A Rural Voice: SexRurality 2019

My trip to Victoria two years ago to attend my first SexRurality conference in Lancefield was invaluable. It took me out of my bubble here in the West and reassured me that there were clinicians, practitioners and researchers experiencing similar frustrations; eager to find solutions to common issues and struggling under the constraints of the rural sexual health sector. I was so excited to head back to Victoria; back to SexRurality and in some ways, back to my people this year in Creswick.

Creswick. Beautiful Creswick.

Where the hell is Creswick, you ask? You and everyone I spoke to about SexRurality before I left. The look of utter confusion on everyone’s faces reassured me that I was heading to the right place. What better setting for rural health focussed conferences than towns that no-one knows about? Or has driven through once on their way to somewhere bigger and better. Creswick was perfect.

Day one: Get political, get connected

Creswick is found on Dja Dja Warrung land, and Rick Kerr was charged with Welcoming us to these lands. Rick is an Elder and a direct descendant of Leonard Kerr, a Dja Dja Warrung man born at Mount Hope in 1854. He spoke to us about the dreaming stories of the area: of Bunjil Dreaming and the actions of the Raven, the Cockatoo and the Rainbow Serpent. Rick spoke of the passing of knowledge and learning through the ages; how the Dja Dja Warrung “danced their stories in to the fire”. We were welcomed to this country – and ready to begin.

Marie Bubnic provided the conference opening on behalf of the Department of Health and Human Services (VIC) and highlighted the number of demand pressures that are felt within sexual health and reproductive health services provision.

There was an acknowledgement of something that rural workers and researchers understand intimately: that rural service provision is often personnel and personality-based. The doctor in a rural town impacts on what services are available. Marie also spoke about how there was a lack of service integration, and that while cost and travel are significant barriers, the Department had found that rural people are more than willing to travel for services that are inclusive and de-stigmatised.

There was also recognition that current funding and structures are focussed primarily on specialist service provision, and that a transition to more place-based primary care was a challenge that will require collaboration with the sexual health workforce. A subtle plug that Health Promotion must be considered within this attempt to reorientate health services is inserted here.

Kylie Stephens, the Senior Health Promotion Manager at CERSH, gave us an update on what was happening in their world, what they were proud of and the areas CERSH needed to pay attention. Kylie discussed the potential to increase the geographical reach of CERSH while also ensuring that we, as the rural sexual health workforce, continue in our efforts to broaden the responsibility of prevention efforts.

In settings where resources and power are contested, there is a need to ensure that rural voices are provided and heard – and that localised solutions and community participation are important in the rural setting. Kylie also highlighted the need to address workplace attitudes and cultures: practitioners and workers learn that sexual health lacks priority and focus from their peers. So much of this overview resonated with me that it pretty much reinforced why travelling across the country was such a good idea this time, and last time.

When someone says something at a conference and you feel vindicated.

Next person to take the lectern was Fiona Patten MLC. Now this isn’t your usual local member address. As the Member for Northern Metropolitan Region in the Victorian Parliament’s Legislative Council, Fiona has been called “Australia’s most effective legislator.” Her legislative achievements put many of our far longer serving elected representatives to shame and her ability to hold us as a crowd was very impressive as she talked about “How do we get politicians to say the ‘S’ word?”

Fiona talked about her engagement with politics before becoming elected and how she went about engaging politicians in ways that aren’t possible now. Fiona spoke of a time when politicians were brave, such as attending a sausage sizzle at a brothel for Open Brothel Day when it coincided with Safe Oral Sex Day. I fear those days are gone. It was also highlighted that sex workers have a strong role in sexual health promotion as educators and should be respected as a resource.

Very, very grateful to return from Crewick with this wonderful souvenir

Fiona highlighted what we know: access, stigma and confidentiality are key determinants underlying rural sexual and reproductive health. Now, just because we know it – it doesn’t mean it isn’t nice to hear someone else acknowledge it. It also flowed in to one of the key takeaway points for me from SexRurality 2019: that we need to talk to our politicians about sex – before they start talking about it. And we, the 150+ people in the room were a clear directive and call to action: go talk to our politicians. Talk to them about the issues in our local areas. Tell them our stories. Go with actions and solutions. We are excellent sexual health communicators doing the best that we can – so we need our politicians on OUR side, advocating and lobbying for OUR needs. They can’t do that if we don’t communicate with them.

“Talk sex to your politicians.”

Go to them. Tell them your stories from the field.Go with action and solutions.

Next up, was Associate Professor Christopher Fisher from the Australian research Centre in Sex, Health and Society giving us some rural focussed findings from the 6th National Survey of Secondary Students and Adolescent Sexual Health (research protocol here).

It was brilliant to get the rural focus on these findings and it generated a lot of discussion on why some things were seen in the data. Rural young people were more confident in using sexual health services – and somewhat more trusting. This is something I’ve seen within my own research, where young people did not feel the same level of anxiety over confidentiality concerns accessing rural GPs as the rural GPs themselves felt.

Young people wanted relationships and sexuality education that was real and useful. They did not want tokenism. Findings highlighted the massive burden that young women bear in terms of provision of informal relationship and sexuality education. It’s great that peers are seen as one of the best places to turn to for advice – but how are we supporting these peers?

We then broke for what seemed like the first of several hundred meal breaks and our first real chance to network. I’d been beating off a sore throat for a few days before travelling and was seriously worried I’d lose my voice before I presented on the second day – but there were far too many people to catch up with and talk to. Oh, and some networking of course.

Inigo Montoya’s guide to conference networking

We came back from break to a panel discussion facilitated by Yumi Stynes, the host of one of the best podcasts going around (go listen to it now!). I think Yumi is pretty cool and I can safely report that I (and a few dozen other delegates) totally kept it together after lunch and didn’t descend into pools of pathetic fan-boy/fan-girl/fan-nb behaviour.

Anyway, cart before the horse – before I embarrassed myself, Yumi facilitated one of the most diverse panels I’ve ever seen at a conference. I don’t want to list the ways in which this was achieved in some diversity checklist/shopping list – but let’s just say there were a lot of boxes ticked and a lot of amazing perspectives.

The thing that hit me very early on in the discussion was how a number of the panellists had been failed by their health professionals when seeking help. From a young trans-person being told they were insane, to a pregnant women with genital mutilation being met with overt fear and stigma, to terrible management of a new HIV diagnosis.

The panel was incredibly brave in what they shared with us and were candid in their responses. Yumi asked the panel what they would like to see included in relationships and sexuality education in schools: they were queer inclusivity, pleasure, abortion, understandings about cultural sensitivities, respect, the need to love yourself first. Nothing shocking – but enough to send a politician scared of gender whisperers into a tizz no doubt. These are not the political times of brothel sausage sizzles.

In closing remarks, Yumi encouraged us to get out there and consider podcasting to communicate what we are up to. Expect a heap of sexual health podcasts coming your way – hell, one even popped out of here! We then broke again for food, the chance to network, and the chance to embarrass ourselves at the feet of Yumi. We launched at those three opportunities with gusto.

Split sessions

After food, we started the first of the split sessions. Conferences always present dilemmas on who to see; who to miss. It brings me back to my early days going to festivals when I would scorn the organisers for putting Machine Gun Fellatio and Shihad against each other. Do I choose provocative on-stage antics or power rock?

Now, I’m not going to say which one was which, I’ll leave that to your interpretation – but I started in the Open Topics stream with Shannon Hill and Siobhan Bourke, before racing across the festival conference to the Place-Based Stream to catch Amy Isham, Cath Tischler and Bernadette Lewis.

Shannon Hill started with a strong question asking ‘What good intention we could put out in our work and make come back to us?’ before presenting on the great work that Women’s Health Grampians had done in developing a Theory of Change – a pathway towards a vision. The Theory of Change was about plotting the way to achieve the vision clearer, thus creating supportive environments and setting foundations for future progress. I liked it. Siobhan Bourke gave a great overview of the Sensitive Physical Examination Program used to teach medical students how to negotiate sensitive examinations. Consent and feedback are key components that students learn – as well as important feedback on body language and how they interact with patients. There was also the great point that we presume medical and nursing students have had great relationships and sexuality education in the past – when often they haven’t.

Across town, Amy Isham and Cathy Tischler gave an overview of how their ethnographic research is embedded alongside (under?) an active participatory action research project to provide deeper understanding of the issues relating to social service delivery and access faced by teenage parents in Horsham. Another great example of regional researchers in a regional area finding local solutions to problems – that will no doubt have value to the wider population. They highlighted the need to address the gaps and ensure that the real world practitioners know as reality is expressed within the research literature. One point Cathy made that ties back to Fiona Patten’s call to action was that politics influences health at all levels and there is a need to empower our regions as a whole. Bernadette Fraser rounded out the session giving an overview of the Storylines project – a collaborative project that gathered women’s lived experiences that highlighted intersections between social determinants, health inequities and barriers to access.

The beautiful paperback vulvas made by BlackGin

After lunch, Edwina Jachimowicz, a fellow out-of-towner presented on a program that SHINE SA had implemented to build workforce capacity within the rural and regional workforce. The project came about from the knowledge that the sexual health workforce is expected to do as much, if not more as before, with the same or less resources. This brought about the need for a partnership approach. This involved negotiating some turf wars and managing expectations but led to considerable knowledge gains. Next up was Jenny O’Connor from CERSH, talking about working with LGAs in trying to install condom vending machines. Now this is something I know about from my area – I’ve been laughed at for suggesting condom vending machines in our area – and as a Councillor as well as a Health Promotion worker, Jenny has a foot in both camps. Navigating very local politics still needs advocacy, nuance and hard work.

Dr Tim Staunton Smith presented a really nice project on the physically-visible and Web search-able signs that rural GP practices are LGBTQI friendly. It was not the most complicated study – but it did what it was designed to do and I’d love to replicate it here in rural WA. Interestingly, in the days after the conference while in Hamilton, I noted several shops and cafes had Rainbow Flag stickers on their doors. It was subtle. It was simple. I don’t know anything about it – if it’s a local scheme – let me know.

Hamilton and the subtle Rainbow Flags

And well – from there, I tapped out for the final 30 minutes and found somewhere quiet to gather myself. Conferences can be really full-on – and with an evening drama performance and dinner ahead – I needed a quiet moment. It wasn’t quite a Bex and a lay-down, but it was close. I followed the Twitter hashtag as I rested, and was again reminded of how useful Twitter can be. Yeah, it can be a waste of time – but #sexrurality was trending locally. I had a heap of interactions from both people at the conference and around the place, and I knew when I got home to write this there would be something to work with. About five years ago, I wrote a little thing for Croakey blog after the PHAA Conference in Perth about joining Twitter. Have a read and a think if you are still to be convinced.

I’ll be honest – I had gone to the chill-out tent for this one. I was cooked, but still followed along via Twitter.

Before we were unleashed on the conference buffet, we were treated to an early showing of ILBIJERRI Theatre Company’s VIRAL. Director Kamarra Bell-Wykes reminded us that the cast were still in the early days of settling into rehearsal and not quite ‘show ready’ – and for us to be kind. This was more of an open rehearsal than a full show.

What followed was gritty, stark and determined story-telling that delved into the realities of health care access, discrimination and colonisation, and the ongoing impacts on the social determinants of health. The sharp and witty dialogue was often split across the three performers (Jessie Butler, Shannon Hood & Nikita Tabuteau) to create power in shared messaging.

It was a raw performance – but a fantastic one. It was great theatre and wonderful to see art and health coming together. Since the last Sexrurality, I’ve gone on a bit of an accidental arts/dance adventure and I think we need to work harder to find synergies between the arts and health – both in terms of messaging, but also advocacy and sharing of ideas and resources.

Shout me a coffee

Enjoyed what you've read here on the 'Grind? Keep me careering towards my PhD completion and churning out content along the way by donating a coffee to me!

A$4.00

Day two: Research, presentations and farewells

I awoke as fresh as a daisy and ready to take on what was going to be another big day of rural sexual health. Today was game day for me – and I could not have asked for a better preparation. It was time to get caffeinated, get excited, warm up our Twitter fingers and get back into it.

Well, SEX(ually transmitted infections anyway)

Associate Professor Eric Chow kicked off the day with what was new in Gonorrhoea control. This was a pretty epic presentation that I’m not sure I can wrap up that easily. From the question of “Can you use saliva as lube for anal sex?” (You can, but should you? The prevalence of gonorrhoea in MSM who did use saliva was greater than 2 times the prevalence in those who didn’t), to exploring if mouthwash can be a novel treatment for oropharangeal gonorrhoea (or dandruff*) – there was a lot of content covered. What is clear, is that with gonorrhoea on the rise – we need to pay more attention to some of the unrecognised risk factors in transmission.

Professor Jane Hocking was next with a focus on Chlamydia Control. Jane asked us about our current practice and if it was evidence based – our focus tends to be on promoting increased testing – however, this doesn’t necessarily reduce the incidence of Chlamydia and ultimately we want to prevent Pelvic Inflammatory Disease. But PID isn’t monitored. Perhaps we need more of a case management approach to reduce reproductive morbidity and minimise reinfection.

Also, with rectal Chlamydia being detected at increased rates in women – is it something to worry about? Literature shows there is 32 fold incidence in women testing positive rectal infection with urogenital infection. Contamination? Problem? Auto-inoculation? Its unclear. What is clear though, is that Chlamydia vaccine development needs to be a priority if we want to effectively control Chlamydia at population level

Dr Kathryn Cook started off telling us about St Denis, who I have to say, sounded a little bit like a late night conference delegate. St Denis was beheaded. Refused to die. Walked off carrying his head. Then died. And is the patron saint of syphilis. We all reach different heights. As wild as this was – Kathryn wanted to remind us that Syphilis is NOT history. We need to be kind contact tracing, we need to be diligent, we need to understand that even “nice ladies” that got to private clinics for IVF might have STIs. Congenital syphilis is not to be messed with.

After the break and just one more cake, I swear, Anne Roseman hit the stage with an intro song (I wanted my own stage entry song) to talk about Aboriginal Community Controlled Health Organisations and the work they are doing in sexual health. We also heard from Belinda Payne, Tara Purcell and Peter Wapoles-Crowe on their perspectives, involvement and insights. They highlighted that there are thousands of things to be done and sexual health is just one of them. There is under-reporting of STIs – most likely due to stigma and shame – and that universal screening is the key to reducing that shame. ACCHOs are also better placed to do holistic health care – but the FTE provided for sexual health is ridiculously low. Also, being aware of the intersections of gender, sexuality and culture cannot be ignored.

We then got more art in our face with the hilarious Alyce Fisher. It started with dancing condoms and ended with the charming word smith, Cameron. Again. Art. Health. Together. So happy. And safe:

Totally normal for a sexual health conference

Split sessions

Before lunch, we split again. Some went and engaged with the MoCCA Project as they ran a session about strengthening Chlamydia management in general practice; while the attention-seekers of the conference headed across to participate in an interactive creative development theatre session with ILBIJERRI. No guessing where I went. We worked hard in the theatre group, and all tried our hardest to be respectful of other people’s creative ideas when ours were clearly better, and came together to produce some really pleasing and thought-providing images through our dramatic staging. I hope ILBIJERRI got half as much out of it as we did.

There was time for one last buffet onslaught before the final split sessions – rural research and abortion care in the rural setting. I was at the research stage for that full set – so apologies for the lack of abortion care round up – but I was able to catch Pamela Doherty, from Children By Choice (another out of stater) talking about the barriers and facilitators that were faced in delivery of Medical Termination of Pregnancy (MTOP) in rural and remote Queensland.

Pamela Doherty

Marieke Dam presented the comprehensive approach taken from Women’s Health Grampians within their Increasing Reproductive Choices project. This was a great example of how you must address multiple socio-ecological and service levels to be effective – your approach must encapsulate top-to-bottom. It starts with the public facing front: it’s important that health centre reception staff have training in how to handle inquiries about accessing MTOP. Something I found fascinating a couple of days after the conference, while on a tour of the Budj Bim National Park, was learning that the Gunditjmara people had used green kangaroo apples to terminate unwanted pregnancies. This was normally when there were incoming harsh seasons and there would be pressure on group in terms of nutrition and health. It seems MTOP has been happening in rural Victoria, on country for a very long time.

Green Kangaroo Apple – used to terminate pregnancy

Dr Cameryn Garrett delivered on the impact evaluation of nurse and midwife contraceptive training. A lack of a Medicare rebate and supportive policies and procedures are barriers to nurses being able to insert contraceptive implants, and must be addressed – regardless of the training. Lily Claringbold presented on research into the factors influencing young women’s contraceptive choices, with fear relating to side-effects and pain, and invasiveness as major potential barriers for the low LARC uptake. Overall, there were many reasons women choose to use a particular contraceptive method, beyond contraceptive effectiveness, and they often make these decisions before speaking to their GP.

Marieke Dam

Is was then my turn to speak on how I accidentally became a PhD candidate how I got over-involved as a volunteer in trying to solve some sexual health problems within my own community. I was lucky enough to deliver effectively two presentations: one on the Delphi methodology that I utilised to validate the framework for sexual health provision in the rural area, and the second on the four key factors that the framework suggests. I realised as I hit the lectern that there was no presenter’s screen for me to look at – and as someone that tends to use the slides as prompts, rather than write a presentation – it made things a little trickier. Oops. Few tense moments.

Fundamentally, the presented framework suggest four key pillars for rural sexual health promotion from the research: we need to be providing credible and consistent relationships and sexuality education to our young people; ensuring that health services are well-connected and accessible; making sure condoms are easy to get and if possible – free; and building collaborative networks amongst traditional and non-traditional youth sexual health stakeholders. In many ways, it’s what people on the ground already know and do day-to-day. This project was about providing evidence, structure and guidance – not just pointing out what should be done. Hopefully it’s useful.

Anna Roberts presented some more exceptional rural research done by rural people explaining their project’s focus on mapping access to emergency contraception and MTOP – not just in terms of pure service access- but also availability or restriction of medication. Madeline Lim then presented about the artist formerly known as the Condom Fairy: a project that saw university students delivered free condoms on campus. The Condom Fairy was ranked the most convenient way for students to access condoms, and has been since renamed the Safer Sex Program. Finally, Jess Wynn brought us home with her research project asking “Do patients prefer a male or female urologist?” The thing that really resonated with me was that patient preferences are dynamic and open to change – a positive interaction has the potential to alter previous considerations. In my previous life as a nurse that happens to be a male, I would suggest that this research replicates my lived experience.

Wrapping up

There were some fantastic presentations this year at SexRurality, but one of the best things about this conference is the collegiality. People want to chat, they want to find out what you do and they want to share what they are doing. It’s an environment of support, encouragement and collaboration. Last time I attended, it was a real boost to my PhD in terms of validating what I was doing and reassuring me that people actually did care. This time around was a similar sense of validation and support – and I always speak highly of SexRurality to my WA-based colleagues. We just need a few more to come next time.

Star studded line up – can’t wait for the next one

In the days after SexRurality, while driving around rural Victoria checking out the Ballarat’s St Patrick’s Cathedral (timely), Grampians (amazing) and Budj Bim (incredible) – I reflected on the wrap-ups. So many fantastic points – but what was my take away? It took me until the flight home to settle, but I really agreed with Shannon Hill’s presentation and Jenny O’Connor’s interpretation of it during the wrap-up. I then kept reflecting on Fiona Patten’s call to action to engage our politicians. Finally, from the research stream, I agreed with Meredith Temple-Smith’s summation of the session – the need for strategic change.

My take away from SexRurality in 2019 is that we need a clear vision for rural sexual and reproductive health. A vision that includes strategically broadening the responsibility of prevention efforts beyond traditional stakeholders and fostering collaboration while championing reform to policy and appropriate resource provision. There are thousands of things to do, too few people and FTE funded positions to do them – but keeping on our current pathway there will be little change. Frameworks, mapping, systems approaches and solutions are the tools we need to strategically advocate for change from our policy makers. We can’t discount or neglect the amazing work that is happening in the field, but if we don’t collect the evidence, and more importantly, hand that evidence to our politicians on a silver platter – they aren’t going to find it before they start talking, and more importantly, deciding about sex.

So, that leaves me at the end. To finish my PhD. To make an appointment with my local members about my framework. To be a little bit more annoying. Oh, and to enrol to attend ASHM. What are you going to do?

Listen to the Southside Grind podcast about Sexrurality here

Shout me a coffee

Enjoyed what you've read here on the 'Grind? Keep me careering towards my PhD completion and churning out content along the way by donating a coffee to me!

A$4.00

What even counts?

I read a great book this week that got me thinking about penile-vaginal sex. Not in that way, you seedy beast, but in how much it rules what we do in terms of sexual health education, societal norms and perspectives.

at all good bookstores…

Please note – I’m going to use the term penile-vaginal sex a lot. If that makes you feel uncomfortable – I want you to know and understand that I could not really care.

Karley Sciortino’s book Slutever is part memoir, part sociological critique of gender and sexuality through a sex-positive lens. It is not for the faint hearted and not a perfect book – but I really enjoyed some of the questioning moments in the book. I particularly enjoyed the section on what is sex and what isn’t. It is something as a researcher I think about in terms of education and information. Its a fascinating thing we’ve constructed as far as our societal definitions and cultural norms.

As a society, we place such a misguided amount of weight around penile-vaginal sex. It is what “counts” in losing your virginity. It is all all our relationships and sexuality education in schools often dares to focus on. Sciortino talks about how it is often the “goal” in sex between cisgendered heteronormative couples. Its great fun, but is it all that sex is? We’ve been having different types of sex since time began, but rarely educate on it.

Within my own research (as in, published scholarly, not google/wikipedia), young people voiced a desire for relationships and sexuality education that acknowledged same-sex attraction as well as diverse sexuality – and they wouldn’t mind some information that they actually need. (gasp) In another paper about to be published in Sex Education, stakeholders I spoke to who deliver sexual health promotion in the community, either as a job or as accidental experts – also talk about the need for education that is relevant and meets young people’s needs [edit: it is now published. read it here]. There is also a fair bit about being afraid of stigma and backlash – but both groups agreed it needs to be more than cross section diagrams of genitals.

So much of our relationships and sexuality education focuses on biology. It targets penile-vaginal intercourse with laser like intensity. Heaven forbid we acknowledge that sex is much more than that. God only knows what would happen if we acknowledged in our education that lesbian, gay and bisexual people have sex that may not involve either a penis or a vagina. Or that penile-vaginal intercourse is just one way to get off. I know the sky would fall in if we delved in to the pleasure zone, so lets keep things functional for now.

We could start by looking at what young people are actually doing. We, as a society could acknowledge that more than 50% of young people in years 10 to 12 have received oral sex (surveyed as part of the 6th National Survey of Australian Secondary Students and Sexual Health). Or that 50% have given oral sex. Or that 65% have already been off touching genitals and/or having their genitals touched. Experience in penile-vaginal sex comes in a lowly 44% of all genders. So what counts as having sex? Does oral sex? What about a hand job? What information is important?

If we think of sex in purely pro-creative and biological terms – of the young people surveyed, 66% were still virgins. And their future partners will be so happy to hear that. Or something. No one wants to marry a sullied “non-virgin”. So with that in mind, how do you lose your virginity if you are gay, lesbian or bisexual and only engage in same-sex relationships? Are you always a virgin, regardless? Frozen in time.

barf

Maybe all these young people are just saving their “Technical Virginity” by giving handjobs, having oral sex and anal sex. If you’ve never heard of “Technical Virginity” – its where you abstain from penile-vaginal intercourse while engaging in everything else. For some reason. Morality probably. It ensures that when they hold your sheets up Day One of your honeymoon that the awaiting crowd can be reassured you were a virgin. If you were a women. Because guys can slut it up as much as they want. Cause that doesn’t matter. Duh!

I find the most confusing part about it all this, is the focus around this coveted virginity test (I am aware the sheet showing doesn’t happen now). Does counting your sexual partners in terms of penile-vaginal intercourse really make sense? Aside from the fact that counting sexual partners in some form of chaste morality contest is pretty strange – does it really make sense saying that giving blow-jobs doesn’t count? What is sex? If blowjobs and going doing aren’t sex, then we don’t need to cover them in education after all. Or, maybe our education can get with the program and start focussing less on preventing pregnancy, and more on giving young people information they need. Lets dump our societal baggage and get real.

To be clear – I think if you’ve chosen to safely and consensually enjoy your body and someone else’s – that is awesome! If that is with a heap of people over time – great. Seriously, who cares? If you’ve decided to wait for “The One” to have penile-vaginal sex with – that is really super too! If while waiting, you’ve decided to have oral sex with a heap of people – again – that is great. But can we please move on from defining sex in terms of penile-vaginal intercourse? Can we perhaps even move on from competitions that spring from maintaining “Technical virginity” and gate-keeping morality and get real?

To true Mr Badger

Sex comes in a heap of different sizes, shapes and styles. Its a heap of fun and it is for a lot more than procreation. Young people for ever and a day have been having oral sex and jerking each other off in the back of their cars/wagons/etc. It is all sex. If you’ve been having a really fantastic time with someone and engaging in oral sex (giving and/or receiving) – I don’t know or care if you’re a virgin (and to be honest, no one really knows – or cares – so get over it). But I do know that it is sexual activity. You are or have been sexually active. You have sexed with people/s. Surprise!

Now you’ve gotten over that shock – we need to think about what we can do about all this sex that is going on.

We all need to learn about sex, about being sexually active and about how to negotiate consent. Preferably before we start doing it. We all need to learn how to do it safely and hopefully well, so everyone involved has a good, wholesome, fun ole’ time.

As adults, we need to advocate for real relationships and sexuality education – stuff that will actually help. When it’s needed. Lets get real and give people what they want. Useful information with a lot less slut shaming.

So hard hitting it hurt

Hard-hitting adverts change behaviour. You have to shock people in to altering their behaviour. Just like the Grim Reaper adverts right? Right?

This week the Heart Foundation launched its new ad campaign targeting everyone who has made a poor life choice in a hard-hitting campaign that drilled in on the idea that if you don’t look after your heart health, you are selfish and don’t love your family. Now, that is not my cynical take on this – the ads were incredibly direct, incredibly focussed on the individual and incredibly brutal.

Its is fair to say, the response online was a little less than supportive of this brave campaign move – with people from advertising panning it (especially Dee Madigan – who called it a “monstrosity”), and public health luminaries also questioning the angle. The Heart Foundation doubled down on their content early on and backed it to the hilt – extolling the fact that so many people had gone to the website and there was a “discussion going on” as proof that this campaign had hit the mark.

Brave move *heart emoji*

Now, overnight – no doubt after a few frantic board discussions, the Heart Foundation has walked their decision back and decided to edit part of their advert, deciding to remove the opening scene of the mother tucking her son in and apologised for offending basically everyone. They stand by their stance that if this campaign drives people to have their heart checks than its a job well done. I don’t begrudge them for feeling the need to do something drastic. Something that shakes up the conversation. I’m just not sure this is it..

Did the baby go out with the bath water?

So is there anything wrong with this kind of hard-hitting mass media if it gets results? Well, putting aside from the heartbreaking tweet I saw from a father who was now stressed his eight year old daughter with congenital heart disease might hear this advert and think her disease is because she didn’t love her family enough; and putting aside the thousands of loved ones who are left behind to hear this message after their family has died from heart disease – what’s the problem?

Everyone gets really excited about the Grim Reaper campaign in the 1980’s that saved Australia from the AIDS epidemic. It was ground breaking advert content that changed the direction of modern Australia and saved many deaths – particularly amongst men who have sex with men. Except it didn’t really do it alone. This ad campaign was incredibly memorable. Definitely striking. It did lead to increases in testing – particularly in people who didn’t need to be tested – but what prevented an rapid increase in the spread of AIDS was not this ad. I feel the Heart Foundation response to double down on this campaign lines up with the champions of the Grim Reaper.

The Grim Reaper ad campaign ran for three weeks on TV, had short run in print marketing and was on the radio for a couple of months. Around the same time there was the early implementation of policy for testing of blood donations. Very solid sexual health promotion work particularly focussing on condom usage. The increase of needle exchange programs. Attempts to improve sexual health education in schools (still a work in progress). Policy and health promotion programs made a difference. Advocacy and interventions made a difference. The Grim Reaper gets the credit.

Surely that is ok though – the work got done. Who cares who gets the credit. Well – some people do. Like the community that the Grim Reaper ad campaign was supposed to help – the men who have sex with men. Who reported significant issues and ongoing negative impacts from this campaign – that continue on.

Mass media health campaigns that focus on fear, stigmatisation and shame are really popular and have been since the 1940s (when the original Grim Reaper campaign ran preventing road trauma – told you it wasn’t ground breaking). Politicians love it – Kevin Rudd’s launch of his government’s “Don’t turn a night out into a Nightmare” Binge Drinking Campaign in 2008 was heavy on negative messaging, fear-based content and targeted a group of young people who thought they were “bullet-proof”. It even had a video game. Neato. Campaigns before and since on everything from road trauma to obesity to smoking to methamphetamines take the same route. This are ongoing questions over the efficacy in actually changing behaviour (Soames Job 1988, DeJong 2002, Stylianou 2010) and while there is evidence and support of its efficacy (Fairchild, Bayer et al. 2018)- employing fear harnesses stigma and must be done with great care

What do you want – love and rainbows?

I know how much people love punchy, scary ad campaigns to “scare ’em straight” – but can we just try and be a little more inventive? I know that is hard when a Minister wants something punchy that “will make a difference” – so advocacy and education is needed.

I’d personally love to see more campaigns that actually addressed some of the Social Determinants of Health and swam a little upstream from blaming individuals and creating stigma and shame. (Tell him his dreaming).

I’d really love to see some that consider the Ottawa Charter for Health Promotion when they are developing a campaign. I’d really love to stop seeing marketing that focuses so purely on the negative and is aspirational and inspirational – that connects with us more at a intellectual levels than through primal fear. That enables us. That creates a supportive environment for change. That strengthens our community – rather than telling people who have had heart conditions they don’t care about anyone else. Would it kill everyone to use some humour for a change?

I’ll leave you with my favourite Grim Reaper advert – and perhaps my favourite injury prevention advert ever. It deserves to be a template of thinking out side the box, but it doesn’t tick enough fear boxes. Social Death is a real winner in my eyes as it taps in to something other than brutal fear of death. Its a little aspirational. A little bit call to action. A little bit funny.

DeJong, W. (2002). “The role of mass media campaigns in reducing high-risk drinking among college students.” Journal of Studies on Alcohol, Supplement(s14): 182-192.

Soames Job, R. F. (1988). “Effective and ineffective use of fear in health promotion campaigns.” American journal of public health 78(2): 163-167.

Stylianou, M. (2010). “The Return of the Grim Reaper.” History Australia 7(1): 10.11-10.18.

Fairchild, A. L., R. Bayer, S. H. Green, J. Colgrove, E. Kilgore, M. Sweeney and J. K. Varma (2018). “The Two Faces of Fear: A History of Hard-Hitting Public Health Campaigns Against Tobacco and AIDS.” American Journal of Public Health 108(9): 1180-1186.

Avoiding greedily snaffling the low-hanging fruit

Sporting clubs are easy pickings for health promotion. They are a captive audience of collective individuals vaguely interested in health and well-being. They are the obvious choice for the latest intervention, program or campaign and provide great bang for buck – but we need to consider when to give clubs a break from being the target.

And you thought low hanging fruit would be easy

Sporting clubs are amazing places – community hubs filled with engaged individuals and plucky volunteers keen to make the world a better place one week at a time. Great venues for social change, for community engagement, for communicating to the masses. Sporting clubs bring people together in a way that many other organisations can not and they allow individuals from varied backgrounds to connect and enjoy their time together. And for forever and day, because of these facts – sporting clubs are the most obvious low-hanging fruit for health promotion programs to target. I should know, I’ve one it several times and been on the receiving end as well.

The problem with targeting sporting clubs is not targeting sporting clubs – but the manner in which you engage them and the long-term sustainability of whatever you are hoping to achieve. One-off funding and sponsorship that gets a club to sign up to a program might sounds great; but I’ve been in many a club that has a health promotion banner tucked behind the bar, or worse, on the wall next to an sign supplied by Big Alcohol. Your Great Health Promotion Message paired with Bush Chook. If there is no ongoing engagement with clubs to keep them on track – a season or two after the funding has ended, once a new committee or batch volunteers rolls in, the message can be very quickly lost or discarded.

If your program does not adequately engage the very fabric of a club – it will not survive long-term.

You can not bring a new idea in to a club and hope it will live on once you’ve left. You can not expect completely under-resourced volunteers to implement a new program or idea (on top the other programs they already run) if you don’t build their capacity. You can not expect clubs to champion your cause if they don’t believe in it and see the clear benefit. Your idea or program might be amazing and really well funded and make everyone in your industry nod with approval – but if Beryl who runs the canteen doesn’t really give a stuff because your idea is going to make her already hard and long day a bit harder and longer – she isn’t going to get on board long-term. Sure, she might do it to help the club secure the funding – but she will outlast your program. Like the last one. And the one before that.

If your program does not ingrain and endear itself to the sporting club champions, you are in trouble.

You ain’t no Gordon.

Sporting club volunteers want to believe in your programs. They want to run them. They really do (well, maybe not Beryl, but someone can sideline her long enough to put up the signs – Geoff behind the bar is trickier to move). The thing is – many sporting clubs are dying. Volunteers are so thin on the ground that they struggle from year to year to find people to do the things that actually HAVE to do. The administrative workload of running a small business for free eventually takes its toll and clubs need more work like a hole in the head.

The next five years are crunch time for clubs.

People don’t want to volunteer to do what has to be done to run a club these days. From ensuring insurance is appropriate and paid, securing coaches, finding players, organising registrations, paying fees, affiliations and memberships to State sporting bodies, organising umpires and game-day helpers, buying uniforms and merchandise, approaching and engaging sponsors, finding or training medical personnel, dealing with internal club politics and regional league or association issues – there is so much to do. Something as simple as putting a team on the park for a weekend requires determination, grit and a bloody minded will to achieve in the face of adversity. And a laptop with a 4G dongle, because everything has be done on a computer these days.

Did you bring the oranges?

Club volunteers are under the pump. Something as critical as becoming the coach of the under-16s footy team requires a full day of face-to-face (unpaid) training with an accompanying online module and work-book; as well as yearly re-registration and proof of competency. All clubs in WA are required to engage with the local department’s own club development program, an online toolkit and management system that is a great idea, but takes huge effort to really sink your teeth in to. If the club has a bar, everyone needs RSA training and you need a trained manager and need to run your cash bar to high standards around documentation and resourcing. Canteen staff are being recommended more an more to do food-handling courses and their are issues around food-preparation and local government. Sometimes food that needs no prep (hot chips and some pies) is just easier than an amazing quinoa salad – especially if your canteen is a bit dodgy. Never mind the fact that you may not have enough time to prepare healthy food options because you picked up the canteen supplies on the way home from work, and are running the canteen in between running water for the juniors and playing your self.

Sporting clubs are struggling to keep up with what they have to do. Volunteers are also players or umpires. There is never enough help. And even getting players is getting harder and harder as our lives get busier and busier – and more interesting options become available. Mountain biking, surfing, trail running, kayaking, mauy thai – all really interesting physical activities that do not involve ensuring 40 other people are ready at the same time (and all are things I now do instead of organised team sport). Plus, you also won’t be asked to volunteer in the canteen after your jog or have to join a committee. People are looking to do sport that fits their lifestyle. Blocking out a large chunk of Saturday to play and then run a canteen for the greater good doesn’t appeal.

Can someone take over in the canteen? I need to go home…..

Does this mean we do nothing? We leave clubs alone? Let sporting clubs run amok. Let them serve wild boar on a bed of hot chips with mead? Well, no – but if you want to set up a program that engages sporting clubs in health promotion – you need to ask yourself a few hard questions first:

  • Is your program going in on top of existing programs? Perhaps long term programs? If you think a club that already runs two programs is ripe for the picking because they are already engaged in health and social change and another wouldn’t hurt – consider what capacity is left in that club?
  • What has been rolled out already in that region?
  • What hasn’t worked or why didn’t it work long term?
  • What real connection does the club have to your program beyond the carrot or money or resources at the start?
  • Do clubs actually believe in your message, or do they want the cash?
  • What is the real human cost of your program? On the volunteers that have to implement it? How easy have you made it for them?
  • Do the local club development officers support your program? Is their department on board?
  • How much does society as a whole care about what you are selling? Have you done the ground work of outlining the problem in a real and relatable way that clubs have already engaged with? Basically, are you answering a need, or providing a solution to a problem no one knows they have?
  • Have you over or underestimated the clubs you are dealing with? No two clubs are the same, and the volunteers within a club drive its direction and motivation.
Consider how your program will meet these areas before you inflict it on unsuspecting volunteers

Once you’ve answered those questions and put yourself in the shoes of a busy parent juggling responsibilities – then you can probably get your program going. However, don’t forget to continually re-evaluate your program implementation and how it is engaging with the volunteer club workforce. Don’t be naive. Don’t be short sighted. Don’t preach. Definitely don’t preach. There is nothing worse. And for goodness sake, don’t think your program will survive without curation, care-taking and support. Unless it really is amazing. Then you might be lucky.

Young Crew and Severe Injury

I have spent some time working with young people on a program attempting to engage them on the concept of choices and consequences, particularly around partying and road safety. It was hard work. It was enjoyable work. Most importantly, it was work that allowed me to hang out with young people and hope that they cared about what I had to say. It sometimes felt a lot like high school.

When you’re in high school you are desperate for people to like you. To talk to you. To think that you are worthy of their attention and they you have something interesting and useful to say. There is so much at stake. What if they hate me? What if what I say sucks? My work allowed me to return to those anxieties, but at seemingly much higher stakes. I wasn’t just hanging out at lunchtime with young crew, I was trying to convince them that keeping their limbs on was worth their attention.

PleaseLikeMe_header

Until recently I worked on a project that involved coordinating and delivering a program that focused on reducing youth trauma – particularly trauma resulting from drinking or high risk behaviour. I was basically trying to teach teenagers how to not be stupid. And really, the focus is predominately on young men not being stupid. In 2016, a staggering 71% of trauma patients through the major trauma centre in WA (15-24 year old age bracket) were young men. And primarily young men that had taken stupid, high risk choices. From my home region – young people accounted for 25% of people killed or seriously injured on our local roads between 2004 and 2013. The excuses of the excesses of youth, the difficulties in delivering programmes or vagrancies of funding can’t be excuses for not trying to educate this group.

stats

I was involved in a really fun program to deliver. I am also the first person to admit it wasn’t always perfect. It could always have been improved, expanded, built upon. Health promotion is most effective when delivered as part of a structured program that is embedded in to multiple areas; rather than one-off field trips – but when you only have the capacity to deliver the one-offs, you have to decide whether one-off interventions are better than no interventions. We endeavoured to ensure the program was delivered in conjunction with other projects and programs, but occasionally it was purely stand-alone. I know what the research says, but sometimes you can only do what you can do.

A major challenge involved in running a project like this, was stakeholder management. So many stakeholders, all very important to the project, all with different needs, goals and motivations for their involvement. There were tense moments during development and delivery that would have been easier to manage with less people to worry about, but that may have reduced the efficacy of the program or the internal and external support. It was a delicate balancing game.

4302981_orig.jpg

After navigating the stress of just getting the project up and running – my main joy was delivering the actual program days. Delivering programs to young people takes a significant amount of energy. You have to just go for it and second best will not do. Program days would first involve juggling presenters and pretending on top of everything; then once that was under control the real fun would begin. It would be my turn to hurtle head first in to an awaiting pack of rabid youths, desperate to make my mark, or at the very least, a smeary smudge against the windshield of their youthful egos.

splat.gif

That is where when head back to high school. Now, this was not peer-education. I’m old. Like grey hair, married with children old. I am so not lit. Sure, I’ve met young people and some of them have even spoken to me in a consensual two way conversation – but I am O. L. D. The young crew I was speaking to were generally in the sticky, messy part of the teenage dream, where parties, booze, sex and risk taking come crashing together with awkwardness, naivety and acne. I’m old enough (if I’d made some dramatic life choices) to be their dad. Or at least their uncle. In fact, for one of the kids – I was their uncle. Now, that was a tough day of trying to balance role duality. The challenges of working in regional areas.

200_s.gif

So, how do you make yourself relevant when speaking to young people without making yourself a grade-A example of an epic toolie? The first step is to sincerely acknowledge that you are not their peer, you are old and you do not know what they are going through. Aside from the fact that this is 90% the truth, it helps establish that you aren’t trying to be cool – you’re trying to be useful.

One thing that was VERY successful for me and a I recommend to anyone working with young people: don’t be afraid to ridicule yourself. It helps reduce the feeling that you are holier than thou and preaching to the group. I never felt that I lost standing mixing strong messages with some self targeted ribbing. One of the most talked about slides from my presentations has been my then and now picture. I use it to introduce the concept of choices and consequences to the program – mainly my poor choices in hair style and fashion.

Picture1 (2).jpg

Another tip: find a concept and deliver it well. We worked hard on the choices and consequences concept – reduce your risks, help your mates, beware the ripple effect. Trying to convince a group of young people that a potentially silly error could lead to ongoing and possibly lifelong effects is a tough sell – one that can be achieved through making what you are talking about real, relatable and raw. A participant has to be able to put themselves or someone they know in the picture.

Slide6.jpg

The ripple effect was one of the key tenements of the program. It sprung in to existence from almost nowhere one day and became a core principle of explaining the concept of road trauma to young people. We don’t give young people much credit – they can be portrayed as lazy and self-absorbed. An unfair generalisation that doesn’t allow for the fact that there is great compassion and empathy in amongst our young crew. I would often explain the concept that health workers – the paramedics, doctors and nurses that dealt with front-line trauma are not robots. They are people, with families, and friends and lives that went on beyond delivering emergency health care. The concept that their decisions may actually impact on me and my children’s lives proved to be surprisingly effective in gaining their attention.

robot.jpg

Another pointer: tell real stories. Scenarios are great. Real life is even better. I have, unfortunately, lost far too many friends and peers through road accidents. Some were drinking driving. Some were speeding. Some remain unexplained, many, many years later. All were young men. All were tragedies. All ripped the heart and soul out of families, communities, sporting groups. There is nothing like the jarring finality of the loss of a young life through road trauma. There is a jarring reality when you stand in front of a group of young people and speak candidly about how hard it can be to see the mother of a dead friend, even years later. Explain the times you catch yourself day dreaming about the possible children a mate could have had, what type of dad he may have been, what type of partner. Retelling the reality of a life lost aids with cut-through.

3676653593_38e0dc78eb_b.jpg

There was great opportunities to learn from the groups. Not just from what they were saying, but their actions, their responses, their feedback. There is something really exposing about presenting to young people (if you care). You are putting yourself out there – and they will provide direct and cutting feedback if what you are serving up isn’t to standard. The groups I spoke to had no qualms in questioning what was presented, how it was presented. They were fair but harsh critics – and they demand the best of you as a presenter.

The content we delivered was hard going and the manner it was interactive, challenging and occasionally fun. There can be a misconception that if you are learning about a serious topic you can’t enjoy yourself. It is widely accepted that children learn best through play. Surely adults and young adults are the same. This week I was reading an article by Dorothy Lucardie, who highlights that having fun and experiencing enjoyment were recognised by adult learners and teachers as a significant motivators to attendance and learning the knowledge and skills; while fun and enjoyment were considered a mechanism that encouraged concentration by learners and helped in the absorption of learning. We shouldn’t be afraid of making learning about serious topics fun. Why not engage a group, have them invested and involved when talking about the challenges of managing a trauma patient?

PIC_0074.jpg

The element of fun, some self-depreciation and relatability and acknowledging that while I definitely wasn’t a peer, I was at least worth listening to – meant that I had a lot of fun delivering this program and excellent feedback from my harsh, teen critics. Delivering alongside some exceptional presenters made my job that little bit easier, and definitely ensured that we had maximum impact on participants. This project was heavily evaluated, and the feedback forms were always glowing – but the biggest things that I would take from delivering the program were the unexpected outcomes, the remembrances, and the relationships with my fellow presenters.

2016-05-10-07-38-01.jpg

The value in presenting that program was always the things on top of the content. The outcomes no-one knew would exist. Two male students chose to study nursing after attending the project, changing their study preferences in perhaps the biggest professional compliment I have ever received. One student spent the day seemingly ignoring the key points of the program, before everything clicked in the final 15 minutes of the day. He solemnly shook my hand at the end of the day, staying back explicitly to do so – and still welcomes me in the street 2 years after he attended the program. The young people who remind me they were participants as they serve me coffee in local cafes, thanking me for the program. The parents who approach me and tell me their child raved about the program at home and that they hope it continues. Those were the things that made it really worthwhile, and are the things that cannot be captured on an evaluation or wider expansion of a program. The intangibles, the connections you make, the moments of realisation in a participant’s eyes. You can’t capture that – but it makes it worth throwing so much of yourself in to it.