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Interdictions and benedictions : an analysis of AIDS prevention materials in Vancouver Canada Egan, John Patrick 1999

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INTERDICTIONS AND BENEDICTIONS: AN ANALYSIS OF AIDS PREVENTION MATERIALS IN VANCOUVER CANADA By JOHN PATRICK EGAN B.A., The State University of New York, College at Oswego, 1986 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Educational Studies) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July 1999 © John Patrick Egan 1999 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) Abstract This study identifies differing interests which have impacted how Acquired Immune Deficiency Syndrome (AIDS) prevention programmes in Vancouver have evolved. Drawing largely upon the writings of Michel Foucault with respect to power, knowledge and sexuality, discursive trends in materials are identified, categorized and compared to consider how pertinent subjugated knowledges have developed. The interplay between knowledge-regimes (the benedicted) and subjugated knowledges (the interdicted) are explicated through textual analyses of the materials collected. The findings suggest that knowledges cultivated within the male homosexual communities of Vancouver ensured the implementation of prevention programmes contextually relevant to their own milieu. These strategies were also integrated into broader prevention initiatives designed for society in-general, once their efficacy was apparent. Implications for community education and public health education are discussed, and areas for future research are identified. Table of Contents Page Abstract ii Table Of Figures v Acknowledgements v i Chapter One: AIDS In Vancouver 1 Contextual Aspects of AIDS 2 Subjectivities 5 Nature Of The Study 7 Significance of Materials Analyzed 9 Interdictions and Benedictions 11 Research Questions 13 Chapter Two: Foucault, Sex, Knowledge & Power 14 Power and Interests 15 Discourses on Sexuality: Internal and External 16 Subjugated Knowledges 19 Criticism and Activism 21 Sexuality 22 Dissemination Of Knowledges 22 Exclusions And Inaction 23 Chapter Three: Materials Analyzed 26 Personal Materials 28 Display Materials 31 Analysis Of Materials 32 Origins 32 Differentiations in Discourses 34 Graphic Images 36 Community Specificity 37 Other Noteworthy Aspects 38 iv Chapter Four: Analytic Strategies 40 Discursive Trends 40 Discourses on Sexuality 41 Community-Specific Discourses 44 Organizational Origins. 46 Public Health Publications & Gay Male Sexuality 47 Discursive Images And Sexuality 48 Posters and Erotic Imagery 50 Temporality of Trends 53 Summary 54 Chapter Five: Conclusions 56 Evolution of AIDS Education In Vancouver 56 Sexuality and Discursive Product 57 Subjugated Knowledges 58 Interdictions And Benedictions 59 Transferable Findings 62 The Importance of Local Knowledges 63 Interaction Between Local Knowledges and Regimes of Thought 63 Discourses Evolve, as do Knowledges 63 Commentary 64 A Praxis for Effective Community Education 65 AIDS, and the Current Generation of Gay Men 67 Future Research Areas 68 Closing Remarks 71 Bibliography 73 Appendix: Images from Publications 80 V Table of Figures Page Figure 1 - Frequency of Materials, by Type 28 Figure 2 - Types of Discourses Identified 36 Figure 3 - Materials by Targeted Cornmunity 38 Figure 4 - Posters, Terence Fliggins Trust 51 Acknowledgements Professor Shauna Butterwick must be thanked for shepherding me through the process of writing this manuscript; her advice, support, insight and humour made the sometimes daunting process much less so. Professors Jean Barman and Kjell Rubenson, my other committee members, each availed themselves to help me find my feet as a scholar. And Professor Roger Boshier helped me to commence my research process. These four members of the Educational Studies Department were keystones in this process of discovery and learning. Thank you! Many of my colleagues contributed greatly to this process, by critiquing my scholarship and offering their emotional support. Anne Zavalkoff, Adnan Quayyum and Lara Taylor come immediately to mind, though many others played a significant role. Several of my activist peers ensured that the practice of community-centred, grassroots AIDS prevention programmes remained in the forefront: Andrew Johnson of AIDS Vancouver and Susan Craigie of the Portland Hotel Society were particularly helpful. Denise Tang, my peer both as an activist and in the Educational Studies MA programme, helped me remain focussed when to do so was especially challenging. I offer them all my heartfelt thanks. Finally, Sherry Yano, Noel Currie and Tony Flavell nurtured my intellect, inspired me to return to university for graduate studies, and provided much spiritual and emotional sustenance throughout this process. I cannot thank them enough. 1 For millennia, man remained what he was for Aristotle: a living animal with the additional capacity for a political existence; modern man is an animal whose politics places his existence as a living being into question -Michel Foucault, 1990, p. 143 Chapter One: AIDS in Vancouver Acquired Immune Deficiency Syndrome (AIDS) began appearing in Vancouver's gay male community in the early 1980's. By the time an infectious agent was identified as the cause of AIDS, thousands of gay men were already sick or had died. With their apparently healthy immune systems stripped of their ability to fight off disease, a plethora of illnesses followed which were horrific not merely for their apparently inevitable morbidity, but also for the suffering which accompanied them. When gay men in cities across North America took it upon themselves to provide their communities with information about this malady, they did so due to government inaction. Working with their peers, and borrowing largely from each others' programmes, these communities initiated a variety of services for their members, including prevention education. No previous grassroots community-centred disease prevention campaign was as ambitious as these programmes were, but no modern community faced circumstances as dire as those experienced in North America's urban gay communities in the 1980s (Shilts, 1987; Patton 1990; Majoribanks, 1995). Nearly two decades into its AIDS epidemic, 75 percent of British Columbians who have been infected with the human immunodeficiency virus (HIV, the infectious agent which causes AIDS) have identified being gay or bisexual men as their primary risk factor (Strathdee & Schechter, 1995; Strathdee, 1997). As more non-gays have become infected with HIV, the profile of state agencies in prevention strategies has increased. Likewise the means by which persons were told to protect themselves from HIV infection, and the language used to disseminate prevention information, have changed. Subsequently many of the prevention 2 programmes employed today in other contexts have been adapted from the programmes implemented by gay men. Contextual Aspects of AIDS The North American urban gay male milieu has been characterized as largely inhabited by men of European descent whose social standing is middle-class or higher; the grassroots AIDS prevention campaigns of the early 1980s reflected this (Patton, 1987; Shilts 1987; Weeks, 1991). While these campaigns realized a dramatic reduction in new HIV infections, some of the assumptions of this milieu as being homogeneous with respect to social standing, education and ethnocultural background were ultimately problematized in AIDS education efforts. Vancouver, in particular, is a culturally pluralistic metropolis, nor are all the members of its gay male community affluent; adjacent to the West End (Vancouver's gay male enclave) is the Downtown East Side (DTES), perhaps the most impoverished urban setting in Canada. As epidemic has diffused beyond this initially affected community, the continued perpetuation of an eurocentric, middle class-focussed grassroots strategy for AIDS education became increasingly untenable. As the scope of the epidemic has broadened beyond the West End of Vancouver, so too has AIDS education evolved. In addition to AIDS Vancouver, the first AIDS service organization (ASO) in Vancouver, other programmes now attend specifically to the needs of substance abusers, women, and the aboriginal, Latin, Asian and South Asian communities. This diversification has occurred as more communities (differentiated in terms of gender, ethnocultural background, social status, and sexual orientation, among others) came to consider their members to be at significant risk for HIV infection. A distinction between terms here is important. Whereas homosexual describes in behaviourally the sexual desire for members of one's own sex, words such as gay, lesbian, and 3 gay male/man describe the full range of lived experiences of those who identify themselves as having a homosexual orientation. These latter terms encompass areas of experience much broader than sexual proclivities. Aside from the gender-linked term lesbian, homosexuals often use the term "gay" to describe either male homosexual or homosexuals in general (not without controversy). Alternately, some employ the.term gay man/male to distinguish between all homosexuals (gays), homosexual men (gay men/males), and homosexual women (lesbians). For this report I have used the terms gay, lesbian and gay man when discussing issues related to community. For consideration of differences in sexual desire—usually binarized in public health materials as heterosexual versus homosexual—-these latter two terms are used. In some instances I will use the term "gay community", though there are a plurality of gay communities; these communities can be differentiated geographically, culturally, in terms of gender, age, or in other ways. In the early 1980s, a nascent North American social movement for gay and lesbian civil rights was entering its second decade; gay communities were enjoying a previously unseen level of visibility in Canadian and U.S. cities (Seidman, 1993). Locations such as Toronto's Church and Wellesley, and the West End of Vancouver became overt, unapologetic sites of visible gay enclaves. While an unprecedented level of optimism prevailed, the process of dispelling the many myths and misconceptions about homosexuality was just beginning. This incrimination of same-sex desires was centuries old (Foucault, 1990a, 1990c); assuaging it would be difficult. With the advent of AIDS this already daunting task seemed impossible. The gay community then not only re-apportioned much of its resources to care and prevention efforts necessitated by this mysterious new epidemic, but also faced an invigorated opposition to its campaigns for civil liberties (Shilts, 1987; Weeks, 1991). Two simultaneous wars were being fought. The gay rights 4 movement's loss of many of its male combatants to AIDS further exacerbated this (Shilts, 1987; Seidman, 1993). To abandon the battle for civil liberties would have almost certainly inculcated a continued resistance from government to support AIDS programmes. With its resources overtaxed, and finding the government response inadequate, the gay community found itself challenged from within as well as from without. The practice of promiscuity by some gay men in the 1970s and 1980s was never universally endorsed, and for some gay men AIDS was evidence of its indefensibility. Not all who considered AIS a "self-inflicted" malady were antigay, or even heterosexual. Others who had participated in this promiscuity amended their behaviours as the epidemic manifested itself, in hopes of escaping infection. Few therefore pushed for a gay rights agenda which espoused sexual liberty when one of its perceived manifestations was a deadly pandemic. Rather quickly, the gay civil rights movement changed its focus from individual civil rights towards the pursuit of state sanctification of gay romantic relationships in the forms of "spousal" employee benefits and "gay marriage" (Seidman, 1993). With the de facto removal of sexual liberty from the movement, and in its pursuit of an agenda which conformed more closely to widely-entrenched normative paradigms of adult relations (specifically long-term, monogamous partnerships), a broader base of support for gay rights was sought. To some extent this mainstreaming of the gay communities seems to have succeeded; certainly it has succeeded enough to help abate the initial anti-gay backlash which accompanied the emergence of AIDS. But for some gay men, these changes in gay rights strategy were difficult to accept. Meanwhile AIDS continued burning through the community. Gay men were fostering inchoate networks to disseminate information about what might cause the unknown illness (Patton, 1987; Shilts, 1987). Like the milieus from which they sprang, these mostly professional, often university-educated and affluent, Caucasian gay men had social networks which were centred in neighbourhoods like Vancouver's West End. Their foci for prevention outreach activities were gay bars and bathhouses. These sorts of sites, used to present information to Vancouver's gay male community since the first decade of the epidemic, were both common venues where men sought to meet others for possible sexual liaisons. In initiating education programmes here, activists hoped to slow the spread of whatever was causing AIDS (Majoribanks, 1995). Subjectivities North America's gay male communities have been decimated by AIDS, and I am a member of Vancouver's gay male community. To claim any sort of detachment from the deaths and illnesses of too many good friends (and innumerable acquaintances) goes against my moral sensibilities. Similarly my own interest in remaining HIV-free makes the means by which relevant, practical and reliable prevention strategies are disseminated for sexually active gay men, to be a highly personal one. I rely upon HIV prevention programmes to obtain the information necessary to ensure my own survival. Additionally, through my activism with substance abusers I have learned that while in its pathology HIV may be an equal-opportunity scourge, the incessant, everyday challenges of injection drug use are wholly different from the circumstance under which many gay men live. Yet gay men, IDUs and the mentally ill are all considered to be among the more vulnerable for HIV infection in Canada. To distance myself from these personal and professional perspectives would be to contradict the very values which compelled me to commence this study: I could see no benefit in seeking any sort of "objectivity". With my personal experiences related to AIDS serving as the impetus for my conducting this study, anything less than a thorough research 6 process would defeat my own interests. So the integration of my activist values with those introduced to me in the academy was quite natural; primacy to either allegiance was unnecessary. My next question was to identify some means by which I could analyze the development of the prevention programmes created in Vancouver to prevent the spread of AIDS. With such differing contextual realities between the two communities at the greatest risk for their members contracting HIV, the pursuit of a broader study of AIDS education in Vancouver presented several challenges. Different at-risk communities each priorize different modes of infection in their prevention strategies. Whereas the West End-centred gay male community largely focuses on how to protect one's self from HIV infection through sexual activity, in the Downtown East Side (DTES) injection drug-using practices are the focus of most prevention strategies. Yet women of lower socio-economic status—many of whom live in the DTES—are in jeopardy of infection through their own injection drug use but also through sexual contact with IDUs. There are a multitude of other realities and circumstances, with significant overlaps between them. The scope of such an all-encompassing project was much too large for my undertaking. I chose to narrow my study to aspects of AIDS prevention with respect to gay men. My own identification as a member of the gay male community should not be perceived as identification as inhabitation within the urban, gay male milieu of Vancouver's West End. The former is a subset of the latter. Though I have lived in the West End in the past, and count among my acquaintance many men who are rooted in this neighbourhood, I live on the East side of Vancouver, in a neighbourhood which is perhaps second only to the DTES in its prevalence of injection drug use. Though like many gay men I am university educated, my upbringing was working class, a perspective which still largely shapes my frame of reference today, both as a 7 scholar and as an activist. So in conducting this research, I speak as a gay man among gay men for whom urban gay male milieus like the West End have played a high-profile role as a centre of social interaction but one who does not consider himself a citizen of this same milieu. I also lived in poverty in the beginning of the 1990s (due to my own substance abuse). But I do not feel my experiences during six months without a permanent home or any source of income was a representative experience for those who have lived in poverty throughout their lives. Nor I have I ever used injection drugs. As wisely cautioned by Alcoff (1991), it must also be said that I cannot speak to the experiences of IDUs or the impoverished, and certainly not those of women or persons of colour in the which follows. Nature Of The Study Interviews are a popular method of data collection in qualitative research; such first-person accounts can often be an important source of information. Interviews as the primary method of data collection was given serious consideration in the design of this study But some barriers were immediately apparent. With regards to the community itself, most of the men involved with the initial stage of AIDS education in Vancouver (1981-86) have since died of AIDS; their deaths preclude conducting interviews to represent prevention practices of this period of time. Additionally, conducting interviews with other community workers, government officials, and politicians could quite likely seem to perpetuate old controversies and competing interests, rather than elucidate prevention practices. Because AIDS prevention education necessitates some discussion of sexuality and/or drug use, the delivery of these educational programmes is inherently politicized. Both sexuality and substance abuse are extremely contentious issues in Canadian society. Given this, most first-person narratives on the experience of designing and delivering AIDS prevention programmes 8 might well give a specifically oriented perspective. These perspectives are often polarized on one of two binarized positions with regard to these controversies: homosexuality is abhorrent or acceptable; drug addicts are ill and need treatment or are criminals and should be jailed. While preventing HIV infection is priorized across contexts, the secondary and tertiary objectives which follow often differ, due to the interests of different stakeholders: affected community members, public officials, and religious organizations (among others).. With the identification of an alternate methodology without these controversies embedded within, interviews were eschewed. A document analysis of some sort of primary source seemed to assuage both challenges in conducting interviews. Primary sources specifically created for use in AIDS prevention programmes, if systematically analyzed, would inform as to how AIDS prevention was conducted Vancouver between 1981 (when the first AIDS cases were identified in British Columbia) and 1999. In acquiring such documents and analyzing their contents, the specific practices of various prevention programmes could be identified and compared. A comprehensive search for materials created for use in AIDS prevention programmes in Vancouver between 1981 and 1999 was subsequently conducted. These materials were produced by both community and public health entities. Some were created locally, while others were imported from other parts of the world. These documents were initially sought through public venues in which AIDS information seemed likely to be found; gay bars, clubs and bathhouses, physicians' offices, hospitals and other health facilities, and facilities such as community centres and public libraries were among the types of venues visited. Additional materials were sourced via the archives of a local ASO, and others via the World Wide Web (WWW). 9 Significance of Materials Analyzed Printed materials have always played an important role in the efforts to help Vancouverites to protect themselves from HIV infection. Pamphlets, flyers, wallet cards and posters employed in AIDS education constitute a veritable record with respect to the content of prevention programme messages and the milieus in which (or for which) they were created. By analyzing and comparing these materials one can see how the content, mode, and foci of printed AIDS prevention materials have differed. These comparisons were not wholly chronological or linear: this was not a historical study. Rather, identifying how the strategies differed—in terms of content and structure, regardless of any temporal relationships—had precedence. By considering each document's content, origins, and location of dissemination, one can surmise as to each's target audience, the aims of the organization which created or employed each material, and possibly identify the nature of discourses about AIDS over the last two decades. Analyses of documents as "texts" are common in post-structuralist research (Guba & Lincoln 1994). In post-structural research, examining the content of documents to discern how they might inform as to the nature of the milieu from when they came is known as a content analysis. In conducting such analyses, "text" is not limited to printed materials; photographs, graphic arts and transcribed discussions have all been analyzed as "texts" (Smith, 1987; Butler, 1992; Haraway, 1992; Goldberg, 1993). These feminist scholars each have characterized their methodologies as incorporating discursive analyses. While some of the technologies I have used are also found in discursive analyses, unlike the texts analyzed by these women, many of the materials which were examined for this study were quite brief, often less than fifty words per publication. This brevity, compounded by the lack of any common source for the materials' origins, dissuaded me from making the sorts of claims found in discursive analyses; in particular, quantification of word and phrase repetitions seemed inappropriate. And while there have been 10 numerous important and interesting studies done by post-structural scholars, I have found the language used in reporting some such studies to be somewhat exclusive, distracting or alienating. In my efforts to posit both my claims and observations in wholly material terms, I see my analysis as a content analysis. In using a content analysis mode of data collection, I have scrutinized the images, words, and meanings discerned from these printed materials to ask how AIDS prevention has differed in different settings, while retaining the link these documents have to the practice of AIDS prevention education. It is in this practice of education that this study is rooted; its results address both theoretical and material aspects of AIDS prevention education. Content analysis as an instrument of analysis employed by post-structural scholars (Foucault, 1980b) is adapted here for a more materially grounded scholarship. Foucault wrote extensively on knowledge, sexuality and power. In a broad sense his work often addressed not only the overt machinations of power of specific epochs (the Reformation, Victorian and post World War Two Europe), but also focussed on the sometimes covert dynamics of power and their impact. Rarely claiming concretes, he preferred to pose questions which challenged "historical truths". Much of his work expounded a belief that the interests of subjugated groups in a society are usually not well served by the institutions of said society, particularly the institutions of governance. This belief plausibly explains why the practice of grass-roots community education among marginalized or stigmatized communities is perceived to be so vitally important across contexts. But not all whose scholarly endeavours address issues like social inequity and power are supporters of Foucault; some feminist scholars have critiqued the dearth of discussion related to gender in his work (Ramazanoglu, 1993; Butler, 1996), while others have viewed his findings about sex between men and boys quite troubling (Soper, 1993; Alcoff, 1996). His work served well as a referent in consideration of the interests represented or 11 rebutted in each document analyzed. The next chapter of this study examines some of his scholarship, which incorporates the disciplines of philosophy, anthropology and history, and from whence I found the theoretical bases used in my analyses. Foucault himself was a gay man who died of AIDS in 1984. Interdictions and Benedictions Much of the field of medicine is concerned with the biology of illness. Though biological studies of disease are doubtless important, they can be of limited efficacy in preventing the spread of infectious diseases. While the process by which an agent infects its host are important in understanding how to prevent illness, the circumstances in which one becomes vulnerable to infection is of equal importance. We know that HIV is not transmitted through casual contact; sexual intimacy or blood-to-blood contact are necessary for this fragile virus to be spread. Various economic and socio-cultural factors can impact upon access to information, which in turn can determine one's ability to identify means of protecting one's self from infectious diseases like AIDS. Equally important, recent epidemiological studies conducted in Vancouver have shown that some who place themselves at high risk for HIV infection do not take reasonable precautions to minimize these risks, despite having the knowledge of how to do so (Strathdee et al, 1996). The strategy perhaps most often touted to reduce one's risk for sexually transmitted HIV infection is the use a latex condom during sexual relations. Used properly, this barrier contraceptive effectively prevents the depositing of semen into others' bodies, making the probability of HIV infection almost nil. But condom use is not a panacea for preventing the spread of AIDS. For some the greatest barrier to condom use is economic: the cost of condoms can be prohibitive. In some contexts, a request to use a condom is an insulting accusation of 12 promiscuity. The promotion of monogamy and celibacy are concepts which are central to many public health AIDS prevention campaigns, sometimes as an alternative to condom use, but also in lieu of condoms. Why are there such differences with regards to programme foci? What dynamics determine programme priorities and which prevention strategies to be proffered? In discussing interdictions and benedictions, I refer to the manner in which discussions of AIDS prevention strategies are conducted based on the anticipated audience and the venue of education. For example, a fifteen year-old male who attends a Grade Ten discussion on AIDS will get some information about how AIDS is transmitted through sexual contact, but the extent to which the technical aspects of how to prevent infection will vary. Assuming that he is given precise instruction on how to put a condom on his penis, any such instruction most likely will assume he and his (female) partner will engage in vaginal-penile intercourse. If he is participating in anal intercourse with another male, the use of specific lubricants which will not weaken the condom is vitally important. In this case, heterosexual sexuality is benedicted (or approved) for discussion by those who chose the content of the prevention programme. Homosexuality is interdicted, or forbidden to be discussed. It is silenced. Though male-to-male sexual contact is no longer the most common mode of new infection in British Columbia on the whole, in this province sexually transmitted HIV infection among young men aged 15-24 remains the second fastest-growing transmission route among all groups (Strathdee 1997). This dissonance between prevention strategy and contextual realities seems to be an important one. Differing stakeholders' interests, compete for primacy, and the negotiation between these interests in the practice of AIDS prevention affects the vulnerability of such risk groups to HIV infection. 13 Research Questions Drawing upon the work of Michel Foucault, are there different knowledges with regards to AIDS prevention and related issues embedded in the printed materials used to disseminate AIDS prevention information in Vancouver between 1981 and 1999? If so, from whence might these knowledges have come, to what extent did these knowledges develop and interact with one another, and which operated as subjugated knowledges! How do such distinctions map out when compared to the changes in AIDS prevention strategies over the last two decades? The next chapter of this study explicates how my analyses were framed by Foucault's works related to sexuality, power and knowledge. Foucault's writings not only served as an excellent theoretical framework for my analysis; much of my data collection and subsequent analysis were also modelled on his studies of ancient texts. Chapter Three articulates the concepts and categorizations which emerged from my data. The chapter describes how these publications were differentiated based on their form, content and the circumstances under which they were created, is described. The fourth chapter summarizes the integral data culled in my analysis. Commonalties and differences in the materials are examined, queried and explained. Chapter Five examines the results of the study with respect to the research questions; the transferability of the findings are also discussed. How these results might impact prevention education strategies for AIDS and other illnesses is examined, both in terms of practice and policy. Finally, potential areas for future research are postulated. 14 One must set aside the widely held thesis that power in (our) societies has denied the reality of the body in favor of the soul, consciousness, ideality. In fact, nothing is more material, physical, corporal than the exercise of power --Foucault, 1980a, pp.57-58 Chapter Two: Foucault, Sex, Knowledge & Power Michel Foucault's scholarship traverses history, anthropology and philosophy; across these disciplines the subjects of his research have included criminality and punishment, mental illness and sexuality. While he has contributed substantially to each discipline's body of knowledge, his approaches to research have impacted on many other areas of humanities and social science research. Few scholars from the latter half of this century have produced a body of work as oft-referenced as Foucault. Fxonomics, sociology, education, literature, in these (and other) disciplines the ideas of Foucault are commonly cited as important sources for both ideological and methodological considerations in the research process. Apropos to my research on AIDS prevention education, aspects of his methodologies form the frame by which my data was analyzed, but in his writings I found clear articulations for many of the values by which I practiced as a community educator/activist. Much of his work validates a commitment to the importance of priorizing a contextual understanding of practices. Foucault endorses the validity of such bodies of knowledge based on their relevance and utility to those who possess it, and within the settings from which they spring. He rejects any "required level of cognition or scientificity" (1980b, p.82) which have been used previously to denigrate the value of such knowledges, since acceptance and validation of these knowledges has traditionally come from their own milieus. But with his endorsement of transporting these knowledges to other contexts, including into the larger, "mainstream society" (society at-large, or society), Foucault discards existing notions of a concrete hierarchy of knowledges which gives authority to the academy over other forms of knowledge. 15 What has historically been employed to dismiss these contextually-based knowledges— Foucault calls them local, regional, subjugated knowledges—has been whether they are "true" or not. The exclusion of these knowledges by hegemonic regimes of thought (1980b, p.81) has little impact on the context from which the ideas spring; any such exclusion merely precludes those who are outside the context of origin from accessing that which has been subjugated. As such, these knowledges are not disregarded or rejected, rather they are concealed. The question of their veracity or validity is never posed, since what has merely been determined is whether the ideas are overtly or covertly expressed outside their locales of origins. While one might be tempted to extrapolate a rejection of institutional knowledges, existing traditions or positivism from this refutation of academic hegemony, I see Foucault endorsing a greater integration of different types of knowledge. He certainly endorses that there are a plurality of epistemologies in the Western tradition. In describing this "local character of criticism" (1980a, p.81). He writes: ...what this essentially local character of criticism indicates in reality is an autonomous, non-centralised kind of theoretical production, one that is to say whose validity is not dependent on the approval of the established regimes of thought (1980a, p.81). It is a localized criticism of AIDS prevention programmes in which I have engaged here. Power and Interests As will be explicated in the following chapters of this study, it is the differing interests which appear in AIDS prevention strategies in Vancouver—specifically those of the gay male community and public health entities—that significantly shaped how the local response to AIDS took form and subsequently evolved. Taking from Foucault's writings on the intersections of power and knowledge, this study sought to locate differences in interest as expressed in the "discursive product" (Foucault, 1990a, p. 12) of two spheres: gay males and mainstream society. 16 The gay male community's activities give evidence of how, as a subjugated community, their instinctual responses to AIDS not only germinated highly effective prevention campaigns for themselves, but ultimately impacted upon AIDS prevention programmes, created for other contexts. In juxtaposing materials created by the gay male community for its programmes with those created by public health entities, one can see how the nature of these respective prevention strategies differed. These differences have somewhat converged as the efficacy of the gay male programmes has become apparent (Health Canada, 1998). Linear, cause and effect, force and counter-force dichotomizations are dubious according to Foucault, as are superficial applications of the dialectic: "as always with relations of power, one is faced with complex phenomena which don't obey the Hegelian form of the dialectic" (1980a, p.56). By their very nature he sees simplified analyses of power with respect to subjects as complex as AIDS prevention as either irrelevant or inaccurate. My analyses were conducted with this caveat in mind. Discourses on Sexuality: Internal and External. In his The History of Sexuality Volume One: An Introduction (19901. Foucault considers how discourses on sexuality in the Western Tradition have evolved. Temporally this work considers European civilization from the ancient Greeks and Romans up to the 1970s. The roles that the Christian Church, feudal and democratic governance, and the academy have played in shaping our "restrained, mute and hypocritical sexuality" (1990a, p.3) are considered. In particular he delineates the adaptation of the practice of confession, from its sexually candid ecumenical form prior to the Middle Ages (when priests routinely encouraged penitents to disclose the specifics of their sexual sins, as a sort of spiritual purging), to a less detailed identification of transgressive acts, as is the current practice today in the high and orthodox Christian Churches, and its adaptation by medicine, specifically in the study of sexual 17 proclivities. Foucault identifies the practice of confession as having played an increasing role in the development of a taxonomy of sexual practices and desires in the field of medicine in the late 18th and early 19th centuries. These catalogues often served to benedict monogamous heterosexual marriage while demonizing most other forms of sexual expression as "deviant" or "perverted". With the importance of discourses about sexuality in AIDS prevention strategies, distinctions between how sexuality is discussed within comparable prevention strategies informs possible differences in values and practices about sexuality. Thus the importance of differentiating between prevention strategies whose origins were medical (i.e. public health) and those which were instigated by members of an at-risk community. For the purposes of this study, discourses indigenous to the urban gay male milieu are considered internal, with all others viewed as external. With homosexuality's classification not only as a medical deviance but with most of its expressions of desire criminally prohibited, it was suspected that a subjugated knowledge directly related to AIDS prevention could be located within Vancouver's gay male community. But Foucault dismisses any strong linkage between the rule of law and the nature of discourses on sexuality, since such a causality would falsely impose a linearity which does not exist. Instead, he sees our society's "hypocritical sexuality" as the manifestation of innumerable diffuse interactions between differing interests. Subsequently he also challenges the Marxist assumption that power dynamics are most often between "the oppressor" and "the oppressed". To this end he defines power as "not an institution and not a structure; neither is it a certain strength we are endowed with; it is the name that one attributes to a complex strategic situation in a particular society" (1990a, p.93). Consideration of power is then to consider its interactive nature. Rather than looking for instances of opposing forces, the location of different interests' 18 interactions (which may be taken as opposition, in collusion, as compliments, or a myriad of any number of other dynamics) is more informative. In The History of Sexuality Volume One: An Introduction, he asks: (in relation to any discourses on sex and power), what were the most immediate, the most local power relations at work? How did they make possible these kinds of discourses, and conversely, how were these discourses used to support power relations? How was the action of these power relations modified by their very exercise, entailing a strengthening of some terms and a weakening of others, with effects of resistance and counterinvestments, so that there has never existed one type of stable subjugation, given once and for all? How were these power relations linked to one another according to the logic of a great strategy, which in retrospect takes on the aspect of a unitary and voluntarist politics of sex? (1990a, P-97). In other words, what mechanisms of the knowledge-regime seem to have been in use, and how might these mechanisms have interacted with other forces to possibly shape the prevention strategies to AIDS? Here the primary forces were the interests of a largely European and middle-class gay male community being rapidly overwhelmed by a pandemic, and subsequently relying on internal norms with regards to discussions of sexuality in its own prevention materials, rather than the sexual discourses of society. Finally, Foucault differentiates between the technologies of power—its mechanisms—and power itself; practices such as censorship, propaganda, and imprisonment are not examples of power, but are actions which can be taken to demonstrate power and to seek its reinforcement. Censorship requires that knowledge be viewed as dangerous, and propaganda ensures primacy of the knowledge regime over other sources of knowledge: from these one can infer that alternate knowledges have power (1990a, p. 12). This theory of power calls less for any empowerment of the oppressed than for the identification and implementation of strategies which serve to engender one's own community's interests, acknowledge its local pertinent knowledges, and permit one's own community to access its own power. This observation does not binarize the use 19 of knowledges as dominant versus subjugated; communities which have synthesized their own local knowledges can and do use other knowledges, including the dominant knowledge-regime. The embracing of one's local knowledge is not predicated on the total rejection of the knowledge-regime. Subjugated Knowledges Though most of Foucault's writings are not epistemic in their foci, the idea that different ways of knowing exist is reflected in many of Foucault's writings. A cornerstone of his scholarship is that differences in perspective (or outlook) are to be found between those in "authority" and those subject to said authority. Often those in "authority" use the institutions (such as the academy and government agencies) to disseminate their own perspectives as singularly correct. These regimes of thought (1980b, p.81) seek to transgress all institutional and organizational bounds in their denunciation (or silencing) of other views. "Subjugated knowledges", Foucault wrote, "(represent) a whole set of knowledges that have been disqualified as inadequate to their tasks or insufficiently elaborated: naive knowledges, located low down on the hierarchy, beneath the required level of cognition or scientificity" (1980b, p.82). It would seem that the existence of such knowledges should imply their validity within their own contexts, but in fact it may take some precipitous event to focus a community's attention to its own knowledge. Subsequently, dissonance between the dominant knowledge and the local knowledge becomes apparent. Innumerable community projects, organizations, and some social movements were initiated within this paradigm. What is perhaps most intriguing is that sometimes a local knowledge manages to transgress all mechanisms which seek to contain it; as a result, this local and "invalid" knowledge enters the knowledge regime. 20 This phenomenon certainly is true with respect to AIDS prevention education for. gay men in Vancouver; today's public health strategies for HIV prevention have significantly integrated community education practices whose origins are in the gay male community. These "indigenous" practices have also arguably allowed for mainstream (i.e. not for a specific risk group) HIV prevention programmes to discuss sexuality more candidly. Foucault identifies that knowledge itself has power and is shaped by power; he sees that by their nature knowledge and power interact, with each impacting upon the other. In writing about local, regional knowledges he seems to be prophesizing how AIDS education would subsequently evolve. In the early 1980s, many gay men viewed waiting for a government response to the rapidly unfolding health crisis as an unrealistic option. Assuming a response was forthcoming, administrative and bureaucratic constraints would have meant precious time would have been wasted. Seeing a veritable dearth of government response in both the United States and Europe (Shilts, 1987), a group of Vancouver's gay male community took it upon themselves to disseminate information amongst each other, shortly after the first AIDS cases were identified in British Columbia in 1981. Very quickly an emergent community response was formed, which by 1983 evolved into AIDS Vancouver (Majoribanks, 1995). In bypassing the hierarchy of government, these men avoided what was perceived to be inevitable resistance to the candour with which gay male sexual practices were discussed (Shilts, 1987; Majoribanks, 1995). In rejecting the normative communicative practices of society regarding sexuality (including their unwillingness to be complicit in perpetuating its silence about homosexuality), the initiators of this organic, grassroots endeavour engaged in the type of local criticism Foucault deemed both valid and vital. 21 Criticism and Activism While Foucault endorses the inclusion of scholarly criticisms which do not conform to existing paradigms of the academy, he equally endorses other activities as forms of criticism. Grassroots programmes (such as the pre-cursor to AIDS Vancouver) are not only functionary, they also communicate perceived inequities and inadequacies of those existing institutions which they seek to eschew. So while their common focus was preventing the spread of HIV among gay men, one can certainly argue that pursuance by these men of their own programmes also challenged the extent to which citizens needed to acquiesce to the prevailing paradigms of public health. As Foucault wrote, "we are witness (to) an insurrection of subjugated knowledge, those blocs of historical knowledge which were present but disguised within the body of functionalist and systematising theory, and which criticism has been able to reveal" (1980b, p.81). The gay community's "insurrection" against the status quo of public health ensured better prevention strategies for AIDS, but also changed how other communicable disease prevention programmes were designed. Specifically, the actions of community representation, political lobbying, self-advocacy and client empowerment were all eventually priorized in relation to other health issues; breast cancer is perhaps the best example of this adaptation. Materials created by the gay community contained transgressive, local knowledges, and explicated how the specific norms of society regarding discourses on sexuality differed from their own. In its contextualization of sexual practices, the gay community challenged regimes of thought related to disease prevention strategies, which employed medico-scientific information to encourage technical changes of personal practices (i.e. "hygiene"). As more information about the transmission of AIDS became available such knowledge continued to be incorporated into the community's own prevention strategies, but in ways which adapted the materials to the community's own discursive practices regarding sexuality, rather than vice versa. 22 Sexuality Thou shalt not go near, thou shalt not touch, thou shalt not consume, thou shalt not experience pleasure, thou shalt not speak, thou shalt not show thyself; ultimately thou shalt not exist, except in darkness and secrecy -Foucault, 1990a, p.84 Considering analytic strategies, whether to examine the content of the materials textually (as in post-structuralism) or theoretically, was troubling. It was eventually decided that the materials need not be framed by a singular theoretical paradigm, but instead could be linked a posteriori to a variety of Foucault's writings about power, knowledge and sexuality. In fact, putting aside the historical accounts in The History of Sexuality (his seminal trilogy on the intersections of knowledge, power and sexuality), what he addresses most often are the interactions between notions (e.g. knowledges) about sexuality and context, from which he outlines plausible possibilities about the differing powers and knowledges embedded therein. Conjectures such as these serve as much of the findings of this study. Dissemination Of Knowledges This leads to an important question regarding the dissemination of different knowledges: does the wider dispersion of benedicted knowledges grant them a presumed validity over other interdicted knowledges? Though Foucault certainly thought this was true, he did not accept this practice as being in the best interests of society. Indeed he challenged it, going so far as to state his belief that hegemonic paradigms like these almost always were of detriment to society (1990a, p. 159) In this report it is argued that an analysis of AIDS prevention campaigns related to sexuality supports Foucault's work in the areas of sexuality, knowledge and power. The manner in which sexuality was compartmentalized by the knowledge-regime into medical/scientific diagnoses (which gave assent to some desires and practices while repudiating others) made any decontextualized interventions suspicious or dubious to the gay male 23 community. Thus if a cogent community response had not catalyzed, an even more cataclysmic pandemic would likely have ensued. Perhaps we must also be grateful that HIV is a very fragile and slow-progressing infectious agent; a more aggressive organism would have afforded much less time for the piloting of different strategies. So among gay men in Vancouver an internal discourse began about this new and mysterious disease, an insular discourse due to a mistrust of the knowledge-regime, manifest as public health entities. As the crisis heightened need for a stronger response became apparent. A stronger response from within the community developed. This response (and its discourses) evolved into strategies for preventing new infections, which quickly demonstrated their efficacy. One important matter was the manifestations of power in the expression of male homosexual desire in Vancouver. Questions about how differing institutions responded to male-male desire were also considered in the data analysis. How might the way in which this orientation was discussed (or silenced) in public health-sponsored prevention materials inform about the mainstream's interests? The practice of homosexuality between men has been legal in Canada since 1968, but Foucault leads me to reject any assumption that the common law is the primary or most potent mode of power in regulating desire. Foucault said our society "has been more imaginative, probably, than any other in creating devious and supple mechanisms of power.. .why are the deployments of power reduced simply to the procedure of the law of interdiction?" (1990a, p.86). An awareness of the practice of male homosexuality in Vancouver which predates its decriminalization supports this. Exclusions And Inaction With AIDS, in question is not only the impact of illness upon one's life, but the perpetuation of one's continued existence in the face of an inevitably fatal malady. In Canada the 24 role of government in the pursuit of wellness is central. For those in this country whose lives include practices, desires and values which fall outside the norms of society, the wisdom of solely relying upon government to achieve and maintain wellness becomes dubious. Foucault's primary caution is to avoid a solely "jurido-discursive" representation of power (1990a, p. 82.). This reiterates his challenge to any notion of power which concentrates only on the modalities by which hierarchical institutions demonstrate their power. With his hermeneutic that considers multiplicities (rather than a simple polarity) of power, other means of the exertion of power must be considered. So I "moved toward a definition of the specific domain formed by relations of power, and toward a determination of the instruments that will make possible its analysis" (1990a, p.82). Foucault also iterates how analyses based on the more traditional jurido-discursive representations of power are found throughout the Western tradition, and are of limited merit only insofar that they reflect only the normative values of an epoch. They therefor exclude the values (and interests) of those who may not have acquiesced to these norms. The effect of power is less evident when one is informed only of the interests of the powerful, and without those of the transgressors. Like other subjugated identities, homosexuals have experienced this unreliability. But whereas a juridical prohibition against the practice of same-sex desires can drive homosexuals to coversion, prohibitions on the discussion of these desires in the public sphere does not interdict the desire or its expression. But such prohibitions can interdict the development of contextually-relevant programmes in response to issues germane to one's sexual orientation, like AIDS. Exclusion of such issues does not prevent people from pursuing their desires, but they do ensure that the institutions of governance do not serve the needs of all citizens. For some gay men in 25 Vancouver, this exclusion may have led to their deaths. This inaction necessitated the rise of a grassroots community response to AIDS among Vancouver's gay male community. 26 Chapter Three: Materials Analyzed The materials analyzed in this study were collected over a 14 month period between February 1998 and April 1999. In an attempt to replicate the experience of persons with concerns about AIDS prevention but who were circumspect in approaching a person to collect such information, only materials which could be got without assistance were gathered. Gay bars and bathhouses, a gay bookstore, and the privately-run Centre for Lesbians, Gays, Bisexuals, Transgenders and Their Allies ("the Centre") were visited to collect printed information about HIV prevention which targets gay men; each of these facilities are in the West End's gay male milieu. Throughout the City of Vancouver, hospitals, public health clinics, private physicians' offices, city-run community centres and public libraries were visited for the purpose of locating materials which did not target gay men. A surprising lack of materials related to AIDS prevention was found in both the gay and mainstream venues, since the site selected were considered fairly obvious sources to gather information about AIDS. To locate previously used materials, AIDS Vancouver's archive of over 200 publications used in AIDS prevention efforts were examined. Several of these documents were selected and photocopied for more in-depth analysis. Not all printed materials are used in the same manner in AIDS prevention strategies. For the purpose of this study two broad categories of materials were determined: personal materials and display materials. Personal materials are those created for individual use. These materials can be used to disseminate information quite readily to a variety of locales. Persons seeking information about preventing HIV infection can review the materials on-site, or take them elsewhere for perusal. This portability is a primary reason for this format's popularity; their relative inexpense is another. Display materials are much larger than personal materials and as such are not readily transportable from location to location; they are also more costly to 27 reproduce. Unlike personal materials, displays are designed to communicate information to groups of persons rather than individuals. They are commonly placed in areas where persons are likely to seek information about HIV prevention, and often give introductory or general information related to AIDS prevention. Resources for more detailed information are also usually incorporated; information phone lines operated by community organizations or government agencies are common referral resources proffered at AIDS prevention displays. Many displays are also used to distribute personal materials, which serve to more precisely articulate prevention-related issues in greater detail. Technical "how-to" prevent (or minimize) infection guidelines, communication issues related to discussing HIV with sexual partners, and risk-related issues such as domestic violence are some of the many topics explicated in personal materials available at these displays. AIDS Vancouver uses this strategy in gay bathhouses and bars; their information displays incorporate posters, post cards, and booklets, all of which contain prevention information. Figure 1 shows the frequency distribution of materials analyzed in this study, by type. 28 informatior kiosks Figure 1 - Frequency of Materials by Type. Pamphlets and posters constitute over half of the publications located. Personal Materials A variety of personal materials are used in AIDS prevention programmes. The following formats of materials for personal distribution were identified in the course of this study: • pamphlets • advertisements in print media • booklets • newsletters • stickers • wallet cards • World Wide Web Internet Sites Distribution of these materials is accomplished through a variety of means. Most of these materials are available in places where gay men congregate socially; such venues include bathhouses, bars, restaurants, health clubs and other gay-welcoming establishments. Alternately, they are small enough that mailing them is not prohibitively expensive. Medical service 29 providers such as health clinics and private doctors' offices also distribute these materials. Advertisements, and Internet sites rely on unique distribution methods discussed below. Pamphlets and booklets are the most common of these formats found in AIDS prevention strategies. Structured as miniature texts, pamphlets and booklets give specific, detailed information on ways to eliminate or minimize sexually-related HIV exposure risks. For the purposes of this study, materials classified as pamphlets are those with more than one but less than eleven pages. Booklets are materials with between 11 and 20 pages: no materials with more than 20 pages were located (one page materials, categorized as flyers, were considered display materials. Wallet cards give brief but specific guidelines about prevention HIV infection, in a document which fits neatly into a wallet or pocket. This format is designed so one can carry prevention guidelines on their person, but in a form much less cumbersome than a pamphlet. Roughly one-third of the materials analyzed for this study fall into one of these three categories. Advertisements in newspapers, magazines or other print media rarely contain detailed AIDS prevention instruction. Instead prevention issues are introduced in more general terms. One example would be an advertisement in which negotiating condom use with a partner was the major theme. Information on techniques related to condom usage would be excluded, in favour of a discussion on communication strategies. Readers would be given resources to access technical prevention information. Advertisements are a supplemental component of many HIV prevention strategies, but are expensive. Most advertisements related to AIDS prevention are found in publications which are nested within specific at-risk communities, rather than in mass market publications. Stickers most often contain information in a format similar to that found on wallet cards, though they are usually smaller in size. The stickers are placed in locations where men are known to engage in sexual activity with other men, to remind them how to minimize 30 their risks of contracting or spreading HIV. Aside from the gay-identified venues like gay bath houses, these stickers can also be found in adult movie theatres and peep shows. Newsletters are a popular means of internal information distribution among members of organizations, including the workplace. The content of these newsletters ranges from point-form risk reduction guidelines to personal narratives which explore individual experiences and perspectives related to HIV prevention. With the advent of inexpensive Internet access, many organizations engaged in AIDS prevention activities are increasingly putting prevention information on World Wide Web pages (WWW). Several such web pages reviewed for this study were located using a web search engine (www.hotbot.com) by using the key terms "AIDS", "prevention", "sex", and "gay". An interesting aspect of WWW sites used in these programmes is the issue of accessibility. One can only access these resources if a computer connected to the Internet is available. Concomitantly, physical barriers which might make accessing this information quite difficult can be easily transgressed. Persons who might not feel able to discuss their sexuality candidly with local health care providers can locate a great deal of HIV prevention information via the WWW. While some of this information may come from local ASOs which have a presence on the WWW, organizations around the world are equally accessible. Internet resources permit individuals to access information about risk reduction discreetly and privately. Personal materials allow information about HIV prevention to be taken away from a distribution source. This portability allows for review of the materials at the person's convenience, and with respect to each person's own need for privacy. One operational reason for their popularity is the ease in which one can produce many of these materials, particularly pamphlets. Knowledge of word processing and access to a computer, printer, and a photocopier 31 are all that are needed to create and reproduce pamphlets. Many organizations now have this capability and produce their own personal materials which are context-specific for the communities in which their prevention programmes are implemented. As personal computers continue to increase in functionality and decrease in price, many more programmes will be able to create their own materials, rather than rely on those prepared by outside resources. Display Materials Many organizations use displays to give prevention information. The format of these displays include posters, information kiosks, and flyers. These displays can be found in public locations such as community centres, bookstores, gay bars, bathhouses and restaurants. As with personal materials, display materials are also often used in health facilities such as hospitals, clinics and private doctors' offices. Due to the size of many display materials, my data collection methods had to be adapted. Rather than collecting original documents or photocopies as was done with the personal materials, photographs of the display materials were taken. Posters are the most common format for display materials. Usually incorporating graphics that are visually engaging, posters often included specific information about prevention practices or provide referral information to other sources. Information kiosks feature poster-like images which are supplemented with pamphlets, wallet cards, or other personal material-format materials. Flyers are small and poster-like in appearance, and are usually printed on standard letter or legal size paper. Being much smaller than posters they are less expensive to produce and can be displayed in many more settings than larger format materials, but have more limitations in their messages due to the smaller size of these materials. Using displays to disseminate prevention information is less labour-intensive than the use of personal materials, while space considerations and accessibility to these sites can be 32 significant limitations. These resources can only be accessed when the facilities in which they are contained are open. Their prominence in the locations in which they are found can also be variable; the often controversial nature of AIDS prevention-related issues may lead hose who own or manage the facilities in which they are used to have their own interests about the appearance and placement of these displays. Limits regarding the explicitness of graphics used to represent sexuality and drug use are not uncommon. Analysis Of Materials Employing inductive reasoning, several key components of the materials collected were identified. Some components categorized structural aspects of each material, and were used to identify ways in which the different documents were alike or dissimilar. Beyond the mechanics of the writing, different embedded messages were uncovered in reflecting upon the materials' content and the circumstances in which they were created and used. The origins of the materials, the discourses located in their texts and their graphic representations used were analyzed independently and in conjunction with one another. For materials deemed to be created with a specific community in mind, how the interests of this community may have differed from the society at-large were examined. Origins. Foucault encourages scholars to "search for.. .instances of discursive production" (1990a, p. 12), to locate and contextualize knowledge. Doubtless the precision of the information of these materials is vitally important if they are to prevent HIV transmission. But if an explication of how not to become infected with HIV were the only important component of prevention materials, many fewer materials would have been produced and HIV infections should have dropped precipitously once successful technical strategies to avoid AIDS were determined. In 33 reviewing these materials chronologically, it is clear that certain strategies to reduce one's risk for contracting AIDS were discarded, while others became reified. In the epidemic's North American naissance, gay men counselled one another to avoid sex with "unhealthy-looking men" (AIDS Vancouver, 1983). By the mid-1980s, guidelines for using a condom for anal and vaginal intercourse were emphasized, and have remained an integral component in AIDS prevention programmes ever since. That effective technical strategies have been identified and communicated to prevent the spread of AIDS would be challenged by few; how this information has been articulated has varied greatly. So in considering by whom and for whom these materials were produced and how these technical strategies are incorporated into the publications used provided a challenging and fascinating point of inquiry from which I commenced my analysis. In particular, what perspectives about AIDS and (homo)sexuality could be discerned was what emerged from my analysis of these data sources. In addition to the inquiry as for whom these strategies were pursued, my analysis led me to ask why certain strategies have been reified while others have not. Inherent in these two areas of inquiry are their negations: why not, and not for whom. Immediately of significance was the affiliation of organizations with any specific at-risk communities which created each material, and what priorities and interests regarding preventing the spread of AIDS within that community could be surmised. I cannot claim to have definitively identified all such interests; doubtless a continuum of values, ideas and perspectives are to be found in groups of people gathered under a common interest. My analysis is analogous to the concept of direction of travel: just as a compass has 360 degrees to measure direction, so too does it have four broad paths of travel: North, South, West and East. The relevance of measuring direction precisely versus more 34 generally is contextually determined. Similarly, claims made in this study about the perspectives and interests which seem likely to have helped shape the materials produced are more general than specific, yet precise enough to be of value to those interested in the workings of AIDS prevention initiatives. The type of organizations from which these materials originated fell into five distinct categories, with an "other" category for materials from unique sources; one publication in this sixth category was a pamphlet produced and distributed by a condom manufacturer. These categories were AIDS service organizations (ASOs), other non-governmental organizations (NGOs ) whose mandates are not AIDS-focussed, and materials produced by the governments of Canada, British Columbia, or the City of Vancouver. All the organizations which produced the materials were either community-based or were operations of health-related government activities. A distinct difference in perspective between these two groupings was found, and is explored in detail in Chapter Four. Differentiations in Discourses. While it would have been within reason to consider all these documents as parts of one large AIDS prevention discourse, a different tack was chosen. Seven descriptors of discursive trends were chosen from the analysis of the materials, with each trend identifying a recurring theme. Most common was a medical discourse, which used the terminology and language of medicine to communicate how one becomes infected with HIV and the means by which to eliminate or reduce substantially one's risk of infection. Virtually every document reviewed incorporated some medically-framed conception of AIDS prevention, but often in conjunction with at least one other discursive trend. 35 Other trends were also informative. Some of the documents seemed to purposely use the quotidian language with respect to sexuality found in the urban gay male milieus. Examples of this would include "fucking" versus "intercourse" and "sucking cock" versus "oral sex", or "fellatio". This discourse closely paralleled the gay male discourse, in which the materials reflected the norms of the urban gay male community described in Chapter One of this study. In identifying these trends, the terms "gay" and 'homosexual" were determined not to be of importance, since they were not solely used to contextualize materials within the gay male community. Phrases such as "between men", "when two guys", and "rubbing your cock against his ass" are all example where sex between men is represented in a manner which assumes these male-to-male sexual practices are normative. Those materials which did not discernibly contextualize sexual behaviour related to a specific sexual orientation were categorized as neutral, or non-specific with respect to context. A heterosexual discourse was also identified, where these materials described normative sexual desires in terms of sex between men and women, using the language of the medical discourse. But within this heterosexual discourse, an unique and informative sub-discourse was discovered: frequently these heterosexually-focussed materials use qualifications about AIDS not exclusively affecting gay men. This nnot a gay disease" discourse seems to have been used to persuade heterosexuals that they too were at risk for contacting HIV. This strategy is problematized later in this study with respect to its efficacy, whether it is homophobic, and whether "troublesome" discourses like this should have a place in AIDS prevention programmes. Finally, one publication purposely employed plain language in their discussions of AIDS prevention. Since this strategy constitutes a contextualization of materials for persons of limited 36 literacy, it qualifies not only as a technical aspect of the texts, but as a veritable discourse linkable to specific communities. Figure 2 illustrates the distribution of the discourse types identified. plain language 11 "not gay" heterosexual w • o u _ quotidian neutral gay male medical 5 10 15 20 25 Frequency in Materials 30 Figure 2 - Types of Discourses Identified. Note the parallel between the "not gay" and heterosexual discourses. Graphic Images. In most of the documents analyzed the choice of graphics seemed to complement the discursive trends identified. Six types of images— penis, condom, anal intercourse, female-male 37 couple, and male-male couple—were found to recur most frequently. Graphics which did not seem to conform to any identifiable trend were categorized as other.. Not all materials used graphics; their absence (noted as none) appeared also to paralleled certain discursive trends. Since these graphic trends seemed often to be imbedded in the discursive trends, their discussion in Chapter Four is similarly integrated. Community Specificity. For the purpose of this study, communities were identified based on differing ethnic, gender, sexual orientation, or behavioural self-identifications. Each of the categories used for this analysis were culled from the materials themselves. Many of the documents were created by AIDS service organizations (ASOs) and non-governmental organizations (NGOs) founded by self-identified members of specific communities. With respect to ethnicity, South Asian, Asian, Latin and aboriginal categories were used rather than specifying ethnocultural communities such as Chinese, Vietnamese, El Salvadoran, Pakistani, Shuswap, etc. The four categories chosen reflect the existence of parallel ASOs in Vancouver: Healing our Spirit (aboriginal and First Nations), Atish (South Asian and Middle Eastern), Asian Society for the Intervention of AIDS (Asian) and VIDA (Latinas and Latinos). Finding materials targeting gay men and heterosexual women necessitates that they too were incorporated into this taxonomy. Sex trade workers and injection drug users (IDUs) also have unique prevention issues related to sex which were identified in literature specific to their contexts. Other materials reviewed had no perceived focus on a specific group or community. Figure 3 shows the frequency distribution of materials for each community type. 38 Heterosexual Women 2% Gay Men 51% Sex Trade Workers Injection Drug Users 2% None 33% Aboriginal First Nations 4% South Asia/Middle East 2% Figure 3 - Materials by Targeted Community. Slightly more than half of the materials analyzed were contextualized for gay men, with another one-third lacking any clear contextualization. Other Noteworthy Aspects. Key phrases and words were catalogued from the materials; some resources were found to contain as many as four key quotations. These quotations were seen to elucidate different discourses, or supported categorization of materials as specific to a target community. Other quotations were recorded for their relevance to issues identified previously as potential barriers in AIDS prevention strategies. As also identified by Patton (1987), homophobia, and sexphobia were two such themes. 39 One final piece of data for each document proved critical: its year of issue. While this study is not historical, consideration of these materials' chronology facilitated the mapping out of AIDS prevention in Vancouver as an evolutionary process. Juxtaposing the year of creation for materials grouped by similar characteristics (e.g. gay male discourse, condom graphic) facilitated analysis of how these different characteristics impacted upon prevention efforts. For example: why were there few materials targeting gay men 1983, which used the quotidian discourse to describe the sexual activities? In whose interests, and from whose perspectives did this strategy develop? And why did more quotidian language begin to be used in these publications, circa 1984? Could there be a connection between the choice of language to describe sexual activities and the nature of the organization which produced them? Can a consistent differentiation be claimed between public health and NGO-produced materials? These sorts of relationships are considered, argued and explicated in detail in the next chapter. In the final chapter of this thesis, these analyses will be used to map out the evolution of AIDS prevention for gay men in Vancouver. Inferences as to why some discursive trends were more effective than others will be drawn, and a look towards the future of AIDS prevention in Vancouver will also be taken. 40 Chapter Four: Analytic Strategies The materials analyzed were created between 1983 and 1999. As delineated in Chapter Three, five categories of descriptors were used to review each document: material format, origins, differentiations in discourse, graphic images, and community-specific identifications. Adding the year of issue for each document allowed for the chronologizing of materials which shared common characteristics. Initial analyses were conducted comparing year of issue versus community, year of issue versus graphic images, and year of issue versus differentiations in discourse. Additionally, unique and informative words, phrases, images, or designs were identified. A likely relationship between graphic images and differentiations in discourse was evident early in the document review process, so to an extent these two aspects of the materials were analyzed in conjunction with one another. Some commonalties among materials used by non-governmental organizations (NGOs) versus those used by public health entities were also uncovered. Across these two groupings some discourses seemed omnipresent, while others were only identified in materials by NGOs for specific communities. These materials were also analyzed with regard to language; documents were linked together based on shared or similar language used in discussing sexuality. These examinations were done to identify different perspectives and interests which appeared in the publications. Subjugated knowledges were thus identified, and the interplay of these knowledges with the knowledge regime (i.e. medical paradigm of health promotion) was also considered. Discursive Trends Two discourses appeared most consistently: one with respect to male homosexuality (i.e. gay men) as a lifestyle, and another about sexuality. With the initial location of the AIDS epidemic almost entirely within the urban gay male milieu, and the existing normative practice of 41 discussing disease prevention in wholly medical terms, the interaction of these two discourses is quite logical. It also makes sense that the materials produced by the gay male community at the beginning of the epidemic would conform with the dominant medical paradigm. This medical discourse still appears to varying degrees in most materials which discuss HIV prevention techniques, though often in conjunction with other discourses. Discourses on Sexuality The discourses on sexuality were classified as quotidian or medical. With respect to language usage, the medical discourse used terms and conceptions about sexuality which have their origins in medicine. The terms themselves are "neutralized", or "clinicized". This neutralization of sexuality is done to focus on a behaviouristic model of sexual health which ostensibly avoids moral or juridical controversies, such as homosexuality. The exegesis of sexual acts without identifying who might engage in them is superficially neutral, but in pursuing this neutrality, what occurs is a continuation of the silencing of those whose lives do not fall within what medicine considers "normal". While homosexuality is no longer classified as a mental illness, it continues to be considered as deviant by some practitioners of medicine. Adrienne Rich wrote of "compulsory heterosexuality"; so too is there an assumed heterosexuality, in the absence of naming homosexuality or other expressions of desire outside monogamous, heterosexual marriage, prefaced by chastity (1984). Weeks (1991, p.73) saw this decontextualization as more anti-sex than anti-gay. Regardless, with respect to AIDS, this strategy impeded any timely response to AIDS by public health officials. This in turn led to a pandemic of unforeseen proportions throughout North America's gay male communities, including Vancouver. Identifying a quotidian discourse means that non-medical, everyday terms are used to discuss gay male sexuality. The medical terms "penis", "anal intercourse, and "oral 42 sex" (meaning fellatio) have the words "cock", "buttfucking", and "cocksucking" as equivalents in the vernacular of the urban gay male milieu. But these discourses differed not only with respect to terminology. In many instances it was the assumptions embedded in phrases and sentences which disclosed to which discourse a publication could have been attributed. "Use of condoms is the only effective barrier oral contraceptives will not prevent the spread of AIDS or other....", and "If you want to fuck your partner, be sure to use a condom he's worth it!", can serve as examples as to how such determinations were made. It is only in male-female sex that the issue of oral contraception is relevant; with no other qualifiers which neutralize this assumption of heterosexuality, this document would fall into the medical discourse. In the second example, to "fuck" someone is to penetrate orally or anally. Since it can be assumed that the reader is male (the penetrator), and "he" is "worth it", then this is a male-male sexual act; in its articulation of male-male sexual practices as not unusual, this publication employs the quotidian discourse. In some cases the quotidian language appeared with its medical counterpart, but not always. Consider these excerpts, one each from a booklet and pamphlet, both of which were distributed in Vancouver, commencing in 1983: Other than celibacy and masturbation, the trend seems to be toward dating...another pattern is monogamy, absolute or extremely restricted (Information about AIDS from AIDS Vancouver booklet, AIDS Vancouver, 1983) In particular, rimming...increases risk. Fisting...may damage (the rectum's) delicate lining, one of the body's natural defences against infection (What Are My Chances? pamphlet, AIDS Vancouver 1983) These were publications distributed by AIDS Vancouver in its first year of existence; several differences were noteworthy when comparing them. While both used the medical discourse, the former only referred in vague terms to sexual relations as a route of AIDS 43 transmission. The second referred to sexual activities specifically, and used the local vernacular to describe specific practices, and assumed those who might engage in the activities would have been more likely to implement the risk reduction suggestions made because of the language used. In scrutinizing these documents beyond these excerpts, it was clear that the booklet Information about AIDS from AIDS Vancouver presents a detailed discussion about AIDS with precise information about the disease, its transmission, and how AIDS is impacting the socialization patterns of gay men in cities such as New York and San Francisco. Since little was then known about how AIDS was transmitted, there was some conflicting information (which is acknowledged by the authors). The pamphlet addressed the issue of risk, from both past behaviours and today's choices, whereas the booklet, in its use of the medical discourse spoke more often as an authority and employed formal language. In the pamphlet a uniformly peer voice, like the vernacular between friends or peers, was used. These publications' apparently purposeful choice of language indicates each's different relationship with the reader. Some materials targeted through specific discourses audiences that were either heterosexual or homosexual/gay male, though they incorporated the medical discourse when matters of sexual behaviour were discussed. These secondary discourses were less elucidating than the quotidian and medical discourses, they were of significance nonetheless. In the homosexual/gay male discourse, no qualification or apologist stance was offered for homosexuality: desire for one's own gender was consistently framed as normative. Yet in many publications, qualifications of heterosexuality were found. "AIDS is not a gay disease", "even heterosexuals", and "whether you are gay or straight" are all examples of the types of phrases 44 commonly used to engage a heterosexual audience, and to encourage heterosexuals to consider themselves at-risk for HIV infection. A few materials did engage in a neutral discourse with regards to sexuality, but this discourse largely disappeared after 1987. Perhaps after AIDS discussions had been in mass media for several years, any discussion about AIDS which did not engage issues of sexuality appeared irrelevant or antiquated. It is also possible that neutrality and effective AIDS prevention were eventually deemed incompatible, regardless of the sexual orientation of the target audience. Community-Specific Discourses As the information about AIDS and its transmission became more precise, the materials varied less and less in their guidelines for risk reduction. Materials began to appear which focussed less on behaviour and more on aspects of lifestyle. Publications geared towards sex trade workers (1987), Latinas/os (1987), and women (1989) all appeared for the first time. Each document differed in its contextualization of sexuality, but sexuality was only one component of their prevention messages. Consider the following excerpt from a pamphlet published by Healing Our Spirit, a local ASO: HIV/AIDS is preventable by: practising safer sex; protecting your body; respecting your partner, talking to your partner about HIV & hepatitis. Taking care of each other for a safer path through your journey (Healing. Caring And Sharing pamphlet, Healing Our Spirit, 1996). Here were found local values and beliefs at the centre of a prevention strategy for AIDS prevention among aboriginal and First Nations peoples. The medical discourse did appear in its more general form in this pamphlet, though its primary prevention message was that preventing one's self and others from HIV are community concerns. This framing of AIDS prevention as a communal responsibility seems to be unique to the 45 materials created for aboriginal communities. In all other publications the prevention discourse is framed in individual terms, specifically as the protection of one's self. This unique prevention message was further contextualized with aboriginal artwork and depictions of aboriginal men, women and children. For the other ethnocultural communities (Latin, Asian, South Asian/Middle Eastern), few publications for each grouping were located, created by an ASO serving that same cultural group. This implies that if these communities had not created their own materials, such materials might not have been create at all. Each publication stated that it was the absence of materials, germane to their community's precise needs, that was the impetus for the publication's creation. Common to all three publications were information in languages other than English, the offering to persons assistance when seeking information from other "mainstream" ASOs and NGOs, and peer support and counselling. None of these materials discussed technical aspects of HIV transmission or HIV prevention: additional resources were listed for this information. All materials which were male-specific fell wholly within the gay male discourse; no heterosexual-male specific materials were located in the data collection for this study. In the two publications analyzed which were female-specific, the technical aspects of HIV prevention were absent. Instead the importance of self-worth, and strategies for negotiating condom use with sexual partners were emphasized; the role of trust in sexual relations was also highlighted. A missing component from these materials was the issue of violence and abuse; since for some women, "negotiating" is not a realistic option, with either their regular sex partners or their customers in the sex trade, this omission was a critical one. Issues specific to work in the sex trade were incorporated into one of the two female-specific pamphlets. 46 Excluding the publications which were created specifically for the gay male community, the community-specific materials all shared the following commonalties: • They were created by members of the communities themselves; • the language and images used were drawn from their milieus; • the mechanics of risk reduction were excluded ; and • the materials positioned themselves as supplements to existing prevention resources. Organizational Origins Publications which were created for public health programmes were distinctly different from those for ASOs or NGOs. In the public health documents, discussion about sexuality were frequently general and always within the medical discourse; no graphic representations of sexuality were used. Discussions about sexuality were neutral or integrated both homosexual male and heterosexual practices: gay-specific materials created by any Canadian public health entity were not located for this study. These materials consistently adapted the content of public health prevention materials to their own context-specific strategies. Community-created materials used their choice of locally-relevant and community-specific language and graphics to convey to their readers that their prevention messages were of relevance to their lives. With existing mainstream materials already available, these local publications were not as likely to seek credibility in more traditional ways, such as statistics, graphs and tables. In the public health-created publications, such quantifications were a primary means by which to establish this credibility; in pamphlets and booklets which sought to avoid contextualizing issues about HIV risk related to sexuality, few other strategies seem possible. The community materials did not reject quantitative evidence, but it is in their speaking in the first-person plural—we—that the community-created publications most often tried to gain their readers' trust. 47 Public Health Publications & Gay Male Sexuality Homophobia is an oft-used term whose connotative meaning varies according to usage. From its origins as a psychological categorization for an irrational fear of homosexuals, its meaning today in Canada is more akin to a discomfort for, or dislike of, homosexuals. Within the gay community homophobia is also used to describe an extreme hatred for homosexuals. Quite often in discussions about homophobia, the issue-at-hand is actually heteronormativity. "Heterosexual) culture thinks of itself as the elemental form of human association, as the very model of inter-gender relations, as the indivisible basis of all community", according to Warner (1993, p. xxi). This belief of what is perceived to be normal as being universal can be amusing, annoying, frustrating, or life threatening to those whose lives do not reflect this assumption. Certainly knowledge of this dynamic was an impetus behind gay male community strategies in response to AIDS. That heteronormativity was uncovered in materials created by public health officials was not surprising; what was shocking was that long after the first booklet published by AIDS Vancouver appeared (1983), public health-sponsored literature on AIDS prevention could still incorporate messages which were clearly heteronormative. In What EVERYONE Should Know about AIDS (Health Canada, 1990), a neutral discourse on sexuality was employed, stating "your risk of getting AIDS depends on what you do—not who you are". Yet each of the ten cartoon sketches of couples were of male-female pairings. AIDS: This Information could Save Your Life (BCMA, 1987) was less subtly heteronormative. Its cover showed the image of a male-female couple kissing, super-imposed over a tombstone. In its fear-based prevention message, the following admonishment was found: 48 If there is any risk for HIV-infection, practice 'safe sex'. This means you should not perform anal intercourse, and you should always use condoms for all other forms of intercourse, (emphasis original) In its discussion of AIDS in British Columbia, this pamphlet further reified female-male sex by offering risk reduction strategies which would fall almost exclusively within a connotative understanding of normative heterosexual practices. This same understanding in our public sphere locates anal intercourse as a sexual activity which is almost exclusively occurs between men. The creators of this pamphlet seemed to endorse this assumption, which aligned well with moralist rhetoric against homosexuality as the "true" cause of AIDS: if gay men were to cease to engage in buggery, AIDS would not be a public health problem. But this sort of interdiction is not merely a suggested change in behaviour for many gay men. Anal intercourse between men is seen by many gay men as the preferred way of sexually expressing love for one another. Many gay couples would no more willingly give up anal intercourse than would many heterosexual couples forego vaginal intercourse. In the absence of offering an alternative which includes anal intercourse but which reduces the risk of transmitting HIV (such as using a condom), some gay men might choose the risk of unprotected anal intercourse, rather than forgo this important act of sexual intimacy. That this bigoted and inaccurate message was disseminated nearly ten years into the AIDS epidemic is distressing. Discursive Images And Sexuality In the personal-format materials analyzed, the role of graphic images was supplemental to the text which accompanied them. The most common graphic type, organizational logos, did not play a significant part in any of the discursive trends identified. In some instances, other graphics were used to reinforce the themes or concepts contained in the text. This was most 49 consistently used with regards to the "AIDS is not a gay disease" discourse. Nearly every document in this discourse incorporated images of female-male couples. Graphics which showed a condom in its wrapping, a box or condoms, or partially unrolled were also common; condoms in use during sexual relations between men and women did not appear, though they were found in materials targeting gay men. In addition to stand-alone, decontextualized condom images, other materials included instructions on proper condom usage, with graphics that articulated the process of "how to put on a condom". These images were not just of condoms as solitary objects; the condoms were being applied to an erect penis. These demonstration graphics were unique in their visual contextualization of condom use, and in they did not appear in materials created by public health officials. Figure 4 is an example of a condom demonstration graphic from a wallet card distributed by AIDS Vancouver. For sofer oral sex (mouth to vagina or bum), you can use a square piece of latex. Just tear a condom lengthwise and hold the fatex between the mouth and vagina or bum. Remember: Use a different one for the vagina ond bum, and a new one for each person. Remember which side is yours! Figure 4 Condom Demonstration Graphic Why didn't other materials incorporate images such as these? The value of instructing proper condom use seems clear. Perhaps, the exclusion of these images can be linked to the greater candour about matters sexual among gay men, and the relative prudence in matters sexual found in society at-large. This difference in perspective is not limited to homosexuality, but to sexuality in general. Gay male communities, those most severely impacted by AIDS, were already engaging in more candid and less inhibited discourses regarding sexuality prior to the 50 AIDS epidemic; this made these images non-controversial among gay men. In most other contexts, such candour could have impeded prevention efforts by creating controversies which would have derailed the dissemination of precise risk reduction information with rancorous debates on morality. Resistance to the installation of condom dispensers in public high schools in British Columbia is such an example. Posters and Erotic Imagery Unlike personal materials, posters and other display materials were created to provide information to groups of persons rather than individuals. While the images in these materials included logos, cartoons, and condom demonstrations, it is their frequent incorporation of overtly erotic images that was most noteworthy. These images were always linked to gay male sexuality, though how this sexuality was portrayed varied considerably. They included representations of male-male non-sexual intimacy and dating, and of explicitly erotic situations conveyed with full frontal nudity, including erections. These posters were produced by ASOs in San Francisco, Toronto, London England, and Sydney Australia. All of these posters were located on display in one of three gay bathhouses in Vancouver. The three posters in figure 5 were all created by the Terence Higgins Trust, the United Kingdom's largest ASO. Each explicit image places gay male eroticism in a different context. The far left image represents two men in a romantic relationship, the middle image is of two men having a spontaneous sexual encounter, and the final image is of an anonymous sexual encounter between two men in a public toilet. Following the images is an analysis of each poster. 51 Love alone... Anytime, anyplace... Safer sex... Figure 5 - Posters, Terence Higgins Trust "Love alone is no protection. Always use a condom". An important component in many HIV prevention among gay men has been the issue of condom use in monogamous relationships. For some activists, self-protection includes any sexual contact, whether it is with one's partner, or with a stranger. Others see this message as homophobic, in that it characterizes gay men as untrustworthy or unable to be sexually faithful. This poster clearly takes the former stance. The image of two young men on a bed, aroused and intimate, conveys to gay male couples that condom use is important, and can be a natural part of sex, rather than an impedance. "Anytime, anyplace, anyone. Safer sex is the only way". Can one take a holiday from condom use? This poster reminds gay men that regardless of where one has sex, condoms must be used. It cannot be determined whether these two men are lovers or this is a casual sexual encounter, but the message is clear the setting of a sexual 5 2 encounter shouldn't affect whether condoms are used: gay men should carry condoms with themselves if a sexual liaison may occur. "Safer Sex. At your convenience". This is perhaps the most controversial of the posters in the series: two men engaging in an anonymous sexual encounter in a public toilet. While such activity is illegal in many jurisdictions (including Canada), they do occur. One challenge of AIDS prevention strategies is to reach men who may not be strongly affiliated with a gay male community but who engage in sex with other men. Venues for anonymous, clandestine sexual encounters are especially difficult to penetrate for disseminating risk reduction information. The men who frequent places like public toilets or parks often do not consider themselves gay and are rarely accessible to AIDS educators. And with civil authorities are not likely to co-operate with outreach efforts in places in which public sex acts are known to occur (to do so could be perceived as a sanctioning of these activities), virtually no outreach occurs with these men. Since these posters were not displayed in public toilets, the extent to which they reached their target audience is unclear. While these materials are used in Vancouver to promote risk reduction among sexually active gay men, their explicit depictions of sexuality have marginalized their use to gay bathhouses. Whether these posters could play a larger role in AIDS prevention strategies in Vancouver will probably remain speculative. It is their representations of gay male sexual desire which almost certainly precludes their display in more public settings, mainstream or gay. What is also noteworthy about the Higgins poster series (they are five posters in total) are their representations of gay men. Physically toned men who appear to be between the ages of 18 and 30, and whom all but two appear to be of European descent are featured. The diverse population of gay men—older and younger, of different ethnocultural backgrounds, with differing 53 states of wellness and many different body types—is absent. In their contextualizing of safer sexual practices these posters are laudable, but for whom these contexts reflect gay men's real lives is dubious. An incorporation of a broader spectrum of gay male images would possibly facilitate more men identifying their realities in the images used, and hopefully be more inclined to integrate safer sex practices into their lives. Temporality of Trends. A veritable continuum of strategies, appears over the years in which AIDS prevention education has evolved. The differentiations identified in this chapter with respect to issues of sexuality perhaps best demonstrates this. In reviewing materials which fall into either the quotidian or medical streams, clear trends were delineated. By 1983, it was believed by researchers that AIDS was most likely caused by an infectious viral agent, though this agent had not yet been isolated. Without its identification, the precision with which risk reduction strategies could be designed was limited. Though a marginal use of the quotidian discourse was evident, most prevention materials offered very broad, imprecise suggestions on how to avoid getting AIDS. A majority of the materials from the gay male milieu seemed to follow the "only use the real (i.e. crass) words when absolutely necessary" rule. Materials which were not contextualized to reflect gay men's experiences spoke of sexuality only in the most general of terms, avoiding references to any specific sexual acts. The quotidian discourse first appeared in 1983 in materials distributed by AIDS Vancouver. Initially this discourse appeared to supplement the dominant medical paradigm which held sway in the realm of health promotion. Some sexual practices between men did not appear in specific terms in this medical discourse; fisting, the insertion of several fingers or the entire hand into a vagina or rectum, is one example. In other instances a medical term did exist but was quite obscure; few gay men would be familiar with the term analingus, but most would have known what the term rimming meant; both words described stimulation of a partner's anus with the lips and tongue. HIV was identified as the cause of AIDS in 1984, at which time the pathology of AIDS was narrowed to transmission by sex or through blood-to-blood exposure, and two accurate anti-body tests became available shortly thereafter to test for HIV infection. With this discovery, the extremely problematic risk reduction strategy of trying to surmise a potential sexual partner's health by their appearance was no longer necessary. Prevention materials began to focus on the sexual transmission of HIV, and how to eliminate or greatly reduce one's chances of becoming infected. By 1985, two distinct target audiences were identifiable in AIDS prevention efforts in Vancouver: gay men and society at-large. In the former, the medical discourse was taking an increasingly secondary role to the quotidian discourse. The latter's materials continued to discuss sex without contextualizing it as either heterosexual or homosexual. Summary If one were to transfer many of the materials designed for the contexts identified in this study to other milieus, their efficacy would be dubious. Some materials express their prevention messages in language which convey specific meanings to members of pre-identified community. To many, the sexual candour found in the text and images created for gay males is at best irrelevant and at worst offensive. Each community at-risk created materials for themselves, and tailored their prevention messages to local understandings of what constituted "normal" behaviour, particularly with respect to sexual behaviour. Broad or "neutral" public health-centred strategies have most likely always been of dubious efficacy with stigmatized and marginalized communities. With the emergence of 55 conrmunity-driven, context-specific AIDS education strategies, this paradigm of health promotion has been successfully challenged. In Canada today, population health is the current strategy being implemented with regards to health promotion. Population health builds upon "the experience and knowledge gained from lifestyle and health promotion efforts, (and) focuses our attention on inequalities in health status and their determinants" (Edwards, 1999). Direct input from target communities—ethnocultural, sexual identify, geographic—is an integral component of this strategy. AIDS prevention successes among the gay male communities of Canada are a primary force behind this change from health promotion as a government-driven activity towards a more integrated, cooperative effort between government and communities. My commentaries with regards to government AIDS prevention strategies should not be misconstrued as a vilification of the efforts of public health officials. It must be said that numerous accurate, timely and well-designed materials have been published by governments in Canada related to AIDS prevention. In criticizing some aspects of some materials it is not implied that government efforts to help stop the transmission of AIDS have been of no use. But what can be concluded from these critiques is that when a marginalized or stigmatized community encounters a specific health crisis which does not affect the general public, it cannot rely solely upon a government response. And a government which wants to respond effectively and quickly to such a challenge should work co-operatively with community members once such a crisis is apparent, so a relevant response can be formulated. 56 Chapter Five: Conclusions Previous prevention efforts succeeded in reducing HIV infection among gay men the federal government and its partners continue to give information and other kinds of support to those working with at-risk populations. Report on HIV/AIDS 1998, Health Canada Evolution Of AIDS Education In Vancouver Why did AIDS prevention programmes in Vancouver evolve as they did? In the absence of any relevant or effective strategy from public health officials, gay men saw it necessary to identify for themselves AIDS risk reduction techniques, and shared this information through informal social networks. This eventually progressed to the formation of committees and organizations for disseminating prevention information. Though more mainstream government-sponsored programmes also developed, the community's own context-specific endeavours were more readily received. A primary reason for these community-developed strategies' acceptance was their candour with respect to sexuality and sexual practices. Their effective weaving of the dominant medical discourse with their own local, quotidian discourse about sexuality was widely welcomed by gay men. In comparing the annual statistics for newly reported HIV infections by risk group in British Columbia between 1984 and 1997 with the evolution towards more gay male specific prevention efforts (indicated by the more frequent use of the quotidian and homosexual/gay male discourses), one can see that strategies pursued by ASOs and other community groups played a role in helping gay men to reduce their risk for HIV infection (Health Canada, 1998). With the apparent limitations of the medical discourse regarding sexuality, government programmes eventually began to contextualize their prevention efforts towards the specific communities whose members were perceived to be at greater risk for HIV infection . This co-operation with communities in developing health promotion strategies has not been limited to AIDS prevention; population health is now the centrepiece of the national health promotion strategies in Canada. 57 Sexuality and Discursive Product. Foucault described Western society's normative discursive practices around sexuality as "restrained, mute and hypocritical" (1990a, p.3); the results of this study support this characterization. In its efforts to prevent the spread of a sexually transmitted and largely fatal disease, government continued to resist any implementation of more candid discourses about sex, despite sex being the primary route of transmission for AIDS in Canada. Since HIV has been transmitted in Canada mostly via sexual relations, why then have the publications used in government prevention programmes mostly vague in their discussions of sexuality? And why were the discussions themselves routinely decontextualized? In seeking to prevent the further spread of a fatal malady like AIDS, this continued pursuance of a "neutral" discourse seems spurious. What "local power relations" were at work in AIDS prevention education in Vancouver? Certainly among gay men those relations related to sexuality played a critical role in how AIDS prevention in the gay male milieu was advanced. Homosexual desires were expressed and celebrated long before they were permitted under the Criminal Code of Canada, but with the acquisition of some civil rights for homosexuals, these desires were expressed more openly. Immediately prior to AIDS, gay men in Vancouver were exploring sexual activities, customs and relationships without and within the monogamous norms of mainstream society, just as many of their peers across North America were (Shilts, 1987; Seidman, 1993). While these challenges to the mainstream were somewhat problematized in the early years of the AIDS epidemic, the candour with which issues related to sex and sexual relations were discussed among gay men did not substantively change as the AIDS pandemic manifested itself. Today in Vancouver, this discourse on sexuality continues to transgress the mainstream medical discourse on sexuality. 58 Subjugated Knowledges Whereas the mainstream regimes of thought critiqued, ghettoized and silenced homosexuality, in many ways, society's medical discourse on sex did not subvert the local knowledges about sexuality which had already taken root among gay men (Foucault, 1980b, p.81). This local knowledge's most fundamental component was that male homosexual desire was to be celebrated, not loathed. In its challenging of mainstream indictments of homosexuality, a subsequent examination about many other aspects of romantic and sexual relations was a reasonable next step, which many gay men then took. Assumptions about love, relationships, monogamy, promiscuity, intimacy, and innumerable other aspects of sexuality were open to scrutiny, adaptation, acceptance or rejection. This articulation of unique and individual personal moralities about sex and relationships was an integral component of "coming out" for many gay men. The successful integration of this local knowledge into gay male specific AIDS prevention strategies supports my claim of their appropriateness for the gay male milieu. Risk reduction strategies for gay men strove to be non-judgmental about the circumstances in which sex occurs, and instead incorporated many different settings for sex between men. The overall message was that gay men needn't abhor their sexuality in the age of AIDS, regardless of how these desires for other men were expressed: men were simply encouraged to protect themselves and their sex partners regardless of circumstance or activity. And any mainstream discourses in which AIDS was inferred to be a punishment for homosexuality's immorality were rejected. Discourses in society at-large generally demonized homosexual desires,; and while some discourses were nuanced with respect to differences in how these desires were fulfilled, such discourses were rare. Entreatments within the gay male community to ignore these mainstream messages were indeed "insurrection(s) of subjugated knowledges", particularly in their refusal to 59 moralize about sex (Foucault, 1980b, p. 81). There was discussion and dissent within the communities (about promiscuity in particular), but these discussions never significantly impeded prevention efforts. Resources could not be diverted towards infighting or debates on morality: energies needed to be focussed on the immediate struggles of providing care for those ill, and disseminating information to ensure that those uninfected remained so. Interdictions And Benedictions Dubious of the "regimes of thought" which defame it, a subjugated group can turn to its own local knowledge as the basis for its response to a crisis (Foucault, 1980b, p.81). In the mainstream the reality of such a group's existence is not only maligned, it is often silenced or ignored. To most, "those people" do not, or should not exist. The practices of dismissal, silencing and vilification all serve to interdict any discourse which might challenge this dominant perspective. In juxtaposing the materials which were from the gay male milieu with those from society, critiques of (male) homosexual desire are easily discerned. These critiques, which most often operate in collusion with silence about homosexuality, perpetrate this regime of thought. Heteronormative content—both graphic images and text—informs as to the benedicted desire in the mainstream. Interdictions against homosexual desire, or the absence of acknowledgements of the existence of homosexual desires, serve as de facto benedictions of heterosexuality. In the gay male milieu, while male homosexual desire was normative; this was not attained by denigrating heterosexual desire. The celebration of all forms of sexual desire was the mode of benediction. Sometimes these same expressions of homosexual desire were used in the mainstream as evidence of the "baseness" of homosexuality; the practice of anal intercourse between men and aspersion of all gay men as "promiscuous" were among the more common expressions of enmity. But within the gay male milieu these messages were consistently refuted. 60 What was interdicted was not the expression of desires other than homosexuality. Interdictions against any desires, against any intolerance of sexual diversity, were instead the norm. Foucault offers a new mode of inquiry related to analyses of competing knowledges, which he himself employed to examine discourses about sexuality. "Instead of looking for basic interdictions that were hidden or manifested .... it was necessary to locate the areas of experience and the forms in which sexual behaviour was problematized, becoming an object of concern ", he recounts from his own research in The Use of Pleasure: the History of Sexuality. Volume Three (1988, pp.23-24). I submit that to some in the mainstream of society, AIDS represented an opportunity to re-assert belief systems which characterized homosexuality as evil. Within the gay male milieu this has served to reify local knowledges about sexuality. It can now be argued that male homosexual desire is less interdicted than it was prior to AIDS. Knowledges about the practices of male-male sexual desire remain largely subjugated, while tolerance of diversity with respect to sexuality in principle has diffused into the mainstream. This also supports Foucault's theory that criticism's character is not limited to the local, but can impact upon other locales or the mainstream (1980b, p.81). One discursive trend deserved a more critical examination, the "AIDS is not a gay disease" discourse. Among gay men, the connotative meaning of this phrase was often taken as "AIDS is a sexually transmitted disease, not a homosexually transmitted disease": the pathology of AIDS has no moral component. In the mainstream this discourse has been used more to challenge notions of AIDS only affecting "others"--homosexual men, drug addicts, people in the Third World. The message in the mainstream has been that anyone can get AIDS. But does this discourse perpetuate homophobia? If so, do we want AIDS prevention strategies that validate prejudice? 61 Had HIV been identified in 1974 (rather than 1984), what sort of discourse might have evolved in North America regarding AIDS, specifically in the gay male milieu? It is now apparent that HIV was already endemic in much of sub-Saharan Africa by the mid 1970s, more than ten years before AIDS exploded among gay men in North America. How legitimate a threat would a disease spreading among heterosexual Africans been perceived by a largely Caucasian, homosexual community in Western Canada? If a prescient epidemiologist predicted the leap HIV would take from Africa to North America, who would have modified their sexual practices as suggested? Would many have considered such a threat important enough to foster an immediate change in sexual behaviours? Might a discourse have developed which would have centred around an "AIDS is not an African (or Black) Disease" theme? While the tension here is somewhat conjectured, doubtless the genuine "anti-gay" and conjectured "anti-African" trends are rooted in prejudices (homophobia in the former, and racism in the latter). Discourses such as these do not demonize the communities named in them. Instead they serve to challenge notions which are perceived to be significant barriers to many persons taking seriously their risk for HIV infection. The "not a gay disease" discourse is of merit for mainstream prevention strategies because it reflects a contextual reality of society at-large: homophobia is used by heterosexuals to delude themselves about their risks for contracting AIDS. As strategies were integrated into gay-milieu prevention programmes which elsewhere were seen as offensive and disturbing, so too must gay men (and lesbians) permit those who plan mainstream programmes to include elements which may offend some, but which are purposefully chosen for their perceived efficacy in reducing new HIV infections. Educators need also to be cautious in their efforts to create context-specific AIDS prevention strategies; more precise is not always better, nor is it ever all-encompassing. There is 62 evidence from some epidemiological studies (Strathdee & Schechter, 1995; Strathdee et al 1997) that among homosexual men there are those on the margins of the gay male community who might not be receiving adequate prevention information under current programmes. Some men who have sex with other men do not consider themselves gay or bisexual, and do not frequent gay establishments; they might not view "gay" prevention materials as relevant to their lives. Other men might not identify with the affluent images of the gay male milieu which permeate AIDS prevention publications. Illiterate men will be unable to access any gay male-specific prevention materials, since none seem to have been created which are accessible by those who cannot read. These (and other) issues are also found among sex trade workers, injection drug users (IDUs) and society at-large. Developing prevention strategies for those on the margins of the epidemic needs to be made a priority by AIDS educators. The existence of such exclusions is disturbingly similar to the interdicting silences found about homosexuality in mainstream society in the first decade of the North American AIDS epidemic. Is it a coincidence that perhaps the most memorable slogan from AIDS prevention programmes in North America has been "Silence=Death"? Transferable Findings For those who wish to examine their efforts in either community education or public health promotion, to what extent is this study germane to their endeavours? Are the findings in this report of value to those whose practices are in wholly different contexts, or only to those whose work is in settings similar to those described herein? Three specific aspects of how local knowledges and knowledge-regimes interact seem applicable across contexts. 63 The Importance of Local Knowledges. Marginalized and stigmatized communities do, can, and should nurture the synthesis of local knowledge, and both local and broader modes of inquiry will often appear in these knowledges. While to use the mechanisms of validity found in external paradigms (such as those from the academy) cannot extinguish these knowledges, neither should such mechanisms serve as means by which local knowledges are excluded from the mainstream. Seeking commonalties between contexts can aid in determining whether a local knowledge might be transferable to another milieu. A greater number of shared experiences and perspectives may well indicate a greater potential for local knowledge exchanges. Interaction Between Local Knowledges and Regimes of Thought. A perpetuation of practices which binarize local knowledges against mainstream knowledges has not reified regimes of thought over local knowledges. Neither has disdain in a locale of mainstream knowledges, prior to the critical examination of such knowledges, necessarily been of benefit. Knowledges which are of little or no value will not detract from those which have been previously determined to be of importance in a given context. Any out of hand rejection of potentially valuable knowledge due to its origins is defeatist. Discourses Evolve, as Do Knowledges. As demonstrated by how mainstream conceptions of sexuality in health promotion practices are often static and unchanging, any ideas related to human behaviour are likely to lose relevance the longer they remain unchallenged and unexamined. As a context evolves objectives change, are discarded, acquired and clarified; so too will some conceptions change which are related to the subject at hand. Yesterday's local knowledge can operate as a knowledge-regime when it does not yield to other more nascent local knowledges. Already at the close of the second 64 decade of AIDS in Canada, we see the focus of prevention programmes in the mainstream shift from male homosexuality to injection drug use. It follows that the local knowledges which will gain prominence will be those related to injection drug use-transmitted HIV and its underlying issues: addiction, and poverty. Attempts by some gay male AIDS activists to assert their "expertise" in developing HIV prevention strategies actually reify the hegemony of external, hierarchical knowledges. Commentary In its beginnings, the community response to AIDS among gay men involved grassroots outreach and education which conformed to the knowledge-regime of the medical discourse on sexuality. That these activities were initiated by men who were themselves physicians is not coincidental. Most of the other men involved in the founding of what became AIDS Vancouver were university-educated, professional men of European ancestry, a reflection of the West End urban gay male milieu. In describing the gay male communities in this study, I have been circumspect in avoiding the term oppressed. While I would argue that to be outspoken about one's same-sex desires can lead to being oppressed, for many of these men their pursuit of these desires did not include their overt identification as gay men to family, friends and co-workers. They were not all "out". Unlike visible minorities, homosexuals are a somewhat hidden group. Heterogeneity in physical attributes colludes with heteronormativity to perpetuate the heterosexual assumption: most adults are presumed heterosexual unless they are revealed to have same-gender desires. With this concealed identity, either willingly or by assumption, male, Caucasian homosexuals who otherwise are not marginalized can choose to retain privileges by remaining secretive about their proclivities. Concomitantly, persons of colour and women cannot choose to secret that 65 which marginalizes them. Within this dynamic, it seems logical that these men would perhaps have been more likely to integrate some of the normative health promotion practices from the mainstream into the initial community-based AIDS prevention strategies. I see the initial conformity to the medical discourse, through the use of publications which were quite similar in style to public health promotion materials (and were sometimes subsidized by government entities) as direct evidence of this. To ask if these men implement the practices of this knowledge-regime as an extension of their places of relative privilege is not an elucidating area of inquiry. What is of note is that these same men (and those who followed) adapted their programmes to their own local context. In its evolutionary nature, I see that discourse will integrate and discard knowledges as they become available, are tested, and deemed valuable or valueless. But incorporating external knowledges is not a benign act. To integrate knowledges into an existing knowledge base is not synonymous with choosing an external knowledge as a substitute for a local one. This is perhaps the great pitfall of introducing parts of the knowledge-regime to local knowledges in determining local practices: as a subjugated part of the mainstream, it is easy to subsume one's own local knowledge in favour of more widely embraced ideas from the knowledge-regime. While components of such information have a material impact to be certain, the significance of community members perpetuating the hegemony of the knowledge-regime as a dynamic needs to be of equal importance. A Praxis for Effective Community Education. AIDS is perhaps the greatest global health threat in the post-vaccination era. Hopefully, a foolproof prophylaxis for HIV, or a cure for HIV infection will soon appear. Though treatments for Canadians with AIDS-related illnesses have improved dramatically over the last decade, that 66 AIDS is still largely fatal must not be ignored. In the absence of a cure or vaccination, effective prevention programmes must be created and improved, to reduce (if not eliminate) new HIV infections. Sonia Nieto states "all good education connects theory with reflection and action...defined as praxis" (1992). Reflection on one's actions, one's position in the setting of practice, and one's relationship with those being assisted is complemented by consideration of theoretical and ideological underpinnings related to self and society. This integration allows community educators to pursue local change as a part of a broader agenda for a better society. In helping to improve the circumstances under which those on the margins of society live, benefits are realized by society as a whole. The extent to which the findings of this study are of merit to other contexts can be measured by the importance of local knowledges in the setting of the educational programme, how the local knowledge can be differentiated from the knowledge-regime, and in the potential merit of any such determinations to one's practices. But these findings should also be considered by those who direct public policy related to health promotion activities at the municipal, provincial and federal levels of government here in Vancouver. In the last few years, a climate of fiscal austerity has seen a trend towards government support being channelled through a decreasing number of NGOs. This strategic action has been undertaken to reduce administrative expense incurred when organizations with similar mandates deliver overlapping programmes. Is this the policy direction we wish our governments to take? According to a recent study from the BC Centre for Excellence in HIV/AIDS the expected average expense to provide medical care to each person infected with HIV in British Columbia is anticipated to be $150,000, while currently estimates of per capita expenses for each 67 averted HIV infection is $82,500 (Meagher et al, 1998). Cornmunity-based interventions are quite effective in preventing HIV infections, and are quite inexpensive when compared to the treatment costs associated with AIDS. For each HIV infection which occurs due to this centralizing of community-based prevention programmes, money will be lost, not saved. And more women, men and children will become infected with HIV and die prematurely and painfully. AIDS, and the Current Generation of Gay Men. My generation saw many of its young and vibrant members fall by the thousands from AIDS. We had to locate a path of self-care which continued to celebrate our newly-embraced sexual selves, and which stemmed the transmission of HIV. Many men who were infected before anyone knew HIV existed died. Many of us who survived did so perhaps initially by luck, and later on by learning to protect ourselves. The dramatic drop in new HIV infections among gay men serves as evidence that the prevention efforts we designed for ourselves successfully combined technical knowledge of how HIV is transmitted with an accurate contextual understanding of gay men's perspectives about sexuality and desire. This wedding of local knowledge and the knowledge regime now serves as a model for other disease prevention programmes. Yet in 1999, new HIV infections continue among gay men in British Columbia—why? In the dozen or so years since I embraced my identity as a gay man, I have seen many men die. But few younger gay men have had this experience; for them the decimation of AIDS is anecdotal rather than a personal experience. The abstraction of AIDS shadows their lives as an vague spectre, omnipresent their entire lives as gay men, but not in any tangible, human form. Having missed the turmoil of the first decade of AIDS, for them the face of AIDS is unfamiliar. 68 This perhaps is a partial explanation for increased reports of lapses in condom use by some younger gay men. Despite the great amount of reliable prevention information available, younger gay men seemed more inclined to risk HIV infection. And among gay men aged 15-24, HIV infections are once again on the rise (Strathdee, 1997). Young people also continue to smoke cigarettes, despite over thirty years' admonishments of the deleterious effects of tobacco on one's health. That younger gay men would not adhere strictly to sexual risk reduction guidelines should surprise anyone. But it should alarm us all. The community from which the long-held contextualizations of gay male sexuality originated no longer exists. It is time for a rejuvenation of prevention programmes for gay men. These endeavours need many more younger men involved in all aspects of their planning and delivery. Reframing of known efficacious prevention techniques in forms which are relevant to todays gay male communities must be made. It also seems that outreach work within the West End gay male milieu has been reduced to a near complete reliance upon the distribution of information through publications and telephone information hotlines—very little face-to-face intervention work occurs. This strategy which was a key component in most of the AIDS prevention strategies initiated by gay men in the 1980s; there is no evidence that such peer education practices would not still be effective today. To be successful, any such intervention would need to recruit younger gay men to infiltrate gay venues with condoms and literature. These men would also need to be prepared to help clarify individuals' risk reduction concerns one-on-one. Future Research Areas. This study was not quantitative in methodological terms. Perhaps a study which analyzed a similar collection of documents would further article some of themes which have been 69 f introduced here. Possible ways in which the scope of this study could be broadened in future research could include consideration of the financial resources behind each document. Can the origins of these monies be coded in a manner which would be linkable to the trends I have identified with respect to these materials' origins and the discourses contained therein? Are materials whose funding is governmental (including many publications from NGOs) more, or less, likely to incorporate subjugated knowledges than those funded by other means might? With the significant reliance on government coffers by Canadian NGOs, any such linkage could explain how some organizations seem more "grassroots" than others. This study has demonstrated the importance of local, regional knowledges in the creation of contextually-specific AIDS prevention programmes, areas where the "experts" of medicine were unquestioned prior to AIDS. Using candid discourses which originated from shared personal experience, the contextualization of medical knowledge has proven to be highly efficacious in slowing the spread of AIDS among gay men. For the current re-emergence of HIV among younger gay men, this tack seems readily adaptable. We are now learning about the critical differences between the first site of AIDS devastation (urban gay men) and the most recent (injection drug users in the Downtown East Side). These differences make the uncritical transfer of prevention strategies between milieus untenable. Both IDUs and homosexuals have experienced marginalization in our society. But how these marginalizations have manifested themselves are quite different. Unlike the gay men who asserted themselves and drew upon their own resources to create their own prevention programmes, few in the Downtown East Side (DTES) are middle-class, university educated or financially stable. More often their lives are characterized by poverty, functional illiteracy, inadequate nutrition and unstable housing. Focussed on the challenges of surviving, many of the 70 residents of the DTES do not seem to be able to muster the personal agency needed for an internal community response to develop. Any expectation of such a movement to fight the spread of AIDS in the DTES is unrealistic. Without a great deal of assistance from people outside the DTES, the spread of HIV will remain largely unchecked. For the organizations and government programmes fighting against the epidemic among IDUs perhaps the greatest challenges are not in communicating how to prevent becoming infected with HIV. For many whose lives have been typified by violence, sexual abuse, and unstable home lives, the more salient question is perhaps why bother to prevent contracting HIV? In my work with substance abusers, the absence of hope in the lives of those whose life experiences have largely been characterized by difficulties and pain is the primary obstacle of efforts to modify risk-taking behaviours. Addicts who are unable to become drug-free often are unable to find any sustaining inspiration to pursue any sort of self-care. Mezirow's transformational theory of learning offers a clear differentiation between changes in technical or functional knowledge, meaning schemes, and changes in outlook or values, meaning perspectives (Mezirow &Associates, 1990; Mezirow, 1996; Mezirow, 1998). Among gay men condom use was a new meaning scheme, while the shaping of personal moralities about love and sex were changes in meaning perspectives. For IDUs this would be analogous to learning how to clean a syringe with bleach versus acquiring a self concept which is more conducive to self-care. The integration of sexually candid content into materials for gay male-focused prevention efforts was greeted with much controversy. External critics saw the contextualization of safer sex practices in anonymous and casual sexual encounters as irresponsibly promoting risk taking. But among gay men there was a consensus that such expressions of male-male desire would always occur, and to integrate these activities would actually decrease risk taking. With injection 71 drug use, needle exchange programmes have been similarly denounced. Yet again, the power struggle between mainstream society and subjugated communities continues, but IDUs do not have the financial or skill resources that the privileged gay male community accessed to engage in this struggle. Research needs to be conducted to identify ways to inspire IDUs to protect themselves from HIV. Several possible changes to meaning schemes for IDUs are already offered in HIV risk reduction programmes, including cleaning syringes, the importance of not sharing syringes and how to access needle exchange services. How to bring about changes in individuals' meaning perspectives which are sufficient to lead IDUs to seek a drug-free life remains undocumented. But in addition to helping users to prevent infection, strategies for redressing the multitude of other challenges to the DTES must be found. How can the ubiquitous poverty and violence be assuaged, if not eliminated? Few who work in community health will dispute the link between wellness and poverty. Closing Remarks. In 19961 helped co-ordinate a community-focused scholarship programme for XI International Conference on AIDS. At this Conference, my contact with activists and researchers from around the world gave me an awareness of the necessity of ongoing, effective HIV prevention programmes. Those who worked in Harare, Madras, Sao Paolo, Warsaw and San Francisco all seemed to agree on one point: effective grassroots interventions must be contextually relevant and contextually rooted. There was also a significant tension between academy-based researchers and community activists. Those who selected the presentations for the Scientific Program (all of whom had a post-baccalaureate education) seemed to share a strong disdain for the "unscientific" submissions 72 made by cornmunity workers. At the same time, many activists expressed anger at a perceived disregard for "real world" issues in AIDS prevention and treatment by scientists. I met a few activists whose backgrounds included graduate studies—or at least few willing to admit it! And I recalled my own disdain for the "ivory tower" of scholarship, of how I perceived its reification of itself as the primary source of knowledge as a barrier to my pursuits as an activist. Yet I knew that most of these scientists and activists shared a commitment to fighting AIDS that was completely altruistic. The idea that scholarly research could be integrated with activism intrigued me. After the Conference, working as an epidemiological research assistant, I decided to initiate a personal inquiry towards this possibility. I can't claim to have fully resolved the conflicts between academics and activists. But in conducting this study, my ambitions were to create a substantive piece of scholarship which was of significant relevance to community activism. I feel to some extent that I have succeeded with this study. 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Liberal Adult Education: the End of an Era? (pp. 163-179). Nottingham: Continuing Education Press. Warner, M. (1993). Introduction. In M. Warner (Ed.) Fear of a Queer Planet: Queer Politics and Social Theory (pp. vii-xxxi). Minneapolis: University of Minnesota Press. Webster, F. (1995). Theories of the Information Society. New York: Routledge. Weeks, J. (1991). Against Nature: Essays on history, sexuality and identity. New York: New York University Press. Welton, M. (Ed.). (1995). In Defense of the Lifeworld: Critical Perspectives on Adult Learning. Albany: State University of New York Press. Whitmore, G. (1988). Someone was Here: Profiles in the AIDS Epidemic. New York: New American Library. Images from Publications 80 Appendix Sex Safety Tips * tuck only with a condom and a water-based lube. Fucking without condoms is very risky for both tops and bottoms. * Avoid setting com or blood inside your body. Tell him: "Cum on me, not tn me." * Unprotected rimming (ass-JtcJking) is an easy way to diseases such as hepatitis, For safer liiigering and fisting, latex gloves are availabf at the front desk* Condoms ran also be used for fingering* Before sharing sex toys, either wash them between uses or cover them each time with a new condom. Oral sex is a low-risk activity .You can make it even safer by not taking cum in your mouth or by using a condom. Many STD's (Sexually Transmitted Diseases) are transmitted by bodily fluids. To reduce your risk - reduce the amount of bodily fluids you come in to contact with. lay Safely-You're worth it A I D S - WHAT Is IT? A disease caused by a virus called HIV which breaks down the body's ability to fight off other infections. How Is HIV/AIDS S F R E A D ? a) high risk • vaginal or rectal sex without a condom • Wood (sharing used needles and /or works) • babies can be infected during pregnancy b) tower risk • oral sex without a condom • an HIV + Mom breastfeeding a baby after birth How To AVOID GETTING HIV/AIDS? • Use condoms for sex - always. • If you use drugs, never share needles, and use condoms for sex - always. How Do You KNOW IF You ARE INFECTED? A blood tesl will tell you if you have been infected with the virus. fcrt I <to" t ha* tn wwry. f«t i arm" A ^.f*. "th iwy wt lib to v« i rvter. fcrt ti't krte tfc* the aHenwW PLEASURE G R A P H with Genua! »iwt » n-btwi nmowti fthttV) -Than *re *bo*rt 12 STD'j (MXtuMy S/animitted o%e*ses}, (nrhtftkn HIV. To ttop you from getting (or giving) HIV ar sW><?n«>»»r fou'm fucking, tn* a Uxt*i rubber Umiim nAbtn Weak ^ 1 r Tbk «*%*f ft*ntt«r Wl^rtWilaW-taW-ia )W tf fc» ** <a» - *a «J>-***4' Sue vruft Ktal ft bubrwi to (mm *I9S, i** wrm. *H HIV is a serious hea l th issue affect ing o u r c o m m u n i t y t«te.|iwMf»K.«i .< n»v i * * J13ftt*«iT» 'what* or die** )•» Cmnti*. *fw* n n ^ ; *«l P M M I ! My mi « * | sir * » w » *>.000 }ww«s .tmflog Mil*- HR; >•.•.•-.; r « f t e t t ctftm* <*«« * * • '*» vfeMftr nmum <W» e n i i w i w tWB*. f! (Ml «W>r»d»% MjiwrlHi *«i *«KJ>-( * wwat* <j ^ f » t w t w M H i . « M m&sM&vfSi ami-ma wpsaasost t^ snwa*, tigegHx m.*#s* fjpi •# wtf J P * jyp 85 Homophobia is Everyon&'s Problem and It Cart Afityct th& ffifiimmrff of Hiv/AIDS Hi' K i n d of v'«, i. / «(• i i p»rjaii«s tojw»- tttxx tmz. wa. tdwjpw w *a**r*. 49 fan* tl'nwi'iilM « 4 ik: uw*. ^»Wiww»t» * wafer •Mi Tlfc bawli«5 «w t*l»»i«rf»(,W>*ia! I fcs&i*-**. fir? '*a* .sswi *^*r» ill MiMiai * Aim pM§9 awl fcadma fc«% WWW Tiww|lt»At).it.»'«iiji»«*'i-ji»i<faa-~' failfajw4*i» taril&'<faav4ter wJltjiBffaawiylliWii, Start**** ftwpfc HIV* Affect the Spread off Mtv l iaylmUJfe >• jwrwt < * r * » H » w * i . * s « ? i - .n^^Sliir rrilvH - 1 'T 1 r-1"r"l'Mf'*'I **wai*i»w>K ar* ^ i ^ J i i r t i i t i t t i A K l A i ' i W 

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