated skills. To back off supporting people to do that is sending mixed messages. [Walter]

It is clear from these two sets of opposing views that the same argument was seen very differently, and the decision to not disseminate a message about negotiated safety was arrived at using the same information that proponents of TTTT interpreted as evidence of the need to proceed with such a message. Given that the main disagreement between supporters and opponents of TTTT was whether or not the TTTT message would increase the risk of HIV infection in gay men’s relationships, the most obvious approach to provide a who was ‘right’ or ‘wrong’ answer would have been an examination of HIV transmission within regular relationships in which negotiated safety has been adopted and compare this to transmission rates in regular relationships in New Zealand, where no negotiated safety advice was disseminated (Kippax 2002: 6 – 7). For those of an epidemiological persuasion the use of quantitative evidence to make comparisons are commonplace. There were epidemiologists working in the sector who were well placed to interpret such data. However, no such data were collected before, during and after the TTTT implementation phase, and there are also difficulties with this approach in the context of the evaluation of the effectiveness of HIV prevention campaigns. Kippax has argued that the next most stringent test of negotiated safety is a test of compliance with the negotiated safety agreement. Three studies using this method (Kippax et al. 1997; Davidovich, de Wit and Stroebe; Crawford et. al. 2001) found that around 90

171 per cent of men in each study “complied with their negotiated safety agreements and did not place their regular partners at risk of HIV infection” (Kippax 2002: 7).

In my opinion it is not a matter of who is ‘right’ or who is ‘wrong’ in the case of whether or not to disseminate a public health message about negotiated safety in the form of TTTT, mainly because I believe HIV prevention messages and public health campaigns more generally do not operate exclusively at the individual level, but rather integrate with other structural and psychological factors and work more at a collective, cultural or societal level. This view is no doubt influenced by my views of the cultural and social more generally, namely that my academic interests are in social meanings, networks, social practices and processes, ‘doing’ at the collective level, even though it is individuals who collectively, –sometimes in coalition, sometimes in opposition – generate the meanings and so over time the collective practices and eventually maybe even the culture around this ‘doing.’ In short, an evaluation of the effectiveness or otherwise of TTTT using only new infection rates in Australia and New Zealand is not possible because the TTTT intervention and meanings around it operate at a collective level over time, and integrate with a wide range of other reinforcing and/or confounding factors, both individual and collective, psychological and social. It is difficult to disentangle these factors from the general milieux of gay life and sexual practice, and it is not possible to do so using quantitative experimental methods. However, it is possible to analyse, separate out and describe these factors, and make some judgement of the effectiveness or otherwise of TTTT in light of these factors, using a theoretically informed qualitative method. Kippax took a similar view in her chapter ‘Sexual health interventions are unsuitable for experimental evaluation’ in the edited volume Effective Sexual Health Interventions (2003). As she stated “ … sexual health interventions are inherently unsuitable for experimental evaluation …. Assessment of interventions can be achieved, but by means other than experimental evaluation … empirical evaluations of a descriptive kind are needed to evaluate the effectiveness of sexual health interventions” (2003: 17).

To Trust or Not to Trust

The second area that seemed to be the focus of much contestation was that of the complex dynamics of communication and trust within gay men’s relationships – their sexual decision-making and risk-taking – and whether or not a condom is used with a

172 regular partner. Almost all my participants, both Australians and New Zealanders, agreed that successful navigation of TTTT and/or successful negotiated safety agreements rested on trust, and honest open communication within the primary relationship. Views were much more divided about whether this could reasonably be expected, or was even possible, in gay relationships. As with other arguments about negotiated safety and TTTT, divisions were not necessarily simply and neatly trans- Tasman. However, it is probably fair to say most New Zealanders felt that trust and honesty in relationships were too fraught with difficulty, and hence too risky in terms of possible HIV infection, to allow a prevention message to rest upon it. More Australians were willing to give gay couples the benefit of the doubt and so supported a negotiated safety type harm minimisation message aimed at men in relationships. Andrew summed up the situation for many New Zealanders, not only that many felt asking men to negotiate agreements about anal sex without condoms in the relationship was too difficult, but also that this inevitably brought up issues and insecurities around monogamy and sex outside the relationship.

There were discussions, particularly around the negotiated safety thing that came out of that international conference [XI International AIDS Conference, Vancouver (1996)] which was kind of hailed as the second coming. And we kind of understood on one level that what they were saying was true. But the difficulty with it was that … there were serious problems about the assumptions that were made around men’s ability to negotiate, in real terms, in real time, in real situations, over periods of time. That Couples Study42 that [NZAF researchers] did really threw light onto that. I remember one guy saying … have you a negotiated agreement was the question, ‘yes I told him ten years ago that if he fucked anyone else I’d cut his balls off. Have you talked about it since? No.’ And that was construed by the partner, one partner at least, as a negotiated agreement about monogamy. And that was about as good as it actually got. [Andrew]

Desmond summed up the harm minimisation argument supported by most Australian educators. As with the rationale for supporting TTTT as a health promotion message

42 Worth H., Reid A. and McMillan K., ‘Somewhere Over the Rainbow: Love, Trust and Monogamy in Gay Relationships,’ Journal of Sociology 38 (3), Australian Sociological Association, 2002: 237 – 253. This in-depth qualitative study of eleven gay couples leant weight to the argument that gay men had difficulty in communicating about sex outside the relationship. As the authors wrote, “the relationships tended to marked by avoidance of negotiation, lack of disclosure and mutual silence in regard to … sexual activity outside the relationship.” (2002: 239).

173 discussed in the previous section, he again pointed out that the kind of trust TTTT relied upon existed in at least some gay men’s relationships, and this was reason enough to support it as a strategy.

… Well my view on that one is that again like it’s a substantial amount of validity in the argument [that TTTT relies on trust, honesty and communication] … but I do think that there is a significant proportion, what it may be I don’t know, 50%, 30% or 70% of men of men who are able to take on and process those messages and that those messages are consistent with the reality of those men’s lives, that there is an element of trust at least in some percentage of relationships. Do you know what I mean? Like, it wasn’t discordant to the reality for some proportion of men in relationships. What that proportion might have been I don’t know.43 [Desmond]

The question that remains with this approach is whether those men who did not implement TTTT properly – either through misunderstanding, lack of proper testing, or failed attempts at honesty and trust in their relationships – were more at risk of HIV infection. Desmond’s argument (as also outlined in the previous section) was that these men were practising anal sex without condoms anyway so were no worse off, and at no greater risk of HIV infection. It is possible there were another group of men who were using condoms in their relationships who misunderstood the TTTT message and so put themselves at risk of infection by ditching the condoms in an unsafe manner. It is this scenario that concerned opponents of TTTT. However, how likely it was that gay couples using condoms would abandon them solely on the basis of a message like TTTT was not evaluated, quantitatively or otherwise. And indeed, in my view it would not have been possible to evaluate because of the many confounding factors that would be involved. These confounding factors – other reasons for not using condoms, other prevention messages and information – and the

43 While there were no data at the time on what proportion of gay men were successfully implementing TTTT or negotiated safety type agreements, there were quantitative data that indicated 82 per cent of gay men in Sydney (69 per cent in Melbourne and 71 per cent in Brisbane) used their HIV sero-status in agreements with a regular partner about anal intercourse (Prestage et. al. 1997: 42). Data showed that a significant proportion of gay men in regular relationships in Australia did not use condoms for anal intercourse at this time, 47 per cent in Sydney, 50 per cent in Melbourne and 48 per cent in Brisbane (1997: 43). Data for a similar period in New Zealand showed that 46 per cent of men in relationships did not use condoms for anal sex (Worth et. al. 1997: 20). These figures show that regardless of one’s view on whether negotiated safety messages should be disseminated or not, there was a large constituency in both Australia and New Zealand for whom such messages were potentially relevant.

174 wider context of relationships and gay subculture would not be able to be separated out from the specific effects of the TTTT message.

George, who has been involved with AIDS organisations in both Australia and New Zealand, represented a more ambiguous view. While he acknowledged the validity of an argument against negotiated safety on the grounds of the fraught nature of trust and honesty in a relationship, he still believed that negotiated safety (TTTT) had “worked quite well.”

I think it’s absolutely justifiable to mount a logical case against negotiated safety. I wouldn’t reject out of hand, at all, people who say this is incredibly risky, you’re relying far too much on things we all know aren’t necessarily going to be there [trust, communication, honesty]. Nevertheless, with all of that taken on board, I believe that negotiated safety has worked quite well. [George]

Social Aspects of AIDS Conference, Melbourne (1997)

The question of whether gay men had the required negotiation skills and levels of trust and honest communication in their relationships to strike negotiated safety agreements came to something of a head in Melbourne in 1997 at the Social Aspects of AIDS Conference. The views of Australian educators and academics clashed with the differing views of New Zealanders also attending. Again illustrating Beck’s claim of risk in reflexive modernity generating conflicting claims, interests and viewpoints, debate was robust, spirited, perhaps even impassioned for a few delegates. Carl remembers the controversy “I went to [the Melbourne] conference where some learned people … stood up and said they couldn’t countenance condomless sex in long-term relationships because it was a slippery slope.” New Zealander Luke saw wider implications in the debate about negotiated safety not only for the future of prevention campaigns but also for HIV prevention more generally.

... in 1997 [I] went to the conference in Melbourne, I was very aware of the contended topic, um… I was aware that this was an issue that people had strong perspectives on. I was aware that it was an incredible issue in terms of, um, I think the directions that future prevention campaigns would move in. It also posed a big challenge to the existing prevention approaches. [Luke]

175 Tim saw the negotiated safety debate within the context of NZAF’s successful condom-every-time approach over a considerable period. For him it was very much a “if it ain’t broke don’t fix it” situation.

I think that the big debate about it [TTTT] here was before and after the Vancouver AIDS conference in 1996 then following through to Melbourne … I attended that ... I mean don’t forget the context for us was that we had one of the sharpest declines that you could ever wish for in HIV based on a condom promotion campaign. So, you know, it’s a case of if it ain’t broke don’t fix it because, so you would need to have very good evidence, in my view, at least we felt we needed good evidence to move from that model because as you realise by 1996 we hadn’t by any means come to the full zenith of the success of our condom promotion stuff. And that didn’t happen until 97 through 2000 so I mean I think there was, ar, from my point of view I just found it hard to know where this was coming from and why it arrived so suddenly and why it was being backed up with such extraordinarily strong advocacy, like anyone who disagreed with it must be mad, quite frankly… Or homophobic or community disconnected. [Tim]

As should be very clear by now, unlike Tim many Australians felt negotiated safety/TTTT was an important and necessary change to prevention policy and practice. Bryce described the detail of the Melbourne conference debate, identifying the central issue as a perception by some gay men present (particularly Australians supportive of negotiated safety type prevention messages) that the New Zealand position was homophobic because it was suggesting trust and monogamy were problematic in gay relationships, and indeed in relationships more generally.

I remember … at the Social Aspects [of AIDS] Conference in Melbourne and there was that big debate … [Because We Want To Be Together worker] became very inflamed cos he’s a very articulate speaker and he did accuse [New Zealand speaker] of being, I think, homophobic. And I remember being part of the group egging him on. We were incensed. We were absolutely incensed … I think the [speaker’s] take home message was that you couldn’t build, like, how could you trust somebody. Look, people in relationships have trust. People have it all the time for a whole lot of things. For just about everything in their relationships and we’ve got to say at some point, sex, you know, they have a certain level of trust with sex. [Bryce]

Victorian Carl, who also attended the conference, was of the view that it was homophobic to suggest that heterosexuals were capable of the required trust and honesty in their relationships but that homosexual men were not.

176 I think that saying gay men can’t do it but heterosexual couples can is homophobic … I went to a conference where some learned people from New Zealand and even more sadly the San Francisco AIDS Foundation stood up and said that they couldn’t countenance condom-less sex in long term relationships because it was a slippery slope … It makes me angry that there’s a different standard applied to heterosexuals and homosexuals. It’s equally difficult for both of course. Maintaining truthfulness, honesty, trust, you know, everyone is looking for both security and adventure in their relationships. And with HIV the desire for both security and adventure becomes not only a source of friction within a relationship but also potentially life threatening. And that’s the same whether it’s for heterosexuals or homosexuals, male or female. [Carl]

This is a theme that resonated with many of my participants, once again both Australians and New Zealanders.

But while we seem to be able to ascribe those sorts of prerequisites to often elderly heterosexual couples, because there was an assumption that monogamy was the rule, we found it impossible to expect that there were gay couples for instance, who were monogamous, who had integrated, you know, what they did was what they said, they understood the risks, they understood their situation and they’d made a conscious decision about what it was that they were going to do based on the level of risk, which was, in some cases, negligible, if none at all. [Andrew]

It’s interesting because [name] was doing the women partners of bisexual men project at the same time, was doing a campaign on exactly the same topic. Didn’t call it Talk Test Test Trust but she did a booklet that came to the same conclusions and nobody criticised that, nobody even questioned it. It seemed incredibly reasonable for heterosexuals to have this process of agreement in their relationship and there were two tests, three months apart, and you come to an agreement of trust and nobody even questioned whether or not trust could be a question in a heterosexual relationship. And I remember us all saying at the time, thinking, you know, nobody’s saying heterosexuals can’t have trust. Why is it gay men are so untrustworthy? They aren’t … Their relationships are just as valid and their relationships are just as trustworthy. [Bryce]

It was perhaps a misunderstanding to label as homophobic an argument that was trying to point out that in matters of sex, sexuality and relationships it is difficult for everyone, not just gay men, to discuss monogamy and/or be honest about sex outside the relationship. Such discussions may well be central to striking an effective negotiated safety agreement and so should rightly be raised in the context of a debate about the effectiveness, or otherwise, of TTTT. The ongoing history of stigma and

177 discrimination against homosexual men and their relationships may have been a powerful reason why some HIV educators were sensitive to arguments suggesting heterosexual couples were capable of the necessary honesty and trust to negotiate condom-free sex while gay men were not. As chapter three discussed, the ongoing history of the medical, religious and legal spheres in western metropolitan societies and their discursive construction of homosexuality as a physical, psychological and/or moral sickness was intimately connected to the stigma and discrimination experienced by many gay men. This may be particularly true for older men who had lived in an era before much social change had occurred.

This broader historical context may also be a reason why arguments supporting gay men’s active engagement with prevention messages were viewed more favourably by some than more inflexible condom-every-time regardless of context type arguments. As chapter three illustrated, the rise of gay liberation movements in the 1960s and 70s, based on black and feminist consciousness raising and self-defining principles, in which the metaphor of homosexuality as a sickness was resisted and replaced with positive constructions of identity and community has also played into the resistance and agency approach that negotiated safety and TTTT emphasised.

Walter talked about the impact this broader context had on gay men’s relationships, the fact that this context made monogamy more difficult, and indeed that within gay culture an emphasis on sexual expression can be seen as a response to the stigma and discrimination many gay men faced, not only in their individual lives but perhaps even more so as visible gay couples.

Yeah. I mean the thing is because of society it is so extremely difficult for us to have, um, to enter into a, um, faithful monogamous relationship, we made a virtue of having sex with as many people as we could. That was a cultural response to oppression, and that is very common response to oppression. You make a virtue of what you can do ... All the social forces are against you. What you can do is you can go cruising and you might if you’re lucky score a couple of times a week. And then you’re called promiscuous. The reality of most [gay] men’s relationships is serial monogamy not a long lasting relationship because society doesn’t, and still doesn’t, support them. [Walter]

Like Walter, Schoofs also saw connections between the ongoing history of ideas about homosexuality and the balance between monogamy and sex outside the relationship. For Schoofs the new prevention initiative of negotiated safety

178 encapsulated, and in his view overcame, a contradiction between the ideology of gay liberation and the impulse towards intimacy and security in relationships.

This new strategy [negotiated safety] synthesizes two formerly opposed ideologies. One is the celebration of pleasure, a cornerstone of 1970s gay liberation. Then, every act of gay sex – but in particular anal sex, because it epitomizes male homosexuality, was deemed “revolutionary.” The echoes of this philosophy reverberate in the arguments for negotiated safety: that unprotected anal sex is good, and that the condom-every-time message has wrongly imprisoned it in an AIDS-era closet. But one can also hear the affirmation of emotional intimacy and long term relationships, an ethic that flies in the face of gay liberation’s rallying cry, “So many men, so little time.” The subtext of negotiated safety is that gay couples can be strong and trustworthy, and should be.

This new strategy [negotiated safety] wants it all: eros and agape, hot sex and intimacy. Apparently, many gay couples have decided that using a condom prevents them from having both. (1995: 39)

Perhaps the reason why debate was so heated when campaigns promoting negotiated safety first came on the prevention scene in the 1990s, and continue to be contentious today is, as Schoofs argued, that the contradiction between the celebratory sex- positive position of gay liberation and formulations of intimacy and security in long term relationships was never resolved. The two opposing views were never synthesised into a satisfactory whole that could encompass the wide and varied views and differing theoretical perspectives of educators, health promoters, epidemiologists, medicos and the assorted other academics that collectively and uneasily comprise the HIV sector. Again this raises the theme of unifying and fragmenting forces acting in unpredictable ways within the broader sphere of relationships, HIV prevention and indeed wide scale social and historical change. Of course, intimacy does not necessarily reside only in long-term relationships. Many educators would argue it can also be found in casual encounters, and that long-term relationships are not necessarily intimate. Neither state is a guarantee of intimacy or connection.

Travel between Australia and New Zealand was another aspect of the negotiated safety debates that was not so obviously discussed at the Melbourne conference, but was certainly an underlying issue for some of my Australian and New Zealand participants. Inevitably this again brought up arguments about consistency of prevention messages, the differing assumptions and socio-cultural norms that may be operating around those messages, and whether it was appropriate to target particular

179 prevention messages, such as negotiated safety, to particular segments or subgroups of gay populations. As George put it, “I know that there are still lots of gay boys coming from Auckland to live here [Sydney]. So that’s the issue for the Foundation [NZAF] that is kind of different to here [Sydney], that they have that constant kind of out movement of the target group somewhere else …”

It is useful to again recall Clift and Wilkins’ “complex spatial and sociocultural ‘geography’ of many overlapping epidemics … evolv[ing] with higher incidence levels in some physical locations and social ‘spaces’ and lower incidences in others” (1995: 36) when considering whether a negotiated safety message should have been disseminated in both Australia and New Zealand. But again, like many of the arguments surrounding negotiated safety, this is a complex situation with no clear ‘answer’ one way or another. And again, while there is agreement about the need to address travel between Australia and New Zealand in the context of HIV prevention, the same situation is interpreted in very different ways. For George, the pull of Sydney for New Zealand gay men and it being a point of reference for New Zealand gay culture meant that there was no point in attempting to separate out the two populations in terms of prevention messages as there was so much mixing between the groups,

… the Foundation always insisted that there was a different set of cultural parameters prevailing in Auckland and Wellington to those that prevailed in Sydney and Melbourne, and given that I spent much of the early 90s, mid 90s, travelling here [Sydney] at least three or four times a year to go to big dance parties with hundreds of kiwi boys, I always found this a difficult argument to kind of, to sustain, I mean I just found that not so. It didn’t account for the movement of gay men and the fact that gay men are highly mobile. It didn’t account for the fact that Sydney has been, for decades, the metropolitan point of reference for gay culture in New Zealand. [George]

While for Tim it was the success and durability of prevention messages from travellers’ country of origin that equipped them with the “knowledge … instinct and awareness” that kept them from making unsafe decisions, even if various destinations had different socio-cultural norms and assumptions operating within them.

I mean, hopefully what people do is they take with them, if the prevention programs are operating well in the country, they take with them a lot of um knowledge and kind of instinct and awareness that they gain and, you know, there’s been a lot of very interesting discussion,

180 I’ve had this said to me by from people, from Tom O’Donahue used to be on our board of positive men, to various other people over the years have all said, you know, one of the big differences that catches our people unaware is say the difference between um, what happens in a venue, a sex on site venue in Auckland and what happens in Sydney. In Auckland if someone doesn’t want to use a condom the social assumption, without being stated, is that they’re negative whereas the opposite is true often in the venues in Sydney and that is a real problem. You know what I mean. So I agree with you that when our guys do travel they can come up against quite different sort of community or social norms around safe sex which are problematic. [Tim]

This is another issue that perhaps remains unresolved or unanswerable in the context of general HIV prevention, including negotiated safety and TTTT. To me, both positions seem logical and reasonable arguments. However, in terms of the broader social and cultural factors influencing HIV prevention that have so far been elucidated in this thesis, factors generated by the epidemic itself seem to be at least a partial answer to the divergence of Australia and New Zealand over the negotiated safety and TTTT issue, whereas in most other respects AIDS organisations in both countries were remarkably similar in prevention policies and approach (and as they continue to be today), as chapter three illustrated. That factors affecting the epidemic and prevention can differ, even in countries that are remarkably similar in many respects, is good reason for ‘working in one’s own epidemic’ (Dowsett 1996a: 22; Dowsett and McInnes 1996: 32), The factors most relevant to the divergence of opinion over TTTT between Australia and New Zealand are, in my opinion, the larger gay populations in Australia (most particularly Sydney where TTTT originated) and so higher HIV incidence, and connected to this the varying impact of AIDS related deaths44 and the relative strength of a positive voice in prevention.

In discussing areas of varying HIV incidence, Clift and Wilkins described a complicated spatial and socio-cultural geography of HIV infection with many overlapping epidemics. This resulted in higher HIV incidence in some physical locations and/or socio-cultural niches and lower incidences in others (1995: 36). Clearly, cities such as Sydney with large gay populations, and even more so North

44 This is not to suggest that deaths as a result of AIDS in New Zealand were any less devastating and traumatising to the friends and families involved, just that a much larger number of deaths as a consequence of higher HIV incidence and a much larger gay population had a much greater effect cumulatively in Australia, particularly Sydney.

181 American cities, were areas of high HIV incidence while cities in New Zealand were areas of lower HIV incidence. Consequently, the impact of AIDS deaths and associated grief, loss and AIDS fatigue (Odets 1995a) had more impact in Australia and this, along with a larger positive community, led to greater fracturing of the unity of the safe sex message as previously discussed. This in turn allowed for a more formalised movement towards non-condom based prevention strategies that in turn led to the development and implementation of TTTT. This is, of course, not to say that gay men in New Zealand did not privately embrace non-condom based prevention strategies (leaving aside the question of how risky or not such practices may or may not have been), just that no formal prevention strategy at an AIDS organisation level was ever implemented. Again the theme of unifying and fragmenting forces acting in unpredictable ways within HIV prevention is apparent.

To some extent how one answers this question is also connected to how one sees the role of AIDS organisations, how much influence one thinks prevention messages have on people’s behaviour, and how directive one thinks prevention messages should be. As discussed briefly in chapter four with reference to Feeling Our Way, the questions remain: do AIDS Councils simply provide information, or do they provide advice and/or recommendations? Should prevention messages be framed in a way that allows people to make their own risk assessments, or should they be more directive and allow little room for interpretation or individual risk assessment. These are, of course, questions that are central to HIV prevention and perhaps another reason why negotiated safety and TTTT were so controversial, as arguments around it seemed to inevitably lead back to these central questions. This will be discussed further in chapter eight in the section AIDS Organisations and Information Provision.

Finally, it should be reiterated that even though given the difference between Australia and New Zealand in prevention policy, the previous two sections have illustrated a much greater similarity, that of risk being particularly open to social definition and construction (1992: 23) resulting in competing and conflicting claims, interests and viewpoints (1992: 29). After all, it will be recalled some New Zealanders supported negotiated safety and TTTT as a prevention strategy. Clearly Beck’s conceptualisation of risk describes, at least to some extent, educators’ practice in

182 Australia and New Zealand, and in so doing proves itself to be one of the factors acting on and shaping HIV prevention.

Fear, Anxiety, Uncertainty

The previous chapter outlined that for Foucault the control and use of sex was associated with the public interest in talking about and regulating the sexuality of populations for newly emerging capitalist states (1978: 25 – 26). Similarly for Weeks the state’s use of sex and sexuality for population management was connected to rapidly changing social, economic and gender relations associated with industrial capitalism (1985: 74). Lupton made a similar observation, “[d]uring the eighteenth and nineteenth centuries, the early modern European states sought to harness their populations productively and deal with the social changes and upheavals wrought by mass urbanization and industrialization as part of the Industrial Revolution” (1999: 6). But rather than a focus on sex and sexuality Lupton instead highlighted the role of probability and statistics in defining and controlling populations, and, importantly for this discussion, allowing calculations of risk. “The science of probability and statistics was developed as a means of calculating the norm and identifying deviations from the norm, thus embodying the belief that rationalized counting and ordering would bring disorder under control … These fields were to become important to the modernist technical notion of risk” (Lupton 1999: 6).

This brings up another important aspect of risk, namely that risk is a means of assuaging fear and giving the illusion that those things that seem beyond control can in fact be understood, planned for, avoided, or prevented. However, although the science of probability can assess risk on a population basis, it says little or nothing of the risk to the individual. Perhaps Bauman made this point best when he wrote,

Calculations of probability say something reliable about the spread of effects of a large number of similar actions, but are almost worthless as a means of prediction when they are (rather illegitimately) used as a guide for one specific undertaking. Probability, even most earnestly calculated, offers no certainty that the dangers will or will not be avoided in this particular case here and now or that case there and then … (2006: 11)

I am reminded about what I think of as ‘the eternal prevention question’ – the disparity between clearly understood risks at the population, group or community

183 level and individual risk which was a complex interaction of psychological, interpersonal, structural and socio-cultural or societal factors that did not necessarily correlate with risk probabilities and/or perceptions calculated at the group level. Therefore within the conceptualisation of risk lies a contradiction, that by calculating probabilities we have understood, controlled and perhaps even avoided risk, but in fact the risk to the individual is no better understood or predicted (again, the theme of unity and fragmentation, but this time within the late modern conceptualisation of risk). This future component of risk was well understood by Beck. He made a distinction between the destructive consequences of a particular hazard that were already present and observable as opposed to the potential or future harms of a particular risk or hazard. For Beck “[r]isks essentially express a future component” (Beck 1992: 33).

So within the illusion of certainty that calculation of probability of a risk occurring lay an essential uncertainty, an anticipation of potential destruction, an unsure future as to whether the risky event would occur or not. As Beck put it, “[t]herefore, even as conjectures, as threats to the future, as prognoses, they [risks] have and develop a practical relevance to preventive actions. The center of risk consciousness lies not in the present, but in the future” (1992: 34, emphasis in original). As has been discussed in the previous chapter, uncertainty of the future was a key component of love and relationships. And with uncertainty comes anxiety and fear. Before discussing the specific anxieties and uncertainties around HIV and AIDS it is first worth noting that according to Bauman, whose elaborate and at times quite dark ruminations Liquid Fear (2006) and Liquid Times: Living in an Age of Uncertainty (2007) built on Beck’s earlier work, fear and anxiety (as well as uncertainty, rapid change, impermanence and transience) are key components of late modern or risk societies. For Bauman “ … we seek substitute targets on which to unload the surplus existential fear that has been barred from its natural outlets” (2007: 11). For Bauman, with his emphasis on the disembedding elements of late or post-modernity, not only uncontrollable disasters but lack of political control through globalisation, as well as the breakdown of traditional kinship and other community bonds and relations, are the natural outlets for fear and anxiety. But these fears are too large and incomprehensible and unable to be changed or dealt with on the individual level so substitute targets, as he calls them, have become the fear scapegoats, the targets of our collective societal

184 angst and anxiety. “[W]e find such makeshift targets in taking elaborate precautions against inhaling someone else’s cigarette smoke, ingesting fatty food or ‘bad’ bacteria … exposure to sun, or unprotected sex” (2007: 11). Bauman is of view that “dangers one is afraid of (and so also the derivative fears they arouse)” are of three main types: dangers that threaten the body and the possessions; those that threaten the “durability and reliability of the social order on which security of livelihood (income, employment) or survival in the case of invalidity, or old age, depend” and finally; “dangers that threaten one’s place in the world – a position in the social hierarchy, identity (class, gender, ethnic, religious)” (2006: 4). Clearly, risk of HIV infection and AIDS are potential dangers to the body, disability arising from sickness could lead to loss of income and unemployment and loss of social position could occur through the stigma and discrimination connected to HIV and AIDS, and by association homosexuality. There is also resonance here with Giddens’ fateful moments (1991: 131), as these are areas that clearly bring a changed set of circumstances and that have ample potential to generate existential anxiety.

Other authors also discussed categories of risk in late modern societies. Lupton identifies six major risk categories that occurred in specific socio-cultural contexts and predominated “the concerns of individuals and institutions in western societies.” They are:

…‘environmental risks’, or those posed by pollution, radiation, chemicals, floods, fires, dangerous road conditions and so on; ‘lifestyle risks’, those believed to be related to the consumption of such commodities as food and drugs, engagement in sexual activities, driving practices, stress, leisure and so on; ‘medical risks’, those related to experiencing medical care or treatment (for example, drug therapy, surgery, childbirth, reproductive technologies, diagnostic tests); ‘interpersonal risks’, related to intimate relationships, social interactions, love, sexuality, gender roles, friendship, marriage and parenting; ‘economic risks’ implicated in unemployment or under- employment, borrowing money, investment, bankruptcy, destruction of property, failure of a business and so on; and ‘criminal risks’, those emerging from being a participant in or potential victim of illegal activities (1999: 13 – 14).

It is immediately obvious that in Lupton’s formulation lifestyle risks, in particular engagement in sexual activity and interpersonal risks related to intimacy, love, and sexuality were highly relevant not only to risk of HIV infection generally but

185 specifically relationships and negotiated safety as the previous chapter has discussed in detail. As with Bauman’s formulation, HIV and AIDS were also obviously associated with Lupton’s medical and economic risks. And again, Giddens’ fateful moments (1991: 131) also seem pertinent to a number of Lupton’s categories.

Weeks has also made comment in this area. Following on from his earlier work in which he characterised sexuality as a surrogate medium through which other battles were waged (1985: 74), he later discussed a number of what he described as sexuality morality concerns that had “become the focus of public agonizing and personal anguish” and “the major theme of social policy debates” in western metropolitan societies (1995: 4). He listed them as “[i]llegitimacy and the future of the family; surrogate parenthood and embryological research; teenage pregnancy and the ‘age of consent’; divorce and the fate of marriage; violence and explicit sexual imagery; sex education and child sex abuse; sexual diversity and sexual identity; the changing claims of women and the ‘crisis of masculinity’; the balance between individual freedom and collective obligations; disease and sexual health.” (1995: 4). Clearly, the balance between individual freedoms and collective or community affiliations and obligations and its connection to illness, public and sexual health are pertinent not only to risk of HIV infection generally, but were specific areas for arguments about whether or not to disseminate TTTT as a mass media message, as chapter six illustrated. Many of the other issues related to sexuality and sexual identity have impacted on broader debates about homosexuality and so discourse about appropriate safe sex education campaigns for gay men. Weeks also picked up the theme of anxiety for the future being expressed through societal ‘worries’ about sex and sexuality, “[i]t is not that sexuality has ever been absent from social, cultural and political debate… What is new, however, is the way in which worries about changing sexual behaviour and gender and sexual identities have become the explicit focus for debates about the current shape and desirable future of society” (1995: 4 – 5).

For Weeks uncertainty was also a particular quality of living with HIV and AIDS. As he put it, “the person with HIV or AIDS must live with the resulting uncertainty all the time: the uncertainty of diagnosis, of prognosis, of reactions of friends, families, loved ones of anonymous and fearful or hate-filled others. Everyone else must live with the uncertainty too: the uncertainty bred of risk, of possible infection, of not

186 knowing, of loss” (1995: 17). For Weeks, uncertainty about AIDS bred anxiety and fear: about the past, and for the present and future,

Yet the truth of AIDS is that its impact is not predetermined, but haphazard. There is no straightforward correlation between lifestyle and HIV infection. The virus itself, though potentially potent in its effects, is itself a relatively weak one. People who ‘do risky things’ do not necessarily fall ill. As yet ill-understood co-factors (way of life, general health, incidence of poverty and other diseases) may ease the way; but a high element of chance determines who will get HIV, and then who among these will succumb to opportunistic diseases. (1995: 17).

So the formulations of Bauman, Lupton, Giddens and Weeks all illustrate that uncertainty, fear, anxiety and morality concerns in late modern societies can be strongly associated with many areas within the broader sphere of HIV and AIDS. It is not surprising then the political upheavals and stigma and discrimination that the arrival of AIDS in the world caused. However, Giddens does offer some hope in the sphere. Giddens’ concepts of ‘sequestration of experience’ and ‘fateful moments’ suggest that with the existential insecurities and anxieties that come from moral problems or at times of personal crisis also comes the potential or opportunity for people to respond creatively and proactively, to empower themselves in making life political decisions. Sexuality, relationships (particularly their formation and cessation), illness and death are all identified as examples of these fateful moments and AIDS has been described as a life political issue ‘par excellence’ that highlights new risks and contingencies that threaten the reflexive self (Heaphy 2007: 163). Life political issues also offer the opportunity for people to act collectively and proactively in a sphere of particular concern, such as HIV and AIDS (forces of both unity and fragmentation acting with the same sphere or upon a particular life political issue).

However, this is not yet the end of the story. As previous chapters have illustrated, relationships themselves have also been singled out by some authors as particular sources of anxiety and uncertainty. In earlier work Bauman connected ‘free floating post modern eroticism,’ – which he argued was ‘decoupled from both sex and love’ – with “an exhilaratingly vast freedom but also the cause of extreme uncertainty and anxiety” because in late modern relations there were “… [n]o authoritative solutions to go by, everything to be negotiated anew and ad hoc …” (2001: 230). This anxiety caused through constant negotiation is pertinent to both relationships generally

187 (Giddens’ pure relationship) and negotiated safety as interview material has illustrated, but it is also pertinent to the epidemic and learning to live with risk of HIV more generally. I am reminded here of the comment made by Worth et. al. that in late modern societies gay relationships, while burgeoning and diverse through increased societal tolerance, are also characterised by the anxiety brought from negotiations of socially, ethically and sexually complex hazards (2002: 238). That great new site for gay connection, the internet, comes in for some scrutiny by Bauman in this context who is of the view the increased speed, ease and commitment free connection (‘light and loose’ relationships) it offers has a downside. Its fleeting and impermanent nature also breeds confusion, uncertainty and anxiety (2003: xiii). Again, the theme of the future is also discussed, “[t]he smaller your mortgage loan, the less insecure you’d feel when exposed to the fluctuations of the future housing market; the less you invest in the relationship, the less insecure you’d feel when exposed to the fluctuations of your future emotions.” (2003: 21).

By using Bauman’s and others’ arguments on displaced fear and anxiety in late modern societies I do not mean to suggest that the study of risk of HIV infection, or, indeed, the debates around negotiated safety and the development and implementation of TTTT, are misguided, or not real, or misplaced, or misunderstandings. Rather I am illustrating that the sphere of HIV more generally, let alone prevention and risk of HIV infection, is an area that is fraught with anxiety, uncertainty and complexity. Since the enlightenment western societies have been relying increasingly on technological fixes and the rationality of science to expunge all dangers, hazards, and harms from day to day living, and so now there is an expectation that life can be lived free from any outside threat or risk. Sometimes it seems as if, in the area of HIV prevention, there is a similar belief that all HIV infection can be prevented through appropriate health promotion campaigns and other peer, community and outreach education (see for example Ekstrand et. al. 1993). While an admirable aim it seems unlikely that this lofty goal will ever be reached. There will always be those who through a combination of personal and interpersonal factors, as well as wider structural disadvantage, will always be (or will always put themselves) at risk of HIV infection. Characterised by Bauman, and Beck before him, as one of the key components of late modern or risk societies it is surely worth contemplating as a powerful influence in the formulation of future approaches and campaigns in the area.

188 The following chapter will address Kippax and Race’s social public health (2003) and its connection to the concept of agency found in anthropology and sociology. It will then discuss Bourdieu’s habitus (1977) and how it may be useful in drawing together and moving beyond theoretical themes outlined so far. The chapter continues with a discussion on AIDS Organisations and information provision and the ongoing history of the concept of negotiated safety as well as broader socio-cultural factors affecting HIV prevention now and into the future.

189 8. Resistance and Agency

This chapter begins with a discussion of Kippax and Race’s social public health (2003) and its connection to the concept of agency found in anthropology and sociology. It then goes on to outline how Bourdieu’s habitus (1977) can reframe the continuing history of HIV prevention, the HIV sector, and indeed societies learning to live with the epidemic. A discussion about how applying the concept of habitus to HIV prevention can go beyond a ‘social public health’ follows. The chapter continues with a section on AIDS Organisations and information provision and the ongoing history of the concept of negotiated safety as well as broader socio-cultural factors affecting HIV prevention now and into the future.

So following on from the discussion in the previous chapter then, how do gay couples navigate the socially, sexually and ethically complex waters of HIV risk in the face of fear and uncertainty, both at the societal and relationship levels? Much of the emphasis on managing the risk has been placed on individuals. The science of calculating probability of HIV infection, as expressed through epidemiology, while dealing with data at population or group levels, tended to locate the risk in the individual. Modelling the epidemic relied on rational epidemiological methods that measured variables such as risk exposures, rates of condom use and numbers of partners with only passing reference, if any, to the broader socio-cultural contexts that shaped the lives (sometimes profoundly) of the individuals under study. Kippax and Race described the situation in the following way, “[m]edical science most frequently positions risk as a problem for individuals – understood as the individual members of particular populations or groups. Categories of those at risk, ‘risk groups,’ were enumerated by epidemiology: gay men, drug users, and sex workers were typically named …” (2003: 2). This epidemiological construction of risk coincided with other societal forces that were emphasising individualisation, and also incorporating sexuality into concepts of the individual and (sexual or personal) identity. Giddens spoke of ‘reflexive projects of self’ in which sexuality and intimacy played key roles (1992: 175). Clearly this broader historical context has played a part in the ideas of love and intimate relationships being a life journey within which individuals negotiate the terms and conditions of that love, including what sexual practices will be engaged in within the relationship, perhaps the possibility of sex outside that relationship in

190 some instances, and in the case of some gay men, the possibility of not using condoms for anal sex if both partners have the same serostatus.

Ryan (2005) connected the emphasis on the individual and identity in late modern societies with a new form of public health that advocated the self management of illness, “… by the 1970s a new regime of public health had begun to emerge that emphasized the importance of anticipating and preventing the emergence of undesirable events such as illness through techniques of self management” (2005: 209, emphasis in original). She went on to outline the relationship of this self- management with sexual health and avoidance of risky sexual practices, where the individual, rather than the state, should protect themselves from risk.

This new regime of public health developed at a time when attitudes and behaviours around sexuality had been liberalized. These changes, in combination with the appearance of AIDS as a potent new sexual threat, have contributed to a form of public health around sexuality that has produced new forms of knowledge about risky sex as the main threat to the public’s sexual health. The response from the regime of the new public health to sexual risk is that it is best managed through the technique of health promotion (2005: 209, emphasis in original).

The area of HIV prevention and education, and so campaigns about negotiated safety such as TTTT, are specific examples of this new form of public health knowledge (health promotion) put into practice. However, in Australia and New Zealand the sector’s simultaneous committment to a communitarian model, as outlined in chapter three and traced through the debates about negotiated safety in subsequent chapters, meant that the emphasis on the individual was lessened and combined with other more collective ways of thinking about HIV and AIDS prevention and education (see chapter five and Murphy and Ellard (2006) for discussion on collective versus individual approaches in HIV prevention). HIV and AIDS social research in Australasia was sympathetic to this approach. Kippax and Race commented that while social scientists did not ignore epidemiologically constructed risk groups, they focussed attention on practices of groups rather than behaviours of individuals. As they explained, “…‘practices’ unlike ‘behaviours’ are socially produced between people, intersubjectively, and are subjectively meaningful. Social practices inform particular behaviours or actions by particular individuals on particular occasions in particular locations and contexts” (2003: 3). Lupton described this as risk being

191 located “at the level of the local, the private, the everyday and the intimate” (1999: 108).

So within the private intimate sphere of gay life knowledge of risk of HIV infection from medical and epidemiological, as well as the more communitarian health promoting educator, perspectives is integrated and made meaningful. Kippax and Race describe this process as gay men appropriating, incorporating, or ‘enculturating’ medical and social scientific knowledges into their everyday lives to make HIV prevention and harm reduction work for them (2003: 1). This is not a process to be taken lightly as the survival of the individuals concerned could well be at stake. As Kippax and Race wrote, “[t]he case of HIV suggests that there is something important about how the risk sciences’ determination of objects (e.g. whether risk is located in terms of promiscuity or unprotected anal intercourse) must be entertained in conversation by the human subject to whom they pertain and for whom they are meaningful – and who ultimately must invent ways of modifying their … practice if they are to survive” (2003: 9).

Previous chapters have illustrated that TTTT was developed and implemented as a harm minimisation strategy that acknowledged and addressed the fact that gay men made their own assessments about risk in relationships. This was part of a wider debate in prevention about the ongoing interaction of gay men’s knowledge and practices with medical and epidemiological constructions of risk and technological advances in the field such as HIV antibody and viral load testing (see for example Race 2001 and 2003; Kippax and Race 2003). Embracing this perspective and applying it specifically to negotiated safety, Kippax and Race described how, using this line of thought, they arrived at their concept of a “social public health” – an argument about negotiated safety as an expression of gay men’s agency, resistance and sexual freedom.

While ‘dispensing with condoms’ within a monogamous relationship or a negotiated safety agreement may comprise the same behaviour, the practice constituted in the socially produced meanings of ‘dispensing with condoms’ is very different. In negotiated safety, there are no assumptions of HIV-negative seroconcordance and current and continuing fidelity, and men, acting as agents, make sense of the risk of dispensing with condoms within their relationships (both serially monogamous and sexually open) and modify their practice in a

192 comparatively safe way. Public health informed by social science, which was in turn informed by what was going on (empirically) among gay men, acted to strengthen and publicise what was working and authorised negotiated safety. We refer to this socially informed public health as social public health and distinguish it from traditional public health with its focus on structural social and economic determinants. We also distinguish it from a ‘modern’ public health that is sometimes referred to as the ‘new’ public health, which is informed by epidemiology and medical science (2003: 4).

As well as moving away from traditional concepts of public health, and the ‘new’ public health of self management as described by Ryan (2005), this argument is also an interesting development of the concept of agency in HIV prevention, in which gay men’s collective and active engagement with medical knowledge is emphasised and individual behaviour change and epidemiological constructions of risk are recast in this light. It would seem this is at least one way for gay men in relationships to address, engage with, and negotiate the sexual, social and ethical complexities around love, intimacy and risk of HIV infection in late modern societies. It is also the sympathetic approach to prevention that I hoped for in the 1980s and 1990s, one that acknowledged the social context in which gay men lived and had sex, one that acknowledged the humanity or agency of those belonging to affected groups.

However, there are limitations with the concept of a social public health. First, while acknowledging that medical and social science knowledge is integrated with the meanings and practices of gay men’s every day lives, a social public health does not get beyond the dichotomy between the agency friendly communitarian approach and the more restrictive dictatorial behaviourist approach. Bourdieu’s concept of habitus (1977) may provide a way past this difficulty. Second, the concept of a social public health is still very much framed within the bounds of HIV prevention discourse, namely gay men’s engagement with medical and social knowledge is seen primarily as a sexual agency. A broader theoretical framework of agency drawn from social science more generally – social theory of agency and resistance, and the related structure and agency debates found in anthropology and sociology – might shed light on the use of agency arguments in HIV prevention and education.

Race also pointed out another limitation with the concept of a social public health: that not all gay men are engaged with and understand medical, social science and HIV prevention information and knowledge, or are active within gay communities where

193 such knowledge could be contextualised, discussed, interpreted or passed on. He coined the term “homosexually and scientifically active men” for men who were engaged in such a fashion commenting, “[i]t must be remembered that dispositions toward medicine are by no means even … practices emerge in the context of highly sexually and HIV/AIDS literate sub populations of gay men” (2003: 370 – 371). In later work Race also warned “[t]he use of medicine within gay sexual repertoires raises a number of challenges for HIV educators, not least the challenge of enhancing the safety of these practices.” He went on to argue that this involved more than simply supplying people with information about risks of various practices and also “more than a celebration of agency” (2004: 219). As he explains:

Upon the identification of the workings of medicine in gay sex, the field of HIV prevention in Australia became prolific with accounts of ‘sophisticated gay men making complex decisions to reduce risk’. At times, these descriptions seemed to verge on a populist romanticism that celebrated every instance of gay men’s appropriation of medicine as though it were inherently safe. We heard a lot about gay men’s ‘cultures of care’ … Often one was left with the impression that all gay educators needed to do was provide a few scientific facts, trust gay men, and put all stock in lived cultures that were inherently resistant, subversive, communal, sophisticated, and safe … After all, if gay culture is inherently well informed and productive of non-problematic cultures of care, there is not much left for health educators to do. (2004: 219 – 220).

This is a timely warning as it may seem at times the descriptions in this thesis of gay men’s proactive response to the earlier epidemic, and their engagement with medicine and prevention to enact more sophisticated risk reduction strategies (and indeed the earlier appropriation of the nineteenth century category of the homosexual into the empowering and self defining gay liberation and wider social and political movement) does sound like a celebration of agency, that gay men’s lived cultures are inherently resistant, subversive, communal, sophisticated, and safe. However, an important theoretical difference in the argument presented in this thesis is the inclusion of an analysis of these empowering and unifying forces also being at times fragmenting and dissociative, spawning complexity and a diversity and a multiplicity of identities. The contradictory nature of these forces has been commented on throughout earlier chapters, and seems to be present in both factors particular to the epidemic itself and to wider social and cultural forces. The complex interplay of elements of structure and agency have both unifying or positive effects and fragmenting or negative aspects that

194 are not always predictable and that do not necessarily equate to the structural aspects having only negative impacts and the agency aspects having only positive effects on people’s lives.

For example, AIDS itself was identified by Weeks as being the whirlwind that devoured yet at the same time the storm that illuminated, reshaped and provided people with the opportunity “to see a coherence in their sense of the world which ordinary circumstances would not have produced” (Weeks 1995: 113). Negative aspects of the nineteenth century category of the homosexual were also the basis of an emerging homosexual identity. Identity politics played a central role in the formation of gay liberation and the resulting broader social and political movement that was instrumental in a rapid community led prevention response to the onset of HIV and AIDS. Later identity politics played a more fragmentary role with the rise of HIV positive identities and the growing diversity of gay, queer and other sexually ambiguous identities. The initial unity of the safe sex message was later fragmented by a positive voice and by gay men’s more sophisticated risk assessments, and by the continuing impact of the epidemic itself – Odets AIDS fatigue (1995a) – the arrival of treatments, and the fragmenting of gay identities through the influence of post- modernism (Dowsett’s (1996a) post-AIDS era). The concept of gay community attachment, initially a unifying force for instituting and maintaining safe sex practice (Kippax et. al. 1993a), later became more fragmenting as gay community was reconceived as a more complex, nuanced and for some even an alienating concept (Ridge, Minichiello and Plummer, 1997). Schoofs and his comments about the contradiction between the ideology of gay liberation and the supposed/assumed intimacy and security of long-term relationships can also be interpreted as having contradictory elements, an attempt by gay men to have it all, “ ... eros and agape, hot sex and intimacy” (1995: 38). Similarly Worth’s comments about the symbolism of the condom, representing both life and death (1998) and Middlethon’s study (2001) that found condom use and non-use symbolised both trust and lack of it in a partner as a request to use condoms could indicate the possibility of sex outside the relationship while a request not to use condoms could indicate trust, but also raised the question of whether the partner was trustworthy.

195 Those factors that could be described as more generally connected to the broader social and historical context of late or post-modernity have also been commented on in previous chapters as having both unifying and fragmenting aspects. Gidden’s concept of fateful moments indicate the potential for a wide range of life events to be either empowering and life affirming or destructive, anxiety producing and existentially and/or morally shocking. Beck’s conceptualisation of risk also contains contradictory elements. Risk of disease, let alone the onslaught of epidemics and pandemics themselves, can unify and be powerful social and historical forces for change as previous comments about AIDS attest, but at the same time disease, or the risk of it as the contain and control sentiments of early attempts to stop the spread of HIV illustrate, can be discriminatory and destructive. Within the conceptualisation of risk lies another contradiction, that by calculating probabilities we believe we have understood, controlled and perhaps even avoided risk, but in fact the risk to the individual is no better understood or predicted. I argue that Bourdieu’s concept of habitus (1977) provides a way to conceive of these unifying and fragmenting elements of both structure and agency differently, by moving away from the structure/agency, subject/object dichotomies that plague some theory in the area, instead suggesting that each is constitutive of, and generated by, the other (1977: 72).

However, before doing this it is first necessary to briefly outline the concept of agency in social science in order to discuss how this is a broader concept than simply a sexual agency, and also how Bourdieu’s habitus fits within this debate. It will then also be possible to discuss how the concept of habitus may overcome the dichotomy between the agency friendly communitarian approach and the more restrictive dictatorial behaviourist approach to HIV prevention.

Agency and Habitus

Inden (1990: 23) defined human agency as “the realized capacity of people to act upon their world and not only to know about or give personal or intersubjective significance to it. That capacity is the power to act purposively and reflectively, in more or less complex interrelationships with one another, to reiterate and remake the world in which they live, under circumstances where they may consider different courses of action possible and desirable, though not necessarily from the same point of view” (quoted in Holland et. al., 1998: 42). It is immediately obvious from this

196 definition why such a concept is applicable to negotiated safety and other risk reduction strategies where gay men make sense of risk of HIV infection by engaging actively and critically with medical, social scientific and prevention information. However, this interactive subjectivity and reflexivity is engaged in across all aspects of life, not just those relating to sexual activity or health management. Giddens’ reflexive projects of self – the restructuring of a past to conceive of and generate a life narrative into the future – while focussing on love and intimacy in the context of relationships, is a general concept that could equally be applied to other areas of life such as career, or for that matter an individual’s ‘life story.’ Giddens’ concept of fateful moments encapsulates a wide range of life events that have the potential to be both empowering and life affirming or destructive.

However, in the context of structure and agency debates this reflexive engagement is not a simple or straightforward matter. It involves constant struggle, negotiation with and resistance to the powerful social structures – following Foucault (1978), in the form of historically constituted institutions and related discourses – that run parallel to, and, I will argue using Bourdieu’s habitus, integrated with (and to a large extent determinant of) human subjective life. Holland et. al. discussed the relative powerlessness of agency compared to large-scale structural determinants of social and cultural life. As they wrote, “[s]ocially constructed selves … are subject to positioning by whatever powerful discourses they happen to encounter … Perhaps they are resistant to such social forces; they nonetheless remain provisionally at their mercy” (1998: 27). Giddens has also been criticised for placing too much emphasis on agency at the cost of his analysis of power and dominating structural forces. Jamieson argued this in the context of heterosexual relationships, pointing out that Giddens was too optimistic of the pure relationship and its potential to overcome structural gender inequality (1998: 40, 134). Heaphy has also argued, referring to Jamieson’s work, that Giddens overplays agency and undermines structure (2007: 131). He goes on to point out that some feminist thinkers have also claimed Giddens ignores power (2007: 138 - 147). In their discussion of collective identity and how it is built through shared definitions in the context of new social movements Johnson, Laraña and Gusfield referred to a process of “ … interaction, negotiation and conflict over definition of the situation” as ‘laborious adjustment’ (1994: 15). While not referring to large scale social structures or structure and agency debates specifically, this phrase captures the

197 element of continuous struggle against overwhelming odds embodied in human agency – and perhaps the fatigue and hopelessness that arises from this struggle, but also resistance and hope for change, as does Giddens’ fateful moments to some extent. It also characterises the negotiation and conflict around definitions, redefinitions, arguments and debates about negotiated safety and TTTT, as well as HIV prevention generally.

Bourdieu, while remaining a popular theorist in the social sciences, has gained currency in other fields in recent years due to his discussions of the processes of social reproduction in education and its relationship to social and cultural capital (Bourdieu and Passeron 1990; Bourdieu 1977). Policy makers, governments and academics alike have been attracted to the idea of social capital that seems to speak to community resilience, connectivity, and revitalisation – issues of concern in late modern societies where, following Beck (1992), Bauman (2001, 2003, 2006, 2007), and many other theorists, it would seem many perceive this breakdown of traditional kinship bonds and community values as a problem.

However, it is Bourdieu’s concept of habitus that is central to this discussion. Without going into the minutiae of Bourdieu’s arguments, or the detail of the structure and agency debates in anthropology and sociology, suffice to say that habitus overcomes a problem that often rears its head in theoretical discussions about structure and agency, either that too much emphasis is placed on the all encompassing and determinant nature of structure, with little or no room left for agency or resistance to impact on these structures, or, conversely, that too much emphasis is placed on human agency, resistance, identity, subjectivity or reflexivity compared to powerful and determining social structures, institutions, ideologies and discourses. Bourdieu’s habitus gets round this impasse by proposing that structure and agency, and all the corollary and/or dichotomising subject/object arguments that attempt to define and describe them separately, are essentially part of the same much wider and all encompassing social processes.

So what is habitus? It is difficult to get a sense of what exactly habitus is by reading Bourdieu’s original text (1977: 73 – 95). Perhaps this is in part due to the processes of translation, but also because of the density and complexity of the concept and the

198 text.45 However, many commentators have interpreted his work when applying it to their own particular spheres of interest (Maton 2008: 50). I turn now to both Bourdieu’s original text and some of the latter interpretations to tease out the definitions of habitus and the related concepts of practice, fields, and the various ‘capitals.’ First, the thing he is perhaps most well known for, the emphasis on “practices.” In order to escape what he described as the ‘realism of structure’ and the primacy of experience of the researcher during observation (in ethnographic work), Bourdieu proposed it was necessary “ … to construct the theory of practice, or, more precisely, the theory of the mode of generation of practices, which is the precondition for establishing an experimental science of the dialectic of the internalisation of externality and the externalisation of internality, or, more simply, of incorporation and objectification (1977: 72, emphasis in original), what Maton described as how the ‘outer’ social and ‘inner’ self help to shape each other (2008: 50). In this conceptualisation Bourdieu is already moving away from the structure/agency, subject/object dichotomies that are common to theory in the area46, and suggesting instead that each is constitutive of, and generated by, the other. Bourdieu goes on to say that the structures that determine a particular environment, such as the material conditions of existence for a particular class, produce habitus that he defined as:

… systems of durable transposable dispositions, structured structures predisposed to function as structuring structures, that is, as the principles of the generation and structuring of practices and representations which can be objectively “regulated” and “regular” without in any way being the product of obedience to rules, objectively adapted to their goals without presupposing a conscious aiming at ends or an express mastery of the operations necessary to attain them and, being all this, collectively orchestrated without being the product of the orchestrating action of the conductor (1977: 72).

And here the key aspects of Bourdieu’s habitus are already explicit, both internal and external, both structured and structuring. It is structured by an individual’s past and present circumstances, for example family environment and educational experiences. It is structuring in that the individual’s habitus helps to shape present and future

45 Maton describes habitus as “an enigmatic concept” and as “one of the most misunderstood, misused and hotly contested of Bourdieu’s ideas” (2008: 49).

46 As Maton states, “[h]abitus is intended to transcend a series of deep-seated dichotomies [and] structuring ways of thinking of the world” (2008: 49).

199 practices. It is structured because it is ordered and patterned, not random and unpatterned. This structure “compromises a system of dispositions which generate perceptions, appreciations and practices” (Maton 2008: 51). Dispositions are durable because they last over time and transposable because they are “capable of becoming active within a wide variety of theatres of social action” Maton goes on that habitus is therefore “structured by conditions of existence and generates practices, beliefs, perceptions, feelings and so forth in accordance with its own structure (Maton 2008: 51).

So habitus is determining yet undetermined and capable of change into the future, habitus unconsciously shapes and generates the practices of individuals and collectives through history and time and in so doing continues to reproduce, multiply and adapt itself. This shaping occurs through ‘the playing of the game’ of life, and through the interaction of various capitals and fields (Bourdieu and Wacquant, 1992; Bourdieu 1993) – all important concepts in Bourdieu’s formulation. According to Maton, practices are the result of an unconscious relationship between habitus and field. Practice results from relations between an individual’s dispositions (habitus) and their position in a field (capital) “within the current state of play of that social arena (field)” (Maton 2008: 51). In the following discussion, and for remainder of this thesis, it is from this formulation that the terms ‘practice’, ‘disposition’, ‘field’ and ‘capital’ are used.

Adams connects fields back to a collective and historical concept of habitus, but also points out how subjects can act as agents having some (limited) ability to interact with and change how they play the game, how they negotiate the various aspects of the fields in which they are simultaneously constituted and yet also actively engaged:

The habitus engenders countless practices, which, as they reverberate in specific fields of action, reconstitute it in a loop of agency and structure. Fields limit what we can do, make some actions more possible than others, or encourage a certain bodily deportment rather than another, but there is often an opportunity to ‘play the game’ in more than one way …. Agency and autonomy are embodied in the concept of habitus, but they are qualified by the caveat of accumulated history, both personal and collective … (2006: 515)

According to Bourdieu fields are social spaces, ‘patterned systems of objective forces’, a “relational configuration endowed with a specific gravity which it imposes

200 on all the objects and agents which enter in it,” and as well there is the broader conceptualisation of collections or bundles of fields, ‘the field of fields’ that make up the social classes to be considered (Bourdieu and Wacquant, 1992; Bourdieu 1993). As Adams put it:

The field refers to the always existing, obligatory boundaries of experiential context …We move through different fields but the collection of fields we confront tends to be common for different social groupings (e.g. class). Fields engender and require certain responses, ‘hailing’ the individual to respond to themselves and their surroundings in specific ways to the point of habituation. ‘Habitus’ is the collective term for this array of dispositions. Thus, the field instantiates us as subjects and reproduces social distinctions via the enactment of habitus (2006: 514).

In their discussion of immigrant Samoans in Auckland, New Zealand, and how habitus may be applied to understand changes in the next generation, with particular reference to reproduction, both biological and social (the “sex/gender/kinship nexus at the heart of social reproduction”) Park and Morris interpreted field as “… a ‘field of forces’ as well as a ‘field of struggles’ in which agents are engaged” (2004: 235). Thomson interprets Bourdieu’s use of the concept of field and its relationship to capital in the following way: “ … the game that occurs in social spaces or fields is competitive, with various social agents using differing strategies to maintain or improve their position. At stake in the field is the accumulation of capitals: they are both the process within, and the product of, a field” (Thomson 2008: 69). Capital can be economic, cultural, or social. Cultural capital can be: bodily, as in way of dressing and speaking; valued cultural goods or knowledge; and can be institutionalised in educational qualifications and other forms of social recognition of status. Social capital can include group and community memberships, resources, bonds and social networks (Thomson 2008: 69; Park and Morris 2004: 235).47

This connects back to ideas of resistance discussed earlier in this section in which agents struggle against and resist powerful structural determinants, yet in this formulation this struggle occurs through a complex interaction of habitus, fields and capitals. As with other authors, Park and Morris note the unconscious (or not fully

47 Moore provides a much more detailed discussion of the various forms of Bourdieu’s capitals (2008: 101 – 117).

201 conscious at least) nature of habitus, and the relationship between habitus and field, “actors are not imagined as having a fully conscious strategy of engagement. Where habitus points to subjective dimensions, field calls up the social and material relations in which that subjectivity is enmeshed” (2004: 235). They then go on to outline what happens where habitus runs up against fields that are divergent from those in which it was constituted, “it acts as a structuring structure able to selectively perceive and transform the objective structure” and in the process is changed itself (Bourdieu quoted in Park and Morris 2004: 235).

Park and Morris also discussed Bourdieu’s concept of the interrelatedness of fields. Fields are connected by what he calls a ‘field of power’, defined as “the relations of force between different kinds of capital [and] between the agents who possess a sufficient amount of one of the different kinds of capital to be in a position to dominate the corresponding field, whose struggles intensify whenever the relative value of the different kinds of capital is questioned” (Bourdieu 1998: 43). Other authors discussed how, in times of crisis (described by some as endemic in the late modern era), “… individual movement between fields is increased, the boundaries between them blurred, and fields themselves become subject to ‘rapid, pervasive and ongoing changes’ (Adams, 2006: 520). There is little doubt that the onset of the HIV epidemic was a crisis that caused shifts, struggles and contestations, both individual and collective, across many fields. Park and Morris explained the relationship between changing circumstances and environments, practice and consequently altered habitus in the following way, “ ... [i]n new environments habitus shifts to fit the new set of circumstances … Habitus alters as an outcome of strategies to avoid the negative sanctions that practices no longer well fitted to the new environment attract. Social and cultural capitals that have value in one field may not find value in another” (2004: 256).

Of course there is much more that could be said of Bourdieu and his theory of practice but for the purposes of this discussion it must now be limited and applied to the situation under scrutiny. It is quite clear that the above discussion of agency and resistance, and lastly, Bourdieu’s conceptualisation of habitus and fields goes well beyond the sexual agency that is discussed by Kippax and Race (2003) in the context of a social public health. In particular, Bourdieu’s habitus spans across and integrates

202 all social life, both at the individual and collective level, as well as through history and time, and indeed through the social, bureaucratic and political institutions of society. The discussion of fields and the various capitals set in motion against each other can shed a lot of light on the concepts of gender, sexuality, sexual identity, and ‘gay’ in western societies, and indeed on the interaction of the various players in the HIV sector and finally on HIV education and prevention and on factors acting on educators’ individual and collective practice, including negotiated safety and TTTT. It is this discussion that will be taken up in the next and final chapter, the conclusion to this thesis.

Prevention Now and into the Future

The Practice of HIV Prevention

The previous section has illustrated that the continuing history of struggle and resistance of agents against powerful structural determinants can be conceptualised as part of an even bigger picture characterised by, following Bourdieu (1977), the complex relationships between practice, habitus, fields and the various capitals. Many of the theoretical themes discussed so far can be reframed within this conceptualisation. Historical shifts in social structures, ideology and institutions around sex, sexuality, sexual identity and gender has been associated with newly emerging capitalist states and their interest in regulating the sexuality of populations (see for example Foucault, 1978: 25 – 26; Weeks, 1985: 74). These shifts have resulted in changes in numerous fields, and the production of new fields, and large scale changes in fields of fields (in the case of alterations to the various ‘fits’ of everyday life dispositions and practices (habitus) brought about by changing material conditions and class transformations associated with the rise of industrial capitalism).

This process has continued over time and through history. The first historical moment most relevant to this discussion is the formation of the category homosexual in the nineteenth century from various knowledge-power discourses, particularly those of medicine, the law and the church. The next pivotal historical moment was the heightening of these ongoing changes starting from the mid twentieth century and continuing through to today. Against the backdrop of increasing disquiet towards traditional institutions and authority, the social change of the 1960s and the rise of liberation (black, feminist, gay) social movements – with accompanying reflexive

203 narratives of self around ethnic, gender and sexual identity – can be seen as another moment of accelerated change in fields around ethnicity, gender and sexuality. Gay liberation movements around the world slowly began to change ideas of homosexuality as moral and physical sickness to newer constructions of ‘alternative’ personal and sexual identities. Gay life narratives, reflexive projects of gay selves soon followed. Giddens and his concept of the ‘pure relationship’ (1992) can be seen as a realignment or creation of new social spaces within the fields of gender, sexuality, and individuality. While the concept of the pure relationship may not be the whole picture, as Jamieson’s critique (1998) suggested, it is at least a powerful influence (even if only as an ideal) in conceptualisations of intimacy, love and relationships in late modern societies. Perhaps the sexuality/morality concerns noted by Weeks (1995: 4), the risk categories enumerated by Lupton (1999: 13 – 14) and the displaced societal angst, fear, and uncertainty generated by globalised capitalism and the breakdown of traditional ties, institutions and communities described by Bauman (2006, 2007) and Beck (1992) are all responses to the increasing complexity of everyday life (including negotiating individuality and balancing it against love, sexuality, intimacy and relationships) and the associated competing explanations, struggles, negotiations, and renegotiations of various capitals that accompany the realignment, redefinition and creation of numerous fields – processes that are accelerating in late modern societies. Similarly the contradictions (elements of structure and agency having both unifying and fragmenting aspects) seen in many of the factors relating to the HIV epidemic itself, and the wider social and cultural forces acting on HIV prevention can also be recast as renegotiations of various capitals that accompany the realignment, redefinition and creation of numerous fields. It is also an illustration of how people can be seen not simply as passive reactors to and enactors of some ‘system’, but as active agents and subjects of their own history” (Ortner 1984: 143), as Ortner puts it, “history makes people, but people make history” (2006: 2).

As chapter seven discussed the theme of crisis is seen as endemic by some in the late modern era (Adams, 2006: 520), and the risk categories and morality concerns described above have particular resonance in the sphere of HIV and AIDS. The AIDS epidemic was a crisis that caused shifts, struggles and contestations, both individual and collective, across many fields. Dowsett spoke of ‘HIV habitus’ which he

204 described as an ‘ongoing reflexivity, an interrogation of behaviour, experience, bodies and the circumstances of sex’ (2004). Race’s ‘scientifically and homosexually active men’ (2003: 371) could also be seen as embodying this HIV habitus, as they engage in the redefinition and renegotiation of gay men’s sexual practices, hence collectively creating new social spaces within, and perhaps even changing, fields such as ‘gay’ (which could include aspects of fields concerning gender, sexuality, sexual identity, masculinity, femininity, family and marriage), public health, risk in general and risk of HIV infection in particular. Kippax and Race’s social public health (2003) as outlined in the previous chapter can be seen as another example of gay men engaging with and redefining these fields.

HIV prevention and education must be placed in the context of these shifts, negotiating and indeed, in some instances, itself creating new social spaces within relevant fields. However, there is some difference between the range of fields encountered by gay men and those encountered by educators (even though many HIV educators are self identifying gay men). The sphere of HIV education and prevention must also grapple with intersecting interests and various capitals from the rational sciences (medical and epidemiological), the social sciences, sexual health, social and public health policy as well as risk management and ideas specific to campaign development such as the health belief model, health promotion, social marketing, and community empowerment. Medical and scientific practitioners had arrays of social and cultural capitals that trumped social science, educator and affected group capitals in the early days of the epidemic. It will be recalled the heroes of science were to save society from the ravages of the disease by identifying the causal agent and thereafter extinguishing its action with an appropriate cure. This afforded proponents of the area much social and cultural capital. Stigma and discrimination associated with affected groups ensured they had low social status and little access to the privileged knowledges of epidemiology and the risk sciences. Social sciences fared better than affected groups by virtue of their capital as scholars at least, but still the more qualitative, descriptive and theoretical arms of disciplines such as anthropology and sociology could not make (and did not wish to make) the claims to rationality and truth that the sciences were able to, and hence could not compete on the same footing. However, there was much fear of, and uncertainty about, casual agents even within science at the onset of the epidemic. So although medicos and scientists had the social

205 and cultural capital to dominate the area initially, it was much more contested than other areas of medicine and science because of the shifting ground of numerous fields within the sphere of HIV.

Members of affected groups, and soon after educators emerging from these groups, were instrumental in shaping prevention approaches in Australasia, largely due to progressive governments and partnership approaches to public health, as chapter three illustrated. As the epidemic progressed input grew from social science and newly formed AIDS organisations (who had been charged by governments with the responsibility of carrying out HIV education and prevention). Agency and resistance discourses from first gay liberation and then a wider social and political movement48, and also other social movements, led to greater influence of ideas such as community development and empowerment, and acceptance of community and affected groups being best placed to do prevention. Debates began to shift to more social ground. Social and cultural capitals shifted and the more rational scientific approach became less dominant. An article acknowledging the value of community-based prevention in the prestigious medical journal The Lancet (Coates et. al., 1996) is a striking example of the medical sphere giving ground to a more social approach.

Remaining most resistant to these shifts in HIV-related fields was the area of risk, perhaps because of its strong links to rationality and the need for populations to feel that risks, hazards, dangers and harms characteristic of the late modern period could be predicted, prevented or avoided through the reason of mathematics, in particular probability and statistics (in the area of HIV and AIDS, the science of epidemiology). But as Beck observed, ‘there are no experts in risk’ (1992: 29). As chapter seven illustrated, risk is socially constructed.

So it was onto this complex stage that TTTT was to step. As chapter five discussed, TTTT created a social space for educator, policy maker, academic, and gay man alike

48 In Masculine Domination Bourdieu made the comment that “… the gay and lesbian movement brings together individuals who, although stigmatized, are relatively privileged, especially in terms of cultural capital …” and because of this the movement “… tends to atomize into sects engaged in struggles for the monopoly of the public expression of the group” (2001: 123). This is an interesting comment as it suggests another reason why contestation around many issues, including HIV prevention approaches, is perhaps heightened in lesbian and gay communities.

206 to discuss anal sex without condoms in relationships. While not constituting a field within and of itself, TTTT created a new social space within existing and intersecting HIV related fields in which the conversation about anal sex without condoms in gay relationships could take place.

Beyond a ‘Social Public Health’

So, bearing in mind this reframing of many of the theoretical themes so far discussed, it is now possible to see how this characterisation of HIV prevention can get beyond the dichotomy still present in Kippax and Race’s social public health (2003): the idea that the communitarian social public health approach, of which TTTT is an early example, is agency affirming, while the individualistic rational health belief behaviourist approach is deterministic and agency unfriendly. While broadly speaking this may be the case, and hence the value of the concept of a social public health applied to HIV prevention, there are a couple of troubling inconsistencies and contradictions apparent in the idea.

First, HIV prevention via the framework of the health belief model while rational, and assuming a linear relationship between knowledge, attitudes and behaviour, also allowed for a collective and community empowering or agency friendly dimension to be incorporated. Lupton noted that the health belief model operated by individuals recognising they may be at risk and taking preventive action to avoid a serious health threat (1999: 21). Early prevention efforts in both Australia and New Zealand took their lead from San Francisco, as chapter three detailed, and incorporated the idea into the health belief model that support and information from affected communities (and community connected AIDS organisations) could improve the chances that an individual would recognise they were at risk. Furthermore, these communities and organisations could support behaviour change of individuals, and make the change sustainable by maintaining this support and information into the future. The Ottawa charter, a strong influence on educator practice in Australasia in the 1980s and 1990s and continuing today, institutionalised this approach by promoting a holistic view of health within a wider framework of community empowerment (Lindberg and McMorland 1996: 110; Edwards 1997: 47). So a deterministic rational health belief model could also be communitarian and agency friendly, again the blurring of

207 positive and negative aspects within the complex interaction of elements of both structure and agency.

The second example of inconsistency in the assumed dichotomy is the NZAF and its view of HIV prevention. The NZAF did not support disseminating a mass media message about negotiated safety via a TTTT type campaign and maintained a condom every time approach (as outlined in chapters five and seven). However, the NZAF educators I interviewed for this study firmly believed theirs was an agency friendly approach that protected the sexual freedom of gay men by expecting only the minimal behaviour change necessary to minimise risk of HIV infection. Indeed, NZAF educators saw their prevention practice as agency friendly, just like their Australian counterparts, even if they did not support the dissemination of a mass media TTTT message. Luke summed the NZAF position in the following way:

NZAF is on side with the gay community by saying this, that we don’t recommend that gay men use condoms for oral sex … we don’t recommend that gay men reduce their number of sexual partners, we don’t recommend that gay men are monogamous in relationships, we don’t recommend that gay men don’t engage in hard core heavy duty sex, we don’t recommend that gay men don’t have anonymous sex … We haven’t actually asked gay men to do anything bar if you fuck use a condom and that’s seen as the most little interference with gay men’s sexual cultures as we could possibly imagine while maintaining the goal of stopping the HIV epidemic for as many people as possible … we feel a sense of irony that we are sometimes accused of being the condom police or interfering in gay men’s sexual agency. [Luke]

Patton pointed out this view was common to HIV educators generally and stretched back to the beginning of prevention, and indeed beyond that to ideas from gay liberation and feminism, “[r]eliant on a self-help model indebted to the women’s health movement critique of health care and to the gay liberation discussion of sexuality, safe sex was viewed by early AIDS activists, not as practice to be imposed on the reluctant, but as a form of political resistance and community building that achieves both sexual liberation and sexual health” (1990: 42).

Other inconsistencies, contradictions and subtleties were apparent in the interview data. As now has been discussed at length, there were New Zealanders who supported TTTT, there were Australians who opposed it, and there were subtleties in arguments supporting and opposing TTTT on both sides of the Tasman. Some supported TTTT

208 being disseminated as a mass media message, some did not. Some thought a TTTT type message might be appropriate for small group peer education or community outreach; others rejected the whole concept as a prevention message. Some saw TTTT as effective harm minimisation; some saw it as ‘harm maximisation.’ Some thought the complexity of TTTT made it an inappropriate prevention message; others thought it reasonable that gay men follow the steps of TTTT. Some felt that the difficulties around trust and honest communication in gay men’s relationships were reason enough to reject TTTT as a harm minimisation approach, others found it patronising or even homophobic to suggest that gay men should not be given the same opportunity as other groups in society to negotiate not using condoms in their intimate relationships.

Bourdieu’s conceptualisation of the complex relationship between habitus, fields, and practice can better encompass, account for, and explain these seeming contradictions, inconsistencies and complexities. The variations in educators’ practices sometimes expressed as practical prevention actions (including developing and implementing particular campaigns about particular prevention issues such as TTTT, or for that matter, opposing them or not wishing to implement them) resulting from their various views, arguments and strategies about prevention can be see as different ways of playing the game, different ways of engaging various available capitals, different ways of interpreting the factors affecting the epidemic (which themselves can be different in different locations as the New Zealand/Australia divide over TTTT in part illustrated) and the broader social and cultural context, different ways of negotiating the intersecting fields that make up HIV prevention and education, academic and policy maker discourse and of course the practices, sexual and otherwise, of gay men. Similarly, academics, medicos and scientists, policy makers, health workers and gay men themselves (and members of other affected groups) are also subject to the same processes as they participate in the ongoing practices that collectively constitute HIV prevention.

This is not to suggest that people are passive automatons in these processes, trapped within dominant and determining structures within which there is no hope for change. The beauty of Bourdieu’s formulation is that agents’ active and self-determining playing of the game is incorporated into, and in fact is a key constituting factor of, the

209 entire system. It is through agents’ collective dispositions and practices, their habitus, that fields can be transformed. The concept of negotiated safety, expressed through TTTT, can be seen as a particularly dense point of intersection of the various positions and practices of HIV prevention. A particularly active transfer point for the (sometimes highly contested) ideas and debates that circulate within the various fields that constitutes HIV prevention.

However, it must be remembered that fields also function as the boundaries around and the ‘force fields’ within which agents can choose to act. They limit and restrict the ways people can play the game within them. Another stumbling block in agents’ active engagement in the processes so far outlined, in this case the active engagement of HIV educators in the various fields that constitute HIV prevention, is that, at least initially, Bourdieu conceived of habitus as the largely unconscious playing of the game. As Adams wrote,

The various characteristics of the habitus are enacted unthinkingly; that is partly what defines them as habitual. The ticks and traits of our established habitus are the result of an experiential schooling stretching back to childhood. The sense of ease in our surroundings – ‘le sens pratique’ (the feel for the game) as Bourdieu refers to it (Bourdieu 1990: 52) – thus develops as an unconscious competence: the habitus becomes ‘a modus operandi of which he or she is not the producer and has no conscious mastery’ (Bourdieu, 1977: 79). (2006: 514, emphases in original)

However, other authors point out that Bourdieu developed his concept of reflexivity considerably over time (Deer 2008). Crossley pointed out that Bourdieu himself was somewhat contradictory on the subject and that some of his work did suggest a measure of reflexivity in habitus. As Crossley wrote, “[c]ontrary to the implication of at least some of Bourdieu’s formulations, reflexive schemas of self-inspection and reflection constitute an integral part of the normal habitus … Becoming a social agent entails acquisition of a reflexive disposition” (Crossley 2003: 55). Similarly Park and Morris wrote that Bourdieu acknowledged “habitus may be changed by social experience and the tensions that occur when fields change” and that “people also intentionally work on their dispositions” (2004: 256). Again raising the theme of crisis Crossley also pointed out that according to Bourdieu periods of crisis could precipitate an elevated, innovative and critical reflexivity (2003: p 48). As he explained it, “ … habitus falls out of alignment with the fields in which they operate,

210 creating a situation in which ‘belief in the game’ (illusio) is temporarily suspended and doxic [deep and broad level unspoken and pre-reflective] assumptions are raised to the level of discourse, where they can be contested” (2003: 44).

It has already been established that the onset of AIDS was most certainly a period of crisis. And it is clear that HIV prevention was an innovative, conscious and critical response to the situation, arsing first out of affected communities but shortly after joined by various arms of government, health bureaucracy and academia. It is also clear that an understanding of the social context of HIV and AIDS required that discourses about a number of aspects of human life and social behaviour be raised to consciousness, and consequently were then contested and redefined. These included aspects of sexuality and sexual practice, as well as assumptions about health behaviour and risk perception, and the mechanisms of stigma and discrimination, among other things. This would not have occurred in the same way, nor perhaps as quickly, had it not been for the emergence of the epidemic.49 Again the theme of contestation is apparent, as it has been through much of this discussion, particularly around definitions and perceptions of risk and appropriate or ‘safe’ risk avoidance strategies. HIV prevention was a nexus for these contested views and definitions, and TTTT a particularly intense expression of this contestation.

AIDS Organisations and Information Provision

So the question of how this all plays out in the lived experience, the practices, the habitus of educators working in AIDS organisations arises, and also the role of AIDS organisations in disseminating prevention messages. The question has been raised twice during the course of this thesis (in chapter four in the discussion of the book Feeling Our Way, and again in chapter seven), do AIDS organisations simply provide information – depoliticised facts stripped of their social context or relevance (if this is even possible) or do they provide recommendations and/or advice, guidance around possible courses of action and interpretation of the information provided? Clearly the prevention model favoured by the particular AIDS organisation in question has some effect on the answer. An individualist health belief or behaviourist model that

49 As Weeks pointed out AIDS provided people with the opportunity “to see a coherence in their sense of the world which ordinary circumstances would not have produced” (1995: 113).

211 advocates a condom every time regardless of context approach does have the tendency to portray prevention as simple information provision. However, as the previous section illustrated, this model can easily be adapted to a more holistic and communitarian approach with the input of frameworks such as the Ottawa Charter, and this leads to adapted health belief models that do take account of the context and meaning of the sexual practices in gay men’s lives. Further, the influence of health promotion and the use of social marketing techniques in HIV prevention campaigns, while focussing on individual motivations, also encompass the social context by taking account of broader community ‘enabling and reinforcing factors.’

Any discussion about the provision of information, decisions about what to discuss, what not to, attitudes about empowerment and what sexual practices to ‘reinforce’ is also intimately connected with educators’ backgrounds and personal experience (including their HIV antibody status) as well as academic disciplines, social and health policy debates and theories that influence the various fields that impact on educator practices. The context of these various influences determines how the subject of prevention is perceived or constructed, as well as determining the answer to questions like what is ‘knowledge,’ and its relationship to a (scientific) subject, or a community of affected individuals, or a political or social movement learning to live with and adapt to an ongoing epidemic.

The interviewees in this study, both Australians and New Zealanders, demonstrated mixtures of these positions depending on the focus of the discussion, but overall tended to lean towards the latter position in the prevention spectrum regardless of whether they supported TTTT as an appropriate mass media prevention message or not. Most educators also said that people will make their own sense of information provided and that the starting point of prevention was to work with what people were already doing, what sexual practices they were already engaged in. As Jeremy and Duncan put it,

I think that whatever the health promotion campaigns are doing they should be tapping into what are the practices and what we know is that some of the practices aren’t about using a condom every time so … my training would suggest that you start with what people are doing …. [Jeremy]

212 But actually always have to speak the language of the audience, be in the environment the audience is in regardless of what that is, and you have to not be snooty and superior and intellectually rise above the audience. You have to actually go where they are and speak the language otherwise they will make no sense of it. [Duncan]

George made the same point in the context of positive men and negotiated safety, but also brought into the conversation the thorny issue of how proactive HIV prevention should be, should it lead the practice occurring out in the community, or should it follow, or should it be a combination of both?

And one of the really interesting things for me, and I don’t think anyone’s really done work around this, is tracking that journey that gay pos men took about reclaiming the ability to create their own parameters in terms of [risk assessment], and that’s been a journey that I think we as educators, health promoters have kind of followed. We do tend to follow because gay men do this themselves you know. I mean gay men came up with negotiated safety. I mean, it wasn’t invented by educators, it was educators coming in behind and trying to kind of make some sort of concrete sense of what was going on. [George]

In trying to address this situation, educators also tended to emphasis the increasing complexity of the epidemic and people’s responses to it, as well as the need to embrace or come to terms with this complexity when balancing the various interests involved in providing prevention information and messages. Luke described his perspective on these issues in the following way, also pointing out the necessarily innovative and creative nature of HIV prevention:

Is it AIDS organisations’ role to merely present complexity to the communities and say ‘this is what we know, you go and decide what to do with it’ or is it to, as best as we can, engage with that complexity and come up with a series of recommendations that we think are going to protect individuals and communities in the most effective way … you can’t ignore the increasing complexity by saying things are still simple. In fact they’re not. So you always have to change with the circumstances if the circumstances may warrant that and there’s good reasons to change … I mean there will always be people who disagree and I think when you reflect on … the complexity of the AIDS epidemic and the requirement for a certain amount of leadership, of course when you make recommendations you will be interfering in some people’s interests, their sexual interests or whatever. So there’s always going to be resistance. The question is what you do with that resistance. And I think there are always more alternative responses to a particular problem, to a particular sub group of the population. [Luke]

213 Russell spoke of the same problems but in the specific context of negotiated safety and TTTT:

… it’s that problem we’ve always had in education, is do you lead or follow. And once you work out you are following what do you do with that, what’s your role. And we’d been following since the time we put out the [negotiated safety/TTTT] information. You’ve got to make your own sense of it, we had to find out what senses they’re making of it but work out whether it’s a good sense or a bad sense or whether we try to intervene in the sense they’re making of it. [laughs] Another choice is just to ignore it, to say well they’re doing it so it doesn’t matter which is what we did for a couple of years. Cos we knew about negotiated safety, although we hadn’t coined the phrase, several years before the campaign, like we had explicit discussions about what it meant and what we should do about it. [Russell]

Russell also made important points about HIV educators and education campaigns, and how people do and/or do not react to, or take notice of, the “messages”, or the information versus “the advice” or “the recommendations.” This is the broader history of how negotiated safety relates or fits into a wider prevention policy debate picture. It is also the story of how science (technological advance in the area) and social science are interpreted in the context of HIV prevention, sometimes successfully, sometimes not.

But the reality is that there’s a difference between the provision of information and the over recommendations and throughout this epidemic people have made their own sense of the technology and what they should do with it. Cos I think that’s quite important. So we always assumed that we both provided the information and made the recommendations, in terms of behaviour. And I think we were good at providing the information but I think people, the recommendations, they didn’t… they were out of kilter with people’s own needs or the ways in which they adjusted what they did themselves, basically … But it happened in a whole lot of areas. But the decisions, like, so for example while we were recommending not to get tested when SAPA first came out 74% of people in the sample had been tested. When we were recommending using a condom all the time when SAPA came out the majority of people who had a regular partner were not using condoms with their regular partner. We interpreted that completely differently than what it was at the time [laughs] but you know what’s characteristic about both of those examples is that people knew the information but were making different decisions based on what their own needs were, based on how they read information. And also it happened in relation to positive men having unprotected sex with each other. Cos we initially put out an ad saying don’t do it cos the sky will fall in … [Russell]

214 These views illustrate very clearly the reflexive, critical and innovative engagement of educator practice, which must grasp and comprehend gay men’s practice but at the same time stand separate from it and dispassionately as possible assess what prevention messages are possible and what courses of action are appropriate in light of this assessment. One dimension of prevention not discussed at length is the inherently political nature of this engagement, an inevitable outcome of struggle between competing capitals and explanations, with varying degrees of power associated with the different interest and professional groups involved. Good examples of this, and of Weeks’ ‘history as politics’ (1985: 10), were the debates around the implementation of TTTT of course, but also the contestation around the formation of AIDS organisations in NSW, and the machinations around various representative and advisory committee histories at government level as chapter three outlined. There are many other examples in the continuing story of societies learning to live with the epidemic that have not been described in this thesis.

Kevin succinctly summed up the political nature of HIV prevention, but shifts the focus from educators to the community of individuals at whom the messages are aimed,

I think all things are political and how you deal with acquisition of knowledge as a community is quite a difficult process and very uneven and ultimately it ends up being, for a lot of people, questions of belief, and credibility and authority. [Kevin]

This perhaps explains why the answer to how AIDS organisations provide information or recommendations or advice remains unclear, or only partially answered (and so by the same logic the answer as to whether TTTT was a good idea and/or effective as a mass media prevention message will also remain unclear or only partially answered). The answers to these questions are also highly context dependent. It all depends on the specifics of the prevention message in question and how it may or may not be judged relevant or irrelevant to people’s lives, or how it is weighed up against other non HIV or sexual health related matters as the discussion of risk in chapter seven illustrated. People’s responses will always be patchy and ‘uneven’ as Kevin described it. Knowledge acquisition will be at best a hit and miss affair.

The educators in this study seem to accept this situation, to intuitively grasp it and continue to work within it. As the profile of participants in chapter two briefly

215 commented on, many interviewees were influenced by social movements such as gay liberation and other consciousness and community empowering ideologies to inform their practice. There is a connection here between the political nature of HIV prevention, a continuing tradition of ‘consciousness raising,’ liberation and resistance and Bourdieu’s habitus in periods of crisis. Crossley draws these threads together to explain how dispositions predisposed to politicised self interrogation can transform habitus in times of crisis to create new and durable social movements.

Consciousness raising, for example, is an amplified and politicised version of the habitual self interrogation to which most social agents regularly subject themselves and find themselves subject in their everyday lives. Furthermore, this amplified and politicised form of reflexivity, having grown out of the structures of habitus, institutes itself therein as a new structure. Political self-interrogation becomes automatic and taken for granted. At their inception, social movements creatively criticize aspects of habitus and doxa but in order for their creations to have impact, to survive and partake in a cumulative project of change, they must achieve a degree of stability and durability within the behaviours of both their creators and the many others influenced by them. They must become an aspect of the agent’s (and group’s) habitus (2003: 55).

I contend that in light of the evidence presented in this thesis, an argument can be made that within the crisis of AIDS, and within the shifting, intersecting and newly created fields precipitated by it, the reflexive innovative practice of HIV educators, along with equally reflexive input from some academics and various health and social policy debates, has created a kind of durable and stable social movement (both within the HIV sector and in certain social spaces in broader gay communities) that can comprehend and negotiate the various fields that constitute HIV prevention, and on occasion proactively and meaningfully intervene, even if not in an entirely rational manner, still in keeping with Bourdieu’s formulation of the complex interplay between habitus, fields and practice.

The Continuing History of Negotiated Safety and HIV Prevention

Given this characterisation of HIV educator practice, it is time to conclude the negotiated safety story with a brief examination of its continuing history to the present. Other factors affecting the fields that collectively constitute HIV prevention will then be discussed.

216 In 1996 the April – June edition of the journal Venerology published editorials on the subject of negotiated safety, from advocates of it, Kippax and Parnell, and one opposed, Ridge. Kippax reiterated what negotiated safety had been defined as in the 1993 paper (Kippax et. al. 1993b) and responded to criticisms and misconceptions in that same edition of AIDS made by other researchers. Countering the ‘negotiated danger’ view, Kippax restated arguments including that negotiated safety was “not to be equated with monogamy which in itself was not a safe HIV avoidance strategy”, “not to be confused with relapse” (or recidivism), not “negotiated sexual practice between casual partners” and not a term “meant to cover seropositive concordant relationships” (Kippax 1996: 97) Kippax also briefly presented evidence from a cohort of men participating in the SMASH longitudinal study stating that 40 per cent employed strategies that would satisfy the definition of negotiated safety– refuting the claim that negotiated safety was not common in gay relationships. Parnell critiqued the behavioural model of prevention that assumed more sophisticated behavioural research could describe predictors of unsafe sexual practice and that more sophisticated methods of social marketing could then be used to provide appropriate information. He also suggested gay men’s voices who wished to practice, or were successfully practicing, negotiated safety had been conspicuously lacking from the debates to date (1996: 104). Ridge was opposed to the dissemination of negotiated safety type prevention messages on the basis that “[o]pen verbal communication, i.e., honest two-way discussion based on equal relations, around sexual issues is a prerequisite for negotiated safety: however, such communication was not common in [gay] men’s partnerships” (1996: 98).

In 1997 Kippax et. al. published a paper in the journal AIDS entitled ‘Sexual negotiation in the AIDS era: negotiated safety revisited’ in which arguments made in the 1996 Venereology Editorial were restated. Evidence from further studies that supported negotiated was occurring in some segments of gay communities was presented. As the authors stated, “[n]egotiated safety is not a rare or uncommon strategy but a strategy adopted by a significant proportion of men, at least among this cohort of homosexual men, and the findings of this study must be placed in the context of a highly gay-identified Sydney sample with a strong gay community supporting it” (1997: 196). However, like many other commentators in the area, the authors warned, “although the findings of the present study indicate that negotiated

217 safety agreements can be and are kept, they clearly are not kept on all occasions or all the time.” And as with the Report and Process Evaluation of the talk test test trust … together HIV/AIDS Education Campaign (Mackie 1996), the authors also recommended that “[t]he strategy may be more successfully and widely used if well- funded education campaigns that deal with the issues of honesty, testing, trust, and talk between men are implemented. Agreements reached between men must be clear and unambiguous and the trust must not be misplaced” (1997: 196 – 197).

Outside the academic sphere, promotion of the negotiated safety concept continued in Australian AIDS organisations. Also in 1997, the Australian Federation of AIDS organisations (AFAO) produced a twelve page booklet entitled Testing Testing Trusting: A Guide for HIV Negative Couples Who Are Considering Not Using Condoms in their Relationship. This booklet essentially presented the same information as the ACON talk test test trust … together pamphlet had the year before, but in greater detail. ACON itself continued to disseminate various versions of the TTTT pamphlet. When stocks of the original TTTT pamphlet ran out ACON reissued it, but modified it with the addition of a daisy motif and more emphasis in the text on what practical steps could be taken when trust in relationships broke down. The daisy motif played on the ‘he loves me, he loves me not’ theme and had words such as Trust, Fear, Hope, HIV +, HIV -, Lust, Honesty, Together, and Forever on various daisy petals. Some years later, a third version was also printed with Talk, Test, Test, Trust split into stage one, two, three and four respectively. The subject of gay couples not using condoms for anal sex in relationships continued to be discussed in other prevention contexts, peer education, counselling and other services, and the relationship workshops, which ACON continued to run regularly. Workshop content was altered to suit changing attitudes and context.

In recent years, negotiated safety information and prevention messages in the context of gay relationships were also run in magazines produced by ACON such as Lovers and Others and M8 (2005). AFAO put out a similar magazine between the sheets (2006). Volume 1 Issue 1 contained a number of brief articles around the subjects of gay sex, HIV antibody status, sex and relationships and the assumptions that often made in these areas. One article entitled ‘can we talk?’ described ‘four couples sharing the rules that keep them happy and content’ while also addressing the

218 question ‘how safe are their decisions?’ In 2005 both ACON and AFAO were reviewing TTTT and negotiated safety as prevention messages. As part of this review process, AFAO ran a workshop where several presentations were given on negotiated safety. ACON was also involved as they considered when and how to reissue negotiated safety advice. In February 2006 AFAO ran what was described as a ‘research into practice institute’ focussed on relationship agreements. Responding to criticism over the years that negotiated safety and TTTT were too narrow in their intervention, that they focussed on only negative men in relationships and did not consider other serostatus combinations and relationship contexts, Francis described the change in thinking around negotiated safety in the following way.

… we did need to consider the position of HIV negative men in relationships that, you know, given that we were worrying about that and what to do about negotiated safety that perhaps what we should do at the same time is take a step back and think about all couplings and to think about positive/negative couples and positive/positive couples and that we should maybe think about shifting the framework to one of relationship agreements, gay men’s relationship agreements more broadly so that within that framework we could develop advice for men in all of those relationship couples, and also unknown status. And I think in that way, I thought that seemed to me to be a better approach now than just putting out advice for negative men in relationships… [Francis]

It would appear now and into the future that prevention focus and educator practice will shift to this broader framework of gay men’s relationship agreements. It is here that the future of negotiated safety as a prevention strategy will now be incorporated.

Both ACON and AFAO were reviewing TTTT and negotiated safety as prevention messages in part because of the changing context of wider factors affecting gay communities and HIV prevention. And it is to a very brief outline of these factors that this discussion will now turn. Many of the participants in this study spoke of the future, and various large scale historical and other factors that were affecting gay communities and so HIV prevention. These factors included the use of internet by gay men to seek out sexual partners, ‘AIDS fatigue’ (Odets 1995a) and the shift from a crisis and/or fear based response to a post ART period in which HIV and AIDS had become a chronic manageable illness rather than a fatal disease. Treatments and non- condom based risk reduction strategies, such as negotiated safety and TTTT, were seen by Dowsett (2004) as fracturing the unity of both safe sex and positivity. For

219 Race, ART allowed for a revaluation of risk among some homosexually active men that “ … manifested itself, in part, in the appearance of a range of loosely defined prevention tactics that do not always involve using a condom for anal sex” (2003: 369). It is time to turn, for a final time, to the views and opinions of my research participants on the larger scale factors that are now affecting HIV prevention.

On the subject of treatments, Russell summed it up in sentence “…we absolutely haven’t got a handle on the ways people are making sense of the fact the HIV is now treatable.” Francis also spoke of the effect of treatments, that people no longer saw HIV as “risky”, but for him this was just as much due to many people’s lack of exposure to the disease and also ‘fatigue.’ As discussed by Odets, AIDS fatigue was the idea that gay men were tiring of safe sex messages and switching off from them and that this was part of a broader psychological response to the grief and loss associated with death and the AIDS epidemic (1995a).

I think it’s about people not seeing HIV as risky as it was. I think that’s, plus putting in fatigue I think. Fatigue I think is a factor. How do you sustain a response in a very long term? That condoms still are, never have been enjoyable to use ... I think what will make it more difficult is that people don’t have any experience of HIV in their lives at all, or don’t have experience of others who witnessed HIV or the impacts of that. So I think it’s still important to create an awareness of HIV as something that is real and that can and does affect people … I don’t think the younger population, I’m concerned about the younger population and younger gay men who don’t see HIV as, don’t seem to be seeing HIV as an issue of importance to them … because they haven’t experienced the epidemic in the same way that a lot of men in their 30s and 40s have. And yet they’re coming up to an age bracket where testing is important, and practice and risk is increasing particularly as in their 30s people traditionally I think experiment more sexually and [expand] their own repertoire through that period which introduces risk for a lot of us as gay men … [Francis]

For Andrew a consistent condom every time message has its value, but the broader historical and social changes discussed here were what undermined its success over time. For Andrew, a radical message in the crisis era has become an institutionalised and tired message in the current environment.

I think that a consistent message probably had value in its consistency but it’s also been devalued through tiredness and through being corroded by a changing social and political environment. I think that’s really important, that the problem, one of the problems with the message

220 is that it hasn’t been able to successfully be adapted to new environments. In the beginning it was a very radical ‘fuck the system we’re going to keep screwing and we can.’ It was a heroic solution and it became an institutionalised solution … [Andrew]

For Tim, it is maintenance of safe sex behaviour that is by far the most difficult aspect of HIV prevention, partly because of the increasing complexity of the epidemic and the environment but also because “you have to keep the fire and enthusiasm and community support behind something.” Tim also pointed out the irony of the situation when the more successful a prevention and education program is, the less people pay attention to the issues and think them important.

… I think that the model that we’ve always had here is just a simple thing, inform, enable, maintain, and you know, we initially did inform, and then we did enable and we did a lot of policy stuff on Homosexual Law Reform and needles and syringes and Human Rights Act and fights with the religious right and you know what I mean, it’s all about enable. And maintain is the third of the trio, and maintain is inestimably more complex and difficult than any of the first … I don’t think anybody has done maintain well. That’s my view. We haven’t. I’m happy to say I don’t think we have. I don’t think anyone’s done maintain well because of the sheer difficulty of it … and in the last ten years you also throw in the internet and treatments then you have a kind of a, you have a strategic kind of… incredibly complex thing … I think maintain is so difficult because you have to track, you have to keep the fire and enthusiasm and community support behind something … So you know, I think, this is the biggest bug bear of health promotion, is if you are ever successful, if you are ever lucky enough to be successful then you become the victim of your own success because the energy goes out of people’s sense that it’s a problem any more. And now that’s a problem with maintain… [Tim]

For Desmond, there were those individuals who were aware of a new potentially fatal disease who heeded prevention information and changed their behaviour early in the epidemic and there were those whose behaviour was influenced by a set of other factors not necessarily related to sexual health or perception of risk. For Desmond, this situation continues today and the ratio of the two groups changes depending on the ‘consequences’ of HIV infection. Clearly, in an era when treatments are available there will be a perception that the consequences of HIV are less severe, and so a larger percentage who may not heed prevention information, or pay attention to it less often, or think it is not relevant to them more often.

221 … well how it [behaviour change] was sustained was in large part a consequence of how effective strategies were. But the actual initial behaviour change I think would have occurred as soon as people had, again, from a social marketing point of view, we know that there are the early adopters, there’s the later adopters … there’s a group within any population who say we’ve got a new disease out there and it’s HIV… There’s a percentage of the population that as soon as they know that they will do what they need to do to prevent themselves from getting that. You know, yes information does work in that particular context. It won’t work twenty years later when everybody knows it, anyone information’s gonna work for, it’s already worked. But there is a percentage of the population who will change their behaviour purely on the basis of information and it just depends what the consequences are what that percentage will be. And there’s a percentage of the population who won’t change their behaviour because there’s a whole set of other things that influence their behaviour … [Desmond]

Changes in gay communities were also considered to be an important factor in HIV prevention for many participants. Some felt there was a diminishing sense of ‘community’ or lessening community responsiveness to issues of HIV and AIDS at least. As Kim said, “I think there is the loss of community, there is certainly a loss of community responsiveness.” Francis saw it more as a lack of issues to engage people in ‘community.’ As he said, “I think it’s about encouraging responsibility and a sense of community responsibility … but we’re losing a sense of a care amongst the community. We don’t seem to have the issues to engage us in the same way that we did.” However, he also saw the concept of ‘community’ as expressed through various social and friendship networks as dynamic and adapting to new social conditions, including the internet. He saw that these new shifting allegiances and networks could be engaged to capture audiences with relevant prevention messages.

It’s true that the community as we knew it, the gay community as we knew it, has changed and has moved in different ways. And I think that there are um, I don’t think we can say necessarily how [the community has changed]. I think something will emerge from that deconstruction if you like, and good things might happen through internet, friendship networks, you know, pos-negs, gay-straight you know. I think there’s a merging and communities will happen, how we support each other and operate. But that’s not transparent yet so we can’t say this is where people are and how people are supporting each other and relating and inter-relating. We can say clearly that the internet is a very strong way of people negotiating sexual contact and to some extent friendships and other sort of social interactions. We can say that people are more inclined to, I think, engage in their own, younger men in their own area wherever that might be. They don’t see the need to travel to Oxford or to

222 Newtown or to the pubs or the clubs for sex, or, cos they can get that on the internet, or on sex on premises venues. So I think there are shifts there in the way that people are relating and I think what we need to do is to understand more about, that’s what I would like to see us do, positive people as well, is more about the social and sexual networks that people engage in … [this approach] creates lots of opportunities for interventions, health promotion, directly into those various networks. [Francis]

In something of an inspired rave, Andrew sums up the entire situation of AIDS organisations and their provision of information and how this situation has changed hugely from the early days of proactive crisis responses and the immediacy and relevance of information about the epidemic, to the current situation of complacency, lack of interest and ‘fatigue’ despite educators’ best efforts.

There’s a whole range of factors but I think probably fundamentally the organisations that were set up to address the issue are still to an extent planted in an idea of a connected community that could be described as having a few strands of commonality that were very strong. And while those things are still there they don’t occupy the same place that they did and other things have come. We’ve had the commodification and commercialisation of gay culture for a start. So they haven’t adapted. While they’ve dealt with sub groups and done this and done that and done something else fundamentally the issues have changed but the organisations haven’t which is not to say that they haven’t tried to and that they haven’t reacted and responded to various issues as they’ve changed along the way. But that’s just the point. They haven’t set the agenda. They’ve responded or reacted to the agenda, whereas in the beginning they set the agenda. They don’t set the agenda any more. They react at worst, and at best they respond to a changing agenda which is set by a whole lot of other forces … And that was the critical thing at that time, this thing rose up and took a hold of the agenda. It took it off the traditional power brokers and said ‘this is ours, fuck off.’ And everybody went ‘woo hoo’ and that hasn’t happened for a long time. Whether it will ever happen again in any kind of health promotion forum I don’t know. Maybe not. Maybe it was just this amazing thing that happened, in the absence of anything else … [Andrew]

Andrew continued by describing the uniqueness of the situation in the early days of the epidemic, where identifying as gay was a powerful motivator to get information about the new health threat in itself, and where the things that have come to signify ‘gay culture’ or ‘gay life’ fell away in the face of a potentially fatal disease. He concluded by lamenting that perhaps this was a one off, a unique period in the continuing history of the epidemic where information was paramount, where

223 attending to information about HIV and AIDS could make the difference between life and death.

I remember as a young man being told by another gay man that I needed to be very careful to avoid getting this disease. I saw this as revolutionary. It was alerting, it was frightening but it was also this amazing experience of someone like me being concerned about my welfare. It wasn’t about nightclubs. It wasn’t about how big my dick was, it wasn’t about whether I was good looking or not, it wasn’t about my Ferrari or lack of. It was about that I was gay and therefore I was at risk from something which then not many people knew very much about. That was a remarkably bonding kind of thing, a unique experience, that men went out of their way to describe a danger to strangers on the basis that they were gay. And that doesn’t exist any more … and nothing as powerful as that has come along to replace it, or to be the measure of the other influences. So one reason or another, the work has been dissipated to a point where people don’t, where the immediacy of the human condition, desire, lust, love, sex, drugs, rock and roll, whatever, the gambit of human existence is far more immediate and far more attention grabbing than anything an AIDS organisation might have to say in an environment where it’s no longer a certain death sentence. [Andrew]

On this somewhat dramatic note it is time to leave the sphere of educators practice, and the continuing history of negotiated safety and HIV prevention. It is time for me to state my own case, to wrap up this diverse array of arguments and observations, to draw my own conclusions about negotiated safety and TTTT.

224 9. Conclusion

This thesis has argued that in order to better understand the negotiated safety debates, TTTT and HIV prevention and what shapes, moulds and drives it, it is also necessary to understand the broader social, cultural and historical context that influences HIV educator practice (and negotiated safety and TTTT within it), as well as the dynamics of the epidemic itself and gay communities and wider societies’ responses to it. This context has been treated as a number of factors, some related to the epidemic itself and others related to the wider historical context of life in the late twentieth to early twenty-first centuries, the late or post-modern period.

The aim of this thesis was to use negotiated safety and TTTT as a case study to illustrate the contestations that occurred around the practice of HIV prevention and to elucidate and analyse these historical and socio-cultural factors and their relationship to and interaction with each other and their influence on HIV prevention, gay men’s lives, the epidemic, and gay communities’ and wider societies’ responses to it. Once these factors were identified they were applied to a number of areas within the history of the negotiated safety debates and TTTT to explain: why there was a marked change in prevention policy and practice in Australia and not in New Zealand; the contestation around negotiated safety and TTTT on both sides of the Tasman; the machinations around arguments about negotiated safety and TTTT and how arguments on opposing sides of the debate seemed logical and reasonable, in many instances drawing from the same evidence, albeit making different interpretations and arriving at very different conclusions.

Chapter three began the analysis of the various social, cultural and historical factors that influenced HIV prevention and practice. Using Giddens’ concept that expert discourses also have an agency friendly dimension the chapter outlined important factors in the development of gay communities and their response to the epidemic, from the formation of a category of ‘the homosexual’ from the discourse of the sexologists in the nineteenth century to the rise of a self defining and identifying gay social and political movement. The links between the influence of international gay communities, a strong communitarian approach, a ‘sex positive’ stance (Altman 1993: 10), an earlier experience with STIs and the connection to a growing understanding of the new strategies required to address AIDS were demonstrated. The uncertainty,

225 contingency and ambiguity associated with the late or post modern period manifested as conflict, contestation, confusion, fear and anxiety were illustrated with the conflict and contestation within gay communities and AIDS Councils about approaches to prevention. The contradictions between medical and social/communitarian models in government, AIDS Councils and other responses were also explored in this context. Continuing with this analysis chapter four illustrated the ambivalence and ambiguity of negotiated safety specifically as a prevention message, and the conflict and contestation within AIDS Councils implementing such messages.

Chapter five detailed the behind-the-scenes contestations within ACON that led to the policy change of which negotiated safety and TTTT were a part. It then used material from the interviews and other related documents to describe the development and implementation of TTTT, reaction to it, arguments for and against it, and a brief evaluation of its effectiveness. Using TTTT as an example, the chapter continued to extend the discussion about factors that were important in shaping prevention practice introduced in previous chapters but also elucidated a number of new factors related to the epidemic itself such as ‘positive in prevention’, consultation with and inclusion of positive men’s perspectives in HIV prevention and the rise of an HIV/positive ‘identity’ and ‘community’ (Dowsett 1992; Duffin 1990). Extending the discussion about structure and agency the chapter argued that contradictory elements exist within the formation of HIV identities and communities. The chapter discussed that in the previous history of struggle against and resistance to dominant discourses about homosexuality a reasonably coherent group identifying as gay or homosexual had been united in their collective action. Now, with the development of ideas about a positive identity or community (whether or not one is persuaded there is sufficient enough difference between positive and negative men to signify an emerging new identity) came competing and at times conflicting interests.

Chapter five detailed arguments both for and against TTTT from interview material, such as supporting arguments like TTTT creating a ‘space’ for dialogue about negotiated safety amongst gay men, counsellors, and prevention and education workers; and arguments against including that TTTT relies on trust, open and communication and the complexity of the TTTT message. The chapter returned to the theme of contradiction when discussing TTTT and arguments about it, including the

226 dichotomy between a condom-every-time approach versus a more holistic communitarian, agency friend approach that negotiated safety and TTTT exemplify. The chapter connected earlier discussion of gay men’s and HIV prevention’s increasingly sophisticated risk reduction strategies and the rise of a positive voice to Dowsett et. al.’s concept of ‘post-AIDS’ “… a fragmentation and multiplication of gay community responses to HIV/AIDS, a differentiation in both experiences and consequences that warranted a new, multifaceted approach to health education among gay men, whether HIV-positive or negative” (2001: 209). Kippax and Race further added to the definition by observing that the success of combination antiviral therapies was also implicated in ‘post-AIDS’. (2003: 6). The fracturing of the unity of safe sex and the introduction of treatments in the post-AIDS period were identified as factors relating to the epidemic that were also influencing the concept of negotiated safety, TTTT and HIV prevention.

Chapter six explored the wider context of relationships, love, rationality and sexual health behaviour in the late or post modern period as a factor influencing HIV prevention and practice, with particular reference to intimate relationships, drawing on the work of Giddens (1992). The chapter discussed that there is also relevance in Giddens’ concepts to the sphere of HIV prevention and TTTT specifically. The description of mutual trust, openness, communication and discussion characteristic of Giddens’ pure relationship (1992: 2) are similar to the steps advocated for the safe implementation of a negotiated safety agreement, except that it is in the broader sphere of relationships, not the specific context of sexual health and avoidance of HIV infection. The chapter argued it is possible this drive, this transformative shift, towards a new kind of intimacy encapsulated within the pure relationship is another factor influencing negotiated safety and TTTT.

Chapter seven situated the concept of risk in HIV social research within a broader characterisation of risk as discussed by Beck in his defining work in the area Risk Society: Towards A New Modernity (1992) and Bauman in his more recent works (2007, 2006, 2003). As in previous chapters, this chapter argued that negotiated safety and TTTT are particular expressions within a much broader post or late modern conceptualisation of risk, as is HIV prevention more generally, where the certainty of truth and knowledge is undermined creating “ … a culture of radical doubt where all

227 kinds of knowledge, including expert knowledge “are only valid until further notice” (Heaphy 2007: 76).

Addressing the specific areas of interest stated as part of the aim of this thesis, chapter seven argued that the different perspectives of the various players – epidemiologists and assorted other medicos and health promoters, academics of various persuasions, and HIV educators – and the debates about risk of HIV infection in gay relationships and whether or not health promotion negotiated safety messages should be aimed at gay men in relationships were to be expected. The construction of risk from various players’ sometimes complementary sometimes contradictory scientific and/or social knowledge also explained how the same ‘evidence’ was used to construct rational and logical arguments for or against negotiated safety. The chapter argued that although the social construction of risk explains a lot of the contestation around issues of negotiated safety and TTTT, other factors to do with the epidemic must also be taken into account to explain the difference between Australian and New Zealand prevention policy. The chapter suggested most relevant to the divergence of opinion over TTTT between Australia and New Zealand are the larger gay populations in Australia (most particularly Sydney where TTTT originated) and so higher HIV incidence, and connected to this the varying impact of AIDS related deaths and the relative strength of a positive voice in prevention.

Previous chapters illustrated that TTTT was developed and implemented as a harm minimisation strategy that acknowledged and addressed the fact that gay men made their own assessments about risk in relationships. This was part of a wider debate in prevention about the ongoing interaction of gay men’s knowledge and practices with medical and epidemiological constructions of risk and technological advances in the field such as HIV antibody and viral load testing (see for example Race 2001 and 2003; Kippax and Race 2003). Chapter eight outlined Kippax and Race’s (2003) concept of a “social public health” – an argument about negotiated safety as a collective practice, and as an expression of gay men’s agency, resistance and sexual freedom. The chapter also discussed limitations of the concept; that it does not get beyond the dichotomy between the agency friendly communitarian approach and the more restrictive dictatorial behaviourist approach.

228 Again addressing the specific areas of interest stated as part of the aim of this thesis, Chapter eight argued Bourdieu’s conceptualisation of the complex relationship between habitus, fields, and practice can better encompass, account for, and explain these seeming dichotomies, contradictions, inconsistencies and complexities. Application of Bourdieu’s ideas to the field of HIV prevention and health promotion is innovative. By applying concepts to these areas this thesis makes a significant contribution to the ongoing debates about new approaches in HIV prevention and education.

The variations in educators’ practices sometimes expressed as practical prevention actions (including developing and implementing particular campaigns about particular prevention issues such as TTTT, or for that matter, opposing them or not wishing to implement them) resulting from their various views, arguments and strategies about prevention can be see as different ways of “playing the game” (Bourdieu and Wacquant 1992; Bourdieu 1993), different ways of engaging various available capitals, different ways of interpreting the factors affecting the epidemic (which themselves can be different in different locations as the New Zealand/Australia divide over TTTT in part illustrated) and the broader social and cultural context, different ways of negotiating the intersecting fields that make up HIV prevention and education, academic and policy maker discourse and of course the practices, sexual and otherwise, of gay men. Similarly, the chapter argued, academics, medicos and scientists, policy makers, health workers and gay men themselves (and members of other affected groups) are also subject to the same processes as they participate in the ongoing practices that collectively constitute HIV prevention. This finding is significant as this characterisation may be applied to other areas of health promotion and public health and inform how various interested parties (for example health professionals, health educators, NGO workers) can plan, develop and implement health promotion messages in a wide range of health and social contexts.

Chapter eight also discussed the complex interplay of positive and negative elements in both structure and agency. Race commented that the challenges associated with the use of medicine within gay sexual repertoires was more than simply supplying people with information about risks of various practices and also “more than a celebration of agency” (2004: 219). This thesis has discussed and illustrated various examples of

229 interplay of positive and negative elements of structure and agency within the various factors related to the epidemic and the wider historical context. It has discussed how gay men’s proactive response to the earlier epidemic, and their engagement with medicine and prevention to enact more sophisticated risk reduction strategies (and indeed the earlier appropriation of the nineteenth century category of the homosexual into the empowering and self defining gay liberation and wider social and political movement) does sound like a celebration of agency, that gay men’s lived cultures are inherently resistant, subversive, communal, sophisticated, and safe. However, an important theoretical difference in the argument presented in this thesis is the inclusion of an analysis of these empowering and unifying forces also being at times fragmenting and dissociative, spawning complexity and a diversity and a multiplicity of identities. This is a new contribution to the structure and agency debates.

The contradictory nature of these forces has been commented on and illustrated in earlier chapters as being present in both factors particular to the epidemic itself and in wider historical, social and cultural forces acting on and shaping HIV prevention practice. This thesis has argued the complex interplay of elements of structure and agency have both unifying or positive effects and fragmenting or negative aspects that are not always predictable and that do not necessarily equate to the structural aspects having only negative impacts and the agency aspects having only positive effects on people’s lives. A number of examples illustrating this point, both of factors relating to the epidemic and those relating to the broader socio-historical context, were discussed in chapter eight. Chapter eight argued that Bourdieu’s concept of habitus (1977) provided a way to conceive of these unifying and fragmenting elements of both structure and agency differently, by moving away from the structure/agency, subject/object dichotomies that plague some theory in the area, instead suggesting that each is constitutive of, and generated by, the other (1977: 72).

The theme of complexity has appeared in a number of contexts throughout the analysis. It will be recalled some participants pointed out that negotiated safety, and the steps that constituted the framework of TTTT, were too complex for gay men to follow. According to some, this complexity may have led to misinterpretations and mistakes which would have had the opposite effect to that intended and the risk of HIV infection in relationships would have increased rather than decreased. It will be

230 remembered the Report and Process Evaluation of the talk test test trust … together HIV/AIDS Education Campaign provided some evidence that this did not happen, at least initially (Mackie, 1996: 28). For some this meant that TTTT should not have been disseminated as a mass media message but rather discussed in counselling, peer education, small group and outreach settings, for others that it should not have been promoted as a prevention message at all. I agree with the analysis that negotiated safety and TTTT are complex but would suggest that consistent condom use is perhaps more complex than is often portrayed. As was pointed out, condom use also requires negotiation and communication, although admittedly of a less sophisticated nature than TTTT. Condom use, like TTTT, is also subject to the various power imbalances and structural disadvantages that lead to one partner in a relationship perhaps being dominant over the other and hence the couple’s sexual health relies on that individual’s wants and desires, and their perception of risk, whether accurate and safe or not. It will be recalled that various types of disadvantage are linked to increased vulnerability to risk (Beck 1992: 35). Worth et. al. (2002) and other authors, as well as many interviewees, observed that gay men find it as difficult to communicate about issues of trust, monogamy and sex outside the relationship as anyone else. This is relevant as this would support the view that TTTT is likely to not work as envisaged because of these difficulties. There was also the suggestion that in the context of a history of stigma and discrimination, and the contradiction of gay liberation fuelled sexual freedom contrasted against conservative relationship couples, that gay relationships were fundamentally different from heterosexual couplings. Giddens also suggested this, that gay relationships were an example of his ‘pure relationship.’ Using empirical evidence from a range of studies Jamieson demonstrated this was not the case, as did Worth et. al. (2002).

Complexity is also relevant in that the negotiation of HIV and sexual health awareness in gay men’s lives is complex. There are many factors that impact on perception of risk and sexual practice. I have not changed my position that a complex set of contextual factors; biographical, psychological and interpersonal intersect with a broader socio-cultural context to produce a complicated interaction with prevention messages and perceived risk. In the case of TTTT or consistent condom use for anal sex in relationships the wider context of the relationships – the uncertainty of love and the future, the fear of rejection and/or loss of the partner – add another dimension of

231 complexity as does the anxiety, fear and uncertainty of living in a complex detraditionalised individualised late modern world. Is the complexity of negotiated safety, TTTT, sex and relationships any different from that of life in general in late modern societies? My answer is no. Giddens’ discussion of the ‘pure relationship’ (1992) adds some weight to this conclusion. The negotiation of intimacy he postulated, even if a less than all encompassing social influence as Jamieson’s critique (1998) suggested, still demonstrates that individualised reflexive projects of self are powerful narratives in late modern societies that incorporate romantic love and sex into a wider life story that is complex, highly meaningful and multi-layered. The negotiation of sexual health in gay relationships is no more or no less complex than the numerous negotiations, compromises and complexities that arise in any individual’s life around a wide range of issues, including love, sex (sexual health) and intimacy, in late modern societies. Giddens’ concept of fateful moments supports this view as they are not only applicable to sexuality and HIV and AIDS, but also to wide range of broader contexts, life experience and life events that have the potential to be life affirming and empowering or existentially and/or morally threatening and anxiety producing. This leads to the conclusion that the complexity of negotiated safety and TTTT is not a reason, in my opinion, to not disseminate a prevention message promoting it. The argument that it should not have been disseminated as a mass media message, but rather in counselling, group and outreach settings, is more convincing but given that a mass media message reached a large number of people and that there is (admittedly limited) evidence that the message was not misinterpreted in this way (and to my knowledge no studies providing evidence that this did subsequently occur) then this counter argument loses ground.

A further argument to support the view that a mass media TTTT message should have been aimed at a broad cross section of gay men in relationships is that HIV prevention is also complex, and political, and as a consequence knowledge acquisition and uptake is, at best, patchy and incomplete. There will always be those who for a variety of reasons think an HIV prevention message is not relevant to them or have other factors impacting on their lives (including structural disadvantage) that mean HIV awareness is balanced against other factors, not always in a risk reducing way. People will never be 100 per cent protected from risk of HIV infection. Harking back to the discussion of Beck (1992) and Bauman (2006, 2007) there will always be some

232 degree of risk in life, sexual activity and relationships. Given the complexity of HIV prevention and the lives of individuals within which it is trying to intervene, is it really realistic to expect a one on one relationship between a TTTT message and a calculable risk of HIV infection? This thesis has illustrated a wide range of social and cultural factors impacting on, changing, and transforming the practice of HIV education. It will be recalled Kippax (2003) pointed out that sexual health interventions cannot be evaluated within a narrow view of a one to one relationship between an intervention and its effect, but rather must be seen in the wider context of many years of interventions in an ever changing social and cultural environment. To expect a definitive answer as to whether TTTT was an effective message that reduced risk of HIV infection in relationships is not realistic or indeed possible in this context. However, given that TTTT created a space in which gay men could discuss anal sex without condoms in relationships in range of different settings – counselling, groups, outreach, friendship and social networks – then I think it can be said that it was a successful harm minimisation message within the broader context and ongoing history of HIV prevention, because, as some interviewees pointed out, it provided clarified information on negotiated safety and a practical framework in TTTT where previously there had been no prevention information available. Perhaps also relevant here is Beck’s statement that there are no expert on risk (1992: 29). While I can state my own opinion as to how I see many of the arguments and views presented on TTTT, I can still see the ones I do not necessarily agree with as logical and reasonable, and in no way a misunderstanding of negotiated safety, or TTTT, or risk of HIV infection in relationships. This is not sitting on the fence. This is realistically acknowledging that risk is socially constructed and hence contested, defined and redefined in different contexts and disciplines to produce different but equally valid knowledges and views.

As was demonstrated in the final chapters of this thesis, Bourdieu’s habitus (1977) can characterise and unify these different takes on TTTT and the complexity of prevention and also reframe the assumed rationality of health promotion, including TTTT. Bourdieu’s habitus can also contextualise negotiated safety, TTTT, and educator practice into the broader social, cultural and historical factors that effect not only HIV prevention, but the numerous changing and evolving fields that constitute gay communities, other affected groups and also societies’ responses to the epidemic.

233 I have argued that Bourdieu’s habitus can broaden Kippax and Race’s (2003) formulation of a social public health and gay men’s sexual agency within it to a more general concept of agency found in social science that encompasses all aspects of life.

It can also go beyond the dichotomy of an agency friendly communitarian approach as opposed to an agency unfriendly health belief model approach to prevention, as the discussion earlier in this chapter demonstrated. Using Crossley’s (2003) ideas of a critical and political reflexivity arising in times of crisis (such as the onset of AIDS) that brings unconscious discourses to consciousness, I suggested that educator practice and the HIV sector more generally could move beyond these dichotomies, and the particulars of the TTTT debates, and instead be seen as a social movement with broadly similar objectives (indeed a wider social movement that has precipitated sweeping social change over the past two decades). However, like Race’s scientifically and homosexually active men (2003: 371) and Kippax and Race’s social public health (2003) this formulation still leaves out the men who have sex with men who do not identify as gay men and who may be structurally disadvantaged and hence more vulnerable to risk, who cannot safely negotiate condom use in their relationship let alone TTTT. These men who have sex with men do not have the HIV habitus or reflexivity of scientifically and homosexually active gay men, or HIV educators, or HIV and AIDS sector academics or policy makers. Again, this is an example of a partial answer. While Bourdieu’s habitus is an advance on a social public health, it still cannot account for those men who fall outside the sphere of the gay identified and HIV aware communities. Still the concept of habitus captures the interaction between gay men’s practice and HIV educators, and the academic sector, well and gives hope that the innovation within educator practice will continue to attempt to address the problems of non relevance of HIV and the difficulty in pitching relevant messages in a rapidly changing world. A continuing and constantly adapting social movement can also expand its influence and perhaps in time conscientise those who currently still fall outside its domain.

In many ways HIV prevention is the victim of its own initial success. It will be recalled Kippax et. al. remarked that gay communities’ response to the epidemic was “one of the most profound changes of practice ever found in the social science and public health literature” (1993a: 157). This early success may have created an

234 unrealistic expectation in HIV prevention when it was always going to be an inevitable process that people would begin to adapt to the epidemic, learn to live with its characteristics and its risks, learn about and adapt to and eventually proactively use technologies associated with it (such has the negotiated use of condoms, as well as using HIV testing and viral load to access relative risk). Also, broader change factors further facilitated this, such as the appearance of treatments in the mid nineties and the shift of AIDS from a fatal disease to a chronic manageable illness. It was inevitable that people’s engagement with the epidemic would become more nuanced and sophisticated. AIDS organisations were always going to have an uphill battle with effective prevention messages and maintenance.

This conclusion (and the preceding chapter) has discussed and summarised the wider social, cultural and historical factors that influence HIV educator practice, and negotiated safety and TTTT within it, Dowsett’s “many other forces at work in shaping the practices of HIV/AIDS health education” (2001: 220). The identification and discussion of these factors is unusual in the sphere of HIV prevention, health promotion or public health. My approach has shown that a focus on a dynamic epidemic, the broader historical context of love, intimacy and relationships, on risk and the uncertainty, anxiety and fear of living in a complex detraditionalised individualised and globalised world can shed light on the specific arguments made about negotiated safety and TTTT. Further, applying Bourdieu’s formulation of the complex interaction of habitus, fields and practice makes sense not only of the arguments made for and against negotiated safety and TTTT, but of educator practice and of HIV prevention, of the broader HIV and AIDS sector, and of how societies continue to learn to live with and adapt to the epidemic. By applying Bourdieu’s concepts to these areas this thesis makes a significant contribution to the ongoing debates about new approaches in HIV prevention and education, and also to debates abnout structure and agency. These findings may also be applied to other areas of health promotion and public health and so inform how to develop and implement health promotion messages in a wide range of health and social contexts.

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248 Appendix One: Interview Guide

1) Biographical/Introductory

Age, sexuality where have you worked, how long, what trained in etc how long in HIV education/prevention, why did you come to this field of work?

2) The Campaigns

Who do you think the Talk Test Test Trust/NSW Campaign (negotiated safety) was aimed at?

Probes:

The inner city gay community vs gay men elsewhere (provincial, rural, urban but not involved in the inner city ‘scene’)

When does it work best – what factors allow it to work well

When does it not work so well, why?

Does it work better for some men than others, who, why, in what contexts?

Who do you think the ‘Use a Condom Every Time’/NZ Campaign was aimed at?

3) Prevention, Education and Organisational Context

What do you draw on to inform your health promotion, education or campaign planning/work?

Probes: gay community/ experience as a gay man health promotion and education ideas or literature science/medical/epidemiology ideas or literature other (social marking, past work or other biographical/historical factors)

Do these things inform your prevention and education work? If so, how exactly?

249 What is the influence of your organisation’s policy, previous campaigns, prevention strategies, frameworks, guidelines etc

Organisational dynamics, restraints

Your ideas/information versus others, how modified, what modified, why modified

Does the Australian context, in particular Talk Test Test Trust/NSW Campaign (negotiated safety), influence the NZ context, especially with so much travel from the periphery (NZ) to the centre (Sydney)?

4) Rationality and Safe Sex Campaigns

Briefly remind the participants of the two different approaches to health promotion behind the NSW and NZ campaigns, the inner Sydney ‘sophisticated’ gay men’s agency/resistance sensitive negotiated safety approach and the NZ ‘Use a Condom Every Time’ approach, for everyone, everywhere, no sensitivity to or taking account of social or sexual context etc.

Then ask whether they think the decision to have safe sex is rational or not, or sometimes is, sometimes not,

How does the participant see it?

How does Talk Test Test Trust and/or ‘Use a Condom Every Time’ fit into this rationality, or lack of it?

Does it matter for HIV prevention and education in the long run?

5) General Prevention/Education

Targeted Campaigns aimed at specific groups or communities sexual subcultures, +ve men, -ve men

Other risk reduction strategies (apart from neg safety) – serosorting; strategic positioning; undetectable viral load

What is gay community or culture

Why the recent rise in infections in both Australia and NZ, despite safe sex campaigns and other forms of HIV/AIDS prevention and education?

Wider changes in gay sexual culture – internet; increase in anal sex

Any other comments you’d like to make?

250 Appendix Two: Campaign Details

VAC’s Because We Want To Be Together

Launch and Dissemination

The launch and dissemination proceeded with the printing of the A4 flyer proceeded and was distributed in Victoria through mail to gay and HIV specialist services, 250 GPs attending an HIV/AIDS medicine training course at the time, VAC’s regular newsletter mailing list, to gay and lesbian and AIDS telephone counselling services and as a series of advertisements in the gay press. The bulk of this activity occurred from July to September 1994. A formal campaign launch was held on August 12th 1994 (1995: 9). A media kit including an editorial written by the project officer was provided to gay and HIV/AIDS journals and to other gay media outlets, and in some instances editorial on the campaign was published. However, while VAC had reconciled its internal contestation there was still much contestation and ambivalence about the negotiated safety message externally. The VAC project officer noted a reluctance by some media to carry information or editorial about the campaign. A notable exception was The National AIDS Bulletin that carried an article in its September 1994 issue written by the project officer entitled ‘A First Campaign on Negotiated Safety.’ Picking up on when ‘negotiations commonly go awry’ and using the consultations with GPs to ‘clarify key points’ the article outlined a comprehensive and detailed list: ‘assumed own status’ described as not testing at the beginning of the relationship; ‘assumed other status’, not asking about a partner’s status; ‘false questions’ explained as asking about a partner’s status in a way that was likely to reduce the chances of getting an honest answer, for example, immediately before having sex; ‘false answer’, described as ‘lies being told about one’s known HIV status, for example, through fear of rejection; ‘the monogamy myth’, ‘not reaching a clear acknowledgement of (at least) the possibility of sex by either partner outside the relationship’; ‘unstated responsibility’ explained as not reaching a clear agreement about course of action should ‘slip-ups’ occur; and finally ‘responsibility anxiety’ described as not disclosing to a partner about unsafe sex outside the relationship through fear of punishment or rejection (1994: 16). While these issues are now well understood, and since have been documented in some studies focussing on gay men’s relationships and agreements in New Zealand and Australia (see for example Worth,

251 Reid and McMillan 2002 and Murphy 2006 respectively), this list stands as one of the earliest and more insightful, succinct yet comprehensive characterisations of the difficulties and points of possible failure in negotiated safety agreements.

Reaction

The campaign materials were sent to all the Australian AIDS Councils as well as the NZAF, and to “other gay press and key gay HIV/AIDS education organisations nationally and internationally with a view to gauging wider reaction to the approach of the campaign” (1995: 10). Early feedback about the campaign included that from GPs and HIV testing counsellors in Victoria who reported that the materials were ‘long overdue’ and had prompted them and their clients to discuss issues around ‘trust, honesty, disclosure and negotiation’ rather than just testing and that, according to the project officer, this represented a shift from an expectation of a “purely clinical medical service delivery toward holistic involvement in counselling on … social/psychological needs” (1995: 11).

In NSW ACON’s managers of the Education and Community Development Programs initially gave positive feedback and expressed an interest in distributing the flyers but concerns over the content and message of the materials and the relevance to Sydney gay culture, the material assumed gay men came to the message not knowing their HIV status and so were less relevant to men who already knew they had HIV, and also similar criticism from a NSW HIV positive organisation50, tempered ACON’s response. ACON was itself planning a four page lift-out supplement in the gay newspaper, the Sydney Star Observer, addressing the issues of ‘fucking without condoms’ (which the next section will discuss in detail) so it was decided to wait for this “before distributing any message to their community on negotiated safety” (1995: 11 - 12).

According to the Summary Report, feedback from other interstate AIDS Councils and gay HIV/AIDS educators was “very mixed” with most suggesting that while the

50 The criticism was that the campaign was primarily aimed at negative men and that although this may be appropriate for Melbourne, given the greater prevalence of HIV in Sydney this would marginalise people with HIV (Summary Report “Safe Relationships” Campaign, 1995: 11 – 12). The role of positive men in HIV education and prevention has, in the past, been contentious and to some extent, continues to be so.

252 campaign might be appropriate for Melbourne it was “culturally inappropriate” for their particular State. A number of different reasons and examples were given for this cultural inappropriateness including that the inclusion of a Qantas ticket on the bedside table was “too bourgeois” and that the “indoor, warm, cosy” atmosphere of the bedside table was “too Melbourne” (1995: 12). The project officer voiced his concerns at the time that this was perhaps an overly sensitive reaction about the context and characteristics of members of target groups in these States and that it was not a practical or justifiable position for AIDS Councils to take given their limited resources for developing and producing campaign materials. I tend to agree with this argument and although it is clear an awareness of class and other social divisions and differences within populations of gay men is important, these differences in interstate context are minor compared to the broader social and cultural similarities of being a gay man addressing the risk of HIV infection in a relationship in Australia.

Perhaps what was not being articulated (except for ACON) was that there were significant concerns about the aims and objectives of the campaign itself, and that breaking the now well established safe sex norms of a condom every time, even if to address a potentially risky practice that was understood to be already occurring within gay relationships, was more challenging to AIDS Councils than arguments about cultural appropriateness of campaign materials would suggest. However, illustrating a need for information about negotiated safety in other gay communities around Australia – particularly Sydney – the VAC project officer commented while being interviewed for this thesis that there was a demand amongst his friendship and other informal networks for the A4 flyer. With a lack of any information available in other States, he sent large numbers of flyers by mail to various friends and acquaintances so they could distribute them throughout their social networks.

253 American academic in the HIV and AIDS field, perhaps best known for his 1995 book In the Shadow of the Epidemic: Being HIV-Negative in the Age of AIDS, wrote to the project officer congratulating VAC on the campaign saying it was “excellent” and “we have to support and assist this obvious possibility.” However, he continued that the campaigns were very controversial in the United States adding that while there was “much acceptance” there was also “the predictable response” that such campaigns were “encouraging men to fuck without condoms” (personal correspondence with VAC officer). He also put these sentiments into the academic arena when in 1995 he wrote in the AIDS and Public Policy Journal that the Victorian AIDS Council and AIDS Vancouver, British Columbia, Canada (who had also released a campaign on the issues around negotiated safety in 1994) had “both released campaigns … providing guidelines for ‘negotiated safety’ within serodiscordant relationships” and that “[t]he campaigns are remarkable for their acknowledgement of the real issues of uninfected men, as well as the respectful and validating way they portray gay sexuality and relationships” (1995b: 16).

Gabriel Rotello, later to be famous (or perhaps infamous) for his 1997 book Sexual Ecology: AIDS and the Destiny of Gay Men, which blamed much of the devastation of AIDS on the gay sub culture’s own ‘excesses’ and ‘irresponsibility’, described the VAC campaign in a one pager entitled ‘Beyond Condoms’ in the February 1995 edition of the influential and widely distributed American gay magazine The Advocate. Surprisingly, given his later views, this piece was largely neutral and simply described the A4 flyer. A more substantial piece in the January 1995 edition of the New York based Village Voice, which mentioned the VAC campaign, came from Mark Schoofs. While the bulk of the article entitled ‘Can You Trust Your Lover: Gay Couples Weigh the Risk of Unprotected Sex’ was a discussion of unsafe sex between gay couples in the American context, the Because We Want To Be Together flyer was described as an example of a campaign trying to address the issues involved after the author had stated that the ‘tragedy’ of seroconversion in relationships “will happen again and again unless … couples are educated about what it takes to safely have sex unsheathed” (1995: 38).

254 ACON’s Fucking Without Condoms

Printed on green paper to separate it from the rest of the newspaper, and addressed as ‘An open letter to the gay community from the AIDS Council of NSW’, the Fucking Without Condoms insert began by declaring “It’s time to talk about the fucking without condoms that’s happening in our community.” The insert went on to state that “[d]ifferent people take different risks in sex” and “there are lots of reasons why.” Over pages one and two the lift-out then outlined eleven reasons (with accompanying explanatory passages) for taking risks that were by now well known to prevention and well described in social research. For example, research on perceptions of risk of HIV infection had repeatedly demonstrated the commonly held belief among many gay men that the insertive partner in anal sex was not at risk of HIV infection (see for example McNab and Worth, 1999: 17). ‘It’s OK, I’ll pull out before I cum’ addressed this issue, pointing out that people overestimated their ability to control their orgasm, that fluid from the Cowper’s gland (known colloquially and described in the insert as pre-cum) could be infective and that both active and receptive partners were at risk. On page two of the insert the issue was again addressed with an ACON ‘Expose the Myth’ cartoon, which illustrated the risks involved in not using a condom and pulling out before ejaculation.

Two reasons for taking risks, ‘Belonging’ and ‘Feeling Lousy About Yourself’, tackled the issues of poor self worth, another factor that social research had connected to risk of HIV infection (McNab and Worth 1999: 16). Connecting a past history of stigma and discrimination to risk of HIV infection ‘Belonging’ spoke of “social disapproval of homosexuality”: that some men only felt they belonged when they were having sex and that these things could “lead to some people taking risks they otherwise wouldn’t” while ‘Feeling Lousy’ suggested “some men don’t feel good about themselves and don’t really think much about staying safe.” Other reasons discussed included ‘But Condoms Remind Me of AIDS’ and ‘What If You Are Just Over AIDS and Over Safe Sex and Don’t Care Anymore’. In both instances it was recommended talking about the issue would be beneficial. The emphasis on open discussion is a recurring theme in the insert.

‘But Condoms Just Kill the Feeling’ offered practical advice to improve sensation (lack of sensation is a reason often given by gay men for their reluctance to use

255 condoms) while ‘It Won’t Happen to Me’ addressed denial and assumptions about appearance (someone healthy or old or young or good looking – which another reason ‘But He Was Gorgeous’ also covered – could not be infected). ‘Whoops! I Just Assumed He Was Negative Too or Whoops I Just Assumed He Was Positive Too!’ warned against making any assumptions about another’s HIV status and emphasised joint responsibility in a sexual encounter. Assumptions about HIV status based on appearance and joint responsibility were perennial themes in prevention by this time and again, described in detail by social research.

Unlike VAC’s Because We Want To Be Together that only mentioned sex between positive men in the context of negative health effects around reinfection, Fucking Without Condoms addressed issues around sex between and with HIV positive men more extensively. ‘Because We’re Already Both Positive’ discussed the risks of STD co-infection or reinfection with HIV from not using condoms for anal sex, but acknowledged that people will make their own sense of prevention information (and assess risk relative to their own context) by adding “[s]ome of us know this, but have decided that as we have a terminal condition anyway, the pleasure from fucking without condoms is worth any further risk or damage to our health.” A section appearing later in the insert, ‘When you are both positive’, returned to the subject of positive men and covered the risk, if having anal sex without condoms with each other, of contracting a range of STIs and other infections “which work with HIV to further damage the immune system.”

Asking ‘So When Exactly Is It Safe without Condoms?’ the remainder of the lift-out responded to the question by splitting the text into three separate sections: “When both of you are negative or are not sure if you have HIV”; “When one of you is HIV negative and the other positive”; and “When you are both positive.” The first section was the lengthiest and detailed the precise process that should be followed: testing, even if both people are negative then continuing to have safe sex for three months; testing again, and if both people are still negative then negotiating a clear agreement about no sex, no anal sex or safe sex outside the relationship, and what do if the agreement is broken (use condoms again and start with the steps from the beginning).

256 ACON’s Talk Test Test Trust … Together

Planning

In January 1996 the ACON Eduction Management Team developed a campaign creative brief and action plan which stated that the objectives of the campaign were to: “provide clear direction to couples considering negotiating to practice unprotected anal intercourse; send a clear message that giving up condoms in a relationship is not just something couples can ‘slip into’, and; provide direction for educators to use as a starting point to talking through issues with clients” (Mackie 1996: 10).

Guidelines for the four steps of negotiated safety were outlined and were very similar to steps laid out in ACON’s Fucking Without Condoms lift-out. These steps were the now familiar HIV testing with accompanying discussion around being ‘completely honest’ about test results and continuing to practice safe sex, then testing again after three months and if both partners were negative, then reaching a clear agreement about sex outside the relationship, or not, and making a clear agreement about what to do if either partner broke the agreement, had a ‘slip-up’ or accident.

The creative brief outlined campaign components, ‘it’s target, style and communication objectives’ while the action plan also outlined other ACON activities that supported the campaign. These included: the ‘Lovers’ Workshops which were described as workshops developed to “promote the negotiated safety guidelines, and also to provide skills development and a space to talk about gay relationships”, and; outreach events and peer education workshops which would also be used to promote negotiated safety guidelines (Mackie 1996: 11). It will be remembered that the Lovers Workshops discussed issues around finding, being in, and ending a relationship, along with communication skills and negotiating not using condoms, and were originally designed to complement Fucking Without Condoms. Similar relationship issues were discussed in ACON peer education workshops including Rural Project, youth and western Sydney workshops (1996: 11).

Initially it had been planned that TTTT be launched in January 1996 to coincide with ACON peer eduction workshops but the launching of AFAO’s nationwide ‘One Community’ campaign in that same month resulted in the decision to defer the launch until May (Mackie 1996:12). This allowed more time to develop the brief and plan

257 and negotiate new and innovative dissemination outlets for the campaign, including large street banners and a television community service announcement (1996: 12). Focus testing involving a questionnaire and viewing of text and images of campaign materials was carried out in March of 1996 with both HIV positive and negative men “selected from outside of ACON and conducted within small discussion groups” (1996: 12). Feedback from the focus testing resulted in photographs of people from a wider range of ages and cultural backgrounds being used, and a background image of two men embracing being made “more visible … in order to make the material more attractive” (1996: 13).

Consultation with ACON staff occurred in April 1996 with two open staff meetings where campaign materials were presented. Individual presentations of materials to a number of ACON staff members, the ACON Beats Team and counselling staff from the Albion Street AIDS Centre were also made. According to the TTTT evaluation report “for the most part feedback from staff, especially from education staff, was highly complementary” (Mackie 1996: 13). Feedback from the staff consultation resulted in a number of changes being made, including: adjusting the tone of the text from directing people to follow the steps of TTTT to “a message asking people who are considering having unprotected anal sex in a relationship to follow the steps”; starting the text with “using a condom is the safest way of having anal sex”; adding text about the need for open communication in a relationship “and that counselling and other assistance is available around this issue, if people felt they required it”; and, a number of other minor editorial changes (1996: 14).

Launch and Dissemination

The campaign was launched on May the 7th 1996 at the Australian National Museum in central Sydney, just a few blocks away from Oxford Street (the main gay precinct of the city since the late seventies). Over eighty people attended. Press kits containing “key facts about the campaign, its components and distribution, the target audience and a brief analysis of the social research supporting the campaign” were distributed to gay community journalists prior to the launch (1996: 15).

The campaign’s distribution was broad and innovative, surpassing previous ACON prevention initiatives in both breadth and scope. Eight full page and eight horizontal strip advertisements of the Talk Test Test Trust … Together slogan appeared in the

258 Sydney Star Observer and Capital Q over a two-month period from the campaign launch. The campaign pamphlets and posters were distributed to “gay community bars, clubs, saunas, backrooms, shops, bookshops and gyms” in the inner city and inner west areas (Mackie 1996: 17). Campaign materials were also distributed to a wide range of ACON eduction projects and branches including: youth (fun and esteem), Asian, mature aged gay men, venues outreach and liaison, HIV Living, gay and lesbian injecting drug use and ACON information projects; ACON Sydney Reception and Beats Team; and Hunter, Mid-North coast, Northern Rivers, and Illawarra branches of ACON (each branch receiving 500 pamphlets and 25 venue posters and advertising and distributing them through organisational and social networks).

Five hundred street posters, which carried the Talk Test Test Trust … Together slogan, were pasted around building sites in eastern, central and inner western Sydney suburbs during the course of the campaign. Two hundred and fifty posters were pasted up on two different occasions, the first batch straight after the launch in May and the second in June. The three large banners displaying the Talk Test Test Trust … Together slogan were hung on buildings and on freeway overpasses during the campaign. The two larger ten metre banners were hung from freeway overpasses in the inner city and east for periods of up to five days at a time (Mackie 1996: 19), and according to study participant Bryce, who worked on the campaign, also over a western Sydney freeway.

A thirty-second television advertisement was run over thirty times (after 8.30 pm) on a Sydney commercial channel from the 8th of May to the 28th of June 1996. This ‘community service announcement’, the use of which was a first for an ACON campaign, consisted of the Talk Test Test Trust … Together slogan displayed in the campaign colours on the screen while a voice over said “An Important message for gay men about relationships. For more information contact the AIDS Council on [telephone number].” In the background played the introductory bars of Kylie Minogue’s “What Do I Have to Do (To Get the Message Through)” (Mackie 1996: 19). From humble beginnings as the parochial spiral permed ‘Charlene’ in the Australian soap opera Neighbours, Kylie Minogue had risen to gay icon status in the 1990s with a succession of dance/pop hits and pop princess celebrity. The singer

259 allowed the use of the song without the payment of royalties (1996: 19). Overall, the total campaign budget, reported in the process evaluation, was $22, 715 (1996: 20 – 21).

Initial Reaction

According to the process evaluation report the response from ‘the community’ to Talk Test Test Trust … Together was “for the most part highly favourable” with letters to the editor in the Sydney Star Observer praising ACON and the campaign for “leadership, market reach and innovative manner in tackling … a difficult issue” and articles in the gay community press discussing the campaign favourably. The Star Observer cartoon ‘Living with Adam’ also referred to the campaign which was considered a big success by campaigner organisers as the cartoon was widely read and the reference was not solicited by ACON project staff. (Mackie 1996: 23). The campaign was also commended by “community leaders, academics and fellow educators” at the AFAO National Educators conference held in mid May 1996 (1996: 23).

Questions asked about recognition of campaign message and materials also produced favourable results. Forty eight per cent of post campaign respondents could name TTTT without prompting when asked about recent ACON campaigns, with 80 per

260 cent responding that they had seen the slogan when prompted. Showing the effectiveness of advertising in the gay press 81 per cent of post campaign respondents had seen these campaign advertisements (and 77 per cent reported reading them), with 78 and 71 per cent saying they had seen campaign posters in gay venues and on the street respectively.

When asked what they thought the main message of the campaign was sixty-nine per cent of respondents reported it was to “talk, get tested, get tested again and form an agreement if you are not going to use condoms within a relationship.”... From the results of this survey no-one thought the message was not to use condoms in a relationship although almost a quarter, 23 per cent, thought it was either to use condoms always (12 per cent) or to get tested regularly when in a relationship (11 per cent). The process evaluation report commented that this was an encouraging result as it meant no-one had mistaken the message in a highly risky way, to not use condoms in a relationship and not know partners’ HIV status (1996: 29) The process evaluation commented the responses to the questions about the impact and importance emphasised “the relevance of the message in the campaign to gay men’s lives” while also remarking that the survey had limited capacity in “measuring the objectives of the campaign”, and that a comprehensive independent impact and outcome evaluation would be required to do this (1996: 30).

A small survey of six questions was sent out to 250 service providers who had previously received the campaign materials. Only fourteen organisations returned the surveys but those who did commented positively about the message and felt it was relevant (Mackie 1996: 36). The ACON Education Unit also carried out interviews with other ACON staff and the Albion Street clinic counselling team to assess reaction to the campaign. The ACON Youth Project (Fun and Esteem) had used TTTT in its relationships and coming out workshops, ACON having trained volunteer facilitators on the issues addressed in the campaign (Mackie 1996: 31). A weekly drop-in group for young gay men devoted a session to discussing the campaign and unprotected sex in relationships. The television advertisement was considered an ‘important step forward’ but the street posters and large banners that carried only the slogan and no other information about the message ‘made little sense.’

261 The ACON Beats Outreach Team had distributed campaign materials to about forty men during the course of the campaign. They had attempted to target men who had regular partners. The process evaluation reported that the feedback from beat users was that the campaign was ‘good and clearly visible around town’ and that it was ‘about time ACON released a campaign in which the reality of what’s going on for gay men was addressed.’ However, according to the report some men commented that the issues involved would be difficult to communicate, too complex to talk about in a relationship or that they felt they did not have the skills to negotiate the four steps and were afraid of the conflict such negotiations might bring to their relationships (1996: 31). While the objectives TTTT had been quite specific, to arm men with the skills to talk about and negotiate sex without condoms in their relationships, an objective of the earlier Fucking Without Condoms lift-out had been to encourage an open general dialogue on the subject within gay communities. It would appear from the beat users’ comments that perhaps this is much easier said than done, and harks back to the complex dynamics of relationships more generally, as well as negotiating matters of sex and sexual practice within them.

262 Appendix Three: Fucking Without Condoms (ACON Lift-out)

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263 Page 2

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264 Page 3

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