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Masculinity, heteronormativity and young men's sexual health in British Columbia, Canada Knight, Rodney Eric 2011

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   MASCULINITY,	
  HETERONORMATIVITY	
  AND	
  YOUNG	
  MEN’S	
  SEXUAL	
  HEALTH	
  IN	
   BRITISH	
  COLUMBIA,	
  CANADA	
   	
   	
   by	
   	
   	
   Rodney	
  Eric	
  Knight	
   	
   B.A.,	
  University	
  of	
  Alberta,	
  2004	
   	
   	
   	
   A	
  THESIS	
  SUBMITTED	
  IN	
  PARTIAL	
  FULFILLMENT	
  OF	
   THE	
  REQUIREMENTS	
  FOR	
  THE	
  DEGREE	
  OF	
   	
   	
   Master	
  of	
  Science	
   	
   	
   in	
   	
   	
   The	
  Faculty	
  of	
  Graduate	
  Studies	
   	
   (Health	
  Care	
  and	
  Epidemiology)	
   	
   	
   	
   THE	
  UNIVERSITY	
  OF	
  BRITISH	
  COLUMBIA	
   (Vancouver)	
   	
   	
   APRIL	
  2011	
   	
   	
   	
   ©	
  Rodney	
  Eric	
  Knight,	
  2011	
    Abstract 	
   Background:	
  Young	
  men	
  account	
  for	
  a	
  substantial	
  proportion	
  of	
  reported	
  sexually	
   transmitted	
  infection	
  (STI)	
  and	
  HIV	
  cases	
  in	
  Canada.	
  However,	
  STI/HIV	
  testing	
  rates	
  remain	
   low	
  among	
  young	
  men.	
  While	
  men’s	
  health-­‐related	
  behaviour	
  have	
  been	
  linked	
  to	
  masculine	
   expectations	
  that	
  demand	
  stoicism,	
  independence	
  and	
  denial	
  of	
  illness,	
  little	
  is	
  known	
  about	
   how	
  dominant	
  masculine	
  and/or	
  heteronormative	
  expectations	
  may	
  affect	
  men’s	
  sexual	
   health-­‐related	
  practices	
  that	
  can	
  put	
  them	
  at	
  both	
  an	
  elevated	
  risk	
  of	
  acquiring	
  an	
  STI(s)/HIV	
   and/or	
  affect	
  their	
  ability	
  to	
  access	
  STI/HIV	
  testing	
  services.	
  The	
  objectives	
  of	
  this	
  thesis	
  are	
   to:	
  (1)	
  explore	
  how	
  heteronormative	
  and	
  heterosexist	
  discourses	
  function	
  within	
  clinical	
   settings	
  where	
  young	
  men	
  access	
  STI	
  testing	
  services	
  to	
  better	
  understand	
  the	
  extent	
  to	
   which	
  dominant	
  masculine	
  ideals	
  are	
  (re)produced	
  or	
  resisted	
  in	
  these	
  clinical	
  contexts;	
  (2)	
   identify	
  the	
  social	
  and	
  contextual	
  conditions	
  which	
  facilitate	
  or	
  create	
  barriers	
  to	
  effective	
   sexual	
  health	
  communication	
  amongst	
  men,	
  paying	
  special	
  attention	
  to	
  how	
  idealised	
   masculinities	
  influence	
  these	
  interactions;	
  (3)	
  develop	
  recommendations	
  for	
  sexual	
  health	
   services	
  and	
  future	
  research	
  to	
  improve	
  the	
  sexual	
  health	
  of	
  young	
  men	
  in	
  BC.	
  Results:	
  The	
   findings	
  drawn	
  from	
  this	
  research	
  highlight	
  how	
  idealized	
  masculinity	
  influences	
  young	
  men’s	
   sexual	
  health,	
  including	
  their	
  sexual	
  health-­‐seeking	
  behaviour,	
  sexual	
  practices	
  and	
  the	
  ways	
   in	
  which	
  they	
  talk	
  about	
  sexual	
  health.	
  Specifically	
  revealed	
  are	
  instances	
  in	
  which	
  dominant	
   heternormative	
  expectations	
  ‘hurt’	
  all	
  men	
  in	
  clinical	
  encounters	
  (e.g.,	
  by	
  stereotyping	
  gay	
   men	
  as	
  ‘risky’,	
  thereby	
  alleviating	
  STI/HIV	
  concern	
  for	
  straight	
  men	
  by	
  virtue	
  of	
  their	
  sexual	
   identity).	
  Men’s	
  conversations	
  about	
  sexual	
  health	
  focused	
  primarily	
  around	
  their	
  sexual	
    ii	
    encounters	
  (e.g.,	
  using	
  ironic/teasing	
  humour	
  to	
  embody	
  masculine	
  identities	
  that	
  neither	
   dismiss	
  nor	
  actively	
  express	
  concerns	
  about	
  sexual	
  health),	
  amid	
  processes	
  of	
  ‘manning	
  up’	
  to	
   break	
  with	
  dominant	
  masculinity	
  (e.g.,	
  stoicism)	
  to	
  permit	
  talk	
  about	
  sexual	
  health	
  with	
  peers	
   or	
  sex	
  partners.	
  Discussion:	
  By	
  examining	
  situations	
  in	
  which	
  men	
  (and	
  clinicians)	
  align	
  with	
   or	
  socially	
  reconfigure	
  idealized	
  notions	
  of	
  masculinity	
  related	
  to	
  sexual	
  health,	
  theorists	
  and	
   interventions	
  will	
  better	
  understand	
  how	
  more	
  equitable	
  gender	
  relations	
  can	
  be	
  produced,	
   thereby	
  improving	
  the	
  sexual	
  health	
  of	
  men	
  (and	
  women).	
   	
    iii	
    Preface The	
  research	
  in	
  this	
  thesis	
  was	
  conducted	
  according	
  to	
  the	
  guidelines	
  of	
  the	
  University	
  of	
   British	
  Columbia	
  Behavioural	
  Research	
  Ethics	
  Board.	
  Interviews	
  of	
  human	
  subjects	
  and	
   secondary	
  data	
  analyses	
  were	
  approved	
  by	
  UBC	
  BREB	
  H10-­‐00132.	
  Data	
  is	
  drawn	
  from	
  an	
   ongoing	
  program	
  of	
  research	
  investigating	
  youth’s	
  sexual	
  health	
  in	
  British	
  Columbia,	
  led	
  by	
   Dr.	
  Jean	
  Shoveller	
  (PhD,	
  UBC).	
  These	
  studies	
  included:	
  (1)	
  Investigating	
  the	
  Structural	
  and	
   Socio-­‐economic	
  Forces	
  Affecting	
  STI	
  Testing	
  and	
  Treatment	
  Among	
  Youth	
  in	
  Northeastern	
  BC	
   (UBC	
  BREB	
  H05-­‐1198);	
  (2)	
  Sex,	
  Gender	
  and	
  Place:	
  An	
  analysis	
  of	
  youth’s	
  experiences	
  with	
  STI	
   testing	
  in	
  British	
  Columbia	
  (UBC	
  BREB	
  H05-­‐81000);	
  and	
  (3)	
  Young	
  Men	
  and	
  Sexually	
   Transmitted	
  Infections	
  (UBC	
  BREB	
  H10-­‐00132).	
  Under	
  the	
  primary	
  supervision	
  of	
  Dr.	
  Jean	
   Shoveller	
  (PhD,	
  UBC)	
  and	
  co-­‐supervision	
  of	
  Drs	
  John	
  Oliffe	
  (PhD,	
  Deakin	
  University)	
  and	
  Dr.	
   Mark	
  Gilbert	
  (MD,	
  University	
  of	
  Ottawa;	
  MHSc,	
  UBC),	
  Knight	
  conducted	
  the	
  following	
   research	
  activities:	
   1. Data	
  collection.	
  Knight	
  conducted	
  40	
  qualitative,	
  in-­‐depth	
  interviews	
  with	
  young	
  men	
   (out	
  of	
  a	
  total	
  of	
  77	
  involved	
  in	
  this	
  thesis)	
  and	
  7	
  clinicians	
  (out	
  of	
  total	
  of	
  25	
  involved	
   in	
  this	
  thesis).	
   2. Data	
  analysis.	
  Data	
  analysis	
  was	
  primarily	
  conducted	
  by	
  Knight,	
  with	
  ongoing	
  research	
   team	
  consultation.	
  Feedback	
  from	
  Drs	
  Shoveller,	
  Oliffe	
  and	
  Gilbert	
  were	
  subsequently	
   incorporated	
  into	
  the	
  thesis.	
   3. Manuscript	
  preparation.	
  Each	
  manuscript	
  was	
  written	
  by	
  Knight;	
  theoretical	
  feedback	
   was	
  sought	
  from	
  Drs	
  Shoveller,	
  Oliffe	
  and	
  Gilbert	
  and	
  incorporated	
  into	
  subsequent	
   and	
  finalized	
  versions.	
  Shira	
  Goldenberg	
  (MSc,	
  UBC)	
  provided	
  feedback	
  related	
  to	
  men	
   iv	
    interviewed	
  in	
  the	
  study	
  Investigating	
  the	
  Structural	
  and	
  Socio-­‐economic	
  Forces	
   Affecting	
  STI	
  Testing	
  and	
  Treatment	
  Among	
  Youth	
  in	
  Northeastern	
  BC	
  in	
  Chapter	
  2	
  of	
   this	
  thesis.	
    v	
    Table of Contents	
   	
   Abstract	
  .......................................................................................................................................	
  ii	
   Preface	
  .......................................................................................................................................	
  iv	
   Table	
  of	
  Contents	
  .......................................................................................................................	
  vi	
   List	
  of	
  Tables	
  ............................................................................................................................	
  viii	
   Acknowledgments	
  ......................................................................................................................	
  ix	
   Dedication	
  ...................................................................................................................................	
  x	
   Chapter	
  1.0	
  	
  Introduction	
  ............................................................................................................	
  1	
   1.1	
  	
  Young	
  men	
  and	
  sexually	
  transmitted	
  infections	
  in	
  British	
  Columbia,	
  Canada	
  .................	
  1	
   1.2	
  	
  Young	
  men	
  and	
  STI/HIV	
  testing	
  ........................................................................................	
  2	
   1.3	
  	
  Men	
  and	
  masculinities	
  .....................................................................................................	
  4	
   1.4	
  	
  Men,	
  masculinities	
  and	
  sexually	
  transmitted	
  infection	
  testing	
  ........................................	
  5	
   1.5	
  	
  Masculinities,	
  sexual	
  health	
  and	
  men’s	
  sexual	
  practices	
  .................................................	
  6	
   1.6	
  	
  Thesis	
  objectives	
  ..............................................................................................................	
  8	
   1.7	
  	
  Thesis	
  outline	
  ...................................................................................................................	
  9	
   Chapter	
  2.0	
  	
  Heteronormativity	
  Hurts	
  Everyone	
  ......................................................................	
  10	
   2.1	
  	
  Introduction	
  ...................................................................................................................	
  10	
   2.2	
  	
  Study	
  setting	
  ...................................................................................................................	
  13	
   2.3	
  	
  Methods	
  .........................................................................................................................	
  14	
   2.3.1	
  	
  Recruitment	
  of	
  participants	
  ....................................................................................	
  14	
   2.3.2	
  	
  Interview	
  procedure	
  ................................................................................................	
  15	
   2.3.3	
  	
  Study	
  participants	
  ....................................................................................................	
  16	
   2.3.4	
  	
  Interviews	
  ................................................................................................................	
  17	
   2.3.5	
  	
  Data	
  analysis	
  ............................................................................................................	
  18	
   2.4	
  	
  Results	
  ............................................................................................................................	
  18	
   2.4.1	
  	
  The	
  ‘relativity	
  of	
  risk’	
  ...............................................................................................	
  19	
   2.4.2	
  	
  Alleviating	
  men’s	
  anxieties	
  ......................................................................................	
  22	
   2.4.3	
  	
  (Re)producing	
  the	
  heterosexual	
  status	
  quo	
  ............................................................	
  26	
   2.5	
  	
  Discussion	
  .......................................................................................................................	
  31	
   Chapter	
  3.0	
  	
  Masculinities,	
  ‘Guy	
  Talk’	
  and	
  ‘Manning	
  Up’:	
  Young	
  men’s	
  discussions	
  about	
   sexual	
  health	
  .............................................................................................................................	
  38	
   3.1	
  	
  Introduction	
  ...................................................................................................................	
  38	
   3.1.1	
  	
  Background	
  ..............................................................................................................	
  38	
   3.1.2	
  	
  Young	
  men’s	
  sexual	
  health	
  ......................................................................................	
  39	
   3.1.3	
  	
  Masculinities	
  and	
  men’s	
  sexual	
  health	
  practices	
  ....................................................	
  40	
   3.1.4	
  	
  Men	
  talking	
  about	
  sexual	
  health	
  .............................................................................	
  41	
   3.2	
  	
  Methods	
  .........................................................................................................................	
  42	
   3.2.1	
  Recruitment	
  .............................................................................................................	
  42	
   3.2.2	
  Study	
  setting	
  .............................................................................................................	
  42	
   3.2.3	
  	
  Interviews	
  ................................................................................................................	
  43	
   3.2.4	
  	
  Data	
  analysis	
  ............................................................................................................	
  43	
    vi	
    3.3	
  	
  Findings	
  ..........................................................................................................................	
  44	
   3.3.1	
  	
  Study	
  participants	
  ....................................................................................................	
  44	
   3.3.2	
  	
  ‘Guy	
  talk’	
  .................................................................................................................	
  45	
   3.3.3	
  	
  ‘Manning	
  up’:	
  Talking	
  about	
  STIs	
  and	
  health	
  ..........................................................	
  52	
   3.4	
  	
  Discussion	
  .......................................................................................................................	
  56	
   Chapter	
  4.0	
  	
  Discussion	
  .............................................................................................................	
  60	
   4.1	
  	
  Summary	
  of	
  findings	
  .......................................................................................................	
  60	
   4.2	
  	
  Implications	
  for	
  theory	
  ...................................................................................................	
  62	
   4.3	
  	
  Implications	
  for	
  men’s	
  sexual	
  health	
  interventions	
  and	
  future	
  research	
  .......................	
  63	
   4.4	
  	
  Strengths	
  and	
  limitations	
  ...............................................................................................	
  65	
   4.5	
  	
  Interpretation	
  of	
  findings	
  and	
  reflexivity	
  .......................................................................	
  66	
   References	
  ................................................................................................................................	
  68	
   Appendices	
  ................................................................................................................................	
  76	
   A.1	
  	
  Interview	
  guide	
  for	
  young	
  men	
  ......................................................................................	
  76	
   A.2	
  	
  Interview	
  guide	
  for	
  clinicians	
  .........................................................................................	
  82	
   A.3	
  	
  Interview	
  guide	
  for	
  young	
  men	
  ......................................................................................	
  87	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
    vii	
    List of Tables 	
   Table	
  1.	
  	
  Self-­‐identified	
  characteristics	
  of	
  young	
  men	
  ...............................................................	
  16	
   Table	
  2.	
  Characteristics	
  of	
  clinicians	
  ..........................................................................................	
  17	
   Table	
  3.	
  Self-­‐identified	
  characteristics	
  of	
  young	
  men	
  ................................................................	
  45	
    viii	
    Acknowledgments I	
  would	
  like	
  to	
  thank	
  the	
  young	
  men	
  and	
  service	
  providers	
  that	
  took	
  part	
  in	
  this	
  study.	
  I	
  would	
   also	
  like	
  to	
  especially	
  thank	
  Drs	
  Jean	
  Shoveller,	
  John	
  Oliffe	
  and	
  Mark	
  Gilbert	
  for	
  their	
  support,	
   wisdom	
  and	
  guidance.	
  I	
  also	
  thank	
  the	
  Youth	
  Sexual	
  Health	
  Team	
  investigators,	
  staff	
  and	
   trainees	
  for	
  their	
  ongoing	
  training	
  support.	
  Funding	
  for	
  this	
  study	
  was	
  provided	
  by	
  the	
   Canadian	
  Institutes	
  of	
  Health	
  Research	
  (Grant	
  number:	
  205444).	
  My	
  financial	
  support	
  was	
   generously	
  provided	
  by	
  a	
  Frederick	
  Banting	
  and	
  Charles	
  Best	
  Canada	
  Graduate	
  Scholarship	
   from	
  CIHR	
  and	
  a	
  research	
  stipend	
  from	
  Dr.	
  Jean	
  Shoveller.	
    ix	
    	
    Dedication	
    To	
  mom	
  and	
  dad	
   	
   	
   	
   	
   	
    x	
    Chapter 1.0 Introduction 	
   1.1	
  	
  Young	
  men	
  and	
  sexually	
  transmitted	
  infections	
  in	
  British	
  Columbia,	
  Canada	
   In	
  British	
  Columbia	
  (BC),	
  Canada,	
  sexually	
  transmitted	
  infections	
  (STIs)	
  are	
  high	
  and	
  rising;	
   and,	
  young	
  men	
  account	
  for	
  a	
  disproportionate	
  amount	
  of	
  infections.	
  For	
  example,	
  between	
   2000	
  and	
  2009,	
  genital	
  Chlamydia	
  rates	
  among	
  young	
  men	
  ages	
  15	
  to	
  24	
  years	
  doubled,	
  with	
   1110.4	
  cases	
  per	
  100,000	
  men	
  (compared	
  to	
  the	
  BC	
  average	
  of	
  251.1	
  per	
  100,000)	
  (British	
   Columbia	
  Centre	
  for	
  Disease	
  Control,	
  2010).	
  In	
  2009,	
  men	
  between	
  the	
  ages	
  of	
  20	
  to	
  24	
   experienced	
  the	
  highest	
  rates	
  of	
  genital	
  gonorrhoea	
  in	
  the	
  province;	
  and,	
  these	
  rates	
  have	
   more	
  than	
  doubled	
  since	
  2000	
  (from	
  45.5	
  to	
  111.6	
  cases	
  per	
  100,000)	
  (British	
  Columbia	
   Centre	
  for	
  Disease	
  Control,	
  2010).	
  In	
  2009,	
  HIV	
  incidence	
  rates	
  for	
  men	
  between	
  the	
  ages	
  of	
   20	
  to	
  24	
  were	
  significantly	
  higher	
  than	
  the	
  provincial	
  average	
  at	
  11.2	
  per	
  100,000	
  cases	
   (compared	
  to	
  the	
  provincial	
  average	
  of	
  7.6	
  per	
  100,000)	
  (British	
  Columbia	
  Centre	
  for	
  Disease	
   Control,	
  2010).	
  Of	
  concern,	
  the	
  STI	
  surveillance	
  data	
  indicate	
  the	
  potential	
  for	
  a	
  significant	
   increase	
  of	
  HIV	
  spread	
  among	
  this	
  cohort	
  in	
  the	
  near	
  future	
  (Larkin,	
  Andrews	
  &	
  Mitchell,	
   2006).	
   If	
  left	
  untreated,	
  STIs	
  in	
  men	
  can	
  lead	
  to	
  conditions,	
  such	
  as	
  chronic	
  hepatitis	
  B,	
  infertility,	
   arthritis,	
  skin	
  lesions,	
  epididymitis	
  (a	
  painful	
  ‘clogging’	
  of	
  the	
  ducts	
  attached	
  to	
  the	
  testicles)	
   and	
  inflammation	
  of	
  the	
  urethra	
  (Reiter's	
  syndrome)	
  (United	
  States	
  Centre	
  for	
  Disease	
   Control,	
  2011;	
  Public	
  Health	
  Agency	
  of	
  Canada,	
  2011).	
  Moreover,	
  STIs	
  are	
  synergistic,	
   meaning	
  that	
  acquiring	
  one	
  can	
  increase	
  the	
  risk	
  of	
  others,	
  including	
  HIV	
  (United	
  States	
   Centre	
  for	
  Disease	
  Control,	
  2011;	
  Public	
  Health	
  Agency	
  of	
  Canada,	
  2011).	
  Infected	
  men	
  often	
   1	
    do	
  not	
  experience	
  symptoms	
  and	
  are	
  less	
  likely	
  to	
  seek	
  treatment	
  and	
  therefore	
  contribute	
  to	
   further	
  disease	
  spread	
  (British	
  Columbia	
  Centre	
  for	
  Disease	
  Control,	
  2010).	
  For	
  example,	
  it	
  is	
   estimated	
  that	
  approximately	
  60%	
  of	
  Chlamydia	
  infections	
  in	
  men	
  are	
  asymptomatic	
   (LaMontagne,	
  Fine	
  &	
  Marrazzo,	
  2003).	
  As	
  a	
  result,	
  the	
  higher	
  reported	
  rates	
  of	
  STIs	
  among	
   young	
  women,	
  such	
  as	
  genital	
  Chlamydia,	
  have	
  largely	
  been	
  attributed	
  to	
  asymptomatic	
  cases	
   in	
  heterosexual	
  men	
  who	
  have	
  not	
  been	
  tested	
  and	
  therefore	
  not	
  treated	
  (British	
  Columbia	
   Centre	
  for	
  Disease	
  Control,	
  2010),	
  or	
  who	
  are	
  treated	
  for	
  their	
  symptoms	
  but	
  not	
  tested	
  (and	
   therefore	
  remain	
  unreported	
  in	
  the	
  surveillance	
  data).	
  	
   	
   1.2	
  	
  Young	
  men	
  and	
  STI/HIV	
  testing	
   As	
  a	
  result	
  of	
  the	
  high	
  and	
  rising	
  rates	
  of	
  STI/HIV,	
  there	
  is	
  a	
  strong	
  public	
  health	
   impetus	
  to	
  test1	
  and	
  treat	
  infected	
  men	
  to	
  prevent	
  and/or	
  reduce	
  further	
  disease	
  spread.	
   Unfortunately,	
  STI/HIV	
  testing	
  rates	
  among	
  young	
  men	
  in	
  BC	
  remain	
  disproportionately	
  low,	
   with	
  many	
  clinics	
  reporting	
  that	
  young	
  men	
  represent	
  only	
  5	
  to	
  10	
  percent	
  of	
  youth	
  clientele	
   accessing	
  testing	
  services	
  (Shoveller,	
  Knight,	
  Johnson,	
  Oliffe	
  &	
  Goldenberg,	
  2010;	
  Shoveller,	
   Johnson,	
  Rosenberg,	
  Greaves,	
  Patrick,	
  Oliffe,	
  et	
  al.,	
  2009;	
  Goldenberg,	
  Shoveller,	
  Koehoorn	
  &	
   Ostry,	
  2008).	
  The	
  low	
  rates	
  of	
  testing	
  among	
  young	
  men	
  have	
  often	
  been	
  attributed	
  to	
   1  	
  The	
  terms	
  testing	
  and	
  screening	
  are	
  often	
  used	
  interchangeably.	
  Whereas	
  diagnostic	
  testing	
    involves	
  medical	
  investigation	
  that	
  results	
  from	
  a	
  patient’s	
  symptoms	
  or	
  reports	
  of	
  specific	
   conditions	
  (Wilson,	
  1971),	
  screening	
  refers	
  to	
  testing	
  on	
  individuals	
  who	
  have	
  no	
  apparent	
   symptoms,	
  but	
  are	
  among	
  a	
  population	
  that	
  has	
  been	
  identified	
  as	
  ‘at	
  risk’	
  (Wilson,	
  1971).	
  For	
   the	
  purpose	
  of	
  the	
  current	
  thesis,	
  testing	
  is	
  used	
  as	
  an	
  umbrella	
  term	
  for	
  STI/HIV	
  clinical	
   testing	
  and	
  screening	
  services.	
    2	
    structural	
  deficiencies	
  within	
  health	
  care	
  services	
  and	
  systems	
  that	
  focus	
  on	
  women’s	
   reproductive	
  health,	
  while	
  ignoring	
  men’s	
  sexual	
  and	
  reproductive	
  health	
  (Alt,	
  2002).	
  For	
   example,	
  asymptomatic	
  women	
  are	
  encouraged	
  from	
  a	
  young	
  age	
  to	
  frequently	
  engage	
  with	
   reproductive	
  health	
  services	
  (thus	
  presenting	
  opportunities	
  for	
  STI/HIV	
  testing),	
  whereas	
  men	
   are	
  not	
  routinely	
  encouraged	
  to	
  engage	
  in	
  sexual	
  health	
  services	
  (especially	
  when	
  they	
  are	
   feeling	
  well)	
  (Rieg,	
  Lewis,	
  Miller,	
  Witt,	
  Guerrero	
  et	
  al.,	
  2008).	
  	
   Recently,	
  research	
  attention	
  has	
  turned	
  towards	
  men’s	
  experiences	
  and	
  behaviour	
   patterns	
  as	
  means	
  for	
  better	
  understanding	
  their	
  health-­‐seeking	
  patterns.	
  For	
  example,	
  in	
   Canada,	
  men	
  experience	
  higher	
  rates	
  in	
  14	
  of	
  the	
  15	
  leading	
  causes	
  of	
  mortality	
  (Oliffe,	
   Robertson,	
  Frank,	
  McCreary,	
  Tremblay	
  et	
  al.,	
  2010).	
  Although	
  many	
  of	
  these	
  causes	
  are	
   considered	
  modifiable	
  through	
  behavioural	
  change	
  (e.g.,	
  HIV	
  incidence),	
  researchers	
  argue	
   that	
  gender	
  reduces	
  the	
  likelihood	
  that	
  men	
  will	
  engage	
  in	
  behaviour	
  change	
  (Robertson,	
   Galdas,	
  McCreary,	
  Oliffe	
  &	
  Tremblay,	
  2009).	
  Men	
  are	
  thought	
  to	
  be	
  more	
  likely	
  to	
  avoid	
   regular	
  contact	
  with	
  health	
  services	
  (Courtenay,	
  2000).	
  When	
  experiencing	
  health-­‐related	
   symptoms,	
  men	
  often	
  deny	
  illness	
  because	
  they	
  fear	
  they	
  might	
  be	
  considered	
  weak	
  or	
   effeminate	
  (O’Brien,	
  Hunt	
  &	
  Hart,	
  2005).	
  Men	
  also	
  engage	
  in	
  ‘risk-­‐taking’	
  behaviour	
  (e.g.,	
   excessive	
  consumption	
  of	
  alcohol;	
  excessive	
  speeding)	
  more	
  frequently	
  –	
  perhaps	
  to	
  elevate	
   their	
  masculine	
  status	
  (Giordano,	
  Longmore	
  &	
  Manning,	
  2006).	
  Ultimately,	
  these	
  factors	
   increase	
  their	
  risk	
  of	
  health-­‐related	
  problems	
  (e.g.,	
  liver	
  disease;	
  injury)	
  (Robertson,	
  Galdas,	
   McCreary,	
  Oliffe	
  &	
  Tremblay,	
  2009;	
  Oliffe,	
  Robertson,	
  Frank,	
  McCreary,	
  Tremblay	
  et	
  al.,	
   2010).	
  	
    3	
    1.3	
  	
  Men	
  and	
  masculinities	
   	
    Sociological	
  theories	
  link	
  men’s	
  health	
  behaviour	
  to	
  performances	
  of	
  masculinity	
    (Courtenay,	
  2000;	
  Robertson,	
  2007).	
  Connell	
  (1987	
  and	
  1995)	
  defined	
  masculinity	
  as	
  a	
   structure	
  of	
  social	
  performances	
  that	
  influences	
  men’s	
  identities	
  and	
  practices.	
  Masculinities	
   function	
  hierarchically,	
  with	
  hegemonic	
  masculinity	
  representing	
  the	
  most	
  socially	
  dominant	
   masculinity.	
  Within	
  this	
  framework,	
  hegemony	
  refers	
  to	
  the	
  cultural	
  dynamics	
  that	
  allow	
  a	
   social	
  group	
  to	
  sustain	
  dominance;	
  hegemonic	
  masculinity	
  is	
  the	
  culturally	
  “exalted”	
  gender	
   practice	
  that	
  enables	
  male	
  dominance	
  (Connell,	
  1995).	
  Masculinity	
  theorists	
  often	
  position	
   hegemonic	
  masculinity	
  as	
  an	
  ‘idealized’	
  masculinity	
  that	
  is	
  “just	
  barely	
  out	
  of	
  reach	
  for	
  all	
   men”	
  (Numer,	
  2009,	
  p.	
  383).	
  In	
  other	
  words,	
  while	
  hegemonic	
  masculinity	
  is	
  unattainable	
  to	
   all	
  men,	
  some	
  men	
  are	
  able	
  to	
  align	
  more	
  closely	
  with	
  idealized	
  notions	
  of	
  masculinity,	
   whereas	
  others	
  ‘fall	
  short’	
  –	
  but	
  never	
  quite	
  give	
  up	
  –	
  thereby	
  constituting	
  a	
  social	
  ordering	
  of	
   men.	
  	
   Connell	
  (1995)	
  suggests	
  that	
  hegemonic	
  masculinity	
  is	
  constituted	
  by	
  oppositional	
   relationships	
  consisting	
  of	
  the	
  subordination	
  of	
  ‘others’	
  (i.e.,	
  women	
  and	
  some	
  men)	
  through	
   heterosexual	
  patriarchy.	
  Subordination	
  transpires	
  through	
  cultural	
  stigmatization,	
  violence	
   and	
  inequitable	
  distribution	
  of	
  capital/material	
  wealth	
  (Connell,	
  1995).	
  Subordinated	
   masculinities	
  also	
  are	
  disadvantaged	
  by	
  virtue	
  of	
  their	
  ‘other’	
  intersecting	
  social	
  identities	
   (e.g.,	
  gay	
  identities;	
  racialized	
  identities).	
  While	
  Connell	
  explains	
  that	
  gay	
  masculinities	
  are	
  the	
   most	
  conspicuous	
  among	
  subordinated	
  masculinities,	
  he	
  also	
  acknowledges	
  that	
  heterosexual	
   men	
  embodying	
  weak	
  or	
  effeminate	
  characteristic	
  (e.g.,	
  ‘sissies’)	
  can	
  be	
  subordinated.	
  Some	
   men	
  become	
  marginalized	
  by	
  normative	
  masculine	
  ideals;	
  though,	
  as	
  Connell	
  (1995)	
  explains,	
    4	
    there	
  may	
  be	
  no	
  overt	
  attempts	
  to	
  marginalize	
  these	
  men	
  through	
  masculine	
  social	
  practices.	
   Nonetheless,	
  marginalized	
  men	
  can	
  experience	
  material	
  deprivation;	
  as	
  Robertson	
  (2007)	
   argues	
  is	
  often	
  the	
  case	
  for	
  men	
  who	
  have	
  physical	
  (dis)abilities.	
   Most	
  men	
  are	
  unable	
  to	
  fully	
  embody	
  and	
  practice	
  the	
  hegemonic	
  definitions	
  of	
   masculinity;	
  but,	
  they	
  nonetheless	
  benefit	
  from	
  the	
  ‘patriarchal	
  dividend’	
  as	
  a	
  result	
  of	
  the	
   subordination	
  of	
  women	
  and	
  marginalized	
  men	
  (Connell	
  1995).	
  Therefore,	
  many	
  men,	
   according	
  to	
  Connell,	
  embody	
  a	
  complicit	
  masculinity.	
  Dominant	
  and	
  normative	
  masculinities	
   also	
  are	
  terms	
  used	
  to	
  relate	
  to	
  hegemonic	
  masculinity.	
  These	
  terms	
  have	
  been	
  employed	
  by	
   theorists	
  to	
  account	
  for	
  the	
  disparity	
  between	
  the	
  culturally	
  exalted	
  hegemonic	
  masculinity	
   (at	
  an	
  overall,	
  cultural	
  level)	
  and	
  the	
  masculinities	
  that	
  men	
  experience	
  as	
  dominant	
  and	
   normative	
  in	
  their	
  everyday	
  lives.	
  Despite	
  being	
  subordinated	
  to	
  the	
  culturally	
  “exalted”	
   hegemonic	
  ideal,	
  men	
  who	
  align	
  with	
  dominant	
  and	
  normative	
  masculinities	
  derive	
  benefit	
   (Coles,	
  2009),	
  especially	
  within	
  the	
  realm	
  of	
  sexual	
  practices.	
  For	
  example,	
  many	
  men,	
   regardless	
  of	
  their	
  alignment	
  with	
  dominant	
  and	
  normative	
  masculinities,	
  may	
  align	
  with	
   masculine	
  ideals	
  that	
  valorize	
  (and	
  benefit	
  from)	
  men’s	
  role	
  as	
  a	
  sexual	
  pursuer.	
   	
    1.4	
  	
  Men,	
  masculinities	
  and	
  sexually	
  transmitted	
  infection	
  testing	
   	
    Within	
  the	
  masculinities	
  theoretical	
  framework,	
  men’s	
  health-­‐seeking	
  behaviour	
  is	
    positioned	
  as	
  a	
  performance	
  of	
  masculinity	
  (Robertson,	
  2007).	
  The	
  high	
  and	
  rising	
  rates	
  of	
   STIs	
  among	
  young	
  men	
  have	
  been	
  linked	
  to	
  normative	
  masculine	
  behaviour;	
  and,	
  an	
   emerging	
  literature	
  details	
  how	
  these	
  behaviour	
  often	
  present	
  barriers	
  to	
  men’s	
  engagement	
   with	
  routine	
  STI/HIV	
  testing	
  (Shoveller	
  et	
  al.,	
  2009	
  and	
  2010;	
  Goldenberg	
  et	
  al.,	
  2008a	
  and	
    5	
    2008b).	
  For	
  example,	
  Shoveller	
  et	
  al	
  (2010)	
  highlighted	
  how	
  factors	
  (e.g.,	
  STI	
  testing	
   procedures,	
  such	
  as	
  the	
  ‘swab’)	
  disrupt	
  idealized	
  notions	
  of	
  heterosexual	
  masculinity	
  to	
   prevent	
  men	
  from	
  accessing	
  services	
  (e.g.,	
  ‘real	
  men’	
  penetrate	
  and	
  should	
  not	
  be	
  penetrated	
   by	
  a	
  urethral	
  swab).	
  Clinical	
  encounters	
  also	
  are	
  underpinned	
  by	
  gendered	
  and	
   heteronormative	
  expectations	
  that,	
  when	
  transgressed,	
  can	
  present	
  potentially	
  emasculating	
   outcomes	
  (Shoveller	
  et	
  al.,	
  2004;	
  Shoveller	
  et	
  al.,	
  2010	
  and	
  2009).	
  For	
  example,	
  Shoveller	
  et	
  al	
   (2010)	
  described	
  how	
  men’s	
  heteronormative	
  expectations	
  sometimes	
  cause	
  them	
  to	
  avoid	
  a	
   woman	
  clinician	
  (for	
  fear	
  of	
  getting	
  an	
  erection)	
  or	
  to	
  avoid	
  seeing	
  a	
  man	
  clinician	
  (for	
  fear	
  of	
   a	
  ‘homosexual’	
  gaze).	
  Shoveller	
  et	
  al	
  (2009)	
  described	
  how	
  heteronormative	
  assumptions	
   employed	
  by	
  clinicians	
  within	
  clinical	
  encounters	
  can	
  frequently	
  result	
  in	
  young	
  men	
  being	
   presumed	
  as	
  heterosexual	
  –	
  thereby	
  presenting	
  missed	
  opportunities	
  for	
  discussing	
  sexual	
   health	
  for	
  men	
  who	
  are	
  not	
  engaging	
  in	
  heterosexual	
  sex.	
  And,	
  while	
  emerging	
  literature	
   detail	
  how	
  dominant	
  heteronormative	
  masculine	
  ideals	
  negatively	
  impact	
  heterosexual	
  men	
   (e.g.,	
  stereotypes	
  subjecting	
  heterosexual	
  adolescents	
  to	
  homophobic	
  encounters,	
  including	
   ‘fag	
  discourse’)	
  (Brown	
  &	
  Alderson,	
  2010;	
  Pascoe,	
  2007;	
  Yep,	
  2002),	
  the	
  health	
  literature	
  has	
   yet	
  to	
  address	
  how	
  the	
  impacts	
  of	
  heterosexism	
  and/or	
  homophobia	
  might	
  also	
  negatively	
   affect	
  heterosexual	
  men	
  in	
  STI/HIV	
  clinical	
  encounters	
  (Bryant	
  &	
  Vidal-­‐Ortiz,	
  2008).	
  	
   	
   1.5	
  	
  Masculinities,	
  sexual	
  health	
  and	
  men’s	
  sexual	
  practices	
   Male	
  sexual	
  practices	
  are	
  located	
  at	
  the	
  pinnacle	
  of	
  a	
  complicated	
  nexus	
  of	
  dominant	
   masculine	
  expectations.	
  The	
  sexual	
  practices	
  in	
  which	
  men	
  are	
  ‘permitted’	
  to	
  engage	
  are	
   governed	
  by	
  normative	
  masculinities	
  that	
  can	
  put	
  men	
  (and	
  women)	
  at	
  increased	
  risk	
  of	
    6	
    getting	
  STI(s)/HIV.	
  For	
  example,	
  dominant	
  masculine	
  expectations	
  among	
  young	
  men	
  valorise	
   frequent	
  sexual	
  activity,	
  multiple	
  sex	
  partners,	
  a	
  focus	
  on	
  (self)	
  pleasure,	
  and	
  sexual	
  ‘risk-­‐ taking’	
  practices	
  (e.g.,	
  avoidance	
  of	
  condoms)	
  (Larkin,	
  Andrews,	
  &	
  Mitchell,	
  2006;	
  Giordano,	
   Longmore	
  &	
  Manning,	
  2006;	
  Korobov,	
  2005	
  and	
  2008;	
  Numer	
  &	
  Gahagan,	
  2009;	
  Numer,	
  2008	
   and	
  2009;	
  Duck,	
  2009).	
  In	
  addition,	
  Numer	
  and	
  Gahagan	
  (2009)	
  describe	
  how	
  gay	
  men’s	
   dismissal	
  of	
  health	
  promotion	
  messaging	
  related	
  to	
  “safer	
  sex”	
  is	
  an	
  enactment	
  of	
  hegemonic	
   masculinity	
  that	
  rejects	
  concern	
  or	
  fear	
  for	
  one’s	
  (or	
  others’)	
  sexual	
  health.	
  	
   While	
  many	
  men	
  recognize	
  that	
  sexual	
  practices	
  related	
  to	
  hegemonic	
  masculinity	
   may	
  threaten	
  their	
  ability	
  to	
  be	
  sexually	
  healthy	
  (e.g.,	
  if	
  they	
  become	
  infected	
  with	
  STI/HIV),	
   actions	
  that	
  would	
  restrict	
  their	
  sexual	
  practices	
  (e.g.,	
  getting	
  tested	
  and	
  being	
  diagnosed	
   with	
  a	
  STI/HIV)	
  are	
  frequently	
  rejected	
  as	
  ‘unmanly’	
  (Duck,	
  2009).	
  By	
  avoiding	
  testing	
   services,	
  men’s	
  masculinity	
  is	
  protected	
  from	
  “bad	
  health	
  news”	
  (Duck,	
  2009).	
  Men’s	
   reticence	
  to	
  engage	
  in	
  discussions	
  around	
  health	
  have	
  been	
  linked	
  to	
  dominant	
  and	
   hegemonic	
  expectations	
  that	
  preserve	
  more	
  valued	
  enactments	
  of	
  masculinity	
  over	
  others	
   (e.g.,	
  sexual	
  activity	
  as	
  more	
  valued	
  than	
  actively	
  taking	
  care	
  of	
  one’s	
  sexual	
  health	
  and	
  that	
   of	
  others)	
  (O’Brien,	
  Hunt	
  &	
  Hart,	
  2005,	
  p.	
  1).	
  As	
  a	
  result,	
  men	
  who	
  align	
  with	
  masculinities	
   that	
  require	
  stoicism,	
  independence,	
  self-­‐reliance	
  and	
  disinterest	
  in	
  health	
  frequently	
  position	
   ‘health’	
  as	
  a	
  ‘normal’	
  condition	
  that	
  does	
  not	
  warrant	
  discussion	
  in	
  the	
  absence	
  of	
  illness	
  or	
   symptoms	
  (Robertson,	
  2007).	
  Unfortunately,	
  men	
  who	
  avoid	
  discussing	
  sexual	
  health	
  are	
  at	
   increased	
  risk	
  of	
  becoming	
  infected	
  by	
  an	
  STI	
  (as	
  well	
  as	
  other	
  health	
  problems)	
  (Alt,	
  2002;	
   Courtenay	
  2000a;	
  Brook	
  Advisory	
  Centres	
  2005;	
  Pearson	
  2003).	
  Yet,	
  there	
  is	
  little	
  empirical	
    7	
    and/or	
  theoretical	
  literature	
  examining	
  the	
  contextual	
  and	
  social	
  conditions	
  that	
  affect	
  men’s	
   ability	
  to	
  talk	
  about	
  sexual	
  health.	
   	
   1.6	
  	
  Thesis	
  objectives	
   In	
  the	
  current	
  thesis,	
  the	
  ways	
  in	
  which	
  heteronormativity	
  and	
  idealised	
  notions	
  of	
   masculinity	
  affect	
  men’s	
  sexual	
  health-­‐related	
  practices	
  are	
  examined	
  (e.g.,	
  how	
  men	
  discuss	
   their	
  sexual	
  health;	
  experiences	
  accessing	
  services).	
  An	
  in-­‐depth	
  examination	
  will	
  be	
  provided	
   to	
  detail	
  the	
  social	
  and	
  structural	
  conditions	
  that	
  allow	
  men	
  to	
  ‘do’	
  sexual	
  health.	
  Young	
   men’s	
  (ages	
  15	
  to	
  25	
  years)	
  perspectives	
  represent	
  a	
  starting	
  point	
  for	
  gaining	
  a	
  better	
   understanding	
  of	
  men’s	
  health	
  practices,	
  as	
  well	
  as	
  their	
  conceptualizations	
  of	
  masculinity	
   related	
  to	
  sexual	
  health	
  (Robertson,	
  2007).	
  By	
  distilling	
  the	
  ways	
  in	
  which	
  young	
  men	
   (dis)align	
  with	
  masculinities,	
  much	
  needed	
  advances	
  can	
  be	
  made	
  regarding	
  theory	
  and	
   practice.	
  The	
  objectives	
  of	
  the	
  current	
  thesis	
  are	
  to:	
   (1) Explore	
  how	
  heteronormative	
  and	
  heterosexist	
  discourses	
  function	
  within	
  clinical	
   settings	
  where	
  young	
  men	
  access	
  STI	
  testing	
  services	
  to	
  better	
  understand	
  the	
  extent	
   to	
  which	
  dominant	
  masculine	
  ideals	
  are	
  (re)produced	
  or	
  resisted	
  in	
  these	
  clinical	
   contexts	
  (Chapter	
  2);	
   (2) Identify	
  the	
  social	
  and	
  contextual	
  conditions	
  which	
  facilitate	
  or	
  create	
  barriers	
  to	
   effective	
  sexual	
  health	
  communication	
  amongst	
  men,	
  paying	
  special	
  attention	
  to	
  how	
   idealised	
  masculinities	
  influence	
  these	
  interactions	
  (Chapter	
  3);	
  and	
   (3) Develop	
  recommendations	
  for	
  sexual	
  health	
  services	
  and	
  future	
  research	
  to	
  improve	
   the	
  sexual	
  health	
  of	
  young	
  men	
  in	
  BC.	
   8	
    1.7	
  	
  Thesis	
  outline	
   The	
  current	
  thesis	
  includes	
  an	
  introductory	
  chapter	
  (Chapter	
  1),	
  two	
  manuscripts	
   (Chapters	
  2	
  and	
  3),	
  and	
  a	
  discussion	
  of	
  the	
  overall	
  findings	
  (Chapter	
  4).	
  Chapter	
  2,	
   Heteronormativity	
  Hurts	
  Everyone,	
  draws	
  on	
  qualitative	
  interviews	
  with	
  45	
  men	
  (15-­‐25	
  years-­‐ old)	
  and	
  25	
  clinicians	
  (e.g.,	
  doctors;	
  nurses)	
  collected	
  in	
  2006	
  to	
  2008	
  in	
  British	
  Columbia,	
   Canada,	
  to	
  examine	
  how	
  heteronormative	
  discourses	
  affect	
  STI/HIV	
  testing	
  experiences	
  for	
   young	
  men.	
  Chapter	
  3,	
  entitled	
  Masculinities,	
  ‘Guy	
  Talk’	
  and	
  ‘Manning	
  Up’:	
  Young	
  men’s	
   discussions	
  about	
  sexual	
  health,	
  draws	
  on	
  32	
  qualitative	
  interviews	
  collected	
  in	
  2010	
  to	
  2011	
   with	
  young	
  men	
  (ages	
  17-­‐24)	
  to	
  explore	
  how	
  idealised	
  masculinity	
  can	
  ‘shut	
  down’	
  or	
   facilitate	
  effective	
  sexual	
  health	
  communication	
  (e.g.,	
  with	
  peers;	
  sex	
  partners).	
  The	
   discussion	
  (Chapter	
  4)	
  highlights	
  the	
  need	
  for	
  future	
  men’s	
  sexual	
  health	
  research	
  to	
  attend	
   to	
  a	
  variety	
  of	
  men’s	
  masculine	
  identities	
  and	
  describes	
  future	
  research	
  directions.	
    9	
    Chapter 2.0 Heteronormativity Hurts Everyone 2.1	
  	
  Introduction	
   Young	
  men’s	
  sexual	
  health	
  and	
  well-­‐being	
  is	
  affected	
  by	
  an	
  array	
  of	
  social	
  interactions	
   and	
  structural	
  conditions,	
  which	
  can	
  put	
  their	
  sexual	
  health	
  at	
  risk	
  (Shoveller,	
  Johnson,	
   Langille,	
  &	
  Mitchell,	
  2004).	
  The	
  heterosexist,	
  heteronormative	
  and	
  homophobic2	
  nature	
  of	
   many	
  social	
  contexts	
  can	
  be	
  especially	
  problematic	
  for	
  gay	
  and	
  bisexual	
  men,	
  who	
  either	
  hide	
   their	
  sexuality	
  or	
  cope	
  with	
  a	
  stigmatised	
  identity	
  (Ryan	
  &	
  Futterman,	
  2001).	
  Young	
  gay	
  and	
   bisexual	
  men	
  in	
  many	
  locales	
  including	
  British	
  Columbia	
  (BC),	
  Canada,	
  are	
  at	
  increased	
  risk	
  of	
   social	
  isolation	
  and	
  alienation,	
  including	
  rejection,	
  discrimination	
  and	
  violence	
  from	
  their	
   families,	
  schools	
  and	
  communities	
  (McCreary,	
  2007).	
  Dominant	
  heteronormative	
  cultural	
   ideals	
  can	
  also	
  negatively	
  impact	
  heterosexual	
  men	
  in	
  ways	
  that	
  are	
  particularly	
  harmful	
  to	
   2  	
   Each	
   of	
   these	
   terms	
   –	
   heteronormativity	
   and	
   heterosexism	
   –	
   are	
   useful	
   tools	
   for	
   naming,	
    understanding	
   and	
   responding	
   to	
   anti-­‐homosexual	
   (or	
   heterosexual-­‐focused)	
   attitudes	
   and	
   actions	
   (Bryant	
   &	
   Vidal-­‐Ortiz,	
   2008),	
   yet	
   are	
   each	
   fundamentally	
   different.	
   Historically,	
   the	
   term	
   ‘homophobia’	
   has	
   been	
   used	
   as	
   a	
   tool	
   for	
   collectivities	
   (e.g.,	
   the	
   ‘gay	
   rights’	
   movement)	
   and	
  individuals	
  to	
  name	
  and	
  respond	
  to	
  oppression	
  (Bryant	
  &	
  Vidal-­‐Ortiz,	
  2008).	
  The	
  mind-­‐set	
   of	
   homophobia	
   is	
   backed	
   by	
   a	
   belief	
   in	
   the	
   notions	
   of	
   heteronormativity	
   and	
   heterosexism.	
   The	
  terms	
  have	
  similarities:	
  heterosexism	
  describes	
  the	
  conviction	
  “that	
  everyone	
  is	
  or	
  should	
   be	
   heterosexual”	
   (Yep,	
   2002);	
   heteronormativity	
   suggests	
   that	
   being	
   heterosexual	
   is	
   the	
   social	
   norm,	
   natural,	
   and	
   the	
   only	
   way	
   one	
   can	
   be	
   fully	
   human	
   (Yep,	
   2002).	
   These	
   two	
   attitudes	
  legitimatise	
  and	
  render	
  possible	
  homophobic	
  behaviour.	
  In	
  this	
  article	
  we	
  use	
  each	
   term	
   to	
   delineate	
   particular	
   aspects	
   of	
   heterosexual	
   privilege	
   and	
   ‘non-­‐heterosexual’	
   subordination.	
    10	
    youth	
  (e.g.,	
  social	
  norms	
  inhibiting	
  men	
  from	
  forming	
  close	
  and	
  meaningful	
  relationships	
  with	
   each	
  other;	
  stereotypes	
  subjecting	
  heterosexual	
  adolescents	
  to	
  homophobic	
  encounters,	
   including	
  ‘fag	
  discourse’)	
  (Brown	
  &	
  Alderson,	
  2010;	
  Pascoe,	
  2007;	
  Yep,	
  2002).	
  That	
  said,	
  for	
   the	
  most	
  part,	
  the	
  health	
  literature	
  has	
  yet	
  to	
  address	
  how	
  the	
  impacts	
  of	
  heterosexism	
   and/or	
  homophobia	
  affect	
  heterosexual	
  men	
  (Bryant	
  &	
  Vidal-­‐Ortiz,	
  2008).	
  	
   	
    There	
  is	
  an	
  emerging	
  literature	
  exploring	
  men’s	
  experiences	
  with	
  sexual	
  health	
  services.	
    For	
  example,	
  identified	
  predictors	
  of	
  gay	
  and	
  bisexual	
  men’s	
  engagement	
  in	
  sexually	
   transmitted	
  infection	
  (STI)	
  testing	
  include	
  individual	
  factors	
  (e.g.,	
  knowledge	
  levels),	
  psycho-­‐ social	
  factors	
  (e.g.,	
  fear	
  of	
  homophobic	
  reactions	
  from	
  clinicians),	
  socio-­‐cultural	
  influences	
   (e.g.,	
  stigma	
  of	
  having	
  a	
  ‘non-­‐heterosexual’	
  identity),	
  and/or	
  heteronormative	
  assumptions	
  in	
   the	
  health	
  care	
  system	
  (e.g.,	
  presuming	
  patients	
  are	
  engaged	
  solely	
  in	
  heterosexual	
   relationships)	
  (Shoveller,	
  Knight,	
  Johnson,	
  Oliffe,	
  &	
  Goldenberg,	
  2010;	
  Hoffman,	
  Freeman,	
  &	
   Swann,	
  2009;	
  Makadon,	
  Mayer,	
  Potter,	
  &	
  Goldhammer,	
  2007).	
  The	
  literature	
  examining	
  the	
   predictors	
  of	
  heterosexual	
  men’s	
  participation	
  in	
  STI	
  testing	
  services	
  has	
  revealed	
  psycho-­‐ social	
  factors	
  (e.g.,	
  fear	
  of	
  exposing	
  one’s	
  penis)	
  (Shoveller	
  et	
  al.,	
  2010)	
  and	
  socio-­‐cultural	
   influences	
  (e.g.,	
  dominant	
  forms	
  of	
  masculinity	
  that	
  idealise	
  the	
  male	
  body	
  as	
  robust)	
   (Connelll,	
  1995),	
  as	
  well	
  as	
  structural	
  and	
  institutional	
  factors	
  (e.g.,	
  the	
  public	
  health	
  system’s	
   focus	
  on	
  the	
  reproductive	
  health	
  needs	
  of	
  women)	
  (Alt,	
  2002).	
  	
   	
    Men’s	
  sexual	
  health	
  and	
  masculinity	
  are	
  strongly	
  linked	
  to	
  notions	
  of	
  ‘risk’	
  in	
  which	
  men	
    must	
  reconcile	
  sexual	
  risks	
  and	
  pleasure	
  (Robertson,	
  2007).	
  Sociological	
  critiques	
  of	
   masculinities	
  and	
  men’s	
  health	
  have	
  identified	
  a	
  myriad	
  of	
  influences	
  related	
  to	
  their	
  health-­‐ seeking	
  behaviours	
  and	
  experiences,	
  including	
  denial	
  of	
  illness,	
  reluctance	
  to	
  access	
  health	
    11	
    care	
  services	
  and	
  self-­‐monitoring	
  and	
  -­‐treatment	
  of	
  symptoms	
  (Courtenay,	
  2004;	
  Lee	
  &	
   Owens,	
  2003;	
  Robertson,	
  2007).	
  These	
  critical	
  analytical	
  perspectives	
  suggest	
  that	
  men’s	
   sexual	
  health	
  experiences	
  should	
  be	
  understood	
  as	
  occurring	
  within	
  a	
  wider	
  set	
  of	
  social	
   relations	
  (Shoveller,	
  Johnson,	
  Savoy,	
  &	
  Pietersma,	
  2006;	
  Shoveller,	
  Johnson,	
  Rosenberg,	
   Greaves,	
  Patrick,	
  Oliffe,	
  et	
  al.,	
  2009;	
  Shoveller	
  et	
  al.,	
  2010;	
  Lindberg,	
  Lewis-­‐Spruill,	
  &	
   Crownover,	
  2006;	
  Goldenberg,	
  Shoveller,	
  Koehoorn,	
  &	
  Ostry,	
  2008),	
  detailing	
  the	
  connections	
   between	
  structure,	
  identity	
  and	
  agency.	
  An	
  emerging	
  sociological	
  framework	
  explores	
  how	
   these	
  interactions	
  are	
  underpinned	
  by	
  gendered	
  and	
  heteronormative	
  societal	
  expectations	
   (Shoveller	
  et	
  al.,	
  2004;	
  Shoveller	
  et	
  al.,	
  2010).	
  Under	
  this	
  framework,	
  threats	
  to	
  men’s	
  health	
   can	
  occur	
  due	
  to	
  one’s	
  identity	
  (e.g.,	
  gay	
  masculinities	
  subordination	
  to	
  dominant	
  and	
   hegemonic	
  heterosexual	
  masculinities),	
  and	
  these	
  ‘external’	
  risks	
  can	
  have	
  negative	
   consequences	
  on	
  men’s	
  health	
  (e.g.,	
  limited	
  job	
  opportunities;	
  physical	
  violence)	
  and	
  access	
   to	
  health	
  services	
  (Connelll,	
  1995;	
  Robertson,	
  2007).	
  However,	
  there	
  is	
  a	
  dearth	
  of	
  empirical	
   studies	
  to	
  substantiate	
  how	
  heteronormativity	
  ‘functions’	
  to	
  influence	
  men’s	
  sexual	
  health	
   experiences	
  and	
  outcomes.	
   	
    To	
  date,	
  most	
  research	
  pertaining	
  to	
  re-­‐conceptualisations	
  of	
  social	
  norms	
  and	
  men’s	
    sexual	
  health	
  (e.g.,	
  sexual	
  identities	
  as	
  ‘fluid’	
  rather	
  than	
  ‘fixed’)	
  have	
  largely	
  focused	
  on	
   men’s	
  experiences	
  negotiating	
  sexual	
  encounters	
  (Maxwell,	
  2007).	
  Some	
  studies	
  have	
   provided	
  insights	
  into	
  men’s	
  gender	
  relations	
  that	
  demonstrate	
  the	
  techniques	
  that	
  they	
   employ	
  to	
  reproduce	
  gendered	
  (and	
  especially	
  heterosexist	
  and	
  heteronormative)	
  discourses	
   (Pascoe,	
  2007;	
  Korobov,	
  2005);	
  however,	
  additional	
  insights	
  are	
  needed	
  to	
  better	
  understand	
   how	
  heteronormative	
  discourses	
  are	
  (re)produced	
  within	
  clinical	
  settings	
  where	
  men	
  seek	
    12	
    sexual	
  health	
  services,	
  such	
  as	
  STI	
  testing.	
  These	
  settings	
  represent	
  a	
  space	
  (both	
  physical	
  and	
   social)	
  where	
  heteronormative	
  assumptions	
  and	
  heterosexist	
  stereotypes	
  can	
  profoundly	
   shape	
  men’s	
  experiences	
  (Kehily,	
  2002;	
  Holland,	
  2008).	
  These	
  settings	
  also	
  represent	
  a	
  pivotal	
   juncture	
  in	
  which	
  men	
  and	
  clinicians	
  reify	
  or	
  resist	
  heteronormative	
  assumptions	
  by:	
  (1)	
   engaging	
  in	
  emancipatory/transformative	
  practices	
  and	
  discourses	
  in	
  relation	
  to	
  sex	
  and	
   gender	
  diversities,	
  equity	
  and	
  power	
  relations;	
  or,	
  (2)	
  (re)producing	
  dominant	
  and	
  hegemonic	
   forms	
  of	
  masculinities,	
  while	
  perpetuating	
  heterosexist	
  beliefs	
  and	
  heteronormative	
   assumptions	
  (Pascoe,	
  2007;	
  Holland,	
  Ramazanoglu,	
  Sharpe,	
  &	
  Thomson,	
  1998).	
  	
   In	
  this	
  study,	
  heteronormative	
  and	
  heterosexist	
  discourses	
  are	
  examined	
  to	
  explore	
   how	
  they	
  function	
  within	
  clinical	
  settings	
  where	
  men	
  access	
  STI	
  testing	
  services.	
  Both	
  men’s	
   and	
  clinicians’	
  stories	
  are	
  analysed	
  to	
  describe	
  the	
  extent	
  to	
  which	
  heterosexist	
  or	
   heteronormative	
  discourses	
  are	
  (re)produced,	
  resisted	
  or	
  reified	
  in	
  these	
  clinical	
  contexts.	
  In	
   doing	
  so,	
  the	
  contextual	
  and	
  structural	
  conditions	
  which	
  may	
  facilitate	
  or	
  waylay	
   opportunities	
  to	
  express	
  alternative,	
  more	
  equitable	
  gendered	
  power	
  relations	
  and	
  sexual	
   identities	
  in	
  STI	
  testing	
  clinical	
  settings	
  are	
  described.	
   	
   2.2	
  	
  Study	
  setting	
   Data	
  collection	
  took	
  place	
  in	
  2006	
  in	
  five	
  communities	
  in	
  BC:	
  Vancouver	
  is	
  surrounded	
   by	
  roughly	
  20	
  suburban	
  communities	
  with	
  a	
  total	
  population	
  of	
  2,116,581.	
  Richmond,	
   population	
  174,461,	
  borders	
  Vancouver	
  directly	
  to	
  the	
  south.	
  Located	
  approximately	
  780	
   kilometres	
  north	
  of	
  Vancouver,	
  Prince	
  George,	
  population	
  70,981,	
  is	
  the	
  economic	
  hub	
  of	
   northern	
  BC.	
  Located	
  approximately	
  115	
  kilometres	
  south	
  of	
  Prince	
  George,	
  Quesnel,	
   13	
    population	
  9,326,	
  is	
  a	
  rural	
  community.	
  Fort	
  St.	
  John,	
  population	
  17,402,	
  is	
  an	
  economic	
  hub	
   for	
  oil/gas	
  in	
  northeastern	
  BC,	
  478	
  kilometres	
  from	
  Prince	
  George	
  (Statistics	
  Canada,	
  2007).	
   In	
  Canada,	
  STI	
  testing	
  is	
  available	
  through	
  clinics	
  that	
  specialise	
  in	
  sexual	
  health	
  and/or	
   youth	
  health,	
  as	
  well	
  as	
  through	
  general	
  medical	
  clinics,	
  hospital	
  emergency	
  rooms,	
  and	
   family	
  doctors.	
  Each	
  community	
  had	
  a	
  clinic	
  (or	
  clinic	
  hours)	
  that	
  specialised	
  in	
  providing	
   sexual	
  health	
  services,	
  including	
  STI	
  testing;	
  although,	
  male	
  participation	
  at	
  these	
  clinics	
  was	
   often	
  very	
  low	
  (accounting	
  for	
  approximately	
  5%	
  of	
  youth	
  clientele)	
  (Shoveller	
  et	
  al.,	
  2010),	
   and	
  STI	
  testing	
  is	
  available	
  by	
  appointment	
  or	
  drop-­‐in.	
  Health	
  services	
  in	
  Canada	
  are	
  publicly	
   funded	
  and,	
  in	
  BC,	
  services	
  are	
  available	
  to	
  all	
  residents	
  who	
  pay	
  a	
  monthly	
  premium	
  to	
  the	
   province’s	
  Medical	
  Services	
  Plan	
  (CDN$54	
  per	
  person).	
  Youth	
  clinics	
  did	
  not	
  require	
  proof	
  of	
   being	
  registered	
  in	
  the	
  Medical	
  Services	
  Plan.	
   	
   2.3	
  	
  Methods	
   2.3.1	
  	
  Recruitment	
  of	
  participants	
   Forty-­‐five	
  men	
  between	
  the	
  ages	
  of	
  15	
  and	
  25	
  years	
  old	
  were	
  recruited	
  to	
  participate	
   in	
  in-­‐depth,	
  semi-­‐structured	
  interviews	
  (lasting	
  approximately	
  1	
  to	
  1.5	
  hours)	
  through	
   recruitment	
  posters	
  and	
  pamphlets.	
  Men	
  less	
  than	
  19	
  did	
  not	
  need	
  their	
  guardian’s	
  assent.	
   Research	
  staff	
  recruited	
  at	
  clinical	
  (e.g.,	
  sexual	
  health	
  clinics,	
  walk-­‐in	
  clinics)	
  and	
  non-­‐clinical	
   (e.g.,	
  bus	
  stops,	
  universities	
  and	
  colleges,	
  community	
  centres)	
  sites	
  to	
  include	
  men	
  who	
  had	
   previously	
  accessed	
  STI	
  testing,	
  as	
  well	
  as	
  those	
  who	
  had	
  considered	
  being	
  but	
  were	
  not	
   previously	
  tested.	
  To	
  be	
  eligible	
  for	
  an	
  interview,	
  men	
  were:	
  between	
  the	
  ages	
  of	
  15-­‐25;	
  HIV	
    14	
    negative;	
  sexually	
  active;	
  and	
  English	
  speaking.	
  A	
  purposive	
  sampling	
  strategy	
  included	
  men	
   from	
  a	
  variety	
  of	
  socioeconomic	
  and	
  cultural	
  backgrounds,	
  as	
  well	
  as	
  self-­‐identified	
  gay,	
   bisexual	
  and	
  heterosexual	
  men.	
  A	
  total	
  of	
  25	
  clinicians	
  (i.e.,	
  physicians	
  and	
  nurses)	
  were	
   recruited	
  from	
  clinics	
  and	
  completed	
  in-­‐depth,	
  individual	
  interviews	
  to	
  detail	
  their	
   experiences	
  of	
  providing	
  sexual	
  health	
  services	
  (particularly	
  STI	
  testing)	
  to	
  young	
  men.	
   Research	
  staff	
  recruited	
  clinicians	
  from	
  the	
  clinic	
  sites	
  that	
  men	
  said	
  they	
  accessed	
  for	
  STI	
   testing.	
  Ethics	
  approval	
  was	
  obtained	
  from	
  the	
  University	
  of	
  British	
  Columbia.	
  	
   	
   2.3.2	
  	
  Interview	
  procedure	
   Research	
  staff	
  scheduled	
  interviews	
  to	
  take	
  place	
  at	
  a	
  time	
  and	
  place	
  convenient	
  for	
   the	
  participant,	
  and	
  all	
  interviews	
  were	
  conducted	
  in	
  private	
  spaces	
  (e.g.,	
  research	
  team’s	
   offices;	
  private	
  clinic	
  spaces).	
  The	
  purpose	
  of	
  the	
  interviews	
  was	
  explained	
  to	
  participants	
  to	
   ‘better	
  understand	
  the	
  experiences	
  of	
  young	
  men	
  who	
  have	
  undergone	
  STI	
  testing,	
  as	
  well	
  as	
   those	
  who	
  have	
  not,	
  to	
  guide	
  planning	
  in	
  the	
  area	
  of	
  men’s	
  STI	
  testing.’	
  The	
  interview	
  was	
   started	
  after	
  the	
  study	
  was	
  explained	
  and	
  participants	
  had	
  read	
  and	
  signed	
  a	
  written	
  consent	
   form,	
  along	
  with	
  a	
  brief	
  socio-­‐demographic	
  questionnaire.	
  At	
  the	
  end	
  of	
  the	
  interviews	
  with	
   men,	
  participants	
  were	
  provided	
  with	
  a	
  list	
  of	
  STI	
  testing	
  clinics,	
  as	
  well	
  as	
  other	
  information	
   about	
  sexual	
  health	
  resources.	
  Six	
  interviewers	
  (five	
  female;	
  one	
  male)	
  conducted	
  the	
   interviews,	
  and	
  participants	
  had	
  the	
  choice	
  to	
  have	
  a	
  male	
  or	
  female	
  interviewer.	
  The	
  youth	
   participants	
  received	
  a	
  CDN$25	
  honorarium.	
  	
   	
    15	
    2.3.3	
  	
  Study	
  participants	
   In	
  total,	
  45	
  young	
  men	
  including	
  40	
  heterosexual,	
  4	
  gay	
  and	
  1	
  bisexual	
  participated	
   (table	
  1	
  provides	
  the	
  young	
  men	
  socio-­‐demographic	
  characteristics).	
  Twenty-­‐five	
  interviews	
   were	
  conducted	
  with	
  female	
  (n=19)	
  and	
  male	
  (n=6)	
  clinicians	
  (table	
  2	
  provides	
  the	
  clinician	
   socio-­‐demographic	
  characteristics).	
  	
  	
   	
   Table	
  1.	
  	
  Self-­‐identified	
  characteristics	
  of	
  young	
  men	
   AGE GROUP  (n)  Percent  15-18  9  20%  19-25  36  80%  Aboriginal  11  24%  Black  1  2%  Chinese  1  2%  South Asian  3  7%  South East Asian  2  4%  Latin American  1  2%  Euro-Canadian  26  58%  Fort St. John  12  27%  Prince George  10  22%  Richmond  8  18%  Quesnel  5  11%  Vancouver  10  22%  Never  14  31%  1 time or more  31  69%  Currently involved  29  64%  Not currently involved  16  36%  Heterosexual  40  89%  Homosexual  4  9%  Bisexual  1  2%  ETHNICITY  COMMUNITY  TESTED  SEXUAL RELATIONSHIP STATUS  SEXUAL ORIENTATION  	
    16	
    Table	
  2.	
  Characteristics	
  of	
  clinicians	
   Male (n=6)  Female (n=19)  (n)  Percent  (n)  Percent  25 to 40  1  4%  5  20%  >40  5  20%  14  56%  6  24%  19  76%  Nurse  2  8%  12  48%  Physician  4  16%  7  28%  AGE GROUP  ETHNICITY Euro-Canadian OCCUPATION  2.3.4	
  	
  Interviews	
   Men	
  shared	
  perceptions	
  about	
  their	
  community’s	
  socio-­‐cultural	
  ideals	
  and	
  norms	
   (e.g.,	
  gender	
  roles;	
  attitudes	
  towards	
  straight,	
  gay	
  and	
  bisexual	
  men),	
  and	
  the	
  effects	
  these	
   norms	
  had	
  on	
  their	
  engagement	
  with	
  STI	
  testing	
  services.	
  Men	
  who	
  had	
  been	
  tested	
  (n=23)	
   were	
  asked	
  to	
  reflect	
  on	
  interactions	
  in	
  clinic	
  spaces,	
  including	
  discussions,	
  experiences	
  and	
   procedures	
  (e.g.,	
  comfort	
  level	
  with	
  clinician’s	
  questions).	
  Young	
  men	
  were	
  also	
  asked	
  to	
   describe	
  how	
  their	
  sexual	
  identity	
  might	
  affect	
  experiences	
  with	
  STI	
  testing	
  services,	
  and	
  how	
   the	
  experiences	
  might	
  differ	
  for	
  a	
  man	
  who’s	
  sexual	
  identity	
  differed	
  from	
  their	
  own.	
  See	
   Appendix	
  6.1	
  for	
  the	
  interview	
  guide	
  that	
  was	
  used	
  with	
  young	
  men.	
   Clinicians	
  described	
  practice	
  guidelines	
  and	
  were	
  asked	
  to	
  discuss	
  gendered	
  power	
   dynamics	
  with	
  the	
  young	
  men	
  they	
  serve	
  (e.g.,	
  developing	
  rapport	
  with	
  youth).	
  Clinicians	
   discussed	
  in	
  detail	
  their	
  perspectives	
  on	
  clinical	
  encounters	
  with	
  men	
  seeking	
  STI	
  testing,	
   including	
  patient	
  reactions	
  to	
  risk	
  assessments.	
  Clinicians	
  described	
  the	
  ways	
  their	
  own	
   attitudes	
  of	
  men	
  or	
  the	
  socio-­‐cultural	
  norms	
  of	
  the	
  community	
  in	
  general,	
  influenced	
  the	
   provision	
  of	
  sexual	
  health	
  services.	
  Each	
  clinician	
  was	
  asked	
  to	
  describe	
  their	
  professional	
    17	
    background,	
  education,	
  and	
  professional	
  practice	
  history.	
  See	
  Appendix	
  6.2	
  for	
  the	
  interview	
   guide	
  that	
  was	
  used	
  with	
  clinicians.	
   	
   2.3.5	
  	
  Data	
  analysis	
   Interviews	
  were	
  audio-­‐recorded	
  and	
  transcribed	
  with	
  identifying	
  details	
  removed.	
   Each	
  transcript	
  was	
  checked	
  for	
  accuracy.	
  QSR	
  NVivo	
  8TM	
  was	
  used	
  to	
  code	
  and	
  manage	
  the	
   data.	
  A	
  constant	
  comparative	
  technique	
  was	
  used	
  to	
  develop	
  the	
  initial	
  set	
  of	
  codes	
  that	
   represented	
  key	
  individual	
  level	
  processes	
  described	
  in	
  the	
  interviews	
  (Dey,	
  1999).	
  This	
   consisted	
  of	
  an	
  open	
  coding	
  approach,	
  using	
  participants’	
  language,	
  and	
  avoiding,	
  where	
   possible,	
  the	
  imposition	
  of	
  preconceived	
  theoretical	
  constructs	
  (Glaser	
  &	
  Strauss,	
  1967).	
  As	
   additional	
  interviews	
  were	
  completed,	
  coding	
  was	
  organised	
  into	
  ‘trees’	
  to	
  group	
  the	
  open	
   codes	
  into	
  more	
  abstract	
  conceptual	
  categories.	
  Additional	
  codes	
  were	
  developed	
  as	
  new	
   themes	
  emerged	
  and	
  data	
  collection	
  continued.	
  In	
  developing	
  the	
  coding	
  schema,	
  particular	
   attention	
  was	
  paid	
  to	
  the	
  ways	
  in	
  which	
  gender	
  norms	
  and	
  heteronormative	
  assumptions	
   influenced	
  young	
  men’s	
  and	
  clinician’s	
  experiences	
  with	
  STI	
  testing.	
   	
   2.4	
  	
  Results	
   The	
  findings	
  are	
  presented	
  in	
  three	
  thematic	
  segments	
  in	
  which	
  I	
  distil	
  how	
   heteronormativity	
  functions	
  within	
  STI	
  clinical	
  encounters:	
  (1)	
  The	
  ‘Relativity	
  of	
  ‘Risk’’;	
  (2)	
   Alleviating	
  men’s	
  anxieties;	
  and	
  (3)	
  (Re)producing	
  the	
  heterosexual	
  status	
  quo.	
    18	
    2.4.1	
  	
  The	
  ‘relativity	
  of	
  risk’	
   Most	
  clinical	
  encounters	
  related	
  to	
  STI	
  testing	
  began	
  with	
  an	
  assessment	
  of	
  symptoms	
   and	
  a	
  patient’s	
  risk	
  for	
  exposure	
  to	
  STIs/HIV.	
  Solicited	
  by	
  clinicians	
  were	
  details	
  about	
  STI	
   history,	
  substance	
  use,	
  sexual	
  relationship	
  status	
  and	
  psycho-­‐social	
  history	
  (e.g.,	
  sexual	
   abuse),	
  and	
  sometimes	
  the	
  men’s	
  sexual	
  identity	
  was	
  also	
  questioned.	
  Questions	
  about	
   sexual	
  identity	
  were	
  understood	
  by	
  heterosexual	
  men	
  as	
  a	
  strategy	
  to	
  identify	
  other	
  men	
  –	
  in	
   particular,	
  gay	
  men.	
  Consequently,	
  heterosexual	
  men	
  often	
  reasoned	
  that	
  although	
  their	
   straight	
  identity	
  was	
  obvious,	
  questions	
  around	
  sexual	
  identity	
  guided	
  what	
  STI	
  testing	
  was	
   required.	
  For	
  example,	
  a	
  20-­‐year-­‐old	
  heterosexual	
  man	
  was	
  asked	
  if	
  it	
  was	
  important	
  to	
  him	
   that	
  his	
  clinician	
  knew	
  his	
  sexual	
  identity.	
  He	
  responded:	
  ‘Well,	
  ‘cause	
  I’m	
  straight,	
  so	
  I	
  don’t	
   really	
  care.	
  ‘Cause	
  in	
  society,	
  straight	
  is	
  what’s	
  considered	
  normal,	
  right.’	
  Others	
  described	
   having	
  been	
  ‘assumed’	
  –	
  or	
  having	
  wanted	
  to	
  be	
  ‘assumed’	
  –	
  heterosexual	
  early	
  on	
  in	
  the	
   clinical	
  encounter.	
  	
   Although	
  most	
  men	
  experienced	
  some	
  discomfort	
  being	
  asked	
  about	
  their	
  sexual	
   identity,	
  participants	
  interpreted	
  this	
  as	
  a	
  ‘necessary’	
  component	
  of	
  their	
  sexual	
  health	
   assessment.	
  In	
  a	
  manner	
  similar	
  to	
  clinicians,	
  the	
  youth	
  participants	
  agreed	
  that	
  men	
  who	
   engaged	
  in	
  same-­‐sex	
  sexual	
  practices	
  had	
  a	
  greater	
  risk	
  of	
  STI/HIV	
  transmission	
  and	
  needed	
   to	
  be	
  identified	
  for	
  their	
  own	
  good	
  and	
  for	
  public	
  health	
  reasons	
  (e.g.,	
  collecting	
  data	
  for	
   population-­‐based	
  STI	
  trends)	
  and	
  to	
  order	
  particular	
  STI	
  tests.	
  For	
  example,	
  a	
  24-­‐year-­‐old	
   heterosexual	
  man	
  explained,	
  ‘I	
  was	
  asked	
  if	
  I	
  was	
  a	
  drug	
  user	
  or	
  a	
  homosexual.	
  If	
  I	
  wasn’t,	
   then	
  I	
  was	
  in	
  a	
  much	
  lower	
  risk	
  category	
  […]	
  and	
  my	
  chances	
  of	
  having	
  it	
  [HIV]	
  were	
  seriously	
   low.’	
  Justifying	
  the	
  inclusion	
  of	
  questions	
  about	
  sexual	
  identity	
  was	
  an	
  important	
  part	
  of	
  the	
    19	
    STI/HIV	
  risk	
  assessment	
  process	
  that	
  connected	
  ‘risk’	
  and	
  ‘sexual	
  identity.’	
  Within	
  these	
   explanations	
  heterosexuality	
  was	
  situated	
  as	
  a	
  ‘default’	
  normative	
  discourse	
  aligned	
  with	
  less	
   risky	
  sexual	
  practices.	
  Embedded	
  here	
  are	
  understandings	
  that	
  the	
  clinical	
  rationale	
  for	
  asking	
   identity	
  questions	
  was	
  all	
  about	
  finding	
  the	
  ‘other’	
  (e.g.,	
  gay	
  men).	
   	
  	
    Several	
  men	
  who	
  identified	
  as	
  gay/bisexual	
  explained	
  they	
  had	
  experienced	
  significant	
    anxiety	
  about	
  the	
  risk	
  assessment	
  questions	
  that	
  clinicians	
  asked.	
  Some	
  men	
  experienced	
   these	
  questions	
  as	
  intrusive	
  and	
  refused	
  to	
  respond	
  or	
  provided	
  inaccurate	
  information	
  about	
   their	
  sexual	
  identity	
  and/or	
  practices.	
  For	
  example,	
  a	
  19-­‐year-­‐old	
  bisexual	
  participant	
   explained	
  that	
  he	
  was	
  uncomfortable	
  self-­‐disclosing	
  such	
  details	
  to	
  a	
  stranger:	
   	
   I	
  don’t	
  think	
  they	
  [clinicians]	
  have	
  any	
  right,	
  really.	
  I	
  mean,	
  you	
  can	
  volunteer	
  [this	
   information],	
  but	
  I	
  don’t	
  think	
  there’s	
  any	
  right	
  or	
  reason	
  for	
  them	
  to	
  [know]	
  your	
   identity…even	
  your	
  activity.	
  I	
  don’t	
  really	
  -­‐	
  I	
  mean	
  it	
  doesn’t	
  make	
  that	
  much	
  of	
  a	
   difference.	
   	
   This	
  man’s	
  discomfort	
  appeared	
  rooted	
  both	
  in	
  the	
  stigma	
  he	
  faced	
  in	
  disclosing	
  his	
   bisexual	
  identity	
  and	
  the	
  range	
  of	
  risky	
  sexual	
  practices	
  typically	
  assigned	
  to	
  that	
  identity.	
  He	
   did	
  not	
  accept	
  that	
  these	
  questions	
  were	
  used	
  by	
  clinician’s	
  to	
  gauge	
  one’s	
  potential	
  risk	
  for	
   STI	
  exposure.	
  As	
  a	
  result,	
  the	
  man	
  withheld	
  information	
  arguing	
  that	
  being	
  ‘assumed	
  straight’	
   by	
  the	
  clinician	
  had	
  no	
  impact	
  on	
  the	
  specificity	
  of	
  his	
  STI	
  testing.	
  Some	
  gay	
  participants	
   suggested	
  that	
  STI	
  tests	
  were	
  prescribed	
  based	
  on	
  preconceived	
  identity-­‐specific	
  risk	
  profiles	
   rather	
  than	
  their	
  self-­‐reported	
  sexual	
  practices.	
  A	
  21-­‐year-­‐old	
  gay	
  man	
  explained	
  his	
    20	
    dissatisfaction	
  about	
  having	
  an	
  HIV	
  test	
  because	
  he	
  had	
  not	
  engaged	
  in	
  ‘risky’	
  behaviour	
   associated	
  with	
  HIV	
  transmission	
  (e.g.,	
  receptive	
  anal	
  intercourse):	
   	
   I’m	
  a	
  little	
  uncomfortable	
  with	
  the	
  fact	
  that	
  gay	
  people	
  are	
  the	
  ones	
  who	
  get	
  HIV…	
  and	
   that	
  kind	
  of	
  reflects	
  on	
  the	
  tests.	
  It’s	
  like,	
  ‘Okay,	
  you’re	
  gay	
  so	
  I	
  have	
  this	
  for	
  you.	
  You’re	
   straight,	
  this	
  is	
  for	
  you.’	
  And	
  I	
  think	
  that	
  that’s	
  how	
  it	
  works.	
  Maybe	
  not.	
  	
  Honestly,	
  I	
   don’t	
  know.	
  But	
  it	
  made	
  me	
  feel,	
  I’m	
  part	
  of	
  a	
  certain	
  type,	
  therefore	
  I	
  need	
  to	
  answer	
  all	
   these	
  kinds	
  of	
  questions.	
  They	
  don’t	
  apply	
  to	
  me	
  but	
  I	
  still	
  do	
  it.	
  Because	
  I’m	
  gay.	
   	
   While	
  this	
  man	
  was	
  not	
  engaging	
  in	
  practices	
  that	
  would	
  elevate	
  his	
  risk	
  for	
  acquiring	
   HIV,	
  he	
  explained	
  (and	
  for	
  the	
  most	
  part	
  accepted)	
  that	
  by	
  virtue	
  of	
  his	
  gay	
  identity	
  he	
  was	
   ‘required’	
  to	
  routinely	
  test	
  for	
  HIV.	
  Similarly,	
  a	
  gay	
  22-­‐year-­‐old	
  man	
  who	
  had	
  worked	
  for	
   several	
  years	
  as	
  a	
  peer	
  sexual	
  health	
  educator	
  explained	
  that	
  his	
  own	
  risk	
  assessment	
  was	
   based	
  on	
  his	
  sexual	
  identity.	
  Though	
  he	
  had	
  not	
  been	
  sexually	
  active	
  between	
  the	
  results	
  of	
   his	
  last	
  test	
  and	
  the	
  current	
  test,	
  he	
  thought	
  that,	
  as	
  a	
  peer	
  educator,	
  he	
  should	
  test	
  every	
  six	
   months	
  ‘no	
  matter	
  what,’	
  so	
  he	
  could	
  be	
  a	
  role	
  model	
  to	
  his	
  friends.	
  He	
  described	
  the	
  sexual	
   health	
  counselling	
  he	
  received:	
   	
   The	
  nurse	
  was	
  giving	
  me	
  some	
  tips	
  on	
  how	
  to	
  have	
  a	
  healthy	
  sex	
  life	
  and	
  be	
  as	
  safe	
  as	
   possible.	
  	
  And	
  I,	
  I	
  didn’t	
  really	
  feel	
  like	
  saying,	
  ‘Oh,	
  well	
  I’ve	
  been	
  a	
  sex	
  educator	
  for	
   several	
  years;	
  I’m	
  pretty	
  well	
  informed.’	
  And	
  she	
  said,	
  ‘You	
  know,	
  some	
  people	
  use	
  two	
   condoms	
  at	
  the	
  same	
  time.’	
  	
  As	
  if	
  this	
  was	
  some	
  kind	
  of	
  an	
  excellent	
  option	
  for	
  me!’	
    21	
    	
   Illustrated	
  here	
  is	
  the	
  degree	
  to	
  which	
  ‘externalised’	
  risk	
  can	
  impact	
  men’s	
  ‘internalised’	
   assumptions	
  and	
  practices.	
  The	
  man’s	
  insistence	
  that	
  he	
  needed	
  to	
  test	
  frequently	
  in	
  order	
  to	
   be	
  a	
  gay	
  role	
  model,	
  regardless	
  of	
  his	
  sexual	
  activity,	
  reveals	
  how	
  dominant	
  social	
   constructions	
  of	
  risk	
  can	
  influence	
  gay	
  men’s	
  STI	
  practices.	
  The	
  clinician’s	
  advice	
  also	
  seemed	
   founded	
  on	
  assumptions	
  of	
  ‘externalised’	
  risk	
  of	
  gay	
  men	
  by	
  disregarding	
  the	
  man’s	
   abstinence	
  and	
  providing	
  inaccurate	
  and	
  potentially	
  injurious	
  information	
  (wearing	
  two	
   condoms	
  causes	
  friction	
  which	
  increases	
  the	
  risk	
  of	
  tearing	
  (Alexander,	
  LaRosa,	
  Bader,	
   Garfield	
  &	
  Alexander,	
  2010)).	
  	
   For	
  many	
  men	
  the	
  clinical	
  encounter	
  for	
  STI	
  testing	
  represented	
  a	
  unique	
  and	
  often	
   times	
  intense	
  interaction	
  whereby	
  their	
  sexual	
  identities	
  and	
  practices	
  were	
  overtly	
   interrogated.	
  In	
  what	
  might	
  be	
  construed	
  as	
  positive	
  discrimination,	
  both	
  the	
  straight	
  and	
   gay/bisexual	
  men	
  (usually)	
  answered	
  these	
  questions	
  as	
  a	
  means	
  to	
  assist	
  clinicians	
  in	
   assessing	
  risk.	
  Yet,	
  also	
  evident	
  was	
  a	
  leap	
  of	
  logic	
  whereby	
  the	
  sexual	
  practices	
  of	
  straight	
   men	
  and	
  gay/bisexual	
  men	
  were	
  assumed	
  to	
  be	
  clearly	
  delineated,	
  flowing	
  in	
  unitary	
  and	
   straightforward	
  ways	
  from	
  their	
  sexual	
  identity.	
  Within	
  these	
  assumptions	
  there	
  seems	
  great	
   potential	
  to	
  over-­‐screen	
  the	
  ‘other’	
  (i.e.,	
  gay	
  and	
  bisexual	
  men)	
  while	
  concomitantly	
  under-­‐ screening	
  heterosexual	
  men.	
   	
   2.4.2	
  	
  Alleviating	
  men’s	
  anxieties	
   Almost	
  all	
  of	
  the	
  clinicians	
  recognised	
  that	
  men	
  experienced	
  discomfort	
  when	
  being	
   asked	
  questions	
  about	
  sexual	
  identity	
  and	
  practices,	
  and	
  three	
  key	
  strategies	
  for	
  alleviating	
   22	
    men’s	
  concerns	
  emerged.	
  First,	
  some	
  clinicians	
  explained	
  how	
  they	
  eliminated	
  (or	
  de-­‐ emphasised)	
  questions	
  of	
  sexual	
  identity	
  to	
  reduce	
  men’s	
  anxieties.	
  These	
  clinicians	
  also	
   acknowledged	
  sexual	
  identity	
  as	
  a	
  crude	
  marker	
  of	
  risk	
  because	
  it	
  did	
  not	
  necessarily	
  inform	
   the	
  ‘risky’	
  sexual	
  practices	
  that	
  men	
  engaged	
  in	
  (e.g.,	
  anal	
  sex).	
  Clinicians	
  often	
  described	
   their	
  approach	
  to	
  sexual	
  health	
  service	
  provision	
  as	
  ‘gender	
  neutral’,	
  which	
  they	
  perceived	
  to	
   be	
  a	
  good	
  way	
  to	
  provide	
  comprehensive	
  impartial	
  services	
  for	
  all	
  sexual	
  identities	
  (both	
  men	
   and	
  women).	
  One	
  nurse	
  also	
  boasted	
  how	
  her	
  clinic	
  purposely	
  provided	
  gender-­‐neutral	
   services:	
   	
   I	
  mean	
  we	
  try	
  to	
  keep	
  it	
  really	
  gender	
  neutral,	
  so	
  the	
  interview	
  for	
  women,	
  we	
  go	
   through	
  the	
  pelvic	
  exam	
  because	
  it	
  is	
  a	
  little	
  more	
  invasive.	
  For	
  men	
  –	
  and	
  we	
  don’t	
   have	
  to	
  ask	
  menstrual	
  history	
  on	
  men	
  so	
  it	
  does	
  shorten	
  some	
  of	
  the	
  questions	
  down	
  a	
   little	
  bit.	
  But	
  they	
  can	
  expect	
  the	
  same	
  thing-­‐	
  confidentiality,	
  give	
  them	
  all	
  their	
  options	
   and	
  then	
  we	
  go	
  through	
  our	
  assessment.	
  Yeah	
  it’s	
  really…it’s	
  very	
  similar	
  for	
  both.	
  […]	
   So	
  we’ll	
  ask	
  you	
  know,	
  “When	
  you	
  have	
  sex,	
  do	
  you	
  have	
  anal	
  sex?”	
  	
  	
   	
   This	
  nurse’s	
  explanation	
  of	
  ‘gender	
  neutral’	
  services	
  focuses	
  primarily	
  around	
  the	
   patient’s	
  anatomical	
  sex	
  differences	
  (e.g.,	
  women	
  menstruate	
  and	
  require	
  a	
  pelvic	
  exam).	
   Few	
  clinicians	
  recognised	
  how	
  this	
  approach	
  might	
  fail	
  to	
  respond	
  to	
  men’s	
  different	
   gendered	
  (and	
  heteronormative)	
  expectations	
  and	
  that	
  these	
  behavioural-­‐based	
  questions	
   are	
  themselves	
  inherently	
  gendered	
  (e.g.,	
  ‘When	
  you	
  have	
  sex,	
  do	
  you	
  have	
  anal	
  sex?’).	
   Uninterrogated	
  here	
  are	
  the	
  ways	
  in	
  which	
  clinical	
  practices	
  and	
  interactions	
  (and	
  clinicians	
    23	
    and	
  patients	
  themselves)	
  are	
  inextricably	
  ‘gendered’	
  and	
  ‘sexed’	
  or	
  how	
  supposedly	
  gender-­‐ neutral	
  approaches	
  are	
  potentially	
  co-­‐produced	
  by	
  the	
  men’s	
  and	
  clinicians’	
  heteronormative	
   assumptions.	
  	
   Second,	
  some	
  clinicians	
  said	
  that	
  they	
  would	
  explain	
  to	
  their	
  patients,	
  in	
  detail,	
  why	
   they	
  needed	
  to	
  ask	
  questions	
  around	
  sexual	
  practices.	
  This	
  strategy	
  was	
  described	
  as	
  an	
   important	
  method	
  to	
  help	
  alleviate	
  men’s	
  anxieties	
  with	
  these	
  questions,	
  as	
  a	
  male	
  public	
   health	
  nurse	
  explained:	
   	
   Some	
  of	
  these	
  questions	
  might	
  be	
  embarrassing,	
  so	
  we	
  tend	
  to	
  explain	
  the	
  questions.	
   So	
  we’ll	
  ask	
  you	
  know,	
  ‘When	
  you	
  have	
  sex,	
  do	
  you	
  have	
  anal	
  sex?	
  Somebody’s	
  penis	
  in	
   your	
  bum	
  or	
  your	
  penis	
  in	
  somebody’s	
  bum.’	
  ‘The	
  reason	
  I	
  need	
  to	
  know	
  this	
  is…’	
  so	
  we	
   try-­‐	
  that’s	
  why	
  it	
  takes	
  a	
  long	
  time	
  too	
  is	
  because	
  we	
  do	
  a	
  lot	
  of	
  ‘Why	
  am	
  I	
  asking	
  you?’	
   You	
  know,	
  here	
  I	
  am,	
  a	
  stranger,	
  asking	
  if	
  you	
  take	
  it	
  up	
  the	
  ass?	
  Like	
  it’s…not	
  polite	
   conversation	
  usually.	
   	
   By	
  describing	
  questions	
  around	
  sexual	
  practices	
  (e.g.,	
  anal	
  sex)	
  as	
  ‘not	
  polite	
  conversation’,	
   this	
  clinician	
  acknowledges	
  that	
  transgressing	
  men’s	
  heterornormative	
  assumptions	
  and	
   expectations	
  (e.g.,	
  inquiring	
  about	
  anal	
  sex)	
  can	
  negatively	
  affect	
  men’s	
  comfort	
  levels.	
  While	
   the	
  use	
  of	
  the	
  pronoun	
  ‘we’	
  reveals	
  the	
  institutional	
  power	
  and	
  imperative	
  to	
  identify	
  ‘risky’	
   men,	
  this	
  clinician	
  justifies	
  these	
  ‘heteronormative	
  transgressions’	
  by	
  providing	
  biomedical	
   and	
  epidemiological	
  rationale	
  (e.g.,	
  the	
  rectum	
  provides	
  a	
  route	
  into	
  the	
  bloodstream	
  for	
   STI/HIV-­‐infected	
  fluids	
  or	
  blood).	
    24	
    	
  	
    Lastly,	
  some	
  clinicians	
  emphasised	
  that	
  it	
  is	
  important	
  to	
  discern	
  both	
  a	
  patient’s	
    sexual	
  practices	
  and	
  identity.	
  Failing	
  to	
  do	
  so	
  was	
  positioned	
  as	
  a	
  missed	
  opportunity	
  for	
   tailored	
  sexual	
  health	
  promotion	
  strategies.	
  For	
  these	
  clinicians,	
  sexual	
  identities	
  and	
   practices	
  were	
  ‘clues’	
  for	
  determining	
  the	
  social	
  supports	
  and/or	
  contexts	
  of	
  their	
  patients,	
   rather	
  than	
  exclusive	
  markers	
  of	
  STI	
  risk.	
  Several	
  clinicians	
  gave	
  the	
  example	
  of	
  patients	
  who	
   identify	
  as	
  straight	
  that	
  also	
  have	
  sex	
  with	
  men,	
  identifying	
  the	
  unique	
  sexual	
  health	
  needs	
   and	
  support	
  that	
  these	
  men	
  require.	
  As	
  one	
  clinician	
  explained	
  about	
  this	
  group	
  of	
  men:	
  By	
   the	
  time	
  they	
  get	
  to	
  an	
  STD	
  Clinic,	
  probably…they’re	
  there	
  because	
  they’re	
  at	
  risk	
  and	
   sometimes	
  it’s	
  not	
  so	
  much	
  what	
  they’re	
  doing,	
  it’s	
  the	
  fact	
  that	
  they	
  can’t	
  get	
  any	
  support	
  for	
   it.	
  This	
  scenario	
  illustrates	
  how	
  men’s	
  individual	
  management	
  and	
  perceptions	
  of	
  health	
  risks	
   (e.g.,	
  health-­‐seeking	
  behaviours)	
  are	
  influenced	
  by	
  and	
  interact	
  with	
  external	
  circumstances	
   (e.g.,	
  heteronormative	
  expectations	
  that	
  heterosexual	
  men	
  have	
  sex	
  exclusively	
  with	
  women)	
   and	
  how	
  these	
  can	
  in	
  turn	
  affect	
  clinical	
  interactions.	
  Therefore,	
  sexual	
  identity	
  was	
  described	
   by	
  some	
  clinicians	
  as	
  an	
  important	
  factor	
  to	
  inform	
  strategies	
  for	
  communicating	
  (e.g.,	
   educating	
  and	
  counselling)	
  with	
  patients	
  using	
  a	
  tailored,	
  nuanced	
  and	
  sensitive	
  approach.	
   One	
  public	
  health	
  nurse	
  described	
  how	
  he	
  tailored	
  his	
  language	
  to	
  the	
  patient	
  he	
  was	
  seeing:	
   	
   You	
  use	
  different	
  words,	
  less	
  formal	
  or	
  whatever	
  kind	
  of	
  way	
  that	
  people	
  talk,	
  that’s	
   the	
  way	
  you	
  talk,	
  you	
  know.	
  Guys	
  come	
  in,	
  ‘anal	
  sex’	
  is	
  fucking,	
  I	
  mean	
  it’s	
  just	
  more	
   natural	
  to	
  say	
  it	
  because	
  certainly	
  that’s	
  what	
  they’re	
  calling	
  it.	
  And	
  [otherwise]	
  you’re	
   going	
  to	
  have	
  come	
  up	
  with	
  some	
  ‘prissy’	
  word	
  to	
  describe	
  it.	
  That	
  kind	
  of	
  thing,	
  I	
  think	
   it’s…	
  much	
  more	
  focused	
  on	
  the	
  immediate	
  need	
  of	
  the	
  client.	
    25	
    While	
  many	
  clinicians	
  acknowledged	
  that	
  individualising	
  their	
  communication	
   strategies	
  took	
  time	
  and	
  required	
  experience	
  and	
  thoughtful	
  consideration	
  (e.g.,	
  tailoring	
   language	
  to	
  each	
  man’s	
  vernacular),	
  it	
  was	
  positioned	
  as	
  key	
  to	
  improving	
  the	
  quality	
  of	
   information	
  gathered	
  while	
  concurrently	
  alleviating	
  men’s	
  discomfort.	
  Interestingly,	
  this	
   public	
  health	
  nurse’s	
  avoidance	
  of	
  using	
  ‘prissy’	
  words	
  depicts	
  how	
  gendered	
  power	
  relations	
   are	
  (re)produced	
  within	
  clinical	
  encounters	
  and	
  illustrates	
  how	
  aligning	
  to	
  dominant	
   masculine	
  ideals	
  (e.g.,	
  avoiding	
  ‘prissy’	
  feminine	
  language)	
  can	
  potentially	
  alleviate	
  men’s	
   discomfort	
  in	
  clinical	
  settings	
  (for	
  both	
  patients	
  and	
  clinicians).	
   These	
  strategies	
  for	
  alleviating	
  men’s	
  anxieties	
  were	
  enacted	
  through	
  either	
  the	
   disavowal	
  or	
  acknowledgement	
  of	
  men’s	
  gendered	
  and	
  heteronormative	
  expectations.	
  While	
   both	
  methods	
  present	
  opportunities	
  for	
  potentially	
  (re)producing	
  harmful	
  stereotypes,	
  both	
   premised	
  on	
  the	
  belief	
  that	
  sexual	
  identity	
  is	
  not	
  sufficient	
  for	
  assessing	
  STI	
  risk.	
  However,	
  the	
   latter	
  strategy	
  appreciated	
  men’s	
  management	
  of	
  health	
  risks	
  (e.g.,	
  individual	
  choices;	
  health-­‐ seeking	
  behaviours)	
  are	
  influenced	
  by	
  external	
  ‘moral	
  elements’	
  (Robertson,	
  2007)	
  (e.g.,	
   heteronormative	
  expectations).	
   	
   2.4.3	
  	
  (Re)producing	
  the	
  heterosexual	
  status	
  quo	
   The	
  heterosexual	
  status	
  quo	
  was	
  (re)produced	
  through	
  heteronormative	
  enactments	
   whereby	
  men	
  embodied	
  various	
  straight	
  masculinities.	
  Interestingly,	
  within	
  the	
  research	
   interviews,	
  details	
  around	
  sexual	
  identity	
  were	
  accompanied	
  by	
  the	
  occasional	
  reactive	
   homophobic	
  remark	
  (e.g.,	
  ‘I’m	
  not	
  a	
  fag’).	
  Youth	
  also	
  implicitly	
  ‘othered’	
  gay	
  men	
  when	
  asked	
    26	
    about	
  their	
  own	
  sexual	
  identity	
  or	
  practices,	
  as	
  illustrated	
  by	
  a	
  21-­‐year-­‐old	
  heterosexual	
   interviewee:	
   	
  	
   Interviewer:	
  Did	
  the	
  receptionist	
  or	
  the	
  nurse	
  or	
  the	
  doctor	
  ask	
  you	
  whether	
  you’re	
   straight	
  or	
  gay	
  or	
  bisexual?	
   Participant:	
  Yeah	
  they	
  did.	
   Interviewer:	
  Okay.	
  And	
  were	
  you	
  comfortable	
  being	
  asked	
  that?	
   Participant:	
  Yeah,	
  it’s	
  –	
  I	
  thought	
  it	
  was	
  funny!	
   Interviewer:	
  Yeah?	
   Participant:	
  [laughs]	
  Yeah	
  I’m	
  straight,	
  I	
  said	
  “I’m	
  straight”,	
  you	
  know,	
  it’s	
  just	
  funny,	
  I	
   thought	
  it	
  was	
  funny	
  [laughs].	
   	
   This	
  man’s	
  production	
  of	
  heterosexual	
  masculinity	
  and	
  his	
  embodiment	
  of	
  these	
  norms	
   rendered	
  the	
  idea	
  that	
  anyone	
  would	
  really	
  need	
  to	
  question	
  his	
  ‘obviously’	
  straight	
  identity	
   as	
  implausible	
  and	
  absurd,	
  thereby	
  positioning	
  the	
  questions	
  as	
  emerging	
  from	
  a	
  clinical	
   protocol	
  that	
  asks	
  everyone	
  their	
  sexual	
  identity	
  –	
  even	
  when	
  the	
  answer	
  is	
  ‘obvious’. 	
    There	
  were	
  also	
  more	
  subtle	
  reassertions	
  of	
  men’s	
  masculinities	
  and	
  reproductions	
  of	
    the	
  heterosexual	
  status	
  quo.	
  For	
  example,	
  some	
  men	
  suggested	
  that	
  society	
  has	
  ‘moved	
   beyond’	
  sexual	
  identity	
  issues,	
  arguing	
  that	
  equality	
  had	
  emerged,	
  and	
  many	
  explained	
  that	
   they	
  were	
  comfortable	
  with	
  all	
  sexual	
  identities.	
  For	
  example,	
  a	
  20-­‐year-­‐old	
  heterosexual	
  man	
   explained:	
  Like,	
  myself…I	
  know,	
  like	
  I	
  got	
  buddies	
  who	
  were	
  in	
  high	
  school	
  and,	
  turns	
  out,	
   they’re	
  gay…like	
  I	
  really	
  don’t	
  have	
  a	
  problem	
  with	
  that.	
  As	
  long	
  as	
  no	
  lines	
  get	
  crossed	
  or	
    27	
    anything	
  like	
  that.	
  While	
  seemingly	
  resistant	
  to	
  dominant	
  or	
  hegemonic	
  masculine	
  ideals	
   (e.g.,	
  explicit	
  homophobia	
  as	
  a	
  foundation	
  for	
  heterosexual	
  identities),	
  this	
  man	
  concurrently	
   reaffirmed	
  his	
  own	
  straight	
  identity,	
  implicitly	
  laying	
  claim	
  through	
  a	
  disclaimer	
  that	
   simultaneously	
  serves	
  heterosexual	
  privilege.	
  His	
  readiness	
  to	
  interact	
  with	
  gay	
  men	
  is	
   contingent	
  on	
  the	
  condition	
  that	
  ‘no	
  [heterosexual]	
  lines	
  get	
  crossed’.	
  Other	
  men	
  were	
  less	
   conditional	
  in	
  their	
  acceptance	
  of	
  sexual	
  diversities.	
  For	
  example,	
  a	
  22-­‐year-­‐old	
  heterosexual	
   man	
  explained:	
   	
   	
  I	
  think	
  the	
  majority	
  is	
  okay	
  with	
  sexuality	
  and	
  not	
  just	
  homosexuality,	
  any	
  type.	
  Like	
   more	
  openness	
  or	
  even	
  talking	
  about	
  it.	
  	
  It’s	
  kind	
  of	
  like	
  when	
  I	
  say	
  majority,	
  it’s	
  almost	
   like	
  this	
  is	
  how	
  it	
  is,	
  we’re	
  open	
  and	
  whoever	
  doesn’t	
  agree	
  is	
  just	
  like,	
  so	
  few	
  of	
  them,	
   that	
  you’re	
  kind	
  of	
  like	
  ‘Catch	
  up	
  or	
  we’re	
  going	
  to	
  ignore	
  you	
  otherwise!’	
   	
   While	
  downplaying	
  the	
  possibility	
  of	
  masculine	
  hierarchies	
  within	
  men’s	
  social	
  relations,	
  this	
   man’s	
  explanation	
  is	
  somewhat	
  paradoxically	
  claimed	
  from	
  a	
  position	
  of	
  heterosexual	
   privilege.	
  By	
  explaining	
  ‘we’re	
  open’,	
  this	
  man	
  positioned	
  himself	
  within	
  the	
  (heterosexual)	
   ‘majority’,	
  revealing	
  a	
  tolerance-­‐versus-­‐inclusion	
  dichotomy	
  with	
  respect	
  to	
  subordinate	
  gay	
   masculinities	
  and	
  his	
  own	
  enactments	
  of	
  a	
  complicit	
  masculinity.	
  These	
  narratives	
  reveal	
  how	
   men	
  who	
  do	
  not	
  embody	
  hegemonic	
  masculinity	
  can	
  nonetheless	
  benefit	
  from	
  the	
  social	
   organisation	
  of	
  masculinity;	
  the	
  (heterosexual)	
  ‘majority’	
  of	
  men	
  aligned	
  to	
  complicit	
  ideals	
  of	
   masculinity	
  in	
  which	
  they	
  benefited	
  from	
  the	
  patriarchal	
  dividend	
  without	
  taking	
  the	
   ‘frontline’	
  hegemonic	
  position	
  (e.g.,	
  explicit	
  homophobia)	
  (Connell,	
  1995).	
  	
    28	
    	
    Men	
  who	
  embodied	
  subordinate	
  gay	
  masculinities	
  were	
  also	
  complicit	
  in	
  reproducing	
    the	
  heterosexual	
  status	
  quo.	
  One	
  example	
  involved	
  a	
  21-­‐year-­‐old	
  gay	
  man	
  who	
  contested	
  two	
   recent	
  clinical	
  encounters.	
  First,	
  he	
  went	
  for	
  testing	
  at	
  a	
  clinic	
  that	
  was	
  known	
  to	
  be	
  ‘gay-­‐ friendly’,	
  but	
  was	
  anxious	
  when	
  he	
  realised	
  he	
  would	
  be	
  seeing	
  a	
  female	
  clinician:	
   	
   I	
  felt	
  comfortable	
  because	
  I	
  thought	
  he	
  [a	
  male	
  clinician]	
  was	
  going	
  to	
  see	
  me.	
  But	
  then	
   when	
  I	
  saw	
  this	
  person	
  coming	
  in	
  and	
  I	
  was	
  like,	
  ‘Oh!	
  A	
  woman,	
  okay!	
  She’s	
  really	
  butch,	
   so	
  whatever.’	
  [...]	
  Okay…	
  she	
  looked	
  totally	
  butch.	
  I	
  was	
  like	
  ‘Ah,	
  I’ll	
  go	
  with	
  her.’	
  	
   	
   Because	
  this	
  man	
  read	
  the	
  female	
  doctor	
  as	
  ‘queer’	
  (i.e.,	
  butch	
  lesbian),	
  he	
  was	
  comfortable	
   being	
  treated	
  by	
  her.	
  By	
  contrast,	
  when	
  he	
  accessed	
  STI	
  testing	
  at	
  a	
  different	
  clinic	
  that	
   specialised	
  in	
  STI	
  testing	
  (although,	
  it	
  did	
  not	
  explicitly	
  specialise	
  in	
  ‘gay-­‐friendly’	
  testing),	
  he	
   said:	
   	
   I	
  was	
  uncomfortable	
  in	
  the	
  second	
  [clinic]	
  when	
  I	
  was	
  talking	
  to	
  a	
  med	
  student,	
  because	
   the	
  context	
  is	
  not	
  [a	
  queer-­‐friendly	
  neighbourhood],	
  not	
  talking	
  with	
  a	
  butch	
  doctor.	
  I	
   wasn’t	
  sure	
  if	
  she	
  was	
  comfortable.	
  I	
  was	
  more	
  worried	
  about	
  her	
  [laughs]	
  hearing	
  all	
   these,	
  like,	
  things	
  that	
  many	
  people	
  are	
  not	
  used	
  to	
  hearing.	
  […]	
  I	
  was	
  worried	
  or	
  afraid	
   to	
  mention	
  to	
  this	
  straight,	
  really	
  ‘girly’	
  straight	
  med	
  student.	
  You	
  don’t	
  know	
  whether	
   they	
  really	
  feel	
  comfortable	
  with	
  you	
  in	
  the	
  room.	
   	
    29	
    This	
  situation	
  illustrates	
  the	
  degree	
  to	
  which	
  heteronormative	
  assumptions	
  influence	
  (and	
  are	
   (re)produced	
  within)	
  clinical	
  interactions.	
  In	
  each	
  scenario,	
  the	
  man	
  (re)positions	
  himself	
  with	
   a	
  heteronormative	
  lens.	
  Based	
  solely	
  on	
  his	
  clinician’s	
  appearance,	
  he	
  explains	
  he	
  is	
  far	
  more	
   comfortable	
  openly	
  discussing	
  his	
  sexual	
  history	
  with	
  a	
  woman	
  who	
  appears	
  ‘butch,	
  lesbian’.	
   On	
  the	
  other	
  hand,	
  he	
  explains	
  a	
  ‘straight’	
  ‘girly’	
  clinician	
  will	
  experience	
  significant	
   discomfort	
  around	
  discussions	
  of	
  his	
  same-­‐sex	
  sexual	
  practices.	
  His	
  responses	
  reveal	
  how	
   gender	
  relations	
  in	
  clinical	
  encounters	
  can	
  be	
  underpinned	
  by	
  heteronormative	
  assumptions	
   –	
  not	
  only	
  for	
  those	
  who	
  identify	
  as	
  heterosexual	
  –	
  but	
  also	
  by	
  those	
  who	
  identify	
  as	
  gay	
  and	
   embody	
  subordinate	
  masculinities.	
  	
   	
    The	
  degree	
  to	
  which	
  institutionalised	
  heterosexuality	
  (re)produced	
  the	
  distribution	
  of	
    heterosexual	
  power	
  was	
  revealed	
  within	
  some	
  clinics	
  through	
  their	
  attempts	
  to	
  create	
  ‘gay-­‐ friendly’	
  services.	
  For	
  example,	
  one	
  nurse	
  explained	
  that	
  she	
  hung	
  a	
  poster	
  promoting	
  safe	
   sex	
  depicting	
  two	
  gay	
  men	
  embracing	
  in	
  the	
  STI	
  clinic	
  where	
  she	
  worked.	
  Shortly	
  after,	
  she	
   received	
  a	
  complaint	
  from	
  a	
  clerical	
  worker	
  at	
  the	
  clinic:	
   	
   A	
  lot	
  of	
  the	
  front	
  line	
  staff	
  have	
  no-­‐	
  they’re	
  clerical.	
  	
  You	
  know,	
  and	
  they’re	
  very	
  good	
  at	
   what	
  they	
  do,	
  but	
  that	
  doesn’t	
  mean	
  they	
  were-­‐	
  they	
  didn’t	
  necessarily	
  come	
  here	
   knowing	
  what	
  they	
  were	
  getting	
  into,	
  and	
  knowing	
  that	
  they	
  may	
  have	
  to,	
  you	
  know,	
  be	
   aware	
  of	
  some	
  issues	
  around	
  that.	
  	
   	
   The	
  nurse	
  filed	
  a	
  complaint	
  about	
  the	
  incident	
  to	
  clinic	
  management,	
  but	
  no	
  action	
  was	
  taken.	
   As	
  the	
  nurse	
  explained:	
    30	
    	
   I	
  would	
  have	
  liked	
  to	
  have	
  seen	
  it	
  be	
  kind	
  of	
  an	
  instigation	
  of	
  change.	
  Like,	
  something	
   made	
  them	
  really	
  uncomfortable,	
  so	
  we	
  need	
  to	
  deal	
  with	
  that	
  because	
  that’s	
  not	
  fair	
  to	
   them	
  either,	
  to	
  be	
  uncomfortable,	
  and	
  not	
  have	
  some	
  resolution.	
  Most	
  of	
  these	
  people	
   are	
  pretty	
  good,	
  solid	
  people,	
  and	
  they	
  wouldn’t	
  say	
  something	
  like	
  that	
  if	
  they	
  weren’t	
   feeling	
  threatened	
  or	
  scared.	
  Something	
  was	
  really	
  upsetting	
  them,	
  on	
  some	
  level.	
   	
  	
   This	
  scenario	
  illustrates	
  how	
  transgressing	
  heteronormative	
  expectations	
  can	
  be	
  threatening,	
   uncomfortable	
  and	
  scary	
  for	
  people	
  who	
  work	
  in	
  clinics	
  that	
  are	
  accepting	
  of	
  diversity	
  in	
   principle,	
  as	
  well	
  as	
  how	
  institutions	
  can	
  fail	
  to	
  mobilise	
  emancipatory	
  opportunities	
  and	
   perhaps,	
  inadvertently,	
  reinforce	
  the	
  heteronormative	
  discourse.	
  These	
  situations	
  reveal	
  how	
   reproductions	
  of	
  the	
  heterosexual	
  status	
  quo	
  can	
  be	
  enacted	
  not	
  just	
  by	
  the	
  heterosexual	
   men	
  accessing	
  STI	
  testing,	
  but	
  also	
  by	
  gay	
  men,	
  clinic	
  staff	
  and	
  institutional	
  policies.	
  	
   	
   2.5	
  	
  Discussion	
   Hetero-­‐patriarchal	
  societies	
  depend	
  on	
  the	
  binary	
  of	
  Self-­‐Other	
  (e.g.,	
  homosexuals	
   positioned	
  as	
  the	
  deviant	
  ‘Other’)	
  (Schilt	
  &	
  Westbrook,	
  2009).	
  It	
  is	
  in	
  response	
  to	
   heteronormativities	
  that	
  men	
  shape	
  their	
  sexualities,	
  rendering	
  visible	
  the	
  discourses	
  of	
   power	
  and	
  how	
  power	
  is	
  socially	
  organised	
  to	
  benefit	
  heteropatriarchy.	
  These	
  findings	
  reveal	
   the	
  complex	
  processes	
  that	
  govern	
  heteronormative	
  power	
  distributions	
  and	
  the	
   heterosexual	
  status	
  quo	
  during	
  STI	
  clinical	
  encounters.	
  Ever	
  present	
  in	
  the	
  data	
  were	
   examples	
  illustrating	
  how	
  gay	
  and	
  bisexual	
  men	
  respond	
  to	
  heteronormative	
  expectations	
  in	
   31	
    STI	
  clinical	
  encounters	
  by	
  deferring	
  to	
  the	
  authority	
  of	
  heterosexuality	
  and	
  complying	
  with	
  the	
   rules	
  of	
  'successful	
  heterosexuality,'	
  (re)producing	
  institutionalised	
  gender.	
  These	
   performances	
  of	
  ‘the	
  hetero	
  in	
  the	
  head’	
  parallel	
  with	
  Holland	
  et	
  al.’s	
  (1998)	
  notion	
  of	
  ‘the	
   male	
  in	
  the	
  head’	
  whereby	
  women	
  were	
  considered	
  collaborators	
  and	
  enablers	
  in	
  the	
   production	
  of	
  male-­‐dominated	
  heterosexuality.	
  These	
  findings	
  illustrate	
  how	
  gay	
  men	
  can	
  be	
   complicit	
  and	
  perhaps	
  collude	
  with	
  the	
  reconstructions	
  of	
  institutionalised	
  heterosexuality,	
   thereby	
  portraying	
  a	
  ‘hetero	
  in	
  the	
  head’.	
  	
   Similar	
  to	
  qualitative	
  interviews	
  that	
  attempted	
  to	
  elicit	
  responses	
  related	
  to	
  gendered	
   behaviour	
  by	
  Haines,	
  Johnson,	
  Carter,	
  &	
  Arora	
  (2009)	
  participants	
  avoided	
  acknowledging	
  the	
   possibility	
  of	
  (male)	
  heterosexual	
  privilege.	
  While	
  these	
  discourses	
  appeared	
  resistant	
  to	
   explicit	
  homophobia,	
  many	
  participants	
  concurrently	
  reaffirmed	
  their	
  heterosexual	
   masculinity	
  through	
  disclaimers	
  about	
  readiness	
  to	
  interact	
  with	
  gay	
  men	
  (e.g.,	
  contingent	
  on	
   the	
  condition	
  that	
  ‘no	
  lines	
  get	
  crossed’),	
  underscoring	
  the	
  notion	
  that	
  dominant	
  forms	
  of	
   masculinity	
  are	
  often	
  contradictory	
  and	
  inconsistent	
  (Connelll,	
  1995).	
  This	
  nuanced,	
  yet	
   pervasive,	
  construction	
  of	
  normative	
  masculinity	
  is	
  consistent	
  with	
  previous	
  masculinities	
   work	
  where	
  homophobia	
  and	
  sexism	
  can	
  be	
  mitigated	
  through	
  disclaimers,	
  innuendos	
  or	
   humour	
  (Korobov,	
  2005).	
  The	
  resistance	
  to	
  acknowledge	
  that	
  gay	
  and	
  bisexual	
  men	
  might	
   experience	
  barriers	
  to	
  accessing	
  STI	
  testing	
  often	
  enabled	
  a	
  more	
  liberal	
  and	
  egalitarian	
   masculinity	
  (Korobov,	
  2005)	
  (e.g.,	
  suggesting	
  that	
  there	
  is	
  equality	
  for	
  all	
  sexual	
  identities).	
   However,	
  the	
  disavowal	
  of	
  gay	
  and	
  bisexual	
  men’s	
  subordinated	
  social	
  positioning	
  represents	
   a	
  gap	
  between	
  reality	
  and	
  rhetoric	
  that	
  is	
  underpinned	
  by	
  a	
  neoliberal	
  political	
  discourse	
  that	
   positions	
  gender	
  and	
  sexuality	
  as	
  ‘no	
  longer	
  mattering’	
  (Brodie,	
  2008).	
  As	
  Brodie	
  (2008)	
    32	
    points	
  out,	
  this	
  discourse	
  can	
  threaten	
  gender	
  equality	
  efforts	
  by	
  de-­‐legitimising	
  subordinate	
   groups	
  (e.g.,	
  gay	
  men).	
  	
   Bonding	
  identities	
  to	
  moral	
  accounts	
  of	
  health	
  helps	
  to	
  maintain	
  self-­‐surveillance	
  (e.g.,	
   to	
  prevent	
  men	
  from	
  engaging	
  in	
  ‘risky’	
  same-­‐sex	
  relations)	
  through	
  technologies	
  of	
  the	
  self	
   (Foucault,	
  1988).	
  As	
  Connelll	
  (1995)	
  explains,	
  these	
  discourses	
  may	
  play	
  part	
  of	
  a	
  larger	
  socio-­‐ political	
  function	
  to	
  promote	
  surveillance	
  and	
  regulation	
  by	
  the	
  individual,	
  thereby	
  taking	
   responsibility	
  out	
  of	
  the	
  realm	
  of	
  the	
  State.	
  This	
  function	
  situates	
  agency,	
  rather	
  than	
   structural	
  (e.g.,	
  help-­‐seeking	
  versus	
  health	
  service	
  and	
  systems)	
  and	
  socio-­‐cultural	
  influences	
   (e.g.,	
  sexual	
  diversities	
  in	
  heteronormative	
  cultures),	
  as	
  the	
  most	
  influential	
  determinant	
  of	
   sexual	
  health	
  outcomes	
  (e.g.,	
  STIs).	
  As	
  a	
  result,	
  the	
  ‘public	
  health’	
  medical	
  system	
  and	
  the	
   State	
  are	
  focused	
  on	
  providing	
  sexual	
  health	
  information	
  on	
  which	
  men	
  should	
  choose	
  to	
  act	
   (e.g.,	
  make	
  healthy	
  choices)	
  and	
  be	
  rewarded	
  for	
  choosing	
  the	
  ‘safe’	
  or	
  ‘correct’	
   (heterosexual)	
  lifestyles	
  (Robertson,	
  2007;	
  Peterson	
  &	
  Lupton,	
  1996).	
  Under	
  this	
  framework,	
   clinicians	
  are	
  positioned	
  as	
  authorities	
  that	
  define	
  and	
  regulate	
  the	
  behaviour	
  of	
  people	
  who	
   belong	
  to	
  “risky	
  groups”	
  (Shoveller	
  &	
  Johnson,	
  2006;	
  Rosenfeld	
  &	
  Faircloth,	
  2006).	
  These	
   technologies	
  of	
  the	
  self	
  produce	
  a	
  moral	
  understanding	
  of	
  sexual	
  identities	
  -­‐	
  not	
  solely	
  at	
  a	
   clinical	
  level,	
  but	
  also	
  at	
  macro-­‐societal	
  levels	
  (e.g.,	
  community	
  norms).	
  Although	
  self-­‐ surveillance	
  technologies	
  are	
  frequently	
  relied	
  upon	
  as	
  a	
  same-­‐sex	
  sexual	
  risk	
  behaviour	
   reduction	
  strategy,	
  the	
  current	
  findings	
  indicate	
  a	
  dearth	
  of	
  similar	
  STI/HIV	
  prevention	
   discourses	
  for	
  heterosexual	
  men.	
  Consequently,	
  these	
  findings	
  demonstrate	
  how	
   technologies	
  of	
  the	
  self	
  function	
  differentially	
  across	
  sexual	
  identities	
  and	
  may	
  contribute	
  to	
   the	
  ‘pronounced	
  silence’	
  around	
  the	
  sexual	
  health	
  needs	
  of	
  heterosexual	
  men	
  while	
    33	
    reproducing	
  the	
  status	
  quo	
  of	
  heterosexual	
  men’s	
  disengagement	
  with	
  discussions	
  around	
   sexual	
  health	
  practices	
  and	
  promotion.	
   These	
  findings	
  are	
  important	
  for	
  clinical	
  practice	
  and	
  promoting	
  sexual	
  health	
  equity	
   among	
  men	
  (and	
  women).	
  Clinical	
  discourses	
  linking	
  sexual	
  identity	
  to	
  risk	
  through	
  superficial	
   markers	
  is	
  inefficient	
  and	
  reproduces	
  and	
  reinforces	
  gay	
  and	
  bisexual	
  men	
  as	
  the	
  risky	
  ‘Other’	
   and	
  heterosexual	
  men	
  as	
  the	
  (hetero)normal	
  patient.	
  While	
  assessing	
  risk	
  based	
  on	
  history	
  of	
   intravenous	
  drug	
  use	
  and	
  anal	
  intercourse	
  are	
  important	
  factors	
  for	
  determining	
  the	
  level	
  of	
   STI/HIV	
  risk	
  exposure	
  (Public	
  Health	
  Agency	
  of	
  Canada,	
  2006),	
  assessing	
  risk	
  solely	
  on	
  the	
   basis	
  of	
  sexual	
  identity	
  (as	
  was	
  described	
  by	
  some	
  participants)	
  (re)produces	
  a	
  discourse	
  that	
   implicitly	
  links	
  risk	
  with	
  gay	
  identities.	
  Concurrently,	
  this	
  discourse	
  ‘frees’	
  heterosexual	
  men	
   from	
  being	
  at	
  high	
  risk	
  for	
  STI/HIV	
  by	
  virtue	
  of	
  their	
  sexual	
  identity,	
  rather	
  than	
  taking	
  into	
   account	
  the	
  sexual	
  risk	
  behaviour	
  in	
  which	
  they	
  engage.	
  As	
  Robertson	
  (2007)	
  argues,	
  such	
   ‘externalizing	
  of	
  risk’	
  occurs	
  as	
  a	
  result	
  of	
  social	
  positioning	
  and	
  identity	
  and	
  uses	
  moral	
   elements	
  to	
  promote	
  individual	
  ‘responsibility’	
  for	
  safety	
  (e.g.,	
  creates	
  a	
  system	
  which	
   systematically	
  identifies,	
  monitors	
  and	
  ‘corrects’	
  gay	
  and	
  bisexual	
  men’s	
  sexual	
  behaviour).	
   Concurrently,	
  these	
  discourses	
  threaten	
  the	
  sexual	
  health	
  of	
  heterosexual	
  men,	
  as	
   heterosexual	
  men	
  can	
  remain	
  disengaged	
  from	
  their	
  sexual	
  health	
  because	
  as	
  a	
  collective	
   they	
  are	
  at	
  ‘minimal	
  risk’.	
  This	
  inevitably	
  results	
  in	
  missed	
  opportunities	
  for	
  sexual	
  health	
   promotion	
  for	
  heterosexual	
  men	
  and	
  may	
  ‘sell	
  short’	
  the	
  epidemiology	
  of	
  STI/HIV	
  as	
  rates	
   continuously	
  changes	
  over	
  time	
  across	
  social	
  characteristics	
  (e.g.,	
  sexual	
  identity;	
  ethnicity).	
  	
   These	
  findings	
  do	
  not	
  imply	
  sexual	
  identity	
  should	
  be	
  discarded	
  from	
  clinical	
   discussions	
  related	
  to	
  STI/HIV	
  testing.	
  Sexual	
  identity	
  provides	
  important	
  clues	
  with	
  respect	
  to	
    34	
    STI/HIV	
  prevention	
  counselling	
  (e.g.,	
  can	
  help	
  the	
  clinician	
  better	
  understand	
  each	
  patient’s	
   social	
  contexts,	
  networks	
  or	
  group	
  affiliations	
  and	
  social	
  norms)	
  (Young	
  &	
  Meyer,	
  2005).	
  It	
  is	
   also	
  useful	
  and	
  efficient	
  to	
  target	
  STI/HIV	
  population	
  intervention	
  and	
  prevention	
   programmes	
  (e.g.,	
  STI	
  testing	
  or	
  screening	
  programmes)	
  to	
  vulnerable	
  populations	
  based	
  on	
   epidemiology	
  (e.g.,	
  because	
  of	
  higher	
  HIV	
  prevalence	
  among	
  gay	
  men,	
  HIV	
  awareness	
  efforts	
   have	
  been	
  focused	
  on	
  this	
  population	
  subgroup).	
  However,	
  clinical	
  protocols	
  (e.g.,	
  STI	
  risk	
   assessments)	
  targeting	
  sub-­‐groups	
  based	
  primarily	
  or	
  solely	
  on	
  a	
  man’s	
  membership	
  to	
  a	
   particular	
  subgroup	
  (e.g.,	
  gay	
  men)	
  may	
  inadvertently	
  sabotage	
  well-­‐intentioned	
  efforts	
  to	
   practice	
  medicine	
  in	
  gender	
  and	
  culturally	
  competent	
  ways	
  (Numer	
  &	
  Gahagan,	
  2009;	
   Makadon	
  et	
  al.,	
  2007;	
  Holmes	
  &	
  O’Byrne,	
  2006).	
  These	
  findings	
  point	
  to	
  the	
  need	
  for	
   clinicians	
  to	
  consider	
  the	
  wider	
  set	
  of	
  social	
  relations	
  that	
  men	
  experience	
  in	
  their	
  everyday	
   lives	
  (Shoveller	
  et	
  al.,	
  2010)	
  and	
  incorporate	
  into	
  their	
  clinical	
  practices	
  strategies	
  that	
  unpack	
   harmful	
  stereotypes	
  about	
  ‘non-­‐heterosexual’	
  sexual	
  identities	
  (Holmes	
  &	
  O’Byrne,	
  2006;	
   Browne,	
  2007).	
  	
   Many	
  clinicians	
  in	
  the	
  study	
  claimed	
  to	
  have	
  implemented	
  ‘gender-­‐neutral’	
  services.	
   The	
  use	
  of	
  the	
  term	
  ‘neutral’	
  fails	
  to	
  recognise	
  the	
  influences	
  of	
  a	
  wider	
  set	
  of	
  social	
  relations	
   (e.g.,	
  gender	
  norms)	
  that	
  everyone	
  is	
  exposed	
  to	
  (and	
  contributes	
  to)	
  in	
  their	
  everyday	
  lives.	
  A	
   theoretically	
  ‘neutral’	
  position	
  often	
  translates	
  into	
  yet	
  another	
  sphere	
  within	
  which	
   heteronormative	
  social	
  norms	
  are	
  re-­‐enacted	
  and	
  remain	
  unquestioned	
  (Snively,	
  Kreuger,	
   Stretch,	
  Wilson,	
  &	
  Chadha,	
  2004).	
  Moreover,	
  sexual	
  health	
  services	
  represent	
  a	
  special	
  case	
   for	
  men’s	
  interactions	
  with	
  and	
  reproduction	
  of	
  (heterosexual)	
  masculine	
  discourses.	
  As	
  these	
   findings	
  illustrate,	
  these	
  are	
  unique	
  encounters	
  where	
  the	
  “natural	
  binary”	
  (Butler,	
  1990)	
  of	
    35	
    biological	
  sex	
  and	
  socially	
  constructed	
  genders	
  are	
  explicitly	
  ‘interrogated’.	
  Censoring,	
   denying	
  or	
  ‘neutralising’	
  gender	
  affirms	
  and	
  gives	
  prominence	
  to	
  the	
  repressive	
  power	
  that	
   heteronormative	
  gender	
  relations	
  currently	
  impose	
  (Foucault,	
  1978).	
  Clinics	
  must	
  also	
   address	
  the	
  reality	
  that	
  some	
  staff	
  members	
  (including	
  clerical	
  staff)	
  enact	
  heteronormative,	
   heterosexist	
  and	
  homophobic	
  beliefs.	
  Educating	
  all	
  staff	
  members,	
  including	
  clerical	
  and	
   administrative	
  staff	
  who	
  interact	
  with	
  patients	
  (e.g.,	
  scheduling	
  appointments;	
  checking	
   patients	
  in	
  upon	
  arrival)	
  may	
  help	
  promote	
  safe	
  and	
  inclusive	
  environments	
  for	
  everyone	
  and	
   could	
  help	
  relieve	
  anxieties	
  for	
  those	
  staff	
  members	
  who	
  are	
  uncomfortable	
  or	
  uncertain	
   about	
  how	
  to	
  engage	
  with	
  sexual	
  diversities	
  (Potter,	
  Goldhammer,	
  &	
  Makadon,	
  2007).	
   The	
  current	
  study	
  has	
  several	
  strengths	
  and	
  limitations.	
  Obviously,	
  heterosexism	
  and	
   heteronormativity	
  are	
  not	
  unilateral	
  or	
  monolithic	
  concepts	
  that	
  are	
  isolated	
  from	
  other	
   social	
  hierarchies	
  (e.g.,	
  gender,	
  class,	
  race)	
  (Bryant	
  &	
  Vidal-­‐Ortiz,	
  2008).	
  The	
  current	
  study’s	
   design	
  offers	
  a	
  contextualised	
  and	
  analytical	
  approach	
  that	
  can	
  describe	
  these	
  forces	
  within	
   cultural	
  contexts	
  and	
  how	
  they	
  interact	
  with	
  other	
  areas	
  of	
  social	
  lives	
  (e.g.,	
  gender	
  relations	
   in	
  their	
  communities).	
  However,	
  the	
  findings	
  are	
  not	
  claimed	
  as	
  generalisable	
  to	
  all	
  men’s	
   experiences	
  or	
  other	
  STI	
  clinical	
  settings.	
  	
   In	
  conclusion,	
  this	
  analysis	
  offers	
  theoretical	
  and	
  empirical	
  insights	
  into	
  how	
   discourses	
  that	
  (re)produce	
  or	
  naturalise	
  heteronormative	
  cultural	
  assumptions	
  ‘hurt	
   everyone’,	
  including	
  those	
  ‘privileged’	
  by	
  embodying	
  heterosexual	
  identities.	
  These	
  findings	
   reveal	
  discourses	
  within	
  STI	
  clinical	
  settings	
  which	
  systematically	
  shut	
  down	
  discussions	
   around	
  heterosexual	
  men’s	
  sexual	
  health	
  and	
  contribute	
  to	
  heterosexist	
  stereotypes	
  for	
  gay	
   and	
  bisexual	
  men.	
  They	
  also	
  highlight	
  the	
  role	
  sexual	
  health	
  clinical	
  services	
  can	
  play	
  in	
  which	
    36	
    clinicians	
  and	
  men	
  either	
  (re)produce	
  dominant	
  and	
  hegemonic	
  forms	
  of	
  masculinities	
  or	
   create	
  transformative,	
  more	
  equitable	
  gendered	
  relations.	
  Ultimately,	
  these	
  findings	
  point	
   toward	
  the	
  need	
  for	
  men-­‐centred	
  sexual	
  health	
  services	
  to	
  provide	
  services	
  that	
  attend	
  to	
  a	
   diversity	
  of	
  social	
  contexts	
  and	
  structural	
  conditions.	
    37	
    Chapter 3.0 Masculinities, ‘Guy Talk’ and ‘Manning Up’: Young men’s discussions about sexual health  3.1	
  	
  Introduction	
   3.1.1	
  	
  Background	
   Popular	
  portrayals	
  of	
  sex	
  and	
  sexual	
  health	
  often	
  claim	
  that	
  women	
  talk	
  too	
  much	
  (with	
  each	
   other)	
  and	
  men	
  talk	
  too	
  little	
  (with	
  anyone)	
  (DeVore,	
  2009).	
  Some	
  authors	
  relate	
  men’s	
   reticence	
  to	
  engage	
  in	
  discussions	
  around	
  health	
  in	
  general	
  to	
  dominant	
  masculine	
  ideals	
  that	
   prescribe	
  stoicism,	
  independence,	
  self-­‐reliance	
  and	
  disinterest	
  in	
  self-­‐health	
  (Connell,	
  1995;	
   Courtenay,	
  2000a	
  and	
  2000b).	
  For	
  example,	
  men	
  are	
  depicted	
  as	
  more	
  likely	
  to	
  deny	
  illness	
   than	
  engage	
  in	
  discussions	
  about	
  their	
  health	
  and	
  well-­‐being	
  (Robertson,	
  2007).	
  A	
  few	
  studies	
   rooted	
  within	
  the	
  contexts	
  of	
  men’s	
  coping	
  with	
  illnesses	
  (Oliffe,	
  2010a)	
  and	
  chronic	
  disease	
   (Charmaz,	
  1995)	
  show	
  that	
  some	
  men	
  engage	
  one	
  another	
  in	
  meaningful	
  conversations	
  about	
   their	
  health.	
  Most	
  studies	
  that	
  have	
  examined	
  young	
  men’s	
  sexual	
  health-­‐related	
  discussions	
   focus	
  on	
  their	
  communication	
  within	
  and	
  about	
  health	
  care	
  service	
  provision	
  situations	
  (e.g.,	
   patient-­‐doctor	
  communication)	
  (Carlisle,	
  Shickle,	
  Cork	
  &	
  McDonagh,	
  2006).	
  To	
  date,	
  there	
  is	
   little	
  empirical	
  and/or	
  theoretical	
  literature	
  examining	
  men’s	
  talk	
  and	
  discussions	
  with	
  one	
   another	
  regarding	
  their	
  sexual	
  health	
  (e.g.,	
  sex	
  practices;	
  contraception;	
  sexually	
  transmitted	
   infections;	
  ‘healthy’	
  relationships).	
  	
   	
    38	
    3.1.2	
  	
  Young	
  men’s	
  sexual	
  health	
   Despite	
  decades	
  of	
  public	
  health	
  intervention,	
  sexually	
  transmitted	
  infections	
  (STIs)	
  and	
  HIV	
   remain	
  a	
  serious	
  health	
  problem	
  among	
  young	
  men.	
  For	
  example,	
  in	
  2007	
  in	
  the	
  United	
   Kingdom,	
  men	
  below	
  the	
  age	
  of	
  25	
  represented	
  57%	
  of	
  all	
  Chlamydia	
  cases	
  (34,626	
  cases)	
  at	
  a	
   rate	
  of	
  1,100	
  per	
  100,000	
  among	
  men	
  aged	
  20-­‐24	
  (Health	
  Protection	
  Agency,	
  2011).	
  In	
  the	
   United	
  States	
  in	
  2009,	
  men	
  between	
  the	
  ages	
  of	
  20	
  to	
  24	
  had	
  the	
  highest	
  rate	
  of	
  Chlamydia	
  at	
   1,120	
  cases	
  per	
  100,000	
  (compared	
  to	
  the	
  national	
  average	
  of	
  409	
  per	
  100,000)	
  (US	
  Centers	
   for	
  Disease	
  Control	
  and	
  Prevention,	
  2007).	
  In	
  Canada,	
  as	
  elsewhere,	
  young	
  men’s	
  STI	
  rates	
  are	
   high	
  and	
  rising.	
  For	
  example,	
  in	
  British	
  Columbia	
  (BC),	
  Canada’s	
  most	
  western	
  province,	
   between	
  2000	
  and	
  2009,	
  genital	
  Chlamydia	
  rates	
  among	
  young	
  men,	
  15	
  to	
  24	
  years	
  old,	
   doubled,	
  with	
  1,110.4	
  cases	
  per	
  100,000	
  men	
  (compared	
  to	
  the	
  BC	
  average	
  of	
  251.1	
  per	
   100,000)	
  (British	
  Columbia	
  Centre	
  for	
  Disease	
  Control,	
  2010).3	
  Those	
  who	
  are	
  racialised,	
   economically	
  disadvantaged	
  as	
  well	
  as	
  men	
  who	
  have	
  sex	
  with	
  men	
  (MSM)	
  bear	
  the	
  largest	
   burden	
  of	
  STIs	
  (British	
  Columbia	
  Centre	
  for	
  Disease	
  Control,	
  2010;	
  US	
  Centres	
  for	
  Disease	
   Control	
  and	
  Prevention,	
  2007).	
  In	
  2009,	
  HIV	
  incidence	
  rates	
  for	
  men	
  between	
  the	
  ages	
  of	
  20	
   to	
  24	
  were	
  significantly	
  higher	
  than	
  the	
  provincial	
  average	
  at	
  11.2	
  per	
  100,000	
  cases	
   (compared	
  to	
  the	
  provincial	
  average	
  of	
  7.6	
  per	
  100,000)	
  (British	
  Columbia	
  Centre	
  for	
  Disease	
   Control,	
  2010).	
  Moreover,	
  the	
  STI	
  surveillance	
  data	
  indicate	
  the	
  potential	
  for	
  a	
  significant	
   3  	
  While	
  women	
  ages	
  15	
  to	
  24	
  experience	
  higher	
  rates	
  of	
  STIs	
  such	
  as	
  as	
  genital	
  Chlamydia,	
    these	
  disparities	
  have	
  largely	
  been	
  attributed	
  to	
  asymptomatic	
  cases	
  in	
  heterosexual	
  men	
   who	
  have	
  not	
  been	
  tested	
  and	
  therefore	
  not	
  treated,	
  or	
  who	
  are	
  treated	
  for	
  their	
  symptoms	
   but	
  not	
  tested	
  (and	
  therefore	
  remain	
  unreported	
  in	
  the	
  surveillance	
  data)	
  (British	
  Columbia	
   Centre	
  for	
  Disease	
  Control,	
  2010).	
    39	
    increase	
  of	
  HIV	
  spread	
  among	
  young	
  men	
  (Larkin,	
  Andrews,	
  &	
  Mitchell,	
  2006).	
  As	
  a	
  result,	
   there	
  is	
  a	
  strong	
  public	
  health	
  impetus	
  to	
  improve	
  young	
  men’s	
  sexual	
  health	
  outcomes.	
  	
   	
    	
    3.1.3	
  	
  Masculinities	
  and	
  men’s	
  sexual	
  health	
  practices	
   	
    Men’s	
  sexual	
  health-­‐related	
  practices	
  have	
  been	
  associated	
  with	
  a	
  plurality	
  of	
    masculinities	
  and	
  emerge	
  as	
  complex,	
  often	
  in	
  contradictory	
  and	
  inconsistent	
  ways.	
  The	
  high	
   and	
  rising	
  rates	
  of	
  STIs	
  among	
  men	
  have	
  been	
  attributed	
  to	
  their	
  disengagement	
  with	
  sexual	
   health	
  services,	
  a	
  reticence	
  around	
  self-­‐help	
  and	
  a	
  lack	
  of	
  meaningful	
  discussions	
  around	
   sexual	
  health	
  informed	
  by	
  masculine	
  ideals	
  (Robertson,	
  2007).	
  Men	
  who	
  avoid	
  discussing	
   sexual	
  health	
  are	
  at	
  increased	
  risk	
  of	
  becoming	
  infected	
  by	
  an	
  STI	
  (as	
  well	
  as	
  other	
  health-­‐ related	
  consequences)	
  (Alt,	
  2002;	
  Courtenay	
  2000a;	
  Brook	
  Advisory	
  Centres	
  2005;	
  Pearson	
   2003).	
  An	
  emerging	
  literature	
  details	
  how	
  the	
  connections	
  between	
  masculinities	
  and	
  social	
   contexts	
  can	
  influence	
  young	
  men’s	
  sexual	
  health-­‐related	
  practices	
  (Shoveller	
  et	
  al.	
  2009	
  and	
   1010;	
  Gautham	
  et	
  al.	
  2008;	
  Goldenberg	
  et	
  al.	
  2008;	
  Mantell	
  et	
  al.	
  2006;	
  Shoveller	
  et	
  al.	
  2006;	
   Shoveller	
  and	
  Johnson	
  2004	
  and	
  2006).	
  For	
  example,	
  Goldenberg	
  et	
  al	
  (2008)	
  described	
  how	
   structural	
  conditions	
  (e.g.,	
  location	
  and	
  hours	
  of	
  STI	
  clinics)	
  amid	
  hyper-­‐masculine	
  oil/gas	
   worker	
  occupations	
  and	
  social	
  contexts	
  intersected	
  to	
  create	
  significant	
  barriers	
  for	
  men’s	
   engagement	
  with	
  STI	
  testing	
  services,	
  while	
  at	
  the	
  same	
  time,	
  creating	
  social	
  situations	
  that	
   put	
  men	
  (and	
  women)	
  at	
  elevated	
  risk	
  for	
  getting	
  an	
  STI.	
  	
   	
    Other	
  critiques	
  have	
  begun	
  to	
  explore	
  how	
  aligning	
  with	
  dominant	
  masculine	
  ideals	
    may	
  also	
  produce	
  health-­‐enhancing	
  behaviour	
  for	
  men.	
  For	
  example,	
  men	
  whose	
  jobs	
  require	
   strength	
  and	
  endurance	
  (e.g.,	
  firemen)	
  may	
  idealise	
  a	
  healthy	
  body	
  and	
  therefore	
  be	
  more	
   40	
    likely	
  to	
  engage	
  in	
  health-­‐promoting	
  behaviour	
  (e.g.,	
  exercise;	
  healthy	
  diet)	
  (O’Brien,	
  Hunt	
  &	
   Hart,	
  2005).	
  These	
  ‘healthy	
  masculinities’	
  are	
  typically	
  positioned	
  as	
  a	
  means	
  to	
  “preserve	
  or	
   restore	
  another,	
  more	
  valued,	
  enactment	
  of	
  masculinity”	
  (O’Brien,	
  Hunt	
  &	
  Hart,	
  2005,	
  p.	
  1).	
   Practices	
  of	
  preserving	
  or	
  restoring	
  preferred	
  enactments	
  of	
  masculinity	
  also	
  have	
  been	
   identified	
  in	
  the	
  realm	
  of	
  men’s	
  sexual	
  health	
  practices.	
  For	
  example,	
  hegemonic	
  masculinity	
   is	
  associated	
  with	
  the	
  valorisation	
  of	
  frequent	
  sexual	
  activity	
  and	
  sexual	
  ‘risk-­‐taking’	
  practices	
   (e.g.,	
  avoidance	
  of	
  condoms)	
  (Numer	
  &	
  Gahagan,	
  2009).	
  However,	
  some	
  men	
  who	
  embrace	
   these	
  ideals	
  also	
  worry	
  about	
  the	
  potentially	
  emasculating	
  effects	
  of	
  ‘falling	
  ill’	
  (e.g.,	
  getting	
   STIs/HIV)	
  (Duck,	
  2009),	
  revealing	
  the	
  complex	
  relationships	
  between	
  masculinities	
  and	
  men’s	
   health	
  practices	
  (Oliffe	
  et	
  al.,	
  2007).	
  	
   	
   3.1.4	
  	
  Men	
  talking	
  about	
  sexual	
  health	
   	
    Some	
  studies	
  have	
  described	
  how	
  portrayals	
  of	
  masculine	
  ideals	
  vary	
  according	
  to	
    contextual	
  features,	
  such	
  as	
  the	
  audience	
  (e.g.,	
  within	
  and	
  among	
  men	
  versus	
  women)	
   (Pascoe,	
  2007;	
  Allen,	
  2003),	
  conversational	
  subjects	
  (Allen,	
  2003),	
  historical	
  context	
  (e.g.,	
   across	
  time)	
  and/or	
  socio-­‐political	
  milieu	
  (Guzman,	
  2006).	
  Emerging	
  analyses	
  suggest	
  that	
   men’s	
  access	
  to	
  cultural	
  and	
  economic	
  capital	
  (e.g.,	
  ethnicity;	
  social	
  class;	
  geopolitical	
   contexts)	
  can	
  bolster	
  or	
  limit	
  their	
  capacity	
  to	
  embody	
  dominant	
  masculine	
  ideals	
  that	
  may	
   put	
  their	
  health	
  at	
  risk	
  (e.g.,	
  discussing	
  sexual	
  health	
  with	
  peers)	
  (Shoveller	
  et	
  al,	
  2010;	
  Duck,	
   2009;	
  Allen,	
  2003).	
  These	
  approaches	
  view	
  men’s	
  health-­‐related	
  behaviour	
  as	
  operating	
   under	
  socio-­‐cultural	
  influences	
  (e.g.,	
  gender	
  norms)	
  as	
  well	
  as	
  structural-­‐level	
  determinants	
   (e.g.,	
  access	
  to	
  capital).	
  In	
  the	
  current	
  study,	
  I	
  examined	
  descriptions	
  of	
  the	
  social	
  and	
   41	
    contextual	
  conditions	
  which	
  facilitate,	
  forbid	
  or	
  ‘shut	
  down’	
  sexual	
  health	
  communication	
   among	
  and	
  by	
  men.	
  I	
  pay	
  special	
  attention	
  to	
  how	
  idealised	
  masculinity	
  influences	
  young	
   men’s	
  social	
  interactions	
  as	
  they	
  discuss	
  their	
  sexual	
  health	
  practices	
  with	
  their	
  peers	
  and/or	
   sex	
  partners.	
  	
   	
   3.2	
  	
  Methods	
   3.2.1	
  Recruitment	
  	
   Using	
  posters	
  to	
  advertise	
  the	
  study,	
  men	
  15-­‐24	
  years-­‐old	
  were	
  recruited	
  from	
  youth	
  STI	
   clinics,	
  bus	
  stops,	
  community	
  centres	
  as	
  well	
  as	
  online	
  forums	
  including	
  FacebookTM.	
   Interested	
  participants	
  telephoned	
  or	
  emailed	
  the	
  research	
  office	
  and	
  were	
  screened	
  for	
   eligibility.	
  The	
  criteria	
  for	
  sampling	
  was	
  sexually	
  active,	
  English	
  speaking	
  men	
  15-­‐24	
  years-­‐old	
   who	
  had	
  previously	
  tested	
  or	
  considered	
  STI	
  testing.	
  Young	
  men	
  of	
  various	
  ethnicities,	
  sexual	
   identities,	
  ages	
  and	
  socioeconomic	
  statuses	
  participated	
  in	
  individual,	
  semi-­‐structured,	
  in-­‐ depth	
  interviews.	
  Ethics	
  approval	
  was	
  obtained	
  from	
  the	
  University	
  of	
  British	
  Columbia.	
   Participants	
  under	
  the	
  age	
  of	
  19	
  did	
  not	
  require	
  their	
  parent’s/guardian’s	
  assent;	
  all	
   participants	
  provided	
  informed	
  consent.	
   	
   3.2.2	
  Study	
  setting	
   	
    Young	
  men	
  were	
  recruited	
  in	
  Metro	
  Vancouver,	
  Canada.	
  Vancouver	
  is	
  located	
  on	
    Canada’s	
  south	
  west	
  Pacific	
  coast	
  and	
  has	
  a	
  population	
  of	
  2,116,581	
  people	
  with	
   approximately	
  215,000	
  men	
  ages	
  15	
  to	
  24	
  yeas	
  old	
  (Statistics	
  Canada,	
  2007).	
  Approximately	
   42	
    40	
  percent	
  of	
  Vancouver’s	
  population	
  are	
  immigrants.	
  Vancouver	
  markets	
  itself	
  as	
  being	
  one	
   of	
  the	
  most	
  ‘gay-­‐friendly’	
  cities	
  in	
  the	
  world	
  (Tourism	
  Vancouver,	
  2011).	
   	
   3.2.3	
  	
  Interviews	
   The	
  individual,	
  in-­‐depth,	
  semi-­‐structured	
  interviews	
  lasted	
  approximately	
  1	
  to	
  1.5	
  hours	
  and	
   took	
  place	
  at	
  private	
  settings	
  (e.g.,	
  research	
  offices).	
  Interviews	
  were	
  scheduled	
  at	
  a	
  time	
   convenient	
  to	
  the	
  participants.	
  During	
  the	
  interviews,	
  participants	
  were	
  asked	
  to	
  describe	
  the	
   situations	
  in	
  which	
  they	
  engage	
  in	
  conversation	
  or	
  discussion	
  about	
  sexual	
  health	
  with	
  their	
   peers	
  and/or	
  sex	
  partners.	
  The	
  interview	
  questions	
  addressed	
  a	
  variety	
  of	
  topics	
  that	
  might	
   arise	
  in	
  conversations	
  with	
  peer	
  and/or	
  sex	
  partners,	
  including	
  STI	
  testing,	
  sexual	
  practices	
   and	
  contraception.	
  In	
  order	
  to	
  better	
  understand	
  how	
  their	
  conversations	
  played	
  out,	
  I	
  asked	
   the	
  participants	
  to	
  describe	
  the	
  social	
  contexts	
  in	
  which	
  these	
  conversations	
  took	
  place	
  (e.g.,	
   location;	
  comfort	
  levels;	
  topics;	
  tone	
  of	
  conversations;	
  reactions	
  of	
  their	
  peers/sex	
  partners).	
   See	
  Appendix	
  6.3	
  for	
  the	
  interview	
  guides	
  used	
  during	
  these	
  interviews.	
  All	
  participants	
  were	
   offered	
  a	
  $25	
  honorarium	
  and	
  the	
  opportunities	
  to	
  “member	
  check”	
  their	
  transcripts.	
   	
   3.2.4	
  	
  Data	
  analysis	
   Interviews	
  were	
  transcribed,	
  checked	
  for	
  accuracy	
  and	
  uploaded	
  to	
  NVivo	
  8TM	
  for	
  coding	
  and	
   analysis.	
  Using	
  a	
  modified	
  grounded	
  theory	
  approach	
  (Strauss	
  and	
  Corbin,	
  1998),	
  interviews	
   were	
  compared	
  to	
  identify	
  broad	
  themes	
  across	
  interviews	
  (Have,	
  1995)	
  with	
  special	
   attention	
  on	
  men’s	
  narratives	
  about	
  the	
  discussions	
  they	
  have	
  with	
  peers	
  and	
  sex	
  partners.	
    43	
    This	
  analytic	
  method	
  was	
  chosen	
  to	
  enable	
  the	
  development	
  of	
  descriptions	
  of	
  young	
  men’s	
   uses	
  of	
  language,	
  rather	
  than	
  the	
  specific	
  grammatical	
  and/or	
  linguistic	
  use	
  of	
  language	
   (Hodges,	
  Kuper	
  &	
  Reeves,	
  2008).	
  From	
  these	
  emergent	
  themes,	
  I	
  developed	
  an	
  initial	
  set	
  of	
   codes.	
  The	
  masculinities	
  literature	
  was	
  consulted	
  to	
  develop	
  conceptual	
  themes	
  and	
  to	
   identify	
  coherent	
  patterns	
  within	
  and	
  across	
  the	
  data	
  (Sandelowski,	
  1995).	
  As	
  data	
  collection	
   and	
  analysis	
  continued,	
  coding	
  occurred	
  iteratively	
  within	
  and	
  across	
  interviews	
  to	
  test	
   emergent	
  ideas	
  about	
  the	
  connections	
  between	
  concepts	
  and	
  to	
  identify	
  new	
  themes.	
  	
   	
   3.3	
  	
  Findings	
   3.3.1	
  	
  Study	
  participants	
   I	
  draw	
  on	
  an	
  analysis	
  of	
  32	
  qualitative,	
  semi-­‐structured	
  in-­‐depth	
  interviews	
  with	
  young	
  men	
   between	
  the	
  ages	
  of	
  17	
  to	
  24.	
  The	
  average	
  age	
  of	
  participants	
  was	
  20.5	
  years.	
  All	
  participants	
   had	
  previously	
  had	
  sex	
  (oral,	
  anal,	
  and/or	
  vaginal).	
  See	
  Table	
  3	
  for	
  the	
  socio-­‐demographic	
   characteristics	
  of	
  the	
  participants.	
    44	
    Table	
  3.	
  Self-­‐identified	
  characteristics	
  of	
  young	
  men	
   AGE GROUP  (n)  Percent  15-19  16  50%  20-24  16  50%  Aboriginal  4  13%  Black  1  3%  South Asian  6  19%  South East Asian  4  13%  Latin American  1  3%  Euro-Canadian  15  47%  Middle East  1  3%  Heterosexual  20  63%  Homosexual  7  22%  Bisexual  5  16%  ETHNICITY  SEXUAL ORIENTATION  	
   The	
  following	
  provides	
  illustrative	
  quotes	
  from	
  participants	
  related	
  to	
  the	
  discussions	
  they	
   have	
  with	
  peers	
  and	
  sex	
  partners	
  about	
  sexual	
  health.	
  The	
  findings	
  are	
  divided	
  into	
  two	
   thematic	
  sections:	
  (1)	
  “Guy	
  talk”	
  and	
  (2)	
  ‘Manning	
  up’.	
  	
   	
   3.3.2	
  	
  ‘Guy	
  talk’	
  	
   	
    I	
  asked	
  participants	
  to	
  describe	
  the	
  situations	
  in	
  which	
  they	
  were	
  able	
  to	
  discuss	
  their	
    sexual	
  health	
  with	
  peers.	
  Most	
  participants	
  explained	
  that	
  their	
  discussions	
  about	
  sex	
   typically	
  consisted	
  of	
  descriptions	
  about	
  their	
  sexual	
  encounters	
  (e.g.,	
  whom	
  they	
  had	
  sex	
   with;	
  what	
  sex	
  acts	
  they	
  engaged	
  in),	
  and	
  several	
  participants	
  called	
  this	
  ‘guy	
  talk’.	
  Few	
  said	
   they	
  had	
  ever	
  talked	
  about	
  sexual	
  health-­‐related	
  issues	
  (e.g.,	
  STI	
  testing;	
  condom	
    45	
    negotiation).	
  As	
  Milo,	
  a	
  straight	
  19-­‐year-­‐old	
  East	
  Asian	
  man,	
  explained,	
  when	
  he	
  and	
  his	
   friends	
  talk	
  about	
  sex,	
  it	
  is:	
   	
   Just	
  ‘guy	
  talk’,	
  I	
  guess.	
  Whatever.	
  Like,	
  if	
  I	
  had	
  sex	
  with	
  a	
  girl	
  last	
  night,	
  I’ll	
  like	
  call	
   my	
  buddies	
  and	
  be	
  like	
  “Yo,	
  last	
  night	
  was	
  fun!”	
  and	
  he’d	
  be	
  like	
  “Oh	
  what’d	
  you	
   do?”	
  Stuff	
  like	
  that.	
  But	
  we	
  don’t	
  really	
  talk	
  in	
  terms	
  of	
  like	
  sexual	
  health	
  [emphasis	
   added	
  to	
  indicate	
  Milo’s	
  voice	
  inflection],	
  like	
  getting	
  STI	
  tests.	
   	
   The	
  inflection	
  in	
  Milo’s	
  voice	
  confirms	
  sexual	
  “health”	
  as	
  taboo	
  and	
  irrelevant,	
  a	
  side	
  issue	
   that	
  could	
  only	
  serve	
  to	
  distract	
  or	
  dilute	
  the	
  details	
  of	
  his	
  sexual	
  conquest	
  and	
  pleasure.	
   Talking	
  about	
  sexual	
  performance	
  (i.e.,	
  who	
  did	
  what	
  to	
  whom	
  and	
  where)	
  is	
  afforded	
  the	
   most	
  airtime	
  within	
  these	
  interactions	
  because	
  these	
  details	
  most	
  readily	
  engage	
  the	
   listener[s].	
  Inversely,	
  the	
  concept	
  of	
  sexual	
  health	
  is	
  inextricably	
  tied	
  to	
  STIs	
  (e.g.,	
  getting	
   tested),	
  which	
  is	
  a	
  subject	
  not	
  conventionally	
  included	
  in	
  conversations	
  with	
  male	
  friends.	
   	
    Some	
  participants	
  surfaced	
  stereotypes	
  regarding	
  the	
  idea	
  that	
  gay	
  men	
  can	
  more	
    freely	
  or	
  openly	
  engage	
  in	
  conversations	
  about	
  sexual	
  health	
  (e.g.,	
  because	
  they	
  are	
  assumed	
   to	
  ‘talk	
  about	
  sex	
  all	
  the	
  time’).	
  Although	
  these	
  data	
  revealed	
  a	
  more	
  complex	
  set	
  of	
   practices,	
  the	
  gay	
  men	
  in	
  this	
  study	
  were	
  more	
  likely	
  to	
  have	
  talked	
  about	
  sexual	
  health,	
  but	
   only	
  with	
  their	
  gay	
  friends.	
  As	
  Bill,	
  a	
  22-­‐year-­‐old	
  Euro-­‐Canadian	
  gay	
  man,	
  said:	
  	
   	
   For	
  gay	
  guys	
  like	
  me,	
  my	
  best	
  resources	
  are	
  my	
  gay	
  best	
  friends.	
  Gay	
  guys	
  talk	
  about	
   sex	
  all	
  the	
  time.	
  Sometimes	
  it’s	
  just,	
  you	
  know,	
  a	
  story….But,	
  if	
  you	
  want	
  advice	
  on	
    46	
    something,	
  you’re	
  probably	
  going	
  to	
  get	
  it.	
  Because	
  somebody	
  probably	
  experienced	
   the	
  same	
  thing.	
   	
   Conversations	
  about	
  sexual	
  health	
  among	
  gay	
  men	
  were	
  also	
  aligned	
  within	
  a	
  dominant	
   masculine	
  discourse	
  around	
  men’s	
  talk	
  relating	
  to	
  sexual	
  performance	
  where	
  descriptions	
  of	
   sexual	
  acts	
  and	
  partners	
  are	
  used	
  to	
  signal	
  virile	
  gay	
  masculinities,	
  marking	
  hierarchies	
  within	
   those	
  masculinities.	
  Many	
  gay	
  participants	
  also	
  acknowledged	
  that	
  heterosexual	
  men	
  tend	
  to	
   focus	
  their	
  ‘guy	
  talk’	
  primarily	
  on	
  their	
  sexual	
  encounters	
  (but	
  with	
  women),	
  relying	
  on	
  the	
   use	
  humour	
  and/or	
  derogatory	
  remarks	
  to	
  relay	
  their	
  stories.	
  As	
  Bill,	
  a	
  22	
  year	
  old	
  gay	
  man,	
   acknowledged:	
  	
   	
   It’s	
  like	
  they	
  [heterosexual	
  men]	
  just	
  make	
  fun.	
  It’s	
  not	
  sexual	
  health….My	
  best	
  friend	
  is	
   straight	
  and	
  I	
  hang	
  out	
  with	
  straight	
  guys	
  all	
  the	
  time.	
  When	
  they	
  start	
  talking	
  about	
   sex,	
  I	
  slowly	
  turn	
  myself	
  off….I	
  don’t	
  want	
  to	
  hear	
  them	
  talking	
  about	
  pussy….Girls	
  are	
   gross….I	
  don’t	
  want	
  to	
  hear	
  a	
  string	
  of	
  short	
  stories	
  about	
  their	
  “times	
  with	
  women”.	
   And,	
  then,	
  they’ll	
  come	
  up	
  with	
  some	
  kind	
  of	
  gay,	
  orgy	
  fantasy.	
  And,	
  I’m	
  just	
  like	
   [pause]:	
  “I	
  don’t	
  even	
  dream	
  about	
  that	
  shit!”	
  Where	
  do	
  they	
  come	
  up	
  with	
  these	
   things?	
   	
   Talking	
  about	
  sexual	
  encounters	
  (including	
  fantasies	
  about	
  gay	
  sexual	
  encounters)	
  in	
  ways	
   that	
  reify	
  hyper-­‐masculinity	
  tended	
  to	
  dominate	
  participants’	
  accounts	
  (even	
  in	
  groups	
  that	
   include	
  a	
  mix	
  of	
  gay	
  and	
  straight	
  men).	
  Revealed	
  here	
  is	
  an	
  example	
  of	
  how	
  patriarchal	
  power	
    47	
    can	
  be	
  (re)produced	
  by	
  a	
  set	
  of	
  ritualistic	
  masculine	
  practices	
  (e.g.,	
  hyper-­‐sexualized	
   hegemonic	
  ideals)	
  which	
  can	
  also	
  be	
  operationalized	
  by	
  (heterosexual)	
  men	
  to	
  include	
  the	
   subordinated	
  ‘other’.	
   	
    Some	
  men	
  described	
  experiencing	
  negative	
  social	
  repercussions	
  if	
  they	
  discussed	
    sexual	
  health.	
  By	
  breaking	
  the	
  taboo,	
  those	
  who	
  broached	
  the	
  topic	
  of	
  sexual	
  health	
  with	
   their	
  men	
  peers	
  were	
  frequently	
  subjected	
  to	
  ridicule.	
  For	
  example,	
  Christopher,	
  a	
  Black	
  17-­‐ year-­‐old	
  straight	
  man,	
  expressed	
  frustration	
  with	
  the	
  teasing	
  he	
  was	
  subjected	
  to	
  by	
  peers	
   after	
  he	
  tried	
  to	
  discuss	
  sexual	
  health.	
  Christopher	
  explained	
  that	
  he	
  has	
  since	
  avoided	
  talking	
   about	
  sexual	
  health,	
  for	
  fear	
  of	
  further	
  mocking:	
   	
   Well…	
  [talking	
  about	
  sexual	
  health]	
  with	
  guys,	
  no,	
  because	
  I	
  don’t	
  know	
  where	
  the	
   conversation	
  is	
  going.	
  I	
  don’t	
  want	
  it	
  to	
  be	
  that	
  I’m	
  going	
  to	
  ask	
  an	
  intelligent	
  question,	
   and	
  at	
  the	
  end	
  of	
  it,	
  I’m	
  being	
  made	
  fun	
  of	
  for	
  being	
  a	
  virgin	
  or	
  something	
  silly	
  like	
   that.	
  […]	
  It’s	
  going	
  to	
  be	
  twisted	
  around	
  and	
  then	
  I	
  hear	
  from	
  the	
  next	
  girl	
  I’m	
  trying	
  to	
   date	
  that	
  she	
  thinks	
  I’m	
  gay	
  or	
  that	
  I	
  might	
  have	
  an	
  STD.	
   	
   Christopher’s	
  narrative	
  reveals	
  the	
  masculine	
  codes	
  that	
  can	
  filter	
  and	
  censor	
  men’s	
  talk.	
  At	
   risk	
  in	
  the	
  moment	
  and	
  in	
  the	
  aftermath	
  is	
  gossip	
  and	
  rumour	
  invoking	
  an	
  irretrievable	
   suspect	
  and	
  subordinate	
  masculine	
  status.	
  For	
  Christopher,	
  his	
  attempts	
  to	
  discuss	
  sexual	
   health	
  with	
  peers	
  were	
  refuted,	
  and	
  instead	
  suspicion	
  was	
  roused	
  among	
  his	
  peers	
  for	
  which	
   they	
  reacted	
  by	
  assigning	
  an	
  array	
  of	
  subordinate	
  masculinities	
  –	
  gay,	
  virgin	
  or	
  a	
  ‘dirty’	
   diseased	
  man	
  with	
  an	
  STD.	
  Without	
  the	
  groups	
  permission	
  Christopher	
  learned	
  to	
  keep	
  silent	
    48	
    about	
  sexual	
  health	
  as	
  a	
  means	
  to	
  avoiding	
  emasculating	
  ridicule	
  and	
  far-­‐reaching	
  rumour.	
   Christopher’s	
  narrative	
  also	
  demonstrated	
  how	
  masculine	
  ideals	
  around	
  heterosexual	
  desire	
   and	
  the	
  capacity	
  to	
  deliver	
  a	
  strong,	
  confident	
  performance	
  muted	
  the	
  ‘talk’	
  with	
  which	
  he	
   wanted	
  to	
  engage	
  about	
  sexual	
  health.	
  Many	
  participants	
  suggested	
  the	
  interview	
  was	
  unique	
   and,	
  for	
  some,	
  the	
  first	
  opportunity	
  to	
  discuss	
  and	
  reflect	
  on	
  issues	
  related	
  to	
  their	
  sexual	
   health.	
  Indeed,	
  several	
  participants,	
  including	
  Christopher,	
  explained	
  that	
  the	
  primary	
  reason	
   for	
  participating	
  in	
  the	
  study	
  was	
  to	
  have	
  the	
  opportunity	
  to	
  confidentially	
  and	
  anonymously	
   discuss,	
  and	
  learn	
  more	
  about	
  sexual	
  health.	
   	
    Some	
  participants	
  explained	
  that	
  conversations	
  about	
  sexual	
  health	
  (e.g.,	
  condom	
    and/or	
  contraception	
  negotiation)	
  were	
  particularly	
  difficult	
  to	
  have	
  with	
  sex	
  partners	
   because	
  issues	
  of	
  trust	
  and	
  fidelity	
  would	
  inevitably	
  arise.	
  As	
  a	
  result,	
  some	
  men	
  explained	
   that	
  they	
  avoided	
  these	
  discussions,	
  thereby	
  deferring	
  to	
  their	
  partners	
  the	
  responsibility	
  of	
   initiating	
  relevant	
  conversations	
  and/or	
  taking	
  relevant	
  action(s).	
  For	
  example,	
  Johan,	
  a	
   straight	
  22-­‐year-­‐old	
  Euro-­‐Canadian	
  man	
  was	
  not	
  monogamous,	
  and	
  he	
  explained	
  that	
  while	
   his	
  preference	
  was	
  to	
  use	
  condoms	
  he	
  often	
  felt	
  uncomfortable	
  discussing	
  this	
  topic	
  with	
  sex	
   partners:	
  	
   	
   	
  I	
  just	
  find	
  myself	
  not	
  making	
  good	
  decisions	
  around	
  it	
  [using	
  condoms]	
  more	
  often	
   than	
  I’m	
  comfortable	
  with.	
  It-­‐	
  the	
  pleasure	
  is	
  definitely	
  a	
  huge	
  part	
  of	
  it.	
  I	
  think	
   another	
  part	
  of	
  it	
  might	
  be	
  that	
  I-­‐	
  I	
  don’t	
  like	
  talking	
  about…	
  It	
  is	
  just…	
  [pause]	
  […]	
   Like,	
  I	
  don’t	
  want	
  to	
  stop	
  to	
  necessarily	
  to	
  bring	
  it	
  up	
  –	
  like	
  if	
  I	
  bring	
  it	
  up,	
  it’s	
  like,	
   almost	
  like…	
  Talking	
  about	
  condoms	
  is	
  almost	
  like	
  discussing	
  having	
  sex,	
  and	
  like…	
    49	
    you	
  know,	
  if	
  it’s	
  just	
  happening,	
  then	
  like,	
  I	
  don’t	
  wanna	
  feel	
  like	
  I	
  am	
  having	
  to	
   discuss	
  it.	
  […]	
  I	
  really	
  do	
  appreciate	
  it	
  when	
  girls	
  bring	
  it	
  up…	
  because	
  yeah,	
  just,	
  it	
   takes	
  that	
  pressure	
  off	
  a	
  bit.	
   	
   Here,	
  negotiating	
  condom	
  use	
  is	
  positioned	
  as	
  a	
  worrisome	
  conversation	
  rooted	
  in	
   expectations	
  about	
  feminine	
  ideals	
  that	
  value	
  health	
  over	
  pleasure	
  and	
  take	
  the	
  lead	
  in	
  that	
   discussion.	
  As	
  a	
  result,	
  initiating	
  this	
  conversation	
  reveals	
  Johan	
  as	
  concerned	
  about	
  safety	
   rather	
  than	
  spontaneity	
  and	
  pleasure.	
  While	
  acknowledging	
  he	
  should	
  care	
  about	
  condom	
   use,	
  Johan’s	
  silence	
  renders	
  him	
  complicit	
  in	
  sustaining	
  masculine	
  ideals	
  around	
  stoicism	
  and	
   hedonism.	
  This	
  places	
  him	
  in	
  a	
  position	
  where	
  he	
  is	
  reliant	
  on	
  his	
  female	
  partners	
  to	
  take	
  care	
   of	
  sexual	
  health	
  decision-­‐making.	
   	
    Some	
  men	
  explained	
  that,	
  although	
  it	
  was	
  difficult,	
  they	
  infrequently	
  engaged	
  in	
    discussions	
  about	
  sexual	
  health	
  with	
  their	
  peers	
  and/or	
  sex	
  partners	
  (e.g.,	
  STI	
  symptoms	
  or	
   testing;	
  notifying	
  sex	
  partners	
  of	
  potential	
  infections).	
  When	
  asked	
  how	
  these	
  conversations	
   ‘played	
  out’,	
  most	
  participants	
  explained	
  that	
  humour	
  was	
  the	
  lynchpin	
  to	
  engaging	
  such	
   discussions	
  –	
  especially	
  when	
  they	
  had	
  talked	
  with	
  male	
  peers.	
  When	
  I	
  asked	
  Tyler,	
  a	
  23-­‐year-­‐ old	
  straight	
  Euro-­‐Canadian,	
  described	
  how	
  he	
  discussed	
  sexual	
  health	
  with	
  his	
  friends,	
  he	
   explained:	
   	
   Once	
  in	
  a	
  while	
  one	
  of	
  my	
  friends	
  will	
  get	
  with	
  somebody	
  very	
  questionable	
  and	
   we’ll	
  kind	
  of	
  poke	
  him	
  and	
  prod	
  him	
  to	
  go	
  get,	
  go	
  get	
  tested.	
  [chuckles]	
  That	
  does	
   happen	
  sometimes.	
  	
    50	
    [Interviewer:	
  What	
  do	
  you	
  mean	
  by	
  “questionable”?]	
   Um,	
  well,	
  first	
  of	
  all,	
  someone	
  we	
  don’t	
  know.	
  Someone	
  we	
  may	
  have	
  heard	
  that	
   sleeps	
  around.	
  Somebody	
  who	
  insists	
  on	
  not	
  using	
  protection.	
  	
   [Interviewer:	
  Okay.	
  And	
  how	
  does	
  the	
  ‘poking	
  and	
  prodding’	
  go?]	
   Usually	
  we	
  tease	
  him	
  and	
  tell	
  him	
  he	
  probably	
  has	
  AIDS.	
  It	
  really	
  gets	
  him	
  going.	
   	
   By	
  employing	
  teasing	
  humour	
  in	
  these	
  conversations,	
  the	
  ‘friend’	
  is	
  encouraged	
  to	
  seek	
  STI	
   testing,	
  while	
  Tyler	
  (and	
  the	
  wider	
  group)	
  implicitly	
  disclaim	
  ‘really’	
  caring	
  about	
  the	
  man’s	
   sexual	
  health.	
  Teasing	
  humour	
  can	
  serve	
  to	
  prompt	
  men	
  to	
  reflect	
  upon,	
  and	
  perhaps	
   recognise	
  and	
  reconsider	
  ‘risky’	
  sexual	
  practices	
  while	
  not	
  explicitly	
  challenging	
  sexual	
   pleasure	
  and	
  conquest	
  as	
  key	
  hyper-­‐masculine	
  performance	
  indicators.	
  	
   	
    A	
  few	
  participants	
  explained	
  that	
  they	
  were	
  able	
  to	
  discuss	
  sexual	
  health	
  in	
  a	
  more	
    serious	
  way,	
  but	
  only	
  with	
  friends	
  that	
  they	
  trusted	
  deeply.	
  For	
  example,	
  Jameel,	
  a	
  straight	
   21-­‐year-­‐old	
  man	
  of	
  Middle-­‐Eastern	
  descent,	
  described	
  how	
  he	
  discussed	
  STI	
  symptoms	
  with	
   his	
  closest	
  friends:	
   	
   It	
  depends	
  on	
  the	
  background	
  of	
  the	
  guys	
  first	
  of	
  all	
  and	
  how	
  long	
  you’ve	
  known	
  the	
   friends	
  for.	
  Like	
  I	
  usually	
  can’t	
  talk	
  to	
  a	
  friend	
  that	
  I’ve	
  just	
  met	
  on	
  campus	
  for	
  like	
  a	
   month	
  or	
  two.	
  Usually	
  I	
  can’t	
  talk	
  about	
  that	
  with	
  him.	
  But	
  I	
  usually	
  prefer	
  to	
  talk	
  to	
   my	
  male	
  guys	
  that	
  I’ve	
  known	
  for	
  six,	
  seven	
  years	
  that	
  I’ve	
  known	
  like	
  my	
  brothers.	
  So	
  I	
   just	
  talk	
  to	
  them	
  with	
  my	
  concerns	
  and	
  they	
  usually	
  come	
  up	
  with	
  some	
  advice	
  and	
   they’re	
  usually	
  like,	
  if	
  I	
  am	
  concerned	
  with	
  some	
  symptoms	
  or	
  if	
  I’m	
  just	
  paranoid	
  they	
    51	
    tell	
  me:	
  “Hey,	
  just	
  calm	
  down	
  and	
  go	
  get	
  tested.	
  Don’t	
  worry	
  about	
  it	
  and	
  hopefully	
  it’s	
   nothing	
  serious.”	
   	
   For	
  Jameel,	
  discussions	
  about	
  STI	
  symptoms	
  (and	
  the	
  like)	
  could	
  only	
  be	
  conducted	
  with	
   friends	
  that	
  he	
  trusted	
  “like	
  brothers”.	
  	
  	
   	
   3.3.3	
  	
  ‘Manning	
  up’:	
  Talking	
  about	
  STIs	
  and	
  health	
   	
    Some	
  men	
  described	
  situations	
  in	
  which	
  they	
  admitted	
  to	
  having	
  an	
  STI.	
  For	
  example,	
    Jameel	
  said	
  that	
  although	
  it	
  would	
  be	
  difficult	
  to	
  reveal	
  an	
  STI	
  diagnosis	
  to	
  even	
  his	
  closest	
   friends,	
  he	
  would	
  self-­‐disclose	
  about	
  the	
  details	
  after	
  he	
  was	
  treated	
  and	
  ‘cured’:	
  	
  	
   As	
  time	
  goes	
  on,	
  I	
  think	
  things	
  tend	
  to	
  be	
  less	
  intense;	
  so,	
  I	
  would	
  actually	
  let	
  them	
   know	
  after	
  a	
  while	
  that	
  “Yeah,	
  I’ve	
  been	
  diagnosed	
  with	
  that	
  like	
  several	
  months	
  ago;	
   but,	
  I’m	
  getting	
  treated	
  or	
  I’m	
  under	
  some	
  kind	
  of	
  treatment,”	
  and	
  then	
  would	
  actually	
   let	
  them	
  know.	
  But	
  at	
  the	
  instance,	
  I	
  don’t	
  think	
  I	
  would	
  be	
  able	
  to.	
  I	
  wouldn’t	
  have	
  the	
   courage	
  to	
  tell	
  them,	
  yeah.	
   Like	
  Jameel,	
  most	
  participants	
  indicated	
  that	
  they	
  would	
  need	
  time	
  to	
  must	
  the	
  strength	
  to	
   break	
  with	
  an	
  idealised	
  masculine	
  performance	
  round	
  stoicism	
  to	
  talk	
  about	
  having	
  an	
  STI.	
   The	
  process	
  of	
  developing	
  the	
  courage	
  to	
  more	
  openly	
  discuss	
  sexual	
  health	
  problems	
   emerged	
  as	
  an	
  important	
  theme	
  during	
  the	
  interviews;	
  however,	
  for	
  the	
  most	
  part,	
  men	
   aligned	
  with	
  Jameel’s	
  suggestion	
  that,	
  when	
  first	
  faced	
  with	
  illness,	
  autonomy	
  and	
  self-­‐ reliance	
  trumped	
  the	
  necessity	
  to	
  talk	
  with	
  or	
  seek	
  the	
  counsel	
  or	
  support	
  of	
  others.	
    52	
    Many	
  participants	
  positioned	
  the	
  strength	
  and	
  courage	
  to	
  ‘man	
  up’	
  as	
  residing	
  in	
   particular	
  actions.	
  For	
  example,	
  Zachary,	
  a	
  gay	
  22-­‐year-­‐old	
  Euro	
  Canadian	
  explained	
  that	
   when	
  he	
  tested	
  positive	
  for	
  STIs,	
  he	
  notified	
  his	
  sex	
  partners	
  directly	
  rather	
  than	
  ask	
  the	
   health	
  department	
  to	
  contact	
  them	
  (in	
  BC,	
  clients	
  have	
  the	
  option	
  to	
  do	
  either):	
   	
   My	
  sexual	
  partners,	
  I	
  don’t	
  exactly	
  know	
  very	
  well.	
  I	
  always	
  try	
  to	
  keep…	
  I	
  always	
  try	
  to	
   contact	
  them	
  if	
  I	
  ever	
  do	
  come	
  down	
  with	
  something.	
  That’s	
  hard.	
  But	
  they	
  have	
  that	
   service	
  available	
  here	
  where	
  you	
  can	
  just	
  give	
  the	
  clinic	
  the	
  phone	
  numbers	
  of	
  the	
   people	
  and	
  they’ll	
  call,	
  which	
  is	
  kinda	
  good.	
  But,	
  I	
  mean	
  you	
  should	
  ‘man	
  up’	
  and	
  tell	
   them	
  yourself.	
   	
   Zachary’s	
  decision	
  to	
  notify	
  his	
  sex	
  partners	
  seemingly	
  contravenes	
  masculine	
  ideals	
  that	
  men	
   deny	
  illness	
  and	
  care	
  for	
  another	
  person’s	
  health.	
  However,	
  by	
  ‘manning	
  up’,	
  Zachary	
   repositions	
  what	
  it	
  means	
  to	
  take	
  responsibility	
  for	
  others’	
  sexual	
  health	
  by	
  emphasizing	
  his	
   decisive	
  honourable	
  actions	
  aimed	
  at	
  doing	
  the	
  principled	
  and	
  perhaps	
  protective	
  thing.	
   Notifying	
  sex	
  partners	
  (which	
  in	
  Zachery’s	
  story	
  is	
  positioned	
  as	
  an	
  act	
  of	
  courage)	
  is	
   characterized	
  as	
  something	
  that	
  ‘real	
  men’	
  have	
  the	
  power	
  and	
  control	
  to	
  do,	
  for	
  greater	
   good	
  with	
  reckless	
  abandon	
  for	
  the	
  implications	
  and	
  potential	
  repercussions	
  for	
  their	
  own	
   safety.	
  In	
  privileging	
  and	
  performing	
  this	
  version	
  of	
  ‘manning	
  up’,	
  many	
  study	
  participants	
   were	
  complicit	
  in	
  sustaining	
  a	
  specific	
  set	
  of	
  masculine	
  ideals.	
  For	
  example,	
  their	
  language	
   positioned	
  ‘real’	
  men	
  as	
  dominant	
  and	
  capable,	
  facing	
  up	
  to	
  a	
  problem	
  for	
  which	
  they	
  might	
    53	
    be	
  implicated,	
  amid	
  steely	
  resolve	
  to	
  withstand	
  any	
  potential	
  conflict	
  or	
  estrangement	
  (e.g.,	
   being	
  blamed	
  for	
  the	
  STI	
  by	
  sex	
  partners).	
  As	
  Tyler,	
  a	
  23-­‐year-­‐old	
  straight	
  guy,	
  confirmed:	
   	
   You	
  should	
  just	
  man	
  up	
  and	
  call	
  them	
  yourself…	
  Straight	
  up.	
  No.	
  No	
  email,	
  no	
  doctor	
   calling	
  you.	
  	
   [Interviewer:	
  So	
  you	
  wouldn’t	
  prefer	
  the	
  doctor	
  or	
  nurse	
  to	
  call	
  your	
  sex	
  partners?]	
  	
   Hell	
  no.	
  No.	
  Go	
  tell	
  them	
  yourself.	
  Quit	
  being	
  a	
  pussy.[…]	
  I	
  think	
  you	
  should	
  call	
  them	
   yourself.	
  Really,	
  I	
  think	
  you	
  should	
  implicate	
  yourself.	
  I	
  think	
  you	
  should	
  put	
  it	
  right	
  out	
   there,	
  yeah.	
  Uh,	
  “I	
  had	
  sex	
  with	
  you.	
  Um,	
  if	
  it	
  wasn’t	
  protected,	
  I	
  may	
  have	
  given	
  you	
   something.”	
  Own	
  up	
  to	
  it.	
   	
   	
    Other	
  forms	
  of	
  ‘manning	
  up’	
  emerged	
  during	
  the	
  interviews,	
  whereby	
  feminine	
  ideals	
    (e.g.,	
  caring;	
  helping)	
  were	
  re-­‐shaped	
  in	
  more	
  subtle	
  ways	
  to	
  reflect	
  masculine	
  ideals	
  (e.g.,	
   taking	
  charge;	
  being	
  strong).	
  For	
  example,	
  Cody,	
  a	
  23-­‐year-­‐old	
  straight	
  Aboriginal	
  man,	
   explained	
  how	
  he	
  helped	
  his	
  young	
  cousin	
  who	
  was	
  experiencing	
  STI	
  symptoms:	
   	
   My	
  little	
  cousin,	
  man,	
  he	
  had	
  Chlamydia	
  and	
  VD	
  [Gonorrhea]	
  and	
  it	
  was	
  bad,	
  man.	
  It	
   was	
  Christmas	
  time.	
  I’m	
  driving	
  around	
  looking	
  for	
  a	
  clinic	
  to	
  get	
  him	
  fixed,	
  man.	
   That’s	
  the	
  pain	
  he	
  was	
  in.	
  Yeah,	
  Gonorrhea,	
  man,	
  it	
  fuckin’	
  hurt	
  him.	
  It’s	
  like,	
  ‘Aw,	
   dude,	
  man.’	
  I	
  found	
  a	
  doctor’s	
  office	
  that	
  was	
  open	
  and	
  they	
  gave	
  him	
  the	
  pills	
  […]	
  He	
   was	
  16!	
  He	
  was	
  16	
  when	
  he	
  caught	
  both	
  of	
  those	
  diseases,	
  man.	
  Like	
  the	
  dude	
  was	
  in	
    54	
    pain,	
  man!	
  […]	
  He	
  was	
  like,	
  “Yeah,	
  I	
  have	
  something…”	
  And	
  I	
  told	
  him,	
  yo,	
  man,	
  I	
  just	
   got	
  rid	
  of	
  Chlamydia	
  myself.	
  There’s	
  pills	
  for	
  it,	
  man.”	
   	
   Here,	
  Cody	
  disregards	
  the	
  conventions	
  of	
  ‘guy	
  talk’	
  and	
  reveals	
  his	
  Chlamydia	
  diagnosis	
  in	
   order	
  to	
  empathize	
  with	
  his	
  young	
  cousin.	
  Cody’s	
  narrative	
  also	
  positions	
  him	
  as	
  a	
  ‘fixer’	
  –a	
   man	
  that	
  is	
  strong	
  and	
  wise	
  enough	
  to	
  take	
  charge	
  handle	
  the	
  problem.	
  Emphasizing	
  his	
   capacity	
  to	
  ‘man	
  up’	
  in	
  any	
  crisis,	
  Cody	
  also	
  told	
  us	
  that	
  his	
  best	
  friend	
  had	
  recently	
  ‘come	
   out’	
  as	
  being	
  homosexual.	
  Cody	
  explained	
  that	
  he	
  was	
  able	
  to	
  support	
  his	
  friend	
  through	
  this	
   process	
  because	
  he	
  had	
  been	
  hardened	
  up	
  (by	
  previous	
  life	
  experiences)	
  and,	
  as	
  a	
  result	
   knew	
  how	
  to	
  behave	
  in	
  difficult	
  situations,	
  especially	
  in	
  those	
  circumstances	
  requiring	
   ‘straight	
  up’	
  actions	
  in	
  order	
  to	
  protect	
  his	
  friend:	
  	
   	
   Just,	
  everybody	
  just	
  thinks	
  I’m	
  cool,	
  man.	
  I’m	
  a	
  good	
  guy	
  to	
  hang	
  out	
  with,	
  like.	
  I’m	
   straight	
  up,	
  there’s	
  no	
  fuckin’	
  lying	
  or	
  anything.	
  I’m	
  straight,	
  man,	
  and	
  you	
  know?	
  If	
  I	
   don’t	
  like	
  someone	
  in	
  the	
  fuckin’	
  crowd,	
  I’ll	
  fuckin’	
  tell	
  ‘em	
  straight,	
  “Yo	
  man,	
  you	
   know,	
  you’re	
  being	
  an	
  asshole,	
  man,	
  you	
  know?	
  Like,	
  fuck,	
  no	
  one	
  likes	
  you.”	
  […]	
  Plus	
  I	
   stick	
  up	
  for	
  my	
  friends.	
  […]	
  I’ve	
  seen	
  some	
  fucked	
  up	
  things,	
  man.	
  Especially	
  for	
  my	
   age,	
  too,	
  man.	
  I	
  can’t	
  believe	
  all	
  the	
  shit,	
  but	
  hey	
  man,	
  out	
  of	
  the	
  fast	
  style,	
  the	
   lifestyles.	
  I’ve	
  done	
  a	
  lot	
  of	
  things	
  in	
  my	
  life	
  and	
  probably	
  will	
  do	
  more.	
  	
   	
   Cody’s	
  narrative	
  demonstrates	
  a	
  complex	
  (re)negotiation	
  of	
  idealized	
  masculinity	
  and	
  what	
  it	
   means	
  to	
  be	
  a	
  ‘real’	
  man.	
  Cody	
  takes	
  pride	
  in	
  being	
  a	
  man	
  that	
  can	
  transcend	
  heterosexist	
    55	
    stereotypes	
  (e.g.,	
  embracing	
  his	
  friend	
  as	
  a	
  homosexual	
  man).	
  Cody	
  also	
  takes	
  risks	
  both	
  in	
   and	
  around	
  adopting	
  behaviour	
  associated	
  with	
  feminized	
  traits	
  (e.g.,	
  caring	
  about	
  others;	
   accepting	
  gay	
  men);	
  but,	
  rather	
  than	
  having	
  his	
  masculinity	
  questioned,	
  Cody	
  deploys	
  these	
   traits	
  in	
  ways	
  that	
  ultimately	
  bolster	
  his	
  ubiquitous	
  hyper-­‐masculinity.	
  Whereas	
  for	
  ‘weaker’	
   men,	
  these	
  situations	
  would	
  present	
  dangerous	
  and	
  emasculating	
  risks,	
  for	
  Cody,	
  these	
   situations	
  elevate	
  his	
  masculine	
  status.	
   	
   3.4	
  	
  Discussion	
   Dominant	
  masculinity	
  produces	
  and	
  governs	
  the	
  ways	
  in	
  which	
  knowledge	
  can	
  be	
   meaningfully	
  discussed	
  (Foucault,	
  1978).	
  The	
  ways	
  in	
  which	
  men	
  talk	
  about	
  sexual	
  health	
   draws	
  on	
  and	
  (re)produces	
  idealised	
  masculine	
  expectations	
  (e.g.,	
  what	
  it	
  means	
  to	
  be	
  a	
  ‘real’	
   man).	
  For	
  the	
  men	
  in	
  this	
  study,	
  discussions	
  about	
  sexual	
  health	
  revolved	
  primarily	
  around	
   their	
  sexual	
  encounters.	
  As	
  Flood	
  (2008)	
  explains,	
  men’s	
  homosocial	
  discussions	
  about	
  sex	
  are	
   often	
  the	
  medium	
  in	
  which	
  male	
  bonding	
  is	
  enacted	
  and	
  internal	
  “pecking	
  orders”	
  of	
  the	
   masculine	
  hierarchy	
  are	
  (re)enforced.	
  	
   Most	
  men	
  in	
  this	
  study	
  employed	
  what	
  Korobov	
  (2005)	
  terms	
  ironic	
  teasing	
  humour	
   which	
  is	
  used	
  to	
  neither	
  cancel	
  out	
  an	
  expression	
  of	
  concern	
  for	
  other	
  men,	
  nor	
  explicitly	
   disavow	
  concern	
  about	
  a	
  male	
  friend’s	
  sexual	
  health.	
  As	
  Korobov	
  describes,	
  this	
  equivocation	
   makes	
  it	
  difficult	
  to	
  determine	
  if	
  men	
  are	
  complying	
  with	
  or	
  resisting	
  normative	
  masculinity.	
   Nonetheless,	
  the	
  focus	
  on	
  men’s	
  sexual	
  exploits	
  through	
  the	
  use	
  of	
  humour	
  reproduces	
  group	
   solidarity	
  between	
  men,	
  thereby	
  reconstituting	
  a	
  form	
  of	
  patriarchal	
  power	
  in	
  which	
  women	
    56	
    and	
  men	
  are	
  often	
  dominated	
  and	
  marginalised	
  (e.g.,	
  through	
  the	
  use	
  of	
  derogatory	
   language).	
  	
   	
    ‘Manning	
  up’	
  permits	
  men	
  to	
  break	
  the	
  silence	
  and	
  move	
  beyond	
  superficial	
    humorous	
  ‘guy	
  talk’	
  about	
  sexual	
  encounters	
  in	
  order	
  to	
  engage	
  in	
  action-­‐oriented	
   discussions	
  aimed	
  at	
  remedying	
  the	
  situation.	
  These	
  data	
  reveal	
  two	
  techniques	
  by	
  which	
   men	
  can	
  ‘man	
  up’:	
  (1)	
  deploying	
  power	
  over	
  others	
  with	
  disregard	
  for	
  the	
  potential	
   repercussions;	
  and	
  (2)	
  deploying	
  power	
  to	
  assist	
  others	
  in	
  ways	
  that	
  reify	
  features	
  of	
  their	
   hyper-­‐masculine	
  identity.	
  ‘Manning	
  up’	
  by	
  deploying	
  power	
  over	
  others	
  emphasises	
  the	
   masculine	
  power	
  of	
  the	
  speaker/performer	
  (e.g.,	
  being	
  tough	
  enough	
  to	
  say	
  anything)	
  and	
   their	
  embodiment	
  of	
  idealized	
  masculinity.	
  For	
  example,	
  the	
  use	
  of	
  ‘manning	
  up’	
  serves	
  to	
   position	
  some	
  men	
  as	
  being	
  sufficiently	
  strong	
  as	
  to	
  not	
  need	
  to	
  worry	
  or	
  care	
  about	
  the	
   repercussions	
  of	
  partner	
  notification	
  –	
  a	
  form	
  of	
  damage	
  control	
  to	
  preserving	
  masculinity	
   (O’Brien	
  et	
  al.,	
  2005).	
  ‘Manning	
  up’	
  is	
  also	
  enacted	
  by	
  using	
  one’s	
  personal	
  power	
  (e.g.,	
  power	
   derived	
  from	
  hyper-­‐masculine	
  status)	
  to	
  help	
  others.	
  While	
  deploying	
  power	
  may	
  permit	
   some	
  men	
  to	
  disrupt	
  some	
  aspects	
  of	
  hegemonic	
  masculinity	
  (e.g.,	
  by	
  permitting	
  them	
  to	
  care	
   for	
  others),	
  its	
  use	
  is	
  not	
  intended	
  to	
  disrupt	
  the	
  hegemony.	
  Rather,	
  this	
  form	
  of	
  ‘manning	
  up’	
   has	
  a	
  symbiotic	
  relationship	
  with	
  idealised	
  features	
  of	
  the	
  dominant	
  male	
  (e.g.,	
  the	
  ‘fixer’).	
   Both	
  of	
  these	
  ‘manning	
  up’	
  techniques	
  rely	
  on	
  men’s	
  ability	
  to	
  use	
  discourse	
  to	
  position	
   themselves	
  at	
  the	
  ‘top’	
  of	
  an	
  idealised	
  masculine	
  hierarchy	
  which	
  suggests	
  that	
  those	
  who	
  do	
   not	
  (or	
  cannot)	
  ‘man	
  up’	
  are,	
  in	
  fact,	
  subordinate	
  (and,	
  therefore,	
  unable	
  to	
  attain	
  a	
  status	
  as	
   ‘real’	
  men).	
  By	
  reconfiguring	
  and	
  reproducing	
  notions	
  of	
  hegemonic	
  masculinity,	
  ‘manning	
  up’	
    57	
    remains	
  an	
  option	
  viable	
  only	
  for	
  some	
  men	
  (e.g.,	
  those	
  who	
  have	
  attained	
  an	
  idealised	
   masculine	
  status).	
  	
   What	
  men	
  cannot	
  say	
  about	
  their	
  sexual	
  health	
  also	
  operates	
  as	
  a	
  mechanism	
  of	
   power	
  (Foucault,	
  1978):	
  in	
  breaking	
  these	
  ‘rules’	
  (e.g.,	
  talking	
  about	
  STI/HIV	
  testing;	
  condom	
   negotiation),	
  men	
  might	
  be	
  teased	
  or	
  mocked	
  and	
  have	
  their	
  masculinity	
  questioned.	
  As	
  a	
   result,	
  for	
  some	
  men,	
  discussions	
  about	
  sexual	
  health	
  are	
  neither	
  possible,	
  nor	
  desirable.	
   Moreover,	
  the	
  practice	
  of	
  relying	
  on	
  female	
  sex	
  partners	
  to	
  take	
  care	
  of	
  sexual	
  health	
   decision-­‐making	
  highlights	
  how	
  some	
  men	
  consider	
  taking	
  care	
  of	
  sexual	
  health	
  as	
  a	
  feminine	
   ideal.	
  Still,	
  other	
  men	
  in	
  the	
  study	
  expressed	
  frustration	
  with	
  the	
  silences	
  imposed	
  by	
  the	
   limits	
  of	
  ‘guy	
  talk’,	
  but	
  they	
  described	
  only	
  a	
  few	
  conditions	
  (e.g.,	
  using	
  humour;	
  ‘manning	
   up’)	
  under	
  which	
  silence	
  can	
  be	
  broken	
  using	
  techniques	
  to	
  ‘man	
  up’	
  in	
  ways	
  that	
  protect	
   and/or	
  bolster	
  masculine	
  status.	
  	
   This	
  study	
  has	
  several	
  strengths	
  and	
  limitations.	
  Describing	
  the	
  contextual	
  and	
  social	
   conditions	
  that	
  facilitate	
  or	
  waylay	
  men’s	
  discussions	
  about	
  sexual	
  health	
  is	
  only	
  helpful	
   under	
  theoretical	
  frameworks	
  that	
  emphasise	
  the	
  diversity	
  within	
  the	
  group	
  “men”	
  (Numer	
   and	
  Gahagan,	
  2009).	
  Masculine	
  hierarchies	
  represent	
  complex	
  social	
  milieux	
  that	
  are	
  not	
   separate	
  from	
  other	
  social	
  identities	
  (e.g.,	
  socio-­‐economic	
  status;	
  racialised	
  bodies)	
  (Connell,	
   1995).	
  While	
  the	
  current	
  analysis	
  offers	
  some	
  rich	
  insights	
  into	
  these	
  social	
  and	
  cultural	
   forces,	
  I	
  was	
  unable	
  to	
  fully	
  address	
  other	
  important	
  issues	
  (e.g.,	
  the	
  classed	
  relations	
  of	
  these	
   men	
  within	
  their	
  communities).	
  While	
  the	
  findings	
  are	
  not	
  claimed	
  as	
  generalisable	
  to	
  all	
   men’s	
  discussions	
  about	
  sexual	
  health,	
  I	
  identified	
  several	
  ways	
  in	
  which	
  men	
  resist,	
   accommodate	
  or	
  transform	
  idealised	
  masculinity	
  as	
  they	
  engage	
  in	
  discussions	
  or	
  remain	
    58	
    silent	
  about	
  sexual	
  health.	
  These	
  practices	
  may	
  have	
  important	
  implications	
  for	
  interventions	
   that	
  aim	
  to	
  promote	
  men’s	
  sexual	
  health	
  (e.g.,	
  sexual	
  health	
  services;	
  education);	
  but,	
  we	
  do	
   not	
  fully	
  understand	
  the	
  mechanisms	
  through	
  which	
  masculinities	
  (particularly	
  the	
  social	
   practices	
  and	
  relations	
  derived	
  from	
  hegemonic	
  masculinity)	
  interact	
  with	
  interventions	
  in	
   ways	
  that	
  might	
  enhance	
  or	
  detract	
  from	
  men’s	
  sexual	
  health.	
  	
   	
    59	
    Chapter 4.0 Discussion The	
  current	
  thesis	
  demonstrates	
  how	
  hegemonic	
  and	
  idealised	
  masculininities	
  and/or	
   heteronormative	
  expectations	
  affect	
  men’s	
  sexual	
  health-­‐related	
  practices.	
  These	
  analyses	
   provided	
  an	
  in-­‐depth	
  examination	
  of	
  the	
  ways	
  in	
  which	
  heteronormative	
  and	
  heterosexist	
   masculine	
  discourses	
  function	
  within	
  clinical	
  settings	
  where	
  men	
  access	
  STI/HIV	
  testing,	
  as	
   well	
  as	
  the	
  social	
  and	
  contextual	
  conditions	
  which	
  allow	
  men	
  to	
  talk	
  about	
  sexual	
  health.	
   These	
  findings	
  advance	
  the	
  empirical	
  and	
  theoretical	
  knowledge	
  about	
  young	
  men’s	
  sexual	
   health.	
   	
   4.1	
  	
  Summary	
  of	
  findings	
   Chapter	
  2,	
  Heteronormativity	
  Hurts	
  Everyone,	
  provided	
  insights	
  into	
  how	
   heteronormative	
  discourses	
  may	
  be	
  (re)produced	
  in	
  clinical	
  settings	
  and	
  influence	
  gay,	
   bisexual	
  and	
  heterosexual	
  men’s	
  health-­‐seeking	
  experiences/behaviour.	
  The	
  STI/HIV	
  testing	
   experience	
  emerged	
  as	
  a	
  unique	
  situation	
  whereby	
  men’s	
  (hetero)sexuality	
  was	
  explicitly	
   ‘interrogated’.	
  STI/HIV	
  risk	
  assessments	
  discursively	
  link	
  sexual	
  identity	
  to	
  risk	
  in	
  ways	
  that	
   reinforced	
  gay	
  men	
  as	
  the	
  risky	
  ‘Other’	
  and	
  heterosexual	
  men	
  as	
  the	
  (hetero)normal	
  and,	
   therefore,	
  relatively	
  low-­‐risk	
  patient.	
  This	
  in	
  turn	
  alleviates	
  concern	
  for	
  STI/HIV	
  exposure	
  in	
   heterosexual	
  men	
  by	
  virtue	
  of	
  their	
  sexual	
  identity	
  (rather	
  than	
  their	
  sexual	
  practices),	
  which	
   mute	
  discussions	
  around	
  their	
  sexual	
  behaviour.	
  To	
  alleviate	
  men’s	
  discomfort	
  with	
  questions	
   around	
  sexual	
  identity,	
  some	
  clinicians	
  implement	
  ‘gender-­‐neutral’	
  services.	
  However,	
  few	
   acknowledge	
  the	
  influences	
  of	
  social	
  relations	
  (e.g.,	
  heteronormativity;	
  idealized	
  notions	
  of	
    60	
    masculinity)	
  on	
  men’s	
  and	
  clinicians’	
  everyday	
  lives.	
  Finally,	
  some	
  clinicians	
  confound	
  sexual	
   identities	
  with	
  sexual	
  practices,	
  relying	
  on	
  their	
  assumptions	
  as	
  ‘clues’	
  for	
  determining	
  how	
   they	
  will	
  approach	
  clinical	
  communication	
  about	
  risk.	
  Thus,	
  heteronormative	
  assumptions	
  can	
   ‘hurt’	
  all	
  men	
  (including	
  those	
  who	
  identify	
  as	
  heterosexual)	
  in	
  sexual	
  health	
  clinical	
   encounters.	
  Heteronormative	
  assumptions	
  systematically	
  ‘shut	
  down’	
  discussions	
  around	
   heterosexual	
  men’s	
  sexual	
  health,	
  while	
  concomitantly	
  contributing	
  to	
  heterosexist	
   stereotypes	
  about	
  gay	
  and	
  bisexual	
  men.	
  The	
  findings	
  in	
  Chapter	
  2	
  also	
  highlight	
  the	
  role	
  that	
   sexual	
  health	
  clinical	
  services	
  can	
  play	
  by	
  either	
  (re)producing	
  dominant	
  and	
  hegemonic	
   forms	
  of	
  heteronormative	
  masculinities	
  or	
  creating	
  transformative,	
  more	
  equitable	
  gendered	
   relations	
  during	
  and	
  beyond	
  the	
  clinical	
  encounter.	
   Chapter	
  3,	
  Masculinities,	
  ‘Guy	
  Talk’	
  and	
  ‘Manning	
  Up’:	
  Young	
  men’s	
  discussions	
  about	
   sexual	
  health	
  identified	
  social	
  and	
  contextual	
  conditions	
  which	
  facilitate	
  or	
  ‘shut	
  down’	
   effective	
  sexual	
  health	
  communication	
  amongst	
  young	
  men	
  (e.g.,	
  with	
  peers;	
  sex	
  partners),	
   with	
  an	
  emphasis	
  on	
  idealized	
  notions	
  of	
  masculinity.	
  Men	
  use	
  ‘guy	
  talk’,	
  including	
  ironic	
  and	
   teasing	
  humour,	
  to	
  take	
  up	
  impartial,	
  manly	
  positions	
  that	
  neither	
  dismiss	
  nor	
  actively	
   express	
  concern	
  for	
  the	
  sexual	
  health	
  of	
  male	
  friends.	
  Opportunities	
  for	
  in-­‐depth	
  discussions	
   about	
  sexual	
  health	
  (e.g.,	
  asking	
  advice	
  about	
  STI	
  testing	
  or	
  symptoms)	
  typically	
  give	
  way	
  to	
   boasting	
  about	
  hyper-­‐masculine	
  sexual	
  performances	
  and	
  encounters.	
  ‘Manning	
  up’	
  is	
  a	
   technique	
  that	
  permits	
  men	
  to	
  break	
  with	
  masculine	
  ideals	
  of	
  stoicism	
  and	
  self-­‐reliance	
  to	
   talk	
  about	
  sexual	
  health	
  issues	
  and	
  concerns	
  via	
  two	
  processes:	
  (1)	
  exerting	
  power	
  over	
  others	
   with	
  disregard	
  for	
  potential	
  repercussions;	
  and	
  (2)	
  deploying	
  power	
  to	
  affirm	
  and	
  reify	
  men’s	
   hyper-­‐masculine	
  identities.	
  	
    61	
    	
   	
   4.2	
  	
  Implications	
  for	
  theory	
   The	
  current	
  thesis	
  explores	
  the	
  ways	
  in	
  which	
  hegemonic	
  masculinity	
  influences	
  young	
   men’s	
  sexual	
  health,	
  including	
  their	
  sexual	
  health-­‐seeking	
  behaviour,	
  sexual	
  practices	
  and	
  the	
   ways	
  in	
  which	
  they	
  talk	
  about	
  sexual	
  health.	
  The	
  findings	
  reveal	
  instances	
  in	
  which	
  hegemonic	
   masculinity	
  ‘hurts’	
  all	
  men	
  –	
  including	
  those	
  who	
  are	
  subordinated	
  as	
  well	
  as	
  those	
  complicit	
   in	
  sustaining	
  hegemonic	
  ideals.	
  While	
  these	
  findings	
  provide	
  support	
  for	
  theories,	
  suggesting	
   that	
  men’s	
  health	
  is	
  at	
  risk	
  if	
  they	
  align	
  and/or	
  interact	
  with	
  hegemonic	
  masculinity,	
  they	
  also	
   reveal	
  instances	
  in	
  which	
  hegemonic	
  masculinity	
  produces	
  opportunities	
  for	
  more	
  socially	
   ‘just’	
  outcomes	
  (e.g.,	
  ‘manning	
  up’,	
  in	
  which	
  power	
  is	
  exerted	
  in	
  order	
  to	
  help	
  others).	
  These	
   social	
  interactions	
  represent	
  instances	
  in	
  which	
  hegemonic	
  masculinity	
  is	
  disrupted,	
  then	
   reinstated,	
  through	
  performances	
  to	
  preserve	
  or	
  restore	
  another,	
  more	
  valued,	
  enactment	
  of	
   masculinity	
  (O’Brien,	
  Hunt,	
  &	
  Hart,	
  2005).	
  Indeed,	
  hegemony,	
  as	
  argued	
  by	
  Howson	
  (2006),	
  is	
   unlikely	
  to	
  be	
  de-­‐gendered,	
  but	
  may	
  represent	
  a	
  potential	
  for	
  overcoming,	
  redistributing	
   (and,	
  reinstating)	
  a	
  more	
  socially	
  just	
  hegemony.	
  As	
  Howson	
  (2006)	
  argues,	
  by	
  focusing	
  on	
  the	
   negativity	
  of	
  hegemonic	
  masculinity,	
  instead	
  of	
  the	
  potential	
  for	
  “progressive	
  equivalential	
   unity”	
  within	
  gender	
  relations,	
  theorists	
  will	
  “…ensure	
  that	
  the	
  politics	
  of	
  gender	
  continues	
  to	
   operate	
  conceptually	
  around	
  the	
  mutual	
  exclusivity	
  of	
  hegemony	
  and	
  social	
  justice”	
  (p.	
  6-­‐7).	
   By	
  examining	
  situations	
  in	
  which	
  men	
  (and	
  clinicians)	
  can	
  socially	
  reconfigure	
  notions	
  of	
   hegemonic	
  masculinity	
  related	
  to	
  their	
  sexual	
  health,	
  theorists	
  will	
  also	
  better	
  understand	
  the	
   ways	
  in	
  which	
  more	
  socially	
  just	
  systems	
  of	
  hegemony	
  can	
  be	
  produced	
  (Howson,	
  2006).	
    62	
    	
   4.3	
  	
  Implications	
  for	
  men’s	
  sexual	
  health	
  interventions	
  and	
  future	
  research	
   The	
  current	
  thesis	
  provides	
  new	
  empirical	
  and	
  theoretical	
  evidence	
  to	
  inform	
  STI/HIV	
   interventions	
  to	
  promote	
  and	
  protect	
  young	
  men’s	
  sexual	
  health.	
  A	
  variety	
  of	
  interventions	
   have	
  been	
  employed	
  to	
  ‘target’,	
  test	
  and	
  treat	
  those	
  most	
  at	
  risk	
  and,	
  recently,	
  technological	
   advances	
  have	
  presented	
  new	
  ways	
  to	
  ‘reach’	
  young	
  men	
  (e.g.,	
  via	
  the	
  internet;	
  on	
  mobile	
   handheld	
  devices).	
  For	
  example,	
  the	
  STI/HIV	
  Division	
  at	
  the	
  British	
  Columbia	
  Centre	
  for	
   Disease	
  Control	
  is	
  developing	
  the	
  new	
  Online	
  Sexual	
  Health	
  Services	
  Program	
  to	
  provide	
   online	
  testing	
  services	
  (e.g.,	
  online	
  risk	
  assessment	
  questionnaires;	
  downloadable	
  lab	
  test	
   requisition	
  forms);	
  online	
  counseling	
  and	
  education	
  (e.g.,	
  online	
  sexual	
  health	
  counseling	
   through	
  chat,	
  forums,	
  or	
  e-­‐mail;	
  referrals	
  to	
  other	
  services);	
  and,	
  online	
  partner	
  notification	
   (e.g.,	
  online	
  greeting	
  cards	
  sent	
  peer-­‐to-­‐peer	
  with	
  personal	
  messages	
  or	
  anonymously).	
  While	
   this	
  program	
  offers	
  new	
  opportunities	
  to	
  reach	
  young	
  men,	
  the	
  current	
  study	
  underscores	
  the	
   reality	
  that	
  men’s	
  online	
  sexual	
  health-­‐related	
  practices	
  (e.g.,	
  how	
  they	
  discuss	
  sexual	
  health;	
   heteronormative	
  expectations)	
  are	
  likely	
  to	
  be	
  mediated	
  by	
  masculine	
  ideals.	
  As	
  some	
   scholars	
  argue,	
  online	
  communication	
  also	
  is	
  constituted	
  by	
  a	
  social	
  ordering	
  of	
  men	
  and	
   women	
  (Armentor-­‐Cota,	
  2011).	
  Therefore,	
  we	
  need	
  to	
  better	
  understand	
  how	
  context	
   (including	
  heteronormative	
  expectations)	
  affects	
  engagement	
  with	
  online	
  sexual	
  health	
   interventions	
  such	
  as	
  STI/HIV	
  testing.	
  	
   While	
  these	
  findings	
  highlight	
  situations	
  in	
  which	
  more	
  ‘socially	
  just’	
  forms	
  of	
   masculinity	
  are	
  manifested	
  (e.g.,	
  ‘manning	
  up’),	
  the	
  current	
  thesis	
  does	
  not	
  fully	
  explicate	
  the	
   mechanisms	
  through	
  which	
  masculinities	
  (particularly	
  the	
  social	
  practices	
  and	
  relations	
   63	
    derived	
  from	
  hegemonic	
  masculinity)	
  may	
  interact	
  with	
  interventions	
  in	
  ways	
  that	
  might	
   enhance	
  or	
  detract	
  from	
  men’s	
  (and	
  women’s)	
  sexual	
  health.	
  For	
  example,	
  interventions	
  that	
   would	
  seek	
  to	
  reconfigure	
  dominant	
  masculine	
  expectations	
  (e.g.,	
  advertising	
  campaigns	
   suggesting	
  young	
  men	
  should	
  ‘man	
  up’	
  and	
  take	
  care	
  of	
  one’s	
  self	
  and	
  others)	
  may	
   inadvertently	
  reproduce	
  narrow	
  gender	
  role	
  definitions	
  (e.g.,	
  stereotypes	
  about	
  men	
  as	
  being	
   sexually	
  irresponsible)	
  and/or	
  contribute	
  to	
  the	
  (re)production	
  of	
  masculine	
  patriarchal	
   hegemony	
  (Larkin,	
  Andrews	
  &	
  Mitchell,	
  2006).	
  As	
  a	
  result,	
  interventions	
  must	
  take	
  a	
  careful,	
   nuanced	
  approach	
  that	
  focuses	
  on	
  better	
  understanding	
  the	
  intended	
  as	
  well	
  as	
  unintended	
   consequences	
  related	
  to	
  young	
  men’s	
  sexual	
  health	
  interventions	
  that	
  attempt	
  to	
  produce	
   more	
  socially	
  just	
  masculinities.	
   The	
  findings	
  of	
  the	
  current	
  thesis	
  also	
  have	
  implications	
  for	
  future	
  research	
  related	
  to	
   STI/HIV	
  population	
  health	
  interventions	
  that	
  ‘target’	
  populations	
  based	
  on	
  socially	
  defined	
   characteristics	
  (e.g.,	
  sexual	
  identity).	
  STI/HIV	
  infectious	
  epidemiology	
  frequently	
  relies	
  on	
  a	
   ‘population-­‐at-­‐risk’	
  approach,	
  whereby	
  a	
  population’s	
  social	
  characteristic	
  (e.g.,	
  sexual	
   identity)	
  serves	
  as	
  a	
  proxy	
  for	
  identifying	
  the	
  subgroup	
  of	
  the	
  population	
  thought	
  to	
  be	
  at	
   increased	
  health	
  risk	
  (e.g.,	
  men	
  who	
  have	
  sex	
  with	
  men).	
  The	
  findings	
  of	
  the	
  current	
  thesis	
   reveal	
  how	
  risk	
  assessments	
  during	
  clinical	
  encounters	
  that	
  solely	
  focus	
  on	
  discrete	
  social	
   characteristics	
  may	
  unintentionally	
  result	
  in	
  positive	
  discrimination	
  and/or	
  stigmatization	
   (e.g.,	
  HIV	
  positioned	
  as	
  a	
  gay	
  concern,	
  thereby	
  alleviating	
  concern	
  for	
  heterosexual	
  men).	
   Nonetheless,	
  clinicians	
  are	
  encouraged	
  to	
  frequently	
  use	
  this	
  approach	
  (e.g.,	
  by	
  clinical	
   practice	
  guidelines),	
  assuming	
  that	
  the	
  costs	
  (e.g.,	
  stigma;	
  inequitable	
  health	
  outcomes)	
  are	
   justified	
  by	
  the	
  benefits	
  (e.g.,	
  improved	
  overall	
  health	
  at	
  the	
  population	
  level	
  and	
  within	
  the	
    64	
    at-­‐risk	
  group)	
  (McLaren,	
  McIntyre	
  &	
  Kirkpatrick,	
  2010).	
  The	
  ethical	
  implications	
  related	
  to	
   population	
  health	
  interventions	
  that	
  target	
  socially-­‐defined	
  characteristics	
  of	
  population	
   subgroups	
  are	
  only	
  beginning	
  to	
  be	
  examined.	
  Little	
  is	
  known	
  about	
  how	
  this	
  approach	
  to	
   intervention	
  may	
  operate	
  differentially	
  within	
  and	
  across	
  ‘targeted’	
  populations	
  and	
  there	
  is	
   some	
  concern	
  that	
  these	
  approaches	
  may	
  exacerbate	
  health	
  inequity	
  –	
  particularly	
  among	
   the	
  most	
  vulnerable	
  population	
  subgroups	
  (Frolich	
  &	
  Potvin,	
  2008).	
  As	
  a	
  result,	
  further	
   research	
  is	
  required	
  to	
  examine	
  the	
  bioethical	
  implications	
  of	
  STI/HIV	
  interventions	
  that	
   ‘target’	
  populations	
  of	
  men.	
   	
   4.4	
  	
  Strengths	
  and	
  limitations	
   	
    The	
  current	
  study	
  focuses	
  on	
  a	
  substantive	
  issue	
  within	
  a	
  population	
  that	
  is	
  currently	
    undertheorized	
  (Frankel,	
  2004).	
  To	
  date,	
  the	
  majority	
  of	
  men’s	
  sexual	
  health	
  research	
  and	
   masculinities	
  focuses	
  on	
  homogenous	
  samples	
  of	
  adult	
  and	
  older	
  adult	
  men	
  based	
  on	
  specific	
   social	
  identities	
  such	
  as	
  race	
  or	
  sexual	
  identity.	
  Most	
  previous	
  work	
  has	
  tried	
  to	
  distil	
  the	
  ways	
   in	
  which	
  subordinated	
  or	
  marginalized	
  masculinities	
  (e.g.,	
  gay	
  masculinities)	
  ‘function’.	
  While	
   the	
  sample	
  size	
  of	
  the	
  current	
  study	
  limits	
  the	
  capacity	
  to	
  examine	
  in	
  detail	
  the	
  intersections	
   of	
  gender,	
  race	
  and/or	
  class	
  (Kimmel	
  and	
  Messner	
  2007;	
  Connell	
  &	
  Messerschmdt,	
  2005;	
   Duck,	
  2009),	
  study	
  participants	
  described	
  diverse	
  experiences	
  and	
  masculine	
  identities.	
  The	
   analyses	
  included	
  here	
  are	
  based	
  on	
  the	
  premise	
  that	
  masculinities	
  do	
  not	
  mean	
  the	
  same	
   thing	
  to	
  all	
  men	
  (Coles,	
  2009).	
  For	
  example,	
  by	
  including	
  men	
  of	
  various	
  sexual	
  identities,	
  this	
   study	
  was	
  able	
  to	
  extend	
  beyond	
  some	
  contemporary	
  masculinity	
  theories	
  that	
  label	
  men	
   subordinated	
  masculinities	
  by	
  virtue	
  of	
  other	
  intersecting	
  ‘subordinate’	
  social	
  identities	
  (e.g.,	
   65	
    racialized	
  bodies;	
  ‘non-­‐heterosexual’	
  identities).	
  Instead,	
  the	
  current	
  thesis	
  is	
  aligned	
   theoretically	
  with	
  new	
  emerging	
  theory	
  that	
  explores	
  masculinities	
  and	
  its	
  functioning	
  by	
   suggesting	
  that	
  “hierarchies	
  within	
  hierarchies”	
  of	
  masculinities	
  must	
  be	
  accounted	
  for	
  in	
   theory	
  (Numer	
  &	
  Gahagan,	
  2009).	
  Lastly,	
  while	
  the	
  raw	
  data	
  available	
  across	
  77	
  interviews	
   with	
  young	
  men	
  and	
  25	
  interviews	
  with	
  clinicians	
  offer	
  rich	
  and	
  varied	
  perspectives,	
  the	
   quotes	
  that	
  are	
  included	
  in	
  this	
  thesis	
  are	
  intended	
  to	
  serve	
  as	
  exemplars	
  of	
  the	
  key	
  concepts	
   and	
  themes	
  featured	
  in	
  the	
  empirical	
  analyses	
  presented	
  in	
  Chapters	
  2	
  and	
  3.	
   	
   4.5	
  	
  Interpretation	
  of	
  findings	
  and	
  reflexivity	
   	
    In	
  interpreting	
  the	
  results	
  of	
  this	
  thesis,	
  my	
  role	
  as	
  an	
  interviewer	
  should	
  be	
    considered.	
  I	
  identify	
  as	
  a	
  gay	
  man;	
  I	
  am	
  white;	
  at	
  6’6”,	
  I	
  am	
  significantly	
  taller	
  than	
  the	
   average	
  man	
  and	
  I	
  am,	
  on	
  average,	
  about	
  8	
  years	
  older	
  than	
  the	
  participants	
  in	
  this	
  study.	
   Overall,	
  I	
  perceived	
  that	
  most	
  of	
  the	
  young	
  men	
  I	
  interviewed	
  seemed	
  to	
  be	
  comfortable	
   talking	
  about	
  their	
  sexual	
  health	
  histories	
  with	
  me.	
  Nonetheless,	
  in	
  writing	
  detailed	
  reflexive	
   field	
  notes,	
  I	
  frequently	
  explored	
  how	
  my	
  own	
  appearance,	
  non-­‐verbal	
  communication	
  and	
   other	
  potential	
  power	
  dynamics	
  (e.g.,	
  age;	
  race;	
  class)	
  could	
  affect	
  the	
  results	
  of	
  the	
  interview	
   processes.	
  For	
  example,	
  in	
  reflecting	
  on	
  my	
  own	
  gendered	
  performances,	
  I	
  frequently	
   wondered	
  how	
  my	
  sexual	
  identity	
  was	
  being	
  ‘read’	
  by	
  the	
  participants	
  and	
  how	
  this	
  might	
   affect	
  the	
  interview	
  dynamics	
  with	
  respect	
  to	
  discussions	
  about	
  sexual	
  identities.	
  My	
  research	
   office	
  space	
  displays	
  several	
  Positive	
  Space	
  Campaign	
  signs	
  (a	
  UBC	
  campaign	
  that	
  strives	
  to	
   create	
  safe	
  spaces	
  for	
  all	
  sexual	
  and	
  gender	
  identities)	
  –	
  though,	
  it	
  is	
  questionable	
  as	
  to	
   whether	
  participants	
  would	
  recognise	
  the	
  purpose	
  of	
  these	
  signs.	
  During	
  interviews,	
  some	
  of	
   66	
    the	
  men	
  expressed	
  explicitly	
  heterosexist	
  (as	
  well	
  as	
  misogynistic)	
  attitudes,	
  beliefs	
  and	
   sentiments.	
  During	
  these	
  discussions,	
  I	
  did	
  not	
  reveal	
  my	
  own	
  discomfort	
  with	
  their	
  beliefs	
  (in	
   the	
  same	
  way	
  that	
  I	
  avoided	
  acknowledging	
  my	
  agreement	
  when	
  my	
  own	
  thoughts	
  aligned	
   with	
  men’s	
  attitudes/beliefs).	
  Instead,	
  my	
  reactions	
  focused	
  on	
  exploring	
  ‘why’	
  and	
  ‘how’	
   men	
  expressed	
  these	
  attitudes	
  and	
  how	
  this	
  might	
  influence	
  their	
  sexual	
  health-­‐related	
   practices.	
  To	
  do	
  this,	
  I	
  frequently	
  relied	
  on	
  probing,	
  prompting	
  and	
  looping	
  –	
  interviewing	
   techniques	
  that	
  have	
  been	
  described	
  elsewhere	
  (Oliffe	
  &	
  Mroz,	
  2005)	
  as	
  being	
  useful	
  for	
   interviewing	
  men	
  about	
  their	
  health	
  behaviour.	
  In	
  the	
  situations	
  in	
  which	
  men	
  expressed	
   homophobic	
  or	
  misogynistic	
  sentiments,	
  I	
  may	
  have	
  appeared	
  to	
  condone	
  and/or	
  support	
   their	
  heterosexist	
  and	
  misogynistic	
  accounts	
  by	
  neither	
  ‘shutting	
  down’	
  nor	
  avoiding	
  these	
   conversations	
  and,	
  instead,	
  acting	
  interested	
  as	
  I	
  probed	
  to	
  learn	
  more.	
  However,	
  similar	
  to	
   an	
  account	
  reported	
  by	
  Flood	
  (2008)	
  in	
  which	
  the	
  men	
  he	
  interviewed	
  frequently	
  denigrated	
   women,	
  my	
  discomfort	
  was	
  only	
  diminished	
  through	
  the	
  acknowledgement	
  that	
  these	
   narratives	
  provided	
  an	
  opportunity	
  to	
  better	
  understand	
  how	
  idealized	
  notions	
  of	
  masculinity	
   are	
  embodied,	
  experienced	
  and	
  lived	
  out	
  in	
  men’s	
  daily	
  practice.	
  Understanding	
  men’s	
   experiences	
  in	
  relation	
  to	
  idealised	
  notions	
  of	
  masculinity	
  is	
  critical	
  to	
  advancing	
  social	
  justice	
   that	
  promotes	
  gender	
  equity	
  and	
  improved	
  sexual	
  health	
  among	
  young	
  men	
  and	
  women.	
  By	
   exploring	
  these	
  narratives,	
  I	
  hope	
  that	
  these	
  sorts	
  of	
  stereotypes	
  and	
  practices	
  that	
  underpin	
   hegemonic	
  masculinity	
  can	
  be	
  problematised	
  and	
  contribute	
  to	
  pathways	
  toward	
  more	
   equitable	
  gender	
  relations.	
    67	
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  1255-­‐56.	
   	
   Yep,	
  G.	
  A.	
  (2002).	
  From	
  homophobia	
  and	
  heterosexism	
  to	
  heteronormativity:	
  Toward	
  the	
   development	
  of	
  a	
  model	
  of	
  queer	
  interventions	
  in	
  the	
  university	
  classroom.	
  Journal	
  of	
   Lesbian	
  Studies,	
  6(3&4),	
  163-­‐76.	
   	
   Young,	
  R.	
  M.	
  &	
  Meyer,	
  I.	
  H.	
  (2005).	
  The	
  trouble	
  with	
  “MSM”	
  and	
  “WSW”:	
  Erasure	
  of	
  the	
   sexual-­‐minority	
  person	
  in	
  public	
  health	
  discourse.	
  American	
  Journal	
  of	
  Public	
  Health,	
   95(7),	
  1144-­‐49.	
   	
    75	
    Appendices A.1	
  	
  Interview	
  guide	
  for	
  young	
  men	
   Interview	
  Guide	
  for	
  Youth	
   	
   Sex,	
  Gender	
  &	
  Place:	
  An	
  Analysis	
  of	
  Youth’s	
  Experiences	
  with	
  STI	
  Testing	
   	
   Review	
  the	
  informed	
  consent	
  and	
  interview	
  structure:	
   • This	
  session	
  will	
  be	
  audio	
  taped	
  and	
  will	
  last	
  about	
  1.5	
  hours.	
  We’ll	
  begin	
  our	
   interview	
  by	
  completing	
  a	
  brief	
  questionnaire	
  (5	
  mins).	
  The	
  information	
  we	
  collect	
   through	
  the	
  survey	
  will	
  be	
  used	
  to	
  describe	
  the	
  characteristics	
  (e.g.,	
  age,	
  education,	
   current	
  sexual	
  activity	
  level)	
  of	
  the	
  overall	
  group	
  of	
  study	
  participants.	
  Then	
  I	
  will	
  ask	
   you	
  some	
  questions	
  about	
  your	
  experiences	
  with	
  STI	
  testing.	
  While	
  we’re	
  talking,	
  I’ll	
   ask	
  you	
  to	
  tell	
  me	
  about	
  your	
  symptoms,	
  what	
  you	
  had	
  to	
  do	
  when	
  you	
  went	
  for	
  your	
   STI	
  test,	
  and	
  the	
  treatment	
  you	
  received	
  (if	
  any	
  was	
  required).	
  During	
  the	
  interview,	
  I’ll	
   be	
  taking	
  a	
  few	
  notes	
  about	
  the	
  events	
  and	
  experiences	
  you	
  describe	
  to	
  me.	
  	
  	
   • Review	
  options	
  for	
  referrals	
  to	
  counseling	
  services.	
   • Any	
  questions	
  about	
  how	
  we’re	
  going	
  to	
  spend	
  our	
  time	
  today?	
   	
   Opening	
  Questions	
   1. Please	
  tell	
  me	
  why	
  you	
  decided	
  to	
  volunteer	
  for	
  our	
  study.	
   	
   Reasons	
  for	
  Getting	
  STI	
  Testing	
   1.	
  Tell	
  me	
  the	
  story	
  about	
  how	
  you	
  came	
  to	
  get	
  tested	
  for	
  STIs.	
  Start	
  anywhere	
  you	
  want.	
  	
   Examples	
  of	
  Probes:	
  	
   • What	
  kinds	
  of	
  symptoms	
  did	
  you	
  experience,	
  if	
  any?	
   • What	
  kinds	
  of	
  symptoms	
  did	
  your	
  partner	
  experience,	
  if	
  any?	
   o If	
  yes:	
  Did	
  you	
  notice	
  that	
  your	
  partner	
  had	
  symptoms	
  that	
  s/he	
  didn’t	
  tell	
   you	
  about?	
  Did	
  you	
  speak	
  to	
  your	
  partner	
  about	
  this?	
  Did	
  your	
  partner’s	
   symptoms	
  influence	
  your	
  decision	
  to	
  get	
  an	
  STI	
  test?	
   • What	
  did	
  you	
  know	
  about	
  STI	
  testing	
  at	
  that	
  time?	
  Where	
  did	
  you	
  learn	
  about	
  this	
   information?	
  What	
  kinds	
  of	
  information	
  did	
  you	
  want	
  [or	
  need]	
  to	
  know?	
   • What	
  did	
  you	
  know	
  about	
  places	
  where	
  you	
  can	
  get	
  STI	
  testing?	
   	
   	
   2. Some	
  young	
  people	
  have	
  told	
  us	
  that	
  they	
  get	
  tested	
  when	
  they	
  end	
  a	
  sexual	
  relationship,	
   even	
  if	
  they	
  do	
  not	
  experience	
  any	
  symptoms.	
  Others	
  have	
  told	
  us	
  they	
  get	
  STI	
  testing	
    76	
    before	
  they	
  start	
  having	
  sex	
  with	
  a	
  new	
  partner,	
  and	
  ask	
  their	
  partners	
  to	
  do	
  the	
  same.	
  Tell	
   me	
  what	
  you	
  think	
  of	
  these	
  reasons	
  for	
  getting	
  tested.	
    	
   Descriptions	
  of	
  the	
  Clinic(s)	
   3.	
  Tell	
  me	
  about	
  the	
  clinic	
  where	
  you	
  were	
  tested.	
  If	
  you	
  have	
  visited	
  more	
  than	
  one	
  clinic,	
   please	
  tell	
  me	
  about	
  each	
  of	
  them.	
   Examples	
  of	
  Probes:	
  	
   • How	
  would	
  you	
  describe	
  the	
  clinic?	
   • What	
  was	
  it	
  like	
  when	
  you	
  walked	
  into	
  the	
  clinic?	
  How	
  was	
  it	
  organized	
  in	
  terms	
  of	
   the	
  reception	
  area,	
  the	
  waiting	
  area,	
  the	
  clinic	
  rooms,	
  the	
  toilets,	
  etc.?	
   • Tell	
  me	
  what	
  it	
  was	
  like	
  to	
  be	
  in	
  the	
  waiting	
  area?	
  What	
  was	
  it	
  like	
  to	
  be	
  in	
  the	
   examination	
  room	
  –	
  when	
  you	
  were	
  waiting	
  for	
  the	
  doctor,	
  after	
  your	
  exam,	
  etc.?	
   • How	
  did	
  you	
  find/locate	
  the	
  clinic?	
  How	
  did	
  you	
  get	
  to	
  the	
  clinic?	
  	
   • Tell	
  me	
  what	
  you	
  know	
  about	
  the	
  clinic’s	
  operating	
  hours	
  and	
  how	
  that	
  fits	
  with	
   your	
  schedule.	
   • What	
  made	
  you	
  decide	
  to	
  get	
  tested	
  at	
  this	
  particular	
  clinic	
  instead	
  of	
  another	
   one?	
  Or,	
  did	
  you	
  have	
  a	
  choice?	
  	
   • When	
  did	
  you	
  get	
  testing	
  at	
  this	
  clinic?	
   • Was	
  this	
  your	
  first	
  visit	
  to	
  the	
  clinic?	
  Have	
  you	
  ever	
  been	
  tested	
  before?	
  Where?	
   When?	
   	
   Experiences	
  at	
  the	
  Clinic(s)	
   4.	
  When	
  you	
  think	
  back	
  on	
  the	
  procedures	
  that	
  you	
  underwent	
  at	
  the	
  clinic,	
  how	
  would	
  you	
   describe	
  those	
  procedures?	
  What	
  took	
  place?	
  Reminder:	
  You	
  do	
  not	
  have	
  to	
  tell	
  me	
  what	
   the	
  results	
  of	
  your	
  STI	
  test(s).	
  If	
  you	
  have	
  visited	
  more	
  than	
  one	
  clinic,	
  please	
  tell	
  me	
  about	
   each	
  of	
  them.	
   Examples	
  of	
  Probes:	
  	
   • Do	
  you	
  remember	
  what	
  STIs	
  you	
  were	
  tested	
  for?	
   • Were	
  your	
  interactions	
  with	
  female	
  or	
  male	
  health	
  care	
  workers	
  (e.g.,	
  nurses	
  or	
   doctors)	
  or	
  both?	
  Tell	
  me	
  about	
  what	
  it	
  was	
  like	
  to	
  interact	
  with	
  those	
  service	
   providers.	
  	
   • What	
  kinds	
  of	
  discussions	
  did	
  you	
  overhear	
  at	
  the	
  clinic:	
   o Between	
  staff	
  and	
  clients?	
   o Between	
  staff	
  themselves?	
   o Between	
  clients?	
   • Tell	
  me	
  whether	
  you	
  have	
  a	
  preference	
  to	
  be	
  seen	
  by	
  a	
  woman	
  or	
  a	
  man.	
  Did	
  you	
   have	
  a	
  choice	
  or	
  did	
  you	
  feel	
  like	
  you	
  could	
  have	
  a	
  choice?	
  How	
  were	
  those	
  choices	
   presented	
  to	
  you?	
   • What	
  kinds	
  of	
  questions	
  did	
  you	
  get	
  asked:	
  at	
  the	
  reception	
  area?	
  When	
  you	
  saw	
   the	
  nurse?	
  When	
  you	
  saw	
  the	
  doctor?	
  	
   o Did	
  you	
  have	
  questions	
  about	
  the	
  reasons	
  they	
  were	
  asking	
  you	
  those	
   questions?	
  About	
  the	
  testing	
  procedures	
  themselves?	
  	
  About	
  follow-­‐up?	
   • Did	
  any	
  of	
  the	
  staff	
  ask	
  what	
  your	
  sexual	
  orientation	
  is?	
  	
    77	
    •  o Did	
  you	
  volunteer	
  this	
  information	
  or	
  did	
  you	
  feel	
  you	
  had	
  to	
  tell	
  staff	
  what	
   your	
  sexual	
  orientation	
  is?	
  How	
  did	
  this	
  make	
  you	
  feel?	
   o How	
  important	
  is	
  it	
  to	
  you	
  to	
  have	
  staff	
  know	
  your	
  sexual	
  orientation?	
   What	
  kinds	
  of	
  questions	
  did	
  you	
  ask	
  or	
  want	
  to	
  ask:	
  the	
  receptionist?	
  (did	
  you	
  ask	
   them?)	
  the	
  nurses	
  (did	
  you	
  ask	
  them?)	
  the	
  doctors	
  (did	
  you	
  ask	
  them?)	
   o How	
  well	
  did	
  the	
  health	
  care	
  providers	
  answer	
  your	
  questions?	
    	
   Waiting	
  for	
  Results	
  of	
  the	
  STI	
  Test	
   5.	
  How	
  did	
  you	
  feel:	
   a. Right	
  before	
  you	
  arrived	
  at	
  the	
  clinic?	
   b. While	
  at	
  the	
  clinic?	
   c. Right	
  after	
  you	
  left	
  the	
  clinic?	
   d. What	
  did	
  you	
  do	
  after	
  you	
  left	
  the	
  clinic?	
   	
   6.	
  How	
  long	
  did	
  you	
  wait	
  to	
  find	
  out	
  your	
  results?	
  How	
  did	
  you	
  feel	
  during	
  that	
  time	
  that	
   you	
  were	
  waiting	
  to	
  hear	
  about	
  the	
  results?	
   Examples	
  of	
  Probes:	
   • •  How	
  did	
  you	
  actually	
  learn	
  about	
  your	
  results?	
  Who	
  told	
  you?	
  	
   How	
  did	
  you	
  feel	
  when	
  you	
  received	
  the	
  results	
  of	
  your	
  test?	
    	
   Being	
  Treated	
  [If	
  the	
  participant	
  discloses	
  that	
  s/he	
  had	
  a	
  positive	
  test]	
   7.	
  	
  What	
  kind	
  of	
  treatment,	
  if	
  any,	
  did	
  you	
  have	
  to	
  undergo?	
  	
   Examples	
  of	
  Probes:	
  	
   • Tell	
  me	
  about	
  what	
  it	
  was	
  like	
  for	
  you	
  physically	
  to	
  receive	
  that	
  treatment?	
  	
   • When	
  did	
  you	
  first	
  notice	
  that	
  your	
  symptoms	
  went	
  away?	
  	
   	
   Reactions	
  –	
  Post-­‐STI	
  Testing	
  	
   8.	
  Some	
  people	
  experience	
  emotional	
  difficulties	
  related	
  to	
  STIs	
  (e.g.,	
  lack	
  of	
  trust;	
   depression;	
  being	
  labeled	
  or	
  stigmatized).	
  Others	
  feel	
  more	
  confident	
  or	
  in	
  control	
  of	
  their	
   sexual	
  health	
  because	
  they	
  are	
  getting	
  tested.	
  What	
  kinds	
  of	
  feelings	
  did	
  you	
  experience	
  as	
   a	
  result	
  of	
  having	
  an	
  STI	
  test?	
   	
   Examples	
  of	
  Probes:	
   • What	
  concerns	
  did/do	
  you	
  have	
  about	
  being	
  blamed	
  or	
  rejected	
  by	
  your	
  current	
  or	
   future	
  sexual	
  partners?	
   • How	
  did/do	
  you	
  think	
  your	
  sex	
  partner	
  (family,	
  friends,	
  peers)	
  would	
  react	
  if	
  they	
   were	
  to	
  find	
  out?	
   • How	
  would	
  you	
  react	
  if	
  sex	
  partner	
  (family,	
  friends,	
  peers)	
  found	
  out	
  that	
  you	
  have	
   had	
  STI	
  testing?	
   • How	
  did	
  your	
  experience	
  with	
  STI	
  testing	
  affect	
  how	
  you	
  think	
  about	
  yourself	
   socially?	
  Psychologically?	
  In	
  any	
  other	
  ways?	
  Do	
  you	
  still	
  feel	
  that	
  way?	
    78	
    •  •  •  •  How	
  does	
  the	
  fact	
  that	
  you	
  got	
  tested	
  make	
  you	
  feel/think	
  about	
  yourself	
  sexually	
   (e.g.,	
  more	
  or	
  less	
  “sexy”	
  or	
  “desirable”)?	
  What	
  do	
  you	
  think	
  it	
  means	
  to	
  be	
   sexually	
  desirable?	
  	
   How	
  do	
  you	
  think	
  you	
  might	
  feel	
  about	
  a	
  partner	
  if	
  you	
  learned	
  that	
  s/he	
  has	
  had	
   STI	
  testing?	
  Would	
  that	
  change	
  how	
  you	
  feel/think	
  about	
  that	
  person	
  sexually	
   (e.g.,	
  more	
  or	
  less	
  “sexy”	
  or	
  “desirable”)?	
  	
   What	
  about	
  in	
  terms	
  of	
  your	
  sexual	
  practices	
  after	
  being	
  tested?	
  And,	
  when	
  I	
  say	
   “sexual”	
  or	
  “sex”	
  it	
  doesn’t	
  just	
  mean	
  penetration	
  or	
  oral	
  sex;	
  it	
  also	
  includes	
  all	
   kinds	
  of	
  things	
  like	
  sexual	
  touching,	
  kissing,	
  phone	
  sex,	
  and	
  use	
  of	
  sex	
  toys.	
   Keeping	
  this	
  in	
  mind,	
  how	
  did	
  your	
  experience	
  with	
  STI	
  testing	
  change	
  how	
  you	
   think	
  about	
  sex	
  and/or	
  your	
  sexual	
  practices	
  (i.e.	
  types	
  of	
  sexual	
  activity,	
   negotiating	
  safer	
  sex,	
  condom	
  use,	
  or	
  choice	
  of	
  sexual	
  partner)?	
  	
   How	
  would	
  these	
  reactions	
  affect	
  your	
  decision	
  whether	
  or	
  not	
  to	
  get	
  STI	
  testing	
  in	
   the	
  future?	
    	
   STI	
  Counseling	
  &	
  Education	
   9.	
  	
  When	
  people	
  visit	
  a	
  health	
  care	
  professional	
  (e.g.,	
  a	
  doctor’s	
  office,	
  a	
  youth	
  clinic,	
  or	
  an	
  STI	
   clinic),	
  they	
  are	
  often	
  receive	
  some	
  counseling	
  about	
  STIs.	
  What	
  kind	
  of	
  counseling	
  did	
  you	
   ask	
  for	
  or	
  receive	
  after	
  you	
  went	
  for	
  your	
  test?	
  	
   Examples	
  of	
  Probes:	
   • • • • 	
    If	
  you	
  received	
  counseling	
  after	
  you	
  went	
  for	
  your	
  test,	
  what	
  was	
  useful	
  about	
  the	
   counseling?	
  Not	
  useful?	
   What	
  do	
  you	
  think	
  are	
  important	
  issues	
  that	
  need	
  to	
  be	
  included	
  in	
  STI	
  counseling?	
   If	
  counseling	
  was	
  available	
  but	
  you	
  did	
  not	
  receive	
  it,	
  tell	
  me	
  why.	
   What	
  kinds	
  of	
  counseling	
  do	
  you	
  think	
  are	
  essential	
  for	
  all	
  young	
  women	
  [men]	
  to	
   receive	
  after	
  having	
  an	
  STI	
  test?	
    Record	
  Keeping	
  	
  	
   10.	
  When	
  people	
  go	
  for	
  STI	
  testing	
  and	
  treatment,	
  records	
  are	
  kept	
  at	
  each	
  location	
   where	
  people	
  access	
  services	
  (e.g.,	
  at	
  the	
  clinic	
  or	
  doctor’s	
  office,	
  the	
  pharmacy,	
  the	
   public	
  health	
  unit,	
  the	
  BC	
  Centre	
  for	
  Disease	
  Control).	
  When	
  you	
  had	
  your	
  STI	
  test	
  done,	
   what	
  were	
  you	
  told	
  about	
  how	
  your	
  records	
  would	
  be	
  kept	
  and	
  who	
  had	
  access	
  to	
  them?	
  	
   Examples	
  of	
  Probes:	
    	
    • •  Is	
  this	
  something	
  you	
  are	
  concerned	
  about?	
  What	
  are	
  your	
  concerns?	
   How	
  did	
  these	
  concerns	
  influence	
  your	
  decision	
  to	
  get	
  STI	
  testing?	
    11. [If	
  the	
  participant	
  lives	
  with	
  her/his	
  family:]	
  How	
  might	
  living	
  at	
  home	
  with	
  your	
  family	
   affect	
  your	
  experience	
  getting	
  STI	
  testing?	
  Examples	
  of	
  Probes:	
   • What	
  would	
  you	
  think	
  about	
  the	
  chance	
  of	
  having	
  the	
  clinic	
  contact	
  you	
  at	
  home	
   by	
  phone	
  or	
  mail	
  about	
  your	
  test	
  results	
  or	
  other	
  issues	
  related	
  to	
  your	
  test?	
   	
   79	
    Where	
  Youth	
  Live	
   12.	
  Where	
  we	
  live	
  affects	
  our	
  experiences	
  in	
  many	
  ways.	
  This	
  includes	
  both	
  the	
  geographic	
   location	
  (e.g.,	
  your	
  town,	
  your	
  neighbourhood)	
  as	
  well	
  as	
  your	
  social	
  standing	
  (e.g.,	
   income	
  level,	
  age,	
  class,	
  ethnicity)	
  within	
  your	
  community.	
  How	
  would	
  you	
  describe	
  the	
   ways	
  in	
  which	
  the	
  place	
  where	
  you	
  live	
  affected	
  your	
  experiences	
  with	
  STI	
  testing?	
   Examples	
  of	
  Probes:	
   • Privacy	
  issues?	
  	
   • Anonymity?	
  Confidentiality?	
   • Transportation	
  issues?	
    	
   13.	
  If	
  STI	
  testing	
  was	
  not	
  available	
  or	
  accessible	
  in	
  your	
  community,	
  what	
  would	
  you	
  do?	
   Examples	
  of	
  Probes:	
   • What	
  do	
  you	
  think	
  it	
  might	
  be	
  like	
  trying	
  to	
  access	
  STI	
  testing	
  or	
  treatment	
  services	
   if	
  you	
  lived	
  in	
  a	
  small	
  town	
  [or	
  big	
  city]?	
  	
   	
   14.	
  In	
  some	
  communities,	
  some	
  ideas	
  about	
  sexuality	
  have	
  changed	
  a	
  lot	
  in	
  the	
  past	
  30	
  years.	
   Tell	
  me	
  about	
  some	
  of	
  the	
  changes	
  that	
  you	
  think	
  that	
  your	
  community	
  has	
  experienced	
   related	
  to	
  this	
  idea.	
   Examples	
  of	
  Probes:	
   • How	
  do	
  you	
  think	
  that	
  attitudes	
  toward	
  sexuality	
  have	
  changed	
  in	
  your	
  community	
   since	
  your	
  parents	
  were	
  your	
  age?	
   • How	
  do	
  you	
  define	
  your	
  community?	
   • How	
  would	
  you	
  describe	
  the	
  way	
  your	
  community	
  feels	
  about	
  young	
  men	
  being	
   sexually	
  active?	
  What	
  about	
  young	
  women?	
   • What	
  does	
  your	
  community	
  define	
  as	
  “acceptable”	
  or	
  “normal”	
  sexual	
  behaviour	
   for	
  young	
  men?	
  For	
  young	
  women?	
   • What	
  happens	
  when	
  a	
  young	
  woman	
  in	
  your	
  community	
  is	
  thought	
  to	
  be	
  engaging	
   in	
  “unacceptable”	
  sexual	
  behaviour?	
  	
  	
   • What	
  happens	
  when	
  a	
  young	
  man	
  in	
  your	
  community	
  is	
  thought	
  to	
  be	
  engaging	
  in	
   “unacceptable”	
  sexual	
  behaviour?	
  	
  	
   • How	
  might	
  your	
  community’s	
  ideas	
  of	
  “acceptable”	
  sexual	
  behaviour	
  differ	
   depending	
  on	
  a	
  young	
  person’s	
  sexual	
  identity?	
  their	
  ethnicity?	
  their	
  religious	
   beliefs?	
  or	
  their	
  peer	
  group?	
   	
   Sociocultural	
  &	
  Religious	
  Attitudes	
  and	
  STI	
  Testing	
  	
   15.	
  Some	
  people	
  have	
  talked	
  about	
  the	
  influence	
  of	
  their	
  religious	
  beliefs	
  or	
  spirituality	
  or	
   cultural	
  background	
  (i.e.,	
  if	
  you’re	
  Irish,	
  Filipino,	
  Indo-­‐Canadian)	
  on	
  decisions	
  around	
   their	
  sexual	
  health.	
  	
   Examples	
  of	
  Probes:	
   • How	
  do	
  you	
  think	
  your	
  own	
  cultural	
  background	
  and/or	
  religious/spiritual	
  beliefs	
   affected	
  your	
  experiences	
  with	
  STI	
  testing?	
   80	
    •  How	
  do	
  you	
  think	
  that	
  the	
  cultural	
  background	
  and/or	
  religious/spiritual	
  beliefs	
  of	
   a	
  STI	
  testing	
  service	
  provider	
  might	
  affect	
  your	
  interactions	
  with	
  them?	
    	
   STI	
  Testing	
  Supports	
   17.	
  Thinking	
  back	
  about	
  to	
  your	
  STI	
  testing	
  experience	
  and	
  to	
  what	
  we	
  have	
  discussed	
  today,	
   what	
  would	
  you	
  tell	
  someone	
  else	
  who	
  was	
  thinking	
  about	
  getting	
  STI	
  testing?	
  Young	
   women	
  [men]?	
   	
   18.	
  How	
  can	
  service	
  providers	
  do	
  a	
  better	
  job	
  of	
  supporting	
  young	
  women	
  [and	
  men]	
  who:	
   • Are	
  getting	
  STI	
  testing?	
   Have	
  been	
  diagnosed	
  with	
  an	
  STI?	
   	
   Closing	
  Remarks	
   19.	
  Is	
  there	
  anything	
  else	
  you	
  want	
  to	
  tell	
  me	
  about	
  your	
  experiences	
  with	
  sexual	
  health	
   behaviour	
  and	
  outcomes?	
   	
   20.	
  Are	
  you	
  interested	
  in	
  participating	
  in	
  a	
  follow-­‐up	
  interview	
  to	
  give	
  us	
  feedback	
  on	
  our	
   preliminary	
  findings?	
   	
   21.	
  	
  Do	
  you	
  know	
  of	
  another	
  youth	
  who	
  might	
  be	
  interested	
  in	
  completing	
  an	
  interview	
  like	
   this?	
  	
  If	
  so,	
  please	
  give	
  them	
  this	
  card	
  and	
  ask	
  them	
  to	
  call	
  our	
  toll-­‐free	
  number.	
   	
    81	
    A.2	
  	
  Interview	
  guide	
  for	
  clinicians	
   	
   Interview	
  Guide	
  For	
  Use	
  With	
  Service	
  Providers	
   	
   Sex,	
  Gender	
  &	
  Place:	
  An	
  Analysis	
  of	
  Youth’s	
  Experiences	
  with	
  STI	
  Testing	
   	
   Review	
  the	
  informed	
  consent	
  and	
  interview	
  structure:	
   • This	
  session	
  will	
  be	
  audio	
  taped	
  and	
  will	
  last	
  about	
  45	
  minutes	
  to	
  1	
  hour.	
  I	
  will	
  ask	
   you	
  some	
  questions	
  about	
  your	
  experiences	
  working	
  with	
  youth	
  who	
  seek	
  STI	
   testing.	
  During	
  the	
  interview,	
  I’ll	
  be	
  taking	
  a	
  few	
  notes	
  about	
  the	
  events	
  and	
   experiences	
  you	
  describe	
  to	
  me.	
  	
  	
   • Any	
  questions	
  about	
  how	
  we’re	
  going	
  to	
  spend	
  our	
  time	
  today?	
   	
   Professional	
  Background	
  &	
  Education	
   To	
  begin,	
  I’d	
  like	
  you	
  to	
  tell	
  me	
  a	
  bit	
  about	
  your	
  professional	
  background	
  and	
  education.	
  	
   o 	
  What’s	
  your	
  current	
  role	
  here	
  at	
  the	
  clinic	
  [or	
  what	
  is	
  your	
  professional	
  role]?	
   Examples	
  of	
  Probes:	
  	
   • Where	
  did	
  you	
  receive	
  your	
  training?	
  Qualifications?	
   • When	
  did	
  you	
  graduate?	
  	
  When	
  did	
  you	
  start	
  your	
  career?	
  	
   • How	
  long	
  have	
  you	
  been	
  practicing	
  your	
  current	
  profession?	
   • How	
  long	
  have	
  you	
  been	
  practicing	
  in	
  this	
  particular	
  community?	
  At	
  this	
  clinic?	
   	
   Accessing	
  STI	
  Testing	
  	
   2.	
  Now,	
  I’d	
  like	
  to	
  hear	
  about	
  the	
  kinds	
  of	
  sexual	
  health	
  services	
  that	
  are	
  available	
  to	
  young	
   people	
  in	
  your	
  community.	
  	
   • What	
  kinds	
  of	
  services	
  do	
  you	
  offer	
  within	
  your	
  clinic?	
  	
   • What	
  other	
  kinds	
  of	
  services	
  are	
  available	
  through	
  your	
  clinic?	
   • How	
  do	
  you	
  determine	
  what	
  STIs	
  each	
  of	
  your	
  clients	
  should	
  be	
  tested	
  for?	
   	
   Examples	
  of	
  Probes:	
  	
   • Where	
  can	
  young	
  women	
  go	
  to	
  receive	
  testing	
  for	
  STIs?	
  Have	
  you	
  ever	
  referred	
  a	
   young	
  woman	
  to	
  one	
  of	
  these	
  services?	
   • What	
  did	
  you	
  tell	
  them?	
   • What	
  kind	
  of	
  feedback	
  have	
  you	
  received	
  from	
  these	
  young	
  women	
  about	
   their	
  experiences	
  seeking	
  an	
  STI	
  test?	
   • Where	
  can	
  young	
  men	
  go	
  to	
  receive	
  STI	
  testing?	
  Have	
  you	
  ever	
  referred	
  a	
  young	
   man	
  to	
  one	
  of	
  these	
  services?	
  	
   • What	
  did	
  you	
  tell	
  them?	
   • What	
  kind	
  of	
  feedback	
  have	
  you	
  received	
  from	
  these	
  young	
  men	
  about	
   their	
  experiences	
  seeking	
  an	
  STI	
  test?	
   82	
    	
   3.	
  In	
  previous	
  studies,	
  some	
  young	
  women	
  have	
  told	
  us	
  that	
  they	
  have	
  requested	
  pap	
  tests	
   with	
  the	
  expectation	
  that	
  they	
  would	
  also	
  be	
  tested	
  for	
  STIs	
  without	
  having	
  to	
  necessarily	
   ask	
  for	
  an	
  STI	
  test.	
  	
   • How	
  often	
  do	
  you	
  think	
  this	
  situation	
  happens	
  at	
  the	
  clinic	
  where	
  you	
  work?	
   • When	
  young	
  women	
  request	
  pap	
  tests	
  at	
  your	
  clinic,	
  what	
  kinds	
  of	
  information	
   about	
  the	
  test	
  do	
  you	
  discuss	
  with	
  them?	
   	
   4.	
  Do	
  staff	
  at	
  your	
  clinic	
  ask	
  clients	
  about	
  their	
  sexual	
  orientation?	
  What	
  about	
  clients’	
  sexual	
   behaviours?	
   • In	
  what	
  ways	
  would	
  this	
  information	
  affect	
  the	
  services	
  that	
  are	
  provided	
  to	
  young	
   women	
  [men]?	
   	
   Observations	
  About	
  Clinic-­‐based	
  Experiences	
   5.	
  We’re	
  interested	
  in	
  hearing	
  about	
  your	
  observations	
  and	
  interpretations	
  of	
  young	
  women	
   and	
  men’s	
  interactions	
  with	
  one	
  another	
  and	
  with	
  staff	
  in	
  your	
  clinic.	
  Tell	
  me	
  about	
  some	
   of	
  the	
  things	
  that	
  come	
  to	
  mind	
  when	
  you	
  think	
  about	
  their	
  interactions	
  with	
  one	
  another?	
   What	
  about	
  their	
  interactions	
  with	
  staff?	
  	
  	
   Examples	
  of	
  Probes:	
   • We’d	
  like	
  to	
  ask	
  you	
  about	
  some	
  of	
  the	
  observations	
  that	
  you’ve	
  made	
  in	
  terms	
  of	
   the	
  gender	
  dynamics	
  amongst	
  young	
  women	
  and	
  young	
  men.	
  For	
  example,	
  how	
   would	
  you	
  describe	
  the	
  gender	
  dynamics	
  between	
  partners	
  [or	
  amongst	
  young	
   women/men	
  in	
  general]	
  in	
  the	
  waiting	
  area?	
   • What	
  about	
  young	
  women’s	
  [men’s]	
  interactions	
  with	
  staff?	
  At	
  reception?	
  In	
  the	
   clinical	
  examination	
  areas?	
  	
   • What	
  kinds	
  of	
  options	
  do	
  you	
  offer	
  youth	
  in	
  terms	
  of	
  choosing	
  to	
  be	
  examined	
  by	
  a	
   particular	
  service	
  provider	
  (e.g.,	
  same-­‐sex	
  service	
  provider)?	
  How	
  and	
  when	
  is	
  that	
   choice	
  presented?	
   	
   6. We’re	
  also	
  interested	
  in	
  the	
  gender	
  dynamics	
  amongst	
  the	
  clinic	
  staff	
  itself.	
  What	
  kinds	
  of	
   things	
  do	
  you	
  think	
  are	
  important	
  for	
  us	
  to	
  know	
  about	
  in	
  terms	
  of	
  this	
  issue	
  and	
  the	
  way	
   your	
  workplace	
  functions?	
  	
   Examples	
  of	
  Probes:	
   • How	
  might	
  those	
  dynamics	
  affect	
  the	
  ways	
  in	
  which	
  you	
  offer	
  services	
  to	
  young	
   women	
  [young	
  men]?	
  	
   • How	
  might	
  those	
  dynamics	
  affect	
  the	
  ways	
  in	
  which	
  your	
  clinic	
  is	
  perceived	
  in	
  the	
   wider	
  community?	
  by	
  young	
  women	
  [men]?	
   	
   Reactions	
  –	
  Post-­‐STI	
  Testing	
  	
   7. How	
  do	
  you	
  and	
  your	
  staff	
  inform	
  clients	
  of	
  their	
  test	
  results?	
  I’m	
  sure	
  you’ve	
  seen	
  a	
   variety	
  of	
  reactions	
  among	
  the	
  young	
  women	
  and	
  men	
  to	
  whom	
  you	
  provide	
  STI	
   testing	
  services	
  in	
  terms	
  of	
  the	
  feelings	
  that	
  they	
  associate	
  with	
  the	
  idea	
  of	
  getting	
  an	
   STI	
  and/or	
  getting	
  an	
  STI	
  test.	
  Tell	
  me	
  about	
  those	
  reactions.	
    83	
    Examples	
  of	
  Probes:	
   • Relief?	
   • Concerns	
  about	
  being	
  blamed	
  or	
  rejected	
  by	
  current	
  or	
  future	
  sexual	
  partners?	
   • Feelings	
  about	
  their	
  sex	
  partner(s)	
  (family,	
  friends,	
  peers)	
  and	
  their	
  reactions	
  if	
  they	
   were	
  to	
  find	
  out?	
   • Social	
  effects?	
  Psychological	
  effects?	
  In	
  any	
  other	
  ways?	
   • How	
  might	
  “getting	
  testing”	
  make	
  them	
  feel/think	
  about	
  themselves	
  sexually	
  (e.g.,	
   more	
  of	
  less	
  “sexy”	
  or	
  “desirable”)?	
  What	
  do	
  you	
  think	
  it	
  means	
  to	
  young	
  women	
   [men]	
  to	
  be	
  sexually	
  desirable?	
  	
   • What	
  about	
  in	
  terms	
  of	
  their	
  sexual	
  practices	
  after	
  being	
  tested?	
  And,	
  when	
  I	
  say	
   “sexual”	
  or	
  “sex”	
  it	
  doesn’t	
  just	
  mean	
  penetration	
  or	
  oral	
  sex;	
  it	
  also	
  includes	
  all	
   kinds	
  of	
  things	
  like	
  sexual	
  touching,	
  kissing,	
  phone	
  sex,	
  and	
  use	
  of	
  sex	
  toys.	
  Keeping	
   this	
  in	
  mind,	
  how	
  might	
  an	
  experience	
  with	
  STIs	
  and/or	
  STI	
  testing	
  affect	
  how	
   young	
  women	
  [men]	
  think	
  about	
  sex	
  and/or	
  their	
  sexual	
  practices	
  (i.e.	
  negotiating	
   safer	
  sex,	
  condom	
  use,	
  types	
  of	
  sexual	
  activity,	
  or	
  choice	
  of	
  sexual	
  partner)?	
  	
   • How	
  could	
  these	
  reactions	
  affect	
  young	
  women’s	
  [men’s]	
  decisions	
  whether	
  or	
  not	
   to	
  get	
  STI	
  testing	
  in	
  the	
  future?	
   	
   8. How	
  satisfied	
  are	
  you,	
  as	
  a	
  service	
  provider,	
  with	
  your	
  ability	
  to	
  follow-­‐up	
  with	
  youth	
   regarding	
  their	
  STI	
  testing	
  results?	
  	
   	
   9. How	
  do	
  young	
  women	
  [men]	
  react	
  when	
  you	
  discuss	
  their	
  test	
  results	
  with	
  them?	
  	
   	
   Record	
  Keeping	
  	
  	
   10.	
  Describe	
  for	
  me	
  the	
  kinds	
  of	
  record	
  keeping	
  activities	
  that	
  your	
  clinic	
  engages	
  in.	
  	
   Examples	
  of	
  Probes:	
   • Who	
  does	
  it?	
  Who’s	
  responsible	
  for	
  it?	
  	
   • Who	
  has	
  access	
  to	
  the	
  records?	
  How	
  are	
  they	
  stored?	
  Who	
  do	
  you	
  share	
  the	
   records	
  with?	
  	
   • What	
  are	
  you	
  obliged	
  to	
  do	
  with	
  the	
  records?	
   	
   11.	
  What	
  kinds	
  of	
  information	
  do	
  you	
  provide	
  to	
  young	
  women	
  [men]	
  about	
  how	
  their	
  health	
   records	
  will	
  be	
  kept?	
  	
   Examples	
  of	
  Probes:	
   • What	
  kinds	
  of	
  things	
  do	
  you	
  tell	
  them	
  about	
  who	
  will	
  have	
  access	
  to	
  this	
   information?	
   • Is	
  this	
  something	
  that	
  youth	
  have	
  expressed	
  concerns	
  about?	
  What	
  were	
  their	
   concerns?	
   • How	
  do	
  you	
  think	
  that	
  these	
  concerns	
  might	
  influence	
  their	
  decisions	
  about	
  STI	
   testing	
  in	
  the	
  future?	
   	
   12.	
  What	
  kinds	
  of	
  discussions	
  do	
  you	
  have	
  with	
  young	
  women	
  [men]	
  about	
  how	
  they	
  want	
  to	
   receive	
  their	
  test	
  results?	
  What	
  kinds	
  of	
  options	
  are	
  presented/available	
  to	
  them?	
    84	
    a. Since	
  many	
  youth	
  live	
  at	
  home	
  with	
  their	
  family,	
  how	
  does	
  that	
  affect	
  your	
   approach	
  to	
  providing	
  follow-­‐up	
  after	
  STI	
  testing?	
  (e.g.,	
  contacting	
  youth?)	
    	
   13. Has	
  you	
  ever	
  faced	
  a	
  situation	
  where	
  a	
  client’s	
  confidentiality	
  was	
  breached?	
  	
   a. If	
  yes:	
  What	
  happened	
  and	
  how	
  was	
  this	
  dealt	
  with?	
   b. If	
  no:	
  How	
  would	
  you	
  deal	
  with	
  such	
  a	
  breach?	
   	
   Where	
  We	
  Live	
  and	
  Work	
   14.	
  The	
  communities	
  where	
  we	
  live	
  and	
  work	
  can	
  affect	
  our	
  experiences	
  in	
  many	
  ways.	
  This	
   includes	
  both	
  the	
  geographic	
  location	
  (e.g.,	
  your	
  town,	
  your	
  neighbourhood)	
  as	
  well	
  as	
   your	
  social	
  standing	
  (e.g.,	
  income	
  level,	
  age,	
  class,	
  ethnicity)	
  within	
  your	
  community.	
  How	
   would	
  you	
  describe	
  the	
  ways	
  in	
  which	
  the	
  community	
  where	
  you	
  live	
  affects	
  young	
   women’s	
  [men’s]	
  experiences	
  with	
  STI	
  testing?	
   Examples	
  of	
  Probes:	
  	
  	
   • Privacy?	
  Anonymity?	
  Confidentiality?	
  Transportation?	
   	
   15.	
  How	
  would	
  you	
  describe	
  the	
  ways	
  in	
  which	
  the	
  community	
  where	
  you	
  practice	
  affects	
   young	
  women’s	
  [men’s]	
  experiences	
  with	
  STI	
  testing?	
  How	
  would	
  you	
  describe	
  the	
  ways	
  in	
   which	
  the	
  community	
  where	
  you	
  live	
  affects	
  young	
  women’s	
  [men’s]	
  experiences	
  with	
  STI	
   testing?	
   Examples	
  of	
  Probes:	
  	
  	
   • Privacy?	
  Anonymity?	
  Confidentiality?	
  Transportation?	
   	
   16.	
  How	
  does	
  the	
  community	
  where	
  your	
  clinic/office	
  is	
  located	
  affect	
  the	
  way	
  you	
  practice?	
   	
   17.	
  In	
  some	
  communities,	
  some	
  ideas	
  about	
  sexuality	
  have	
  changed	
  a	
  lot	
  in	
  the	
  past	
  30	
  years.	
  	
   Examples	
  of	
  Probes:	
   • How	
  would	
  you	
  describe	
  the	
  way	
  your	
  community	
  feels	
  about	
  young	
  men	
  being	
   sexually	
  active?	
  What	
  about	
  young	
  women?	
   • What	
  similar	
  or	
  different	
  (often	
  unspoken)	
  “rules”	
  or	
  expectations	
  do	
  women	
  and	
   men	
  live	
  under	
  in	
  your	
  community	
  when	
  it	
  comes	
  to	
  sex	
  or	
  their	
  sexuality?	
  	
   • What	
  happens	
  when	
  a	
  young	
  woman	
  doesn’t	
  obey	
  or	
  follow	
  the	
  rules	
  or	
   expectations	
  in	
  your	
  community?	
  	
  	
   • What	
  happens	
  when	
  a	
  young	
  man	
  doesn’t	
  obey	
  or	
  follow	
  the	
  rules	
  or	
  expectations	
   in	
  your	
  community?	
  	
  	
   • How	
  might	
  these	
  rules	
  or	
  expectations	
  differ	
  depending	
  on	
  a	
  young	
  person’s	
   sexual	
  identity,	
  ethnicity,	
  religious	
  beliefs,	
  or	
  peer	
  group?	
   • What	
  kinds	
  of	
  discussion	
  have	
  you	
  and	
  your	
  colleagues	
  here	
  had	
  about	
  these	
  kinds	
   of	
  issues?	
  How	
  have	
  your	
  approaches	
  to	
  providing	
  services	
  to	
  young	
  women	
   [young	
  men]	
  been	
  affected	
  by	
  these	
  discussions?	
   	
    85	
    Sociocultural	
  &	
  Religious	
  Attitudes	
  and	
  STI	
  Testing	
   18.	
  Some	
  people	
  have	
  talked	
  about	
  the	
  influence	
  of	
  their	
  religious	
  beliefs	
  or	
  spirituality	
  or	
   cultural	
  background	
  (i.e.,	
  if	
  you’re	
  Irish,	
  Filipino,	
  Indo-­‐Canadian)	
  on	
  decisions	
  around	
  their	
   sexual	
  health.	
  	
   Examples	
  of	
  Probes:	
   • How	
  do	
  you	
  think	
  your	
  ethnic	
  identity	
  and/or	
  religious/spiritual	
  beliefs	
  affected	
   your	
  experiences	
  with	
  providing	
  STI	
  testing	
  to	
  young	
  women	
  [men]?	
   • How	
  do	
  you	
  think	
  that	
  the	
  ethnic	
  identity	
  and/or	
  religious/spiritual	
  beliefs	
  of	
  a	
   young	
  woman	
  [or	
  man]	
  might	
  affect	
  your	
  interactions	
  with	
  them?	
   • What	
  kinds	
  of	
  discussions	
  have	
  you	
  and	
  your	
  colleagues	
  here	
  had	
  about	
  these	
   issues?	
   	
   Tour	
  of	
  Clinic	
   Invite	
  them	
  to	
  take	
  us	
  on	
  a	
  “tour”	
  of	
  their	
  clinical	
  spaces.	
  Ask	
  permission	
  to	
  keep	
  the	
  tape	
   running	
  during	
  the	
  tour.	
  This	
  is	
  also	
  where	
  we’ll	
  be	
  taking	
  photos	
  of	
  the	
  spaces	
  themselves	
   (no	
  people	
  will	
  be	
  photographed).	
   	
   Closing	
  Remarks	
   • Are	
  there	
  further	
  insights	
  you	
  would	
  like	
  to	
  share	
  (e.g.	
  any	
  opinions,	
  feelings)?	
  	
   • Do	
  you	
  know	
  of	
  another	
  key	
  stakeholder	
  who	
  might	
  be	
  interested	
  in	
  completing	
  an	
   interview	
  like	
  this?	
  	
  If	
  so,	
  please	
  give	
  them	
  this	
  card	
  and	
  ask	
  them	
  to	
  call	
  our	
  toll-­‐free	
   number.	
   	
   	
   	
    86	
    A.3	
  	
  Interview	
  guide	
  for	
  young	
  men	
    Interview	
  Guide	
  for	
  Use	
  with	
  Young	
  Men	
   	
   Young	
  Men	
  and	
  STIs	
   	
   Review	
  the	
  informed	
  consent	
  and	
  interview	
  structure:	
  This	
  session	
  will	
  be	
  audio	
  taped	
  and	
   will	
  last	
  about	
  1	
  to	
  1.5	
  hours.	
  We’ll	
  begin	
  our	
  interview	
  by	
  completing	
  a	
  brief	
  questionnaire	
   (3-­‐5	
  minutes).	
  Then	
  I	
  will	
  ask	
  you	
  some	
  questions	
  about	
  your	
  experiences	
  with	
  STI	
  testing.	
   While	
  we’re	
  talking,	
  I’ll	
  ask	
  you	
  to	
  tell	
  me	
  about	
  your	
  symptoms,	
  what	
  you	
  had	
  to	
  do	
  when	
   you	
  went	
  for	
  your	
  STI	
  test,	
  and	
  the	
  treatment	
  you	
  received	
  (if	
  any	
  was	
  required).	
  During	
  the	
   interview,	
  I’ll	
  be	
  taking	
  a	
  few	
  notes	
  about	
  the	
  events	
  and	
  experiences	
  you	
  describe	
  to	
  me.	
  	
   	
   	
   Introduction	
   1. Where	
  did	
  you	
  hear	
  about	
  our	
  study?	
   2. Can	
  you	
  tell	
  me	
  why	
  you	
  decided	
  to	
  volunteer	
  for	
  our	
  study?	
   	
   	
   Experiences	
  with	
  STI	
  Clinical	
  Services	
   So	
  now	
  I’d	
  like	
  to	
  talk	
  about	
  some	
  of	
  your	
  experiences	
  with	
  testing.	
   	
   3. Tell	
  me	
  the	
  story	
  about	
  how	
  you	
  came	
  to	
  get	
  tested	
  for	
  STIs.	
  Start	
  anywhere	
  you	
  want.	
   Remember,	
  you	
  don’t	
  have	
  to	
  answer	
  any	
  questions	
  you	
  don’t	
  want	
  to.	
  	
   	
   Examples	
  of	
  Probes:	
  	
   • What	
  did	
  you	
  know	
  about	
  STI	
  testing	
  at	
  that	
  time?	
  Where	
  did	
  you	
  learn	
  about	
  this	
   information?	
  What	
  kinds	
  of	
  information	
  did	
  you	
  want	
  [or	
  need]	
  to	
  know?	
  What	
  did	
   you	
  learn	
  specifically	
  about	
  men’s	
  sexual	
  health?	
   • Where	
  do	
  you	
  get	
  your	
  sexual	
  health	
  information	
  from?	
  	
  For	
  example,	
  the	
   internet,	
  a	
  family	
  member,	
  friends?	
   	
   	
   	
   	
   	
   4. When	
  you	
  think	
  back	
  on	
  the	
  procedures	
  that	
  you	
  experienced	
  at	
  the	
  clinic,	
  how	
  would	
   you	
  describe	
  those	
  procedures?	
  What	
  took	
  place?	
  Reminder:	
  You	
  do	
  not	
  have	
  to	
  tell	
  me	
   what	
  the	
  results	
  of	
  your	
  STI	
  test(s).	
  	
   	
   87	
    Examples	
  of	
  Probes:	
  	
   • If	
  you	
  can	
  recall,	
  what	
  STIs	
  you	
  were	
  tested	
  for?	
   • Tell	
  me	
  about	
  what	
  it	
  was	
  like	
  to	
  interact	
  with	
  those	
  nurses	
  or	
  doctors.	
  How	
  did	
   they	
  respond	
  to	
  your	
  needs	
  and	
  questions?	
   • Did	
  any	
  of	
  the	
  staff	
  ask	
  what	
  your	
  sexual	
  orientation	
  is?	
  Did	
  you	
  volunteer	
  this	
   information	
  or	
  did	
  you	
  feel	
  you	
  had	
  to	
  tell	
  staff	
  what	
  your	
  sexual	
  orientation	
  is?	
   How	
  did	
  this	
  make	
  you	
  feel?	
  How	
  important	
  is	
  it	
  to	
  you	
  to	
  have	
  staff	
  know	
  your	
   sexual	
  orientation?	
   • How	
  do	
  you	
  think	
  this	
  experience	
  would	
  have	
  differed	
  if	
  you	
  were/for	
  a	
  woman?	
   	
   5. How	
  long	
  did	
  you	
  wait	
  to	
  find	
  out	
  your	
  results?	
  How	
  did	
  you	
  feel	
  during	
  that	
  time	
  that	
   you	
  were	
  waiting	
  to	
  hear	
  about	
  the	
  results?	
  How	
  did	
  you	
  feel	
  when	
  you	
  received	
  the	
   results	
  of	
  your	
  test?	
   • How	
  would	
  you	
  prefer	
  to	
  receive	
  your	
  results?	
   • How	
  did	
  this	
  influence	
  how	
  you	
  look	
  after	
  your	
  sexual	
  health	
  after	
  finding	
  this	
   information.	
   	
   6. Some	
  men	
  have	
  told	
  us	
  how	
  they	
  would	
  not	
  want	
  a	
  male	
  nurse	
  or	
  doctor	
  because	
  they	
   would	
  not	
  want	
  another	
  guy	
  touching	
  or	
  seeing	
  their	
  penis.	
  Others	
  have	
  said	
  they	
  would	
   not	
  want	
  a	
  women	
  nurse	
  or	
  doctor	
  because	
  they	
  were	
  scared	
  they	
  could	
  get	
  an	
  erection.	
  	
   	
   What	
  do	
  you	
  think	
  of	
  these	
  issues?	
   	
   Examples	
  of	
  probes:	
   • Why	
  do	
  you	
  think	
  some	
  guys	
  feel	
  that	
  way,	
  and	
  others	
  don’t?	
   • How	
  do	
  you	
  think	
  this	
  situation	
  could	
  be	
  made	
  easier	
  for	
  young	
  men?	
   • From	
  your	
  experience,	
  what	
  have	
  nurses	
  or	
  doctors	
  done	
  in	
  order	
  to	
  make	
  these	
   sorts	
  of	
  situations	
  easier	
  for	
  you?	
   • Tell	
  me	
  whether	
  you	
  have	
  a	
  preference	
  to	
  be	
  seen	
  by	
  a	
  woman	
  or	
  a	
  man.	
  Did	
  you	
   have	
  a	
  choice	
  or	
  did	
  you	
  feel	
  like	
  you	
  could	
  have	
  a	
  choice?	
  How	
  were	
  those	
  choices	
   presented	
  to	
  you?	
   • Do	
  you	
  think	
  there	
  is	
  anything	
  that	
  can	
  be	
  done	
  to	
  make	
  this	
  easier	
  for	
  young	
   men?	
   • How	
  would	
  the	
  age	
  of	
  the	
  nurse	
  or	
  doctor	
  affect	
  how	
  you	
  feel	
  about	
  getting	
  an	
   exam?	
  	
  For	
  example,	
  a	
  young	
  female	
  doctor	
  versus	
  an	
  old	
  female	
  doctor?	
  	
  A	
  young	
   male	
  nurse	
  versus	
  an	
  old	
  male	
  nurse?	
   	
   7. Thinking	
  back	
  to	
  your	
  experiences	
  with	
  STI	
  testing,	
  what	
  sorts	
  of	
  questions	
  do	
  you	
   remember	
  your	
  nurse	
  or	
  doctor	
  asking	
  you	
  during	
  the	
  examination?	
   	
   Examples	
  of	
  probes:	
   • Who	
  asked	
  you	
  those	
  questions	
  and	
  where	
  were	
  you	
  when	
  they	
  asked	
  these	
   questions?	
    88	
    • • •  Was	
  this	
  done	
  on	
  a	
  form	
  as	
  well?	
  Did	
  your	
  clinician	
  ask	
  these	
  questions	
  again	
  in	
   the	
  exam	
  room?	
   How	
  did	
  these	
  questions	
  make	
  you	
  feel?	
   Are	
  there	
  any	
  examples	
  of	
  some	
  ‘risky’	
  behaviours	
  you’ve	
  been	
  involved	
  with	
  that	
   you	
  felt	
  were	
  important	
  to	
  tell	
  your	
  doctor/nurse?	
    	
   8. Some	
  young	
  men	
  have	
  told	
  us	
  that	
  certain	
  groups	
  of	
  men	
  are	
  at	
  higher	
  risks	
  for	
  STIs.	
  	
   	
   What	
  do	
  you	
  think	
  it	
  is	
  that	
  puts	
  a	
  young	
  man	
  ‘at	
  risk’	
  for	
  having	
  an	
  STI?	
   	
   Example	
  of	
  probes:	
   • How	
  do	
  you	
  think	
  one’s	
  ethnicity	
  or	
  cultural	
  background	
  might	
  affect	
  their	
  STI	
   ‘risk’?	
   • How	
  do	
  you	
  think	
  someone’s	
  religious	
  beliefs	
  might	
  affect	
  their	
  STI	
  ‘risk’?	
   • How	
  do	
  you	
  think	
  one’s	
  age	
  might	
  affect	
  their	
  STI	
  ‘risk’?	
   • How	
  do	
  you	
  think	
  one’s	
  sexual	
  orientation	
  might	
  affect	
  their	
  STI	
  ‘risk’?	
   • How	
  do	
  you	
  think	
  where	
  one	
  lives	
  might	
  affect	
  their	
  STI	
  ‘risk’	
  (e.g.,	
  if	
  they	
  live	
  in	
  a	
   ‘rich’	
  neighbourhood	
  versus	
  a	
  poorer	
  neighbourhood)?	
   • How	
  do	
  you	
  think	
  not	
  having	
  housing	
  might	
  affect	
  their	
  STI	
  ‘risk’?	
   	
   9. Some	
  men	
  have	
  told	
  us	
  that	
  gay	
  men	
  are	
  targeted	
  in	
  health	
  campaigns,	
  so,	
  as	
  a	
  result,	
   they’re	
  more	
  likely	
  to	
  access	
  STI	
  testing	
  than	
  heterosexual	
  men.	
  Others	
  have	
  told	
  us	
  that	
  it	
   might	
  be	
  very	
  difficult	
  to	
  access	
  STI	
  services	
  for	
  gay	
  men	
  because	
  of	
  stigma	
  they	
  would	
   experience.	
   	
   What	
  are	
  your	
  thoughts	
  on	
  how	
  sexual	
  orientation	
  might	
  affect	
  the	
  way	
  men	
  take	
  care	
   of	
  or	
  talk	
  about	
  their	
  sexual	
  health?	
   • How	
  could	
  sexual	
  orientation	
  affect	
  one’s	
  experiences	
  accessing	
  STI	
  testing?	
   • Do	
  you	
  think	
  it’s	
  easier	
  for	
  straight	
  men	
  or	
  gay	
  men	
  to	
  talk	
  about	
  sexual	
  health	
   with	
  their	
  guy	
  friends?	
  What	
  about	
  with	
  friends	
  that	
  are	
  girls?	
   	
   Vignettes	
   Now	
  I’d	
  like	
  to	
  tell	
  you	
  a	
  story	
  about	
  a	
  young	
  man	
  from	
  a	
  previous	
  study	
  we	
  conducted	
   several	
  years	
  ago.	
  This	
  is	
  about	
  his	
  experiences	
  accessing	
  STI	
  testing	
  in	
  Vancouver.	
  This	
  young	
   man’s	
  name	
  has	
  been	
  changed	
  for	
  the	
  story,	
  along	
  with	
  some	
  of	
  the	
  other	
  details,	
  so	
  that	
  his	
   identity	
  remains	
  confidential.	
   	
   “Tim”	
   	
   This	
  story	
  is	
  about	
  “Tim,”	
  a	
  24-­‐year-­‐old	
  White	
  heterosexual	
  male.	
  Tim	
  lived	
  and	
   worked	
  in	
  downtown	
  Vancouver.	
  	
   	
    89	
    When	
  we	
  met	
  Tim,	
  he	
  and	
  his	
  girlfriend	
  had	
  just	
  begun	
  their	
  relationship	
  and	
  they	
   decided	
  together	
  that	
  they	
  should	
  both	
  go	
  for	
  testing	
  before	
  having	
  sex.	
  Tim	
  said	
  that	
   it	
  was	
  fairly	
  easy	
  for	
  him	
  to	
  get	
  to	
  the	
  clinic.	
  There	
  was	
  a	
  walk-­‐in	
  clinic	
  that	
  he	
  knew	
  of	
   downtown	
  near	
  his	
  office,	
  and	
  his	
  boss	
  didn’t	
  mind	
  if	
  he	
  took	
  a	
  couple	
  of	
  hours	
  off	
   now	
  and	
  then.	
   	
   	
   	
   	
   	
   10. 	
  How	
  does	
  Tim’s	
  STI	
  testing	
  story	
  compare	
  to	
  you	
  and	
  your	
  STI	
  testing	
  story?	
  	
   Examples	
  of	
  probes:	
   • Tim	
  said	
  his	
  experience	
  was	
  relatively	
  easy.	
  How	
  does	
  this	
  compare	
  to	
  your	
   experiences?	
   • Tim	
  said	
  it	
  was	
  easy	
  to	
  get	
  to	
  the	
  clinic.	
  How	
  does	
  this	
  relate	
  to	
  your	
  experiences?	
   	
   11. 	
  Let	
  me	
  tell	
  you	
  a	
  bit	
  more	
  about	
  Tim’s	
  story.	
  Tim	
  said	
  that	
  he	
  and	
  his	
  girlfriend	
  are	
  able	
  to	
   negotiate	
  more	
  equal	
  attitudes	
  and	
  behaviours	
  related	
  to	
  their	
  sexual	
  health	
  compared	
  to	
   lots	
  of	
  other	
  (heterosexual)	
  couples	
  (e.g.,	
  as	
  in	
  the	
  brief	
  story	
  I	
  just	
  read,	
  they	
  both	
  agreed	
   testing	
  was	
  a	
  good	
  idea	
  so	
  they	
  both	
  went	
  for	
  testing).	
  This	
  was	
  different	
  than	
  a	
  lot	
  of	
  the	
   other	
  stories	
  young	
  men	
  (and	
  women)	
  told	
  us	
  about	
  (e.g.,	
  we	
  heard	
  that	
  guys	
  sometimes	
   pressured	
  their	
  partners	
  that	
  they	
  shouldn’t	
  use	
  condoms;	
  and,	
  we	
  also	
  heard	
  that	
  some	
   girls	
  pressured	
  their	
  partners	
  not	
  to	
  use	
  condoms).	
  	
   	
   What	
  do	
  you	
  think	
  it	
  is	
  that	
  helped	
  Tim	
  and	
  his	
  girlfriend	
  relate	
  to	
  each	
  other	
  so	
  well,	
   and	
  have	
  that	
  kind	
  of	
  relationship?	
   	
   Examples	
  of	
  probes:	
   • How	
  does	
  Tim’s	
  relationships	
  compare	
  to	
  most	
  of	
  the	
  other	
  relationships	
  that	
   you’re	
  familiar	
  with?	
   • Why	
  do	
  you	
  think	
  some	
  couples	
  decide	
  to	
  get	
  tested	
  at	
  the	
  beginning	
  of	
  a	
   relationship?	
   	
   12. 	
  Tim	
  also	
  said	
  that	
  he	
  was	
  able	
  to	
  talk	
  about	
  sexual	
  health	
  pretty	
  easily	
  with	
  his	
  guy	
   friends.	
  	
   	
   Why	
  do	
  you	
  think	
  some	
  guys	
  are	
  able	
  to	
  talk	
  about	
  sexual	
  health	
  (e.g.,	
  STI	
  testing),	
   whereas,	
  other	
  guys	
  find	
  it	
  difficult	
  or	
  embarrassing?	
   	
   Examples	
  of	
  probes:	
   • What	
  do	
  you	
  think	
  it	
  could	
  be	
  about	
  Tim’s	
  situation	
  that	
  makes	
  him	
  feel	
  more	
   comfortable	
  talking	
  about	
  sex	
  with	
  his	
  friends?	
    90	
    • • • •  Are	
  you	
  able	
  to	
  talk	
  with	
  your	
  guy	
  friends	
  about	
  sexual	
  health?	
  What	
  about	
  your	
   friends	
  who	
  are	
  girls?	
  What	
  about	
  your	
  sex	
  partners?	
  Tell	
  me	
  about	
  this.	
   How	
  do	
  you	
  think	
  getting	
  an	
  STI	
  might	
  affect	
  how	
  guys	
  talk	
  to	
  each	
  other	
  about	
   sexual	
  health?	
   Some	
  men	
  have	
  told	
  us	
  that	
  gay	
  men	
  might	
  be	
  better	
  able	
  to	
  talk	
  about	
  their	
   sexual	
  health.	
  Do	
  you	
  think	
  this	
  is	
  the	
  case?	
   Would	
  you	
  feel	
  more	
  comfortable	
  talking	
  about	
  your	
  sexual	
  health	
  to	
  somebody	
   that	
  shares	
  your	
  sexual	
  orientation?	
  Why?	
    	
   13. 	
  What	
  do	
  you	
  think	
  could	
  have	
  happened	
  to	
  Tim	
  if	
  he	
  hadn’t	
  been	
  able	
  to	
  or	
  didn’t	
   access	
  testing?	
   	
   Examples	
  of	
  probes:	
   • How	
  do	
  you	
  think	
  this	
  could	
  have	
  affected	
  his	
  motivation	
  to	
  get	
  tested	
  in	
  the	
   future?	
  Do	
  you	
  think	
  NOT	
  testing	
  would	
  make	
  it	
  easier	
  or	
  more	
  difficult	
  to	
  go	
  in	
   the	
  future?	
   • What	
  would	
  have	
  happened	
  to	
  Tim	
  if	
  he	
  had	
  an	
  STI	
  that	
  was	
  left	
  untreated?	
  How	
   do	
  you	
  think	
  this	
  would	
  have	
  affected	
  his	
  relationship	
  if	
  his	
  girlfriend	
  became	
   infected?	
   	
   14. 	
  How	
  do	
  you	
  think	
  this	
  experience	
  might	
  have	
  been	
  different	
  for	
  Tim’s	
  girlfriend,	
  as	
  she	
   accessed	
  STI	
  testing?	
   	
   Examples	
  of	
  probes:	
   • How	
  might	
  the	
  experiences	
  of	
  a	
  young	
  woman	
  accessing	
  testing	
  differ	
  for	
  a	
  man?	
   • What	
  do	
  you	
  think	
  about	
  couples	
  going	
  for	
  STI	
  testing	
  together?	
   • Do	
  you	
  think	
  there	
  would	
  be	
  more	
  or	
  less	
  stigma	
  associated	
  with	
  Tim’s	
  girlfriend	
   accessing	
  services?	
  [Note:	
  By	
  stigma,	
  we	
  mean	
  the	
  disapproval	
  society	
  might	
   associate	
  with	
  testing	
  because	
  it	
  goes	
  against	
  what’s	
  considered	
  “normal”].	
  Why	
   or	
  why	
  not?	
   	
   	
   “Don”	
   	
   Now	
  I’d	
  like	
  to	
  provide	
  you	
  with	
  another	
  example	
  from	
  our	
  previous	
  studies.	
  “Don”,	
   again,	
  a	
  false	
  name	
  to	
  protect	
  confidentiality,	
  was	
  a	
  16-­‐year-­‐old	
  Aboriginal	
  Vancouver	
   man	
  who	
  identified	
  as	
  gay.	
  He	
  had	
  recently	
  had	
  sex	
  and	
  he	
  wanted	
  to	
  get	
  tested,	
  just	
   to	
  be	
  on	
  the	
  “safe	
  side.”	
  However,	
  Don	
  was	
  very	
  concerned	
  about	
  testing	
  in	
  his	
  own	
   neighbourhood.	
  	
   	
   Don	
  explained	
  how	
  he	
  thinks	
  if	
  people	
  in	
  his	
  neighbourhood	
  saw	
  him	
  going	
  into	
  the	
   local	
  clinic	
  that	
  they	
  would	
  think	
  –	
  and	
  these	
  are	
  Don’s	
  words	
  -­‐	
  “He’s	
  a	
  “dirty	
  little	
   Indian…	
  Probably	
  getting	
  tested	
  for	
  his	
  dirty	
  stuff	
  there.”	
  	
    91	
    	
   He	
  also	
  was	
  worried	
  that	
  he	
  would	
  get	
  a	
  male	
  nurse	
  or	
  doctor,	
  and	
  hoped	
  for	
  a	
   female.	
  Don	
  didn’t	
  want	
  to	
  be	
  tested	
  by	
  a	
  male	
  service	
  provider.	
  As	
  he	
  explained,	
  he’s	
   only	
  naked	
  with	
  other	
  men	
  if	
  they’re	
  going	
  to	
  have	
  sex.	
  Thankfully,	
  Don’s	
  doctor	
   turned	
  out	
  to	
  be	
  a	
  woman.	
    	
   15. How	
  does	
  Don’s	
  STI	
  testing	
  story	
  compare	
  to	
  you	
  and	
  your	
  STI	
  testing	
  story?	
  	
   	
   16. 	
  Let	
  me	
  tell	
  you	
  a	
  little	
  more	
  about	
  Don’s	
  story.	
  As	
  you	
  remember,	
  Don	
  didn’t	
  want	
  to	
  get	
   tested	
  in	
  his	
  own	
  neighbourhood.	
  He	
  also	
  didn’t	
  want	
  to	
  ask	
  his	
  parents	
  to	
  take	
  him	
  to	
  a	
   clinic,	
  since	
  they	
  considered	
  him	
  to	
  be	
  a	
  “good	
  kid,”	
  and	
  he	
  didn’t	
  want	
  them	
  to	
  know	
  that	
   he’s	
  sexually	
  active.	
  So,	
  Don	
  took	
  himself	
  across	
  	
  the	
  city	
  to	
  a	
  youth	
  clinic,	
  outside	
  of	
  his	
   neighbourhood.	
  	
   	
   Please	
  tell	
  me	
  what	
  you	
  think	
  of	
  Don’s	
  perception	
  that	
  he	
  could	
  be	
  seen	
  by	
  someone	
  he	
   knows	
  if	
  he	
  went	
  for	
  testing	
  in	
  his	
  neighbourhood.	
  	
   	
   17. 	
  What	
  do	
  you	
  think	
  could	
  have	
  happened	
  to	
  Don	
  if	
  he	
  hadn’t	
  been	
  able	
  to	
  access	
  testing	
   because	
  he	
  was	
  too	
  anxious	
  about	
  going	
  to	
  a	
  clinic?	
   	
   Examples	
  of	
  probes:	
   • Do	
  you	
  think	
  this	
  could	
  make	
  testing	
  in	
  the	
  future	
  more	
  difficult	
  for	
  Don?	
   • What	
  would	
  have	
  happened	
  to	
  Don	
  if	
  he	
  had	
  an	
  STI	
  that	
  was	
  left	
  untreated?	
   	
   18. 	
  As	
  Don’s	
  story	
  illustrates,	
  it’s	
  hard	
  for	
  many	
  young	
  people	
  to	
  get	
  testing.	
  	
   	
   From	
  the	
  16-­‐year-­‐old	
  guys	
  you	
  know	
  (or	
  have	
  known),	
  what	
  sorts	
  of	
  actions	
  would	
  they	
   have	
  to	
  go	
  through	
  to	
  get	
  an	
  STI	
  clinic?	
   	
   Examples	
  of	
  probes:	
  	
   • How	
  do	
  you	
  think	
  Don’s	
  story	
  might	
  have	
  changed	
  if	
  Don	
  were	
  older,	
  so	
  let’s	
  say	
   23	
  or	
  24	
  years	
  old?	
   	
   19. 	
  So,	
  thinking	
  about	
  all	
  of	
  the	
  things	
  we’ve	
  just	
  talked	
  about,	
  and	
  based	
  on	
  the	
  stories	
  of	
   Tim	
  and	
  Don,	
  who	
  do	
  you	
  think	
  might	
  be	
  more	
  at	
  risk	
  for	
  having	
  an	
  STI:	
  Don	
  or	
  Tim?	
   Why?	
   	
   Examples	
  of	
  probes:	
   • What	
  is	
  it	
  that	
  puts	
  [Don	
  or	
  Tim]	
  at	
  an	
  elevated	
  risk?	
  	
   • Do	
  you	
  think	
  that	
  testing	
  being	
  easy	
  versus	
  hard	
  for	
  someone	
  would	
  make	
  a	
   difference	
  to	
  their	
  risk	
  of	
  having	
  an	
  STI?	
   	
   	
    92	
    Sexed/Gendered	
  Stereotypes/Implications/Issues	
   	
   20. 	
  Don	
  and	
  Tim’s	
  stories	
  featured	
  a	
  lot	
  of	
  stereotypes,	
  and	
  we’d	
  like	
  to	
  talk	
  a	
  little	
  bit	
  more	
   about	
  some	
  of	
  these.	
  For	
  example,	
  men	
  are	
  expected	
  to	
  be	
  strong,	
  confident,	
  assertive	
   and	
  behave	
  in	
  sexually	
  aggressive	
  ways.	
  	
   	
   How	
  have	
  these	
  expectations	
  influenced	
  you?	
   	
   Examples	
  of	
  probes:	
   • How	
  have	
  these	
  expectations,	
  or	
  your	
  rejection	
  of	
  these	
  expectations,	
  influence	
   your	
  sexual-­‐health	
  decisions	
  and	
  behaviour?	
  	
  For	
  example,	
  using	
  condoms,	
  getting	
   tested	
  for	
  STIs?	
   • How	
  do	
  you	
  think	
  these	
  sorts	
  of	
  expectations	
  affect	
  women	
  you	
  know?	
   	
   21. 	
  If	
  sexual	
  health	
  services	
  could	
  be	
  specifically	
  tailored	
  for	
  young	
  men,	
  what	
  do	
  you	
  think	
   those	
  services	
  should	
  look	
  like?	
   	
   Examples	
  of	
  probes:	
   	
   • What	
  kind	
  of	
  hours	
  would	
  they	
  have?	
  	
  Where	
  would	
  they	
  be	
  located?	
  	
  Would	
  they	
   serve	
  all	
  genders,	
  or	
  be	
  just	
  for	
  men	
  or	
  just	
  for	
  women?	
  	
  What	
  would	
  the	
  testing	
   be	
  like?	
  	
  How	
  would	
  you	
  get	
  your	
  results?	
  	
  Etc	
  	
   • Do	
  you	
  think	
  your	
  experiences	
  with	
  STI	
  testing	
  have	
  been	
  tailored	
  for	
  you	
  as	
  a	
   man,	
  or,	
  do	
  you	
  think	
  they	
  were	
  trying	
  to	
  provide	
  you	
  with	
  “gender-­‐neutral”	
   services	
  (i.e.,	
  not	
  especially	
  made	
  for	
  men;	
  not	
  especially	
  made	
  for	
  women)?	
   	
   	
   	
   Online	
  Sexual	
  Health	
  Services	
  Program	
   So	
  we’ve	
  talked	
  a	
  lot	
  about	
  what	
  it’s	
  like	
  for	
  young	
  men	
  accessing	
  STI	
  testing	
  services.	
  Now	
   we’d	
  like	
  to	
  tell	
  you	
  a	
  bit	
  about	
  a	
  new	
  program	
  that	
  is	
  trying	
  to	
  address	
  some	
  of	
  the	
   difficulties	
  young	
  men	
  might	
  have	
  in	
  getting	
  tested.	
  There	
  is	
  a	
  new	
  program	
  being	
  developed	
   that	
  will	
  bring	
  STI	
  testing	
  online.	
  Patients	
  will	
  be	
  able	
  to	
  fill	
  out	
  an	
  online	
  risk	
  assessment	
  then	
   download	
  a	
  lab	
  requisition	
  for	
  urine/blood	
  tests	
  at	
  a	
  lab	
  (a	
  lab	
  requisition	
  is	
  the	
  sheet	
  that	
  lets	
   the	
  lab	
  know	
  what	
  tests	
  you	
  need	
  to	
  do).	
  	
   	
   Patients	
  will	
  also	
  be	
  able	
  to	
  obtain	
  negative	
  results	
  online,	
  and	
  they	
  will	
  also	
  have	
  online	
   access	
  to	
  sexual	
  health	
  counselors.	
  And,	
  lastly,	
  this	
  program	
  will	
  offer	
  anonymous	
  email-­‐ based	
  partner	
  notification	
  for	
  those	
  patients	
  who	
  have	
  tested	
  positive	
  and	
  need	
  to	
  let	
  their	
   partners	
  know.	
   	
   	
   	
    93	
    22. 	
  How	
  comfortable	
  would	
  you	
  feel	
  filling	
  in	
  an	
  online	
  risk	
  assessment	
  questionnaire?	
  	
   	
   Examples	
  of	
  probes:	
   • How	
  comfortable	
  would	
  you	
  be	
  filling	
  in	
  an	
  online	
  risk	
  assessment	
  questionnaire?	
  	
   • How	
  do	
  you	
  think	
  this	
  might	
  compare	
  to	
  answering	
  the	
  questions	
  ‘in-­‐person’	
  with	
   your	
  doctor/nurse?	
   • Would	
  you	
  trust	
  that	
  the	
  online	
  system	
  would	
  recommend	
  the	
  right	
  tests	
  for	
  you?	
   • How	
  would	
  you	
  feel	
  using	
  the	
  internet	
  to	
  download	
  a	
  lab	
  requisition?	
   	
   23. 	
  How	
  comfortable	
  would	
  you	
  be	
  using	
  online	
  sexual	
  health	
  counseling	
  (e.g.,	
  chatting)	
  with	
   a	
  nurse	
  to	
  get	
  more	
  information	
  about	
  sexual	
  health?	
   	
   24. 	
  How	
  do	
  you	
  think	
  young	
  men	
  might	
  respond	
  to	
  being	
  able	
  to	
  use	
  an	
  anonymous	
  email-­‐ based	
  partner	
  notification	
  system	
  to	
  let	
  their	
  partners	
  know	
  that	
  they	
  tested	
  positive	
  for	
   an	
  STI	
  and	
  that	
  they	
  should	
  get	
  tested	
  right	
  away?	
   • Is	
  this	
  something	
  that	
  you	
  would	
  be	
  interested	
  in?	
  Why?	
   • How	
  would	
  you	
  feel	
  about	
  receiving	
  one	
  of	
  these	
  notifications?	
  	
  How	
  would	
  it	
   compare	
  to	
  receiving	
  the	
  same	
  notification	
  via	
  telephone	
  from	
  a	
  nurse?	
   • How	
  would	
  you	
  feel	
  about	
  sending	
  one	
  of	
  these	
  notifications	
  anonymously?	
  	
  What	
   about	
  non-­‐anonymously?	
   	
   	
   Closing	
  Remarks	
   25. 	
  Is	
  there	
  anything	
  else	
  you	
  want	
  to	
  tell	
  me	
  about	
  your	
  experiences	
  with	
  sexual	
  health	
   services?	
   	
   26. 	
  Lastly,	
  we’d	
  like	
  to	
  ask	
  you	
  if	
  you’d	
  be	
  interested	
  in	
  us	
  contacting	
  you	
  at	
  a	
  later	
  date	
  to	
   see	
  if	
  you	
  could	
  take	
  part	
  in	
  a	
  one-­‐day	
  Participatory	
  Summit	
  on	
  February	
  3?	
  	
  In	
  what	
  way	
   would	
  it	
  be	
  okay	
  to	
  contact	
  you	
  to	
  ask	
  if	
  you	
  are	
  interested?	
    94	
    

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