Masculine enhancement as health or pathology: gender and optimisation discourses in health promotion materials on performance and image-enhancing drugs (PIEDs)

The consumption of performance and image-enhancing drugs (PIEDs) is commonly pathologised in public health discourse as stemming from an unhealthy relationship to masculinity, and is often framed as intrinsically 'risky' and fundamentally at odds with 'good health'. This article examines Australian health promotion materials on PIEDs to analyse their role in shaping notions of good health, normal gender and appropriate self-improvement. To do so, it draws on the work of Butler, Law and Latour to consider how these materials co-constitute men and their health, often in problematic ways. First, we examine the ways in which PIEDs are constituted via a politics of the 'natural', then consider how the health promotion materials on PIEDs participate in the regulation of appropriate, healthy masculinity, and conclude by examining how adolescent masculinity is co-constituted with PIEDs. We observe a key tension between health promotion's avowed interest in improvement and optimisation and its treatment of PIED consumers as aberrant, vulnerable and insecure subjects whose drive to enhance and optimise is characterised by pathology and addiction. We conclude by arguing that health promotion materials on PIEDs fail to acknowledge the exceedingly normative character of enhancement practices in contemporary society.

Perceptions and concerns of hepatitis C reinfection following prison-wide treatment scale-up: Counterpublic health amid hepatitis C treatment as prevention efforts in the prison setting

BACKGROUND

Hepatitis C (HCV) infection is highly prevalent within the prison setting. Direct-acting antiviral (DAA) therapies have changed the HCV treatment landscape, offering simple treatment (with minimal side-effects) and high efficacy. These advances have enabled the first real-world study of HCV treatment as prevention (TasP), the Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study. This paper draws on data from qualitative interviews completed with SToP-C participants following prison-wide DAA treatment scale-up.

METHODS

Semi-structured interviews were undertaken with 23 men in prison following HCV treatment completion to identify ongoing risk practices, perceptions of strategies for HCV prevention within the prison setting, experiences of HCV treatment (as prevention), and perceptions of reinfection following cure. Analysis was undertaken using a counterpublic health lens to identify risks and perceptions of reinfection among people treated for HCV within the prison setting.

RESULTS

Participants identified a number of challenges of meaningful HCV 'cure' in the absence of increased access to prevention strategies (e.g., opioid agonist therapy and prison needle syringe programs) along with concerns that 'cure' was only temporary whilst incarcerated. 'Cure' status included self-perceptions of being "clean", while also imposing responsibility on the individual to maintain their 'cure' status.

CONCLUSION

HCV DAA treatment is provided somewhat under the guise of 'cure is easy', but fails to address the ongoing risk factors experienced by people who inject drugs in prisons, as well as other people in prison who may be at risk of blood-to-blood exposure. Health messaging regarding HCV treatment and treatment for reinfection should be tailored to ensure patient-centred care. Health interventions in prison must address the whole person and the circumstances in which they live, not just the illness.

Understanding facilitators and barriers of direct-acting antiviral therapy for hepatitis C virus infection in prison

Hepatitis C virus (HCV) infection is a major public health concern. Globally, 15% of those incarcerated are HCV-antibody positive (anti-HCV). Even where HCV treatment is available within prisons, treatment uptake has remained low. This qualitative study was conducted to understand the barriers and facilitators for the delivery of HCV treatment in prisons from the perspectives of prisoners. This is important to inform health messaging for HCV treatment within correctional institutions. Thirty-two prisoners (including eight women) with a history of injecting drug use participated in this qualitative study. Participants were equally recruited across four correctional centres (n = 8 per site). Overall, 16 participants (50%) had chronic HCV at their most recent test, and two participants were awaiting test results at time of interview. Structural (eg proximity of health clinic) and patient-level (routine and motivation) factors were viewed as facilitators of HCV treatment within the prison setting. Structural (eg risk of reinfection) and social (eg lack of confidentiality and lack of social support) factors were perceived as barriers to prison-based HCV care and treatment. In conclusion, to increase HCV treatment uptake, prison-based programmes should implement (or advocate for) patient-centred treatment approaches that protect privacy, provide social support, and promote access to clean needles and substitution therapy to protect prisoners from reinfection.

Who goes first? Understanding hepatitis C risk among injecting networks in the prison setting

BACKGROUND

Hepatitis C (HCV) is a blood-borne virus that is most commonly transmitted through shared injecting equipment. Due to the criminalisation of injecting drug use, HCV is highly prevalent among those incarcerated. Using a risk environment framework, this qualitative study sought to understand the role of HCV risk within injecting networks in the prison setting.

METHODS

Thirty-two adult prisoners (n=24 men; n=8 women) with a history of injecting drug use participated in this qualitative sub-study. Participants were recruited across four correctional centres.

RESULTS

Social, economic, and environmental risk factors contributed to injecting practices within prison. Commonly, the person supplying the drugs injected first, with the person who owns the injecting equipment going next. HCV did not regularly factor into determining order of injection within networks (i.e., first, second, third), although it was reported that some prisoners claimed not to have HCV in efforts to "jump the queue".

CONCLUSION

Social, economic, and environmental risk factors contribute to negotiation of injecting order among people who inject drugs in prison. Risk of HCV exposure rarely influenced the injecting order. Harm reduction strategies should consider the social factors influencing injecting drug use in the prison setting especially to optimise the population benefits of the roll-out of highly effective HCV treatments.

'Affording' new approaches to couples who inject drugs: A novel fitpack design for hepatitis C prevention

BACKGROUND

In the West, hepatitis C is predominantly transmitted via the sharing of contaminated drug-injecting equipment. Although the majority of this sharing occurs between sexual partners, the responsibility for avoiding transmission has long been conceived as an individual responsibility, with prevention measures such as the distribution of sterile injecting equipment such as injecting packs ('fitpacks') aimed at individuals without regard for the social contexts of injecting. In this article we draw on the work of Bruno Latour to reconceptualise the fitpack. We argue that the fitpack is not inert or neutral in its meaning or effects, that instead it 'affords' particular meanings and actions, for example, that injecting is an individual practice and safety an individual responsibility.

METHOD

To challenge these affordances, we developed a new fitpack prototype aimed at couples, along with related health promotion messages. We asked 13 couples who inject drugs to examine and reflect on these new objects and messages.

RESULTS

Overall, we found a high level of support for the broad idea of couples-oriented materials, as well as for our prototype and associated materials. Participants identified opportunities for improving the materials and commented on implications of the symbols and language used. Together the interviews demonstrated ways in which the new fitpacks and messages could afford couples-oriented safe injecting, and better recognition of relationships that are often dismissed by researchers and health care providers as insincere.

CONCLUSIONS

These findings demonstrate that first, there is a need and desire for a greater range in harm reduction resources. Second, it is essential to find ways of better acknowledging the validity and value of relationships between people who inject. Third, and more broadly, recognition must be given to the role of technological objects in materialising meanings and, as Latour might put it, 'moralities', and in turn to interrogating these meanings and moralities.

Harm reduction workers and the challenge of engaging couples who inject drugs in hepatitis C prevention

AIMS

Despite injecting-equipment sharing between sexual partners leaving them at increased risk of hepatitis C (HCV), there is scant literature available to guide harm reduction workers in their encounters with couples who inject drugs. This article explored workers' understandings of such couples and their accounts of working with them in relation to HCV prevention.

METHOD

Semi-structured interviews were conducted with 22 staff of harm reduction services located in Sydney and Melbourne, Australia.

RESULTS

Overall, staff represented couples as either absent from the service or as presenting with needs indiscernible from those of individual clients. Responses to questions about HCV and couples were framed primarily in terms of risk. Staff participants questioned 'genuineness' of clients' intimate relationships, instead characterising them as inauthentic and drug-driven. Working with couples was seen to present a number of organisational and clinical challenges. The benefits of recognising and working with such partnerships received scant acknowledgement. Rather, staff tended to perceive couples as being 'impenetrable' to health promotion messaging.

DISCUSSION

The framing and delivery of harm reduction in Australia remains an individualising enterprise with little capacity to recognise the intimate partnerships, including addressing the HCV risks specific to them. More effective harm reduction strategies may be achieved by transitioning to a practice framework that addresses the social context of injecting, including the experience of couples. This would require direct involvement of couples who inject drugs.