How are we talking about non-daily PrEP?

The most common form of oral PrEP is daily dosing — but it’s not the only game in town. In guidelines launched at the recent International AIDS Society conference in Mexico, the World Health Organisation endorsed what it calls ‘event-driven’ PrEP, and the CDC has endorsed ‘consistently’ taking at least four pills per week. While the evidence supporting non-daily PrEP is rock solid, the language we use to talk about it remains unsettled.

Through my work on the Rinse and Repeat campaign, I have first-hand experience of the language challenges posed by non-daily dosing, and with this post I want to raise them for discussion in the global HIV prevention community.

My perspective in this post reflects the communities I work with and belong to — queer people, trans folks, gay and bisexual men and other men who have sex with men (GBM), and people from migrant and refugee backgrounds (and all of these categories overlap all the others).

(Sidebar: I personally identify as a queer nonbinary person who does ‘gay male’ drag when it helps me connect with the communities and colleagues I’m working with. I’ve felt that disconnect since 2004, and this is my coming-out post. My gender is Daniel, my pronouns: just call me Dan.)

Two kinds of non-daily dosing

There are two approaches recognised by the WHO.

  • Taking two pills at least two hours before sex, and then another pill every 24 hours after that, until two days after your last sexual encounter. The WHO calls this ‘event-driven PrEP’ and ‘2+1+1.’
  • Taking a pill on the same four days each week, e.g. Tues & Thurs & Sat & Sun. (Someone needs to make that a t-shirt.) Also known as ‘T&S’ dosing. This is implicitly endorsed by the CDC but not endorsed by name.

Event-based PrEP

This approach is called different things in different places. It has been called on-demand, event-based or event-driven, intermittent or episodic, ‘disco dosing’ and 2+1+1. The approach was first proven to work by the IPERGAY study in Paris and Montréal, and in French, it’s ‘on demand’ PrEP. That’s what it’s commonly called in the UK as well.

Recently, with funding from Dynamix and help from some creative mates, I developed a resource that illustrates the first approach. The dosing schedule is surprisingly complicated — we often describe it in a single sentence, but when you diagram that sentence out (nerd alert), it involves more than seven discrete pieces of information, some of them relative to each other.

One of the few pieces of communication psychology everyone knows is the 7±2 rule — i.e. most people struggle to hold more than 5-9 pieces of information in their head at one time. And that’s just to remember them; the dosing schedule requires you to process them.

So in the Rinse and Repeat resource, we broke down the dosing schedule into six easy steps that anyone can follow. The short film introduces the broad concept and people can visit the website to find the six easy steps.

In that project, after a fair bit of discussion, I went with ‘event-based’ PrEP. It’s not catchy at all and that’s physically painful to me. The main alternative was ‘on-demand’ and that wording is both catchy and agentic.

And my concern is that people hear the name ‘on-demand’ and think they understand how it works. When I talk about the project, people who weren’t familiar with EBP often said ‘so you only take a pill when you have sex?’

In this case, on-demand means as-needed, but in everyday usage ‘on-demand’ usually means at-will, i.e. whenever you feel like it.

Educators are already telling me they are hearing from people who have messed up the dosing schedule because they didn’t understand it clearly when they started.

The WHO has gone with event-driven instead. They didn’t consult me. Again. (It’s okay, I’m fine, I’ll get over it. Eventually.)

But they also went with 2+1+1. I understand this label comes from PrEP roll-out workshops and focus groups with heterosexual folks and people in low-income countries. Again, it’s catchy and it gets the idea across… kind of. It leaves out the timing, which is pretty important information.

I have the same concern that someone might hear it and think they understand it without further research. In the Rinse and Repeat campaign, I went with the slightly jargon-y ‘event-based’ naming because I want people to google it up before they try it out.

The other problem with 2+1+1 is that it embeds a very heterosexual model of sexual life. Sex once a week on Friday after the kids have gone to bed, one and done. It leaves out people who have more than one encounter (or more than one day of encounters).

With EBP, you take a startup dose of two pills, then a follow-up dose every day, around the same time, until two days after your last encounter. Calling it 2+1+1 obscures the fact that if you keep taking a daily follow-up dose, event-based PrEP can protect you for a week, a month, or a whole season of sex. (Shout out to my peeps enjoying summer in Montréal!)

Anticipation, not planning

In my home country of Australia, campaigns about PrEP have universally focused on daily dosing. I’ve argued that ‘take the pill every day’ has become the new ‘use a condom every time.’ The evidence shows it isn’t required — in the iPrEx trial, nobody seroconverted if they were taking at least four tablets per week. But some people are just uncomfortable thinking about sex outside of a prescriptive normative framework.

So while we knew from the IPERGAY study that event-based PrEP is a thing, people talked about it in a very specific way that implied it’s dubious or only marginally relevant. They say it’s only suitable if you can plan your sex life in advance.

And everyone wants to think of themselves as spontaneous.

The Rinse and Repeat campaign emphasises the flexibility of EBP — the tagline is Whatever comes your way, ‘from an occasional fuck to the occasional fuckfest, event-based PrEP has got you covered.’

And instead of talking about planning, we talk about anticipation — if you’re feeling frisky and you think you might be getting some later today, take a startup dose now. If sex doesn’t happen, no harm no foul.

Exactly the same meaning, without the disparaging connotation. EBP was first tested among sex pigs in France. Les cochons were having a lot of sex. They certainly weren’t scheduling their fucks in dainty little date books. During the IPERGAY study and since, there have been no seroconversions among GBM doing event-based PrEP in France.

Cis women and trans folks

This is really tricky and I want to take a moment to put my remarks in context. In the late 80s and 90s, HIV social researchers described how the epidemiology of AIDS was challenging what Michael Warner has called the ethnic model of LGBT civil rights movement — the notion that ‘gay’ or ‘lesbian’ is comparable to an ethnicity, a relatively self-contained community defined by a common identity and shared culture.

Except there were people being diagnosed with HIV, who identified as straight men and were having sex with men. Or lesbian women who were having sex with gay men. And trans folk, whose lives were not and still are not (IN! TWENTY! NINETEEN!) reflected in epidemiological questionnaires.

The lesson from that was: talk about sexual practices, not identities. (If heterosexual people learned one thing from sex ed, it was “AIDS affects everybody.” Well-meaning but a gigantic distraction from the fact HIV impacts hardest on oppressed and underserved communities.)

In my PhD, I document the way in which the Australian health promotion response to HIV began targeting collective social forms, such as networks, sexual cultures, and communities from the late 1990s onwards. This followed (s l o w l y) after social research that identified particular practices, such as use of crystal methamphetamine, and the practice of fisting, are not independent causes of HIV infection; instead, they are markers of sexual cultures and interpersonal networks with higher HIV prevalence and increased (though quite nuanced) practice of unprotected anal intercourse. So I might refer to sex between men and gay culture in the same piece, talking about different things (a sexual practice, a cultural form) in each case.

When we wrote the first draft of the Rinse and Repeat, I didn’t want to single out trans people or cisgender women — because the diversity of people, bodies, lives and experiences isn’t reflected in those broad labels. Instead, we used positive language, saying that EBP offers protection from HIV transmission during anal intercourse only.

However, there’s now evidence that feminising hormones might affect the way the drugs in PrEP are metabolised, which could, in turn, mean that four pills per week are not enough to achieve protective concentrations. We also know that it takes a lot longer to reach protective concentrations in the urinary tract of people with vaginas/front holes, so EBP does not provide protection for vaginal or front-hole intercourse.

(In both cases, we recommend taking a daily dose for 28 days before having condomless intercourse, rather than doing EBP or T&S dosing.)

So I want to hear your thoughts on: how do we talk about these variations in the protection offered by EBP?

As a communications person, I think it’s simpler and therefore easier to understand if we say ‘we recommend daily dosing for trans folks and cisgender women.’ That’s a positive alternative recommendation and avoids a negative and exclusionary framing (e.g. EBP is not for …).

In this usage, the labels ‘trans folks’ and ‘cisgender women’ do not comprehensively identify all the bodies and practices that EBP won’t work for. In a short message (in a voice-over or across the top of a website) they may function as a sensitising device. If you were not assigned male at birth (AMAB), even if you don’t identify with either label, once you know that protection may vary by trans experience and cis-female embodiment, you know that some further research may be warranted before starting EBP.

(IDK, maybe all this dancing around is just me trying to avoid admitting that this is yet another medical innovation that only benefits cisgender men.)

Your thoughts, please.

Activism and forgetting

Lately I’ve been thinking about forgetting. I’ve been writing hard on my dissertation, and a lot of stuff goes by that I’d love to blog about, but I try to stay focused. All the things that tug on my consciousness lately involve forgetting, so I am loath to let them go unmarked. This post is necessarily schematic — touching on things I wanted to note in passing, even though I can’t give them the full consideration I’d like to. (I welcome different perspectives in the comments.)

#PrEP4All means patents for all

Earlier this year, PrEP4All, an off-shoot of ACTUP NYC, launched a campaign to demand the United States enforce the patent held by its National Institutes of Health (NIH) over the use of the drug combination TDF/FTC for pre-exposure prophylaxis (PrEP).

The pharmaceutical company Gilead Sciences holds the patent on the drug combination — for another year or three, at least — and has been targeted by activists over its practice of ransom pricing. Indeed, the campaign explicitly links outrage over greedy pricing and enforcement of the patent over PrEP. It demands the US government tax the profits Gilead makes when its drug is purchased for use as PrEP.

The campaign is quite explicit about calling back to the early days of ACTUP when activists fought the FDA over its sluggish approval process for AZT, and pharmaceutical companies over their patent and pricing strategies.

Peter Staley, the wealthy and photogenic activist who took part in those protests and features prominently in films like How to Survive a Plague, said the campaign reminds him of those early days and has described the epidemiologist James Krellenstein, one of his fellow instigators of the anti-Gilead jeremiad, as the future of the movement.

Who’s missing from this picture? L-R: James Krellenstein, Peter Staley, Jim Eigo, Larry Kramer, Matt Ebert (photo posted by Peter Staley, 9 Dec 2015)

The history-making around AIDS demands heroic ‘leaders’, and leaders are assembled from archival footage without much reflection on who got filmed, who could afford to come out as HIV-positive and get arrested at protests, and who didn’t/couldn’t and for what reasons. This myth-making centres educated white men and erases both queer people of colour and ACTUP’s autonomous collective organising practices.

Forgetting isn’t negligent. Forgetting is enacted. Even in the brain, forgetting is an active process. In culture, forgetting occurs through selectively retelling some narratives instead of others, and letting some narratives and not others shape social action.

The foundational nostalgia of the PrEP4All campaign forgets the entire world outside of white, middle-class, educated New York. What frustrates me is the faith this activism places in the American legal system and intellectual property laws. It consciously forgets the utterly malign role patents played in making HIV treatments inaccessible in low-income countries.

The global patent regime was quite explicitly formulated and advocated by the pharmaceutical industry, prosecuted by the United States Trade Representative, and enacted through the creation of the World Trade Organisation and the Trade Related Aspects of Intellectual Property (TRIPS) regime (Harrison, 2004).

That victory was only overcome, and overcome only temporarily, by the concerted effort of activism encapsulated in the Doha Declaration (2005). The TRIPS regime means that a patent granted in the United States can be enforced around the world. Combined with investor state dispute settlement (ISDS), it means Gilead could sue for expropriation if the United States only enforced the patent in the US itself. Patent enforcement is all or nothing.

It also forgets the trade war and the American exceptionalism that are the official policy of the White House. The ultimate target of the campaign is Trump himself — who has already shown a willingness to appropriate HIV prevention in his political messaging. In the context of a trade war, he is more than capable of announcing plans to enforce the patent worldwide within his favoured rhetoric of ‘making others pay their way,’ as he constantly does with Mexico and has done with NATO.

At a time when we are furiously trying to expand access to PrEP in high-prevalence countries — not all of which are low-income countries eligible for the exemption laid out in the Doha Declaration — encouraging the US government to enforce a patent over PrEP is deeply misguided.

Better than a condom, but undetectable is unmentionable?

My next two case studies are drawn from Australia. This week we saw a poster stuck up in urban Melbourne, announcing that PrEP works better than condoms. It cites a CDC estimate of condom efficacy as a range from 72-91%. This, too, involves a conscious forgetting of the experience of condom use over the nearly 40 years of the HIV epidemic in gay culture and queer communities.

Poster shown on a wall in Melbourne saying "See It Clearly 2020: PrEP BETTER THAN A CONDOM with a bar chart showing PrEP at 99% and Condom, in grey, 72-91%, a CDC citation, and below that, PrEP Works, One Pill A Day, 'concerned about STIs? check out 100mg doxycycline daily.'
The typography alone is homophobic.

A friend who was involved in Australia’s first gay community HIV prevention campaign ‘Rubba Me’ mentions that gay and bisexual men took up condoms before any studies had shown they worked. We knew they worked, he said, because we were having plenty of anal sex with condoms and we kept testing negative. Prof Kane Race calls this a commitment to ‘intimate experiments,’ a willingness to take risks and embrace uncertainties. (Just like the first people to try PrEP.)

Condoms work when they are used correctly. There are countless men who have sex with men who have been HIV-negative for decades, because they used condoms correctly and personally felt no problem with condoms.

I personally hate condoms. I advocate PrEP and use it when I need it, but I strongly prefer U=U. However, condoms are cheap and they are everywhere, and the same cannot be said for PrEP and even HIV treatment, particularly in low-income counties and countries. Telling people that condoms don’t work is bad prevention strategy.

The CDC estimate was calculated by averaging out studies that included populations in which incorrect use of condoms is common. Just as we report on the 99% efficacy of PrEP when used correctly, we should report condom efficacy on the same basis.

In the 1980s, Prof Juliet Richters studied condom use in three cohorts: heterosexuals, gay and bisexual men, and sex workers. This was a rigorous study — participants were asked to save condoms after use and they were inspected by the researchers. (Talk about intimate experiments.) In a six month period, Richters and her colleagues did not find a single breakage among gay and bisexual men and sex workers.

The study was the original source of a claim that circulated widely in the 1990s — asserting that condoms are only 90% effective. It was cited by homophobes and even by some public health experts as an argument against gay men having anal sex at all. It was based on the failure rate of condoms among Richters’ heterosexual study participants. In other words, the circulation of that claim enacted an erasure of queer people and sex workers, and our skills and creativity in protecting ourselves. So I am extremely troubled to see a similar logic being used to promote PrEP.

Crucially, those posters also forget to mention that U=U is even more effective than PrEP. U=U means ‘undetectable equals untransmittable.’ If a positive person has undetectable viral load, they cannot pass on the virus through sex.

That’s an important message at a point in time where people are saying “PrEP 4 PrEP” in their profiles on hookup apps. As Alexander McClelland points out in a recent feature, the widespread uptake of PrEP has, to some extent, severed our shared membership, whether positive or negative, in a community living with HIV. He writes:

I’ve heard this from guys many times: that my viral undetectability is of no interest. They are on PrEP, so it doesn’t matter what’s going on with anyone else. (…) The moment to have a bonded connection over our shared relationship to HIV, negative or positive, is no longer on the table. For some of us who have lived with HIV for a long time, this can be refreshing, and for others, disconcerting. 

McClelland (2018)

As both Bruce Richmon and Damon L Jacobs have argued, in order to avoid these new prevention technologies deepening the ‘serodivide’ in our communities, it is essential that we always talk PrEP and U=U together.

On a more technical note, the poster says ‘PrEP Works, one pill per day’. This completely ignores non-daily dosing strategies like event-based PrEP and T&S dosing, even though the World Health Organisation just came out saying both are just as effective as daily PrEP.

Blood equality

Lastly, we are now seeing a movement for what it calls ‘blood equality’, advocating the right for men who have sex with men (MSM) to donate blood without exclusion periods. This argument is formulated in a few different ways.

One version argues that we’ve achieved marriage equality and this injustice is ‘what’s next’. This forgets many other more pressing needs, like the acceptance of queer people living in areas that overwhelmingly voted ‘no’ on Australia’s marriage plebiscite, or the fact that a significant minority of people living with HIV in Australia don’t have access to Medicare-funded HIV treatment.

Some versions have argued that it’s matter of human dignity to allow blood donation. When I last looked at this issue, in the mid-2000s, I used this argument myself. I drew on Richard Titmuss’ argument that people donate blood out of altruism, which in turn drew on Mauss’ theory of society as gift relationship. Now, I realise that human dignity has to be universal or it is just special pleading. In the case of ‘blood equality’, the claim based on human dignity forgets (or accepts) that people living with HIV are excluded.

A more recent formulation argues that even a 3-month exclusion period is intolerable and that behavioural screening should be enough. The idea is that we can just ask people about their recent sexual behaviour and decide whether to let them donate blood. This forgets nearly forty years of experience, which tells us that choosing partners (or donors) based on self-reported risk is not effective protection.

This claim also forgets the community and clinical experience of seroconversion, which doesn’t always happen overnight; in some people it does take up to 3 months after infection for viraemia to emerge and antibody production to occur. And PrEP actually complicates matters even further — even with resistance mutations, TDF/FTC can be enough viral suppression to prolong the seroconversion process, so any exclusion period less than 3 months is very unlikely.

Finally, this advocacy also forgets the sex-positivity that has always been central to the Australian community-based response to HIV/AIDS. As the law student, student politician, and Labor think-tank staffer Connor Wherrett recently wrote in the queer (sic) edition of Honi Soit,

“The fact is, blanket policies like this discourage healthy MSM giving blood. A same sex male couple, despite being together for a year and only having sex with each other, and being regularly tested, is treated the same way as a gay man who has multiple unprotected sexual encounters with different individuals a week.” (source)

To reiterate: forgetting is not just a matter of not knowing, or letting something that was known slip away. It is produced through social action. Although in social movements we constantly bang on about Foucault’s notion of discourses, my analysis here draws on his conception of the archive — the collective repository of prior discourses and the practices that select which discourses operate in the present. These campaigns and interventions are among those practices.

My work draws heavily on Foucault, who is not typically interested in the role of specific actors and human agency in discursive practices. I ran these reflections in dot-point form past Theodore Kerr, a Brooklyn based writer, organizer, curator and artist, past convenor of Visual AIDS and collaborator in the ‘What Would an HIV Doula Do?’ collective. He reminded me that these acts of forgetting reflect the strategies and social placement of particular individuals — seeking to adopt positions of leadership in social movements, and taking perspectives that reflect their own privilege and their lack of meaningful engagement with the people, politics and lived experience of the Global South (or, indeed, the American South).

I recently re-watched Robin Campillo’s 120 Battements Par Minute (distributed in the Anglosphere under the title BPM). Just like the first time, I sat there in darkness, trying not to howl as all the moisture in my body evacuated via my tear ducts. It is a powerful evocation of the experience of HIV and AIDS in France in the early 1990s, shown through the lens of ACTUP Paris and its actions (and debates) over HIV treatments access. The closing image is of a die-in, on a cobbled street, at night, beside a church, calling on the French government to acknowledge the crisis, and the brutal fact of death and dying. It shows forgetting as a practice of abandonment: people in power knew and did not care.

Further reading

Alexander McClelland’s ‘Unprepared’ in Maisonneuve (Spring 2019)

‘I’m forty now. Some have said that the PrEP era means we are all “HIV equal,” dispensing with the negative and positive. This so-called new era can be confounding, at least to me.’

Meanwhile, Dion Kagan, Positive Images (IB Tauris, 2018) offers a reminder that remembering is complicated, too:

‘Making AIDS into history, as I suggested earlier, can act as a form of temporal estrangement, a kind of prophylactic distancing that disavows the present day conditions and urgencies of HIV. As [Theodore] Kerr writes, the poster campaign (‘Your Nostalgia is Killing Me’, Chevalier & Bradley-Perrin, 2013) was a protest against the negligence of nostalgia, expressing the feeling that the artist’s “current life chances as people living with HIV were being reduced by a focus on AIDS of the past. The stigma, health, and social realities that they experience were being ignored in lieu of a look back.”’ (p227)

‘Candle-lighting’ — the Catholic response to the Pell conviction

In the wake of the Pell conviction for child sexual assault, we are now hearing grave concerns from cultural conservatives and Catholic commentators that the jury verdict was ‘unsafe’.

There’s a distinction between law and fact at the heart of criminal legal proceedings. The judge makes decisions on the legal and procedural issues, while the jury is the tribunal of fact. The facts enliven the law. Judges’ decisions on legal matters are frequently overturned in appeals to higher courts, but it is extremely uncommon for an appellate court to overturn a jury decision.

The legal test for overturning a decision was set out in a case with a similar fact scenario to Pell, M v The Queen [1994] HCA 63. M was a father accused of sexually assaulting his 13 year old daughter, with proceedings brought many years after the event was alleged to have occurred. The majority in that case, Mason CJ, Deane, Dawson and Toohey JJ, found:

If the evidence, upon the record itself, contains discrepancies, displays inadequacies, is tainted or otherwise lacks probative force in such a way as to lead the court of criminal appeal to conclude that, even making full allowance for the advantages enjoyed by the jury, there is a significant possibility that an innocent person has been convicted, then the court is bound to act and to set aside a verdict based upon that evidence [citations omitted].

The advantages enjoyed by the jury are seeing and hearing the witness. The High Court is saying that even an appeal court judge reading the evidence is at a disadvantage compared to the jury. In other words, the complainant’s demeanour is relevant to the judgment of their testimony. In M’s case the majority concluded:

the ultimate question must always be whether the court thinks that upon the whole of the evidence it was open to the jury to be satisfied beyond reasonable doubt that the accused was guilty (18 Chidiac v. The Queen (1991) 171 CLR at 443, 451, 458, 461-462) .

The ultimate question is whether it was open to the jury — we’ll come back to that. For now, I want to reflect on a piece in Eureka Street, no doubt a long time in the drafting, in which the Jesuit priest and lawyer Fr Frank Brennan responds to news of the conviction. I’m told the piece has been circulated to every family with a child enrolled at a Catholic school, indicating that it represents the views of the archdiocese.

These are special, non-flickering votive candles.

Fr Brennan clearly anticipates the considerations in M v The Queen. In so doing, he places himself in the shoes of the jury, despite acknowledging he was only in court for some of the proceedings. In M’s case, Brennan J — that would be Fr Brennan’s own father — noted ‘the appellate court must acknowledge that the primary responsibility for finding the facts rests with the jury, not with the appellate court.’ Fr Brennan acknowledges that he did not even see or hear the principal evidence, and yet, lacking the caution of an appellate court, he considers himself better placed to judge the facts of the case than the jury.

Fr Brennan argues the verdict is unsatisfactory because the jury must not have placed the same weight as he does on the criticisms of the complainant made by the defence. In so doing, he makes a number of assumptions about how the jury must have reached its decision. They are necessarily assumptions, because juries do not give reasons for their decisions and none of the jury has spoken out. I am, to put it mildly, bemused that Fr Brennan imagines himself an unbiased observer and commentator on proceedings involving Cardinal Pell.

Fr Brennan insists the complainant made mistakes in his evidence. Compared to the High Court bench in 1994, we now know from studies of eyewitness evidence and the recollection of traumatic events that discrepancies of recall are common. The whole point of trauma is that it resists being encoded as narrative memory and must be relived, rather than recalled, under conditions of intense distress. It is open to a jury to conclude that the complainant was wrong about some of the particulars but correct about the substance of the allegations.

Defence barristers in proceedings involving sexual assault invariably insist that any small discrepancy is evidence that the whole complaint has been made up. Let me take a moment to note how old that insistence is. I draw here on the work of the historian Barbara Hanawalt (2003) on medieval law-making. She notes that the crime of rape was first codified in legislation in the first Statute of Westminster in 1275 AD, in response to the concern that rape complaints were too easy to make under common law. At first the sentence for rape was punishment in life and member, but this was adjusted downwards in 1285.

Hanawalt describes the common law procedure for prosecuting rape in medieval times. The victim had to tell the first person she encountered after the rape occurred, and then proclaim the rape, in detail and without delay, to the ‘reeve’ — an assembly of all the men in good standing in her town or village. Then, at the next assizes (a travelling court), she had to give an account once again that varied in not one single detail from the earlier accounts she had given. Even the tiniest deviation could be seized upon as evidence the complaint was false, exposing the woman herself to criminal punishment and her family to civil proceedings.

Put simply, rape proceedings have a similar structure to the method of trial by ordeal used in witch hunts, and this underlying frame persists in the modern-day practice of rape prosecutions, even though legislators have sought to defuse it. Indeed, much the same concerns — lack of corroboration, delay in reporting, discrepancies, the victim’s demeanour — were ventilated in M’s case.

Fr Brennan writes:

My only conclusion is that the jury must have disregarded many of the criticisms so tellingly made by Richter of the complainant’s evidence and that, despite the complainant being confused about all manner of things, the jury must nevertheless have thought — as the recent royal commission discussed — that children who are sexually violated do not always remember details of time, place, dress and posture. Although the complainant got all sorts of facts wrong, the jury must have believed that Pell did something dreadful to him. The jurors must have judged the complainant to be honest and reliable even though many of the details he gave were improbable if not impossible.

Tellingly made, indeed. ‘Improbable’ perhaps refers to the High Court’s decision in M’s case. Fr Brennan asserts what lawyers and legal scholars describe as tendency evidence in order to argue that this particular event was ‘improbable or even impossible.’ Tendency evidence is inherently weak. It has the following inferential structure: ‘the assertion that X happened is more likely to be true because of all these other occasions on which X also happened.’ The planned second prosecution of Cardinal Pell, the ‘swimmers’ case’, was abandoned this week after the judge ruled tendency evidence inadmissible in those proceedings, in turn leading to the lifting of the suppression order on news of his conviction.

Fr Brennan argues that Pell could not have been in the sacristy because ‘the Archbishop was a stickler for liturgical form and that he developed strict protocols in his time as archbishop’ — a pattern or tendency that did not include visiting the sacristy alone, or so soon after the Mass ended.

However, ‘generally did not’ is not the same as ‘never did’. It was, again, open to the jury to conclude that on this occasion, however exceptional it might have been, Pell did enter the sacristy alone and soon after the mass. Brennan does not say over what timeframe Pell developed this pattern of behaviour; the complaint concerns a mass very early in his tenure as Archbishop of Melbourne, and David Marr observes that his protocol may not have been set in stone at that point in time.

Likewise, Fr Brennan asserts that the vestments conventionally worn for a mass of that kind include an alb — a garment that would not easily permit a priest access to his genitals. But, again, this involves asserting a general custom as evidence against a particular event. The prosecution led evidence that it is possible to move the customary vestments to one side. (Perhaps for practical reasons: so many old men, so many dodgy prostates.) Pell has a reputation for being a stickler, but reputation is, yet again, another kind of tendency evidence. It does not exclude the possibility of exceptional circumstances, leaving it open to the jury, considering all the evidence as a whole, to conclude that this particular event occurred.

Finally, Fr Brennan explicitly poses the questions he is raising in the piece: ‘Was the verdict unreasonable? Can it be supported having regard to the evidence? Those are questions for the appeal court.’ If so, why the piece?

It pays lip-service to the role of the courts, but Fr Brennan goes on to conclude by saying he ‘hopes and prays’ that justice will be done. That is not something you say if you believe justice has been done. There is a name for this kind of semantic nicety: it’s called being Jesuitical, and only the Jesuits think that’s a compliment.

The thing I find most troubling is the move Fr Brennan makes next. He writes ‘ I can only hope and pray that the complainant can find some peace, able to get on with his life, whichever way the appeal goes.’ This is the ultimate Catholicism. It extends to the person who has been wronged a false pity that simultaneously implies their complaint springs from being troubled. It is a hypocritical gesture that evades moral accountability while further injuring the person bringing the moral claim.

In the context of partner abuse, this move is known as gaslighting. In the case of the Catholic response to the Pell conviction and the findings of the Royal Commission on Institutional Responses to Child Sexual Abuse, we could perhaps call it ‘candle-lighting.’

Cardinal Pell’s legal team have already filed a motion to appeal the decision. An army of Catholics who imagine themselves defenders of a victimised church have turned out in force, on social media and in the press, to insist that Pell cannot be called an abuser until the appeal has been heard. This misunderstands the law: the maxim is ‘innocent until proven guilty,’ not ‘innocent until the guilty verdict survives on appeal.’

But even the Vatican, which refuses to take action against the Cardinal, insists on the latter. There’s a refusal to acknowledge that secular institutions have any authority over church officials, or that a conviction impairs tenure in religious office. This does not bode well for Vatican acceptance of mandatory reporting duties for church officials, or for meaningful cultural change to protect young people in the care of Catholic schools, churches, and welfare organisations from sexual assault.

Renovations in progress

If you notice banging noises or see plaster drifting from the ceiling, it’s because I’m moving Bad Blood and my other blogs away from to a self-hosted setup. So far it’s going pretty smoothly, but that just means I haven’t found the cracks yet.

As they say in PR-speak, we apologise for any inconvenience! Please excuse our improvements! Thanks for your patience!

The ending of ‘The Favourite’

Spoiler alerts don’t come any clearer than the headline of this post. Yorgos Lanthimos’ tragicomedy The Favourite is finishing up its North American run before it heads down under to open in Australia on Boxing Day, and I caught it during the week.


Or it caught me. The trailer makes it look both hilarious and crazed. And it’s both of those things, but I was not ready for it to be so tender and achingly sad. I don’t really have the words to describe it beyond the usual clichés of cinematic review: as Sarah Churchill, Lady Marlborough, Rachel Weisz effortlessly exceeds her turn in My Cousin Rachel, while Olivia Colman gives an arresting, career-defining performance as Queen Anne, at sea with her grief, her vessel breaking down around her, tossed about by tempests of loneliness and rage. Emma Stone is part Mean Girl, part hooker with a heart of glass.

It ends with more dissolution than resolution. (Yes, that’s an editing pun. Not sorry.)  Lanthimos perhaps intends to leave the audience with questions, but I’m a very literal person and I want answers. My thoughts after the jump.

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Being a ‘platypus’ researcher

No, I’m not a biologist studying monotremes! I have a short presentation coming up, where I’ll be introducing myself as a visiting researcher. And I’ve noticed lately that when I describe my research program in outline, people sometimes (visibly!) struggle to see how it all fits together.

As a trainee researcher I’m constantly inspired by Dr Crystal Abidin, who studies internet influencers and microcelebrities (among other things), and the way she narrates her experiences and adventures as an early career researcher. These narratives help make visible the challenges of navigating the rapidly-changing employment landscape for doctoral graduates. In  documenting their negotiation, Crystal sets down way-markers for researchers making their own journeys across the same terrain. 

In developing this presentation I was thinking about how to introduce myself as an academic and an Australian. I’ve long felt an affinity for the platypus, since we both have very poor hearing and vision – and this is something I am increasingly having to disclose in work contexts. But the analogy goes deeper – the platypus caused a major problem for taxonomy.


When naturalists taking  part in the British invasion of Australia first brought a platypus back to England, leaders of their field were so bamboozled by its mix of features – a duck’s bill, otter feet and beaver tail – they insisted it must be fake and cut it open looking for the stitching. It represents defiance of those scholars who are committed to taxonomy – dividing scholarship into discrete faculties and disciplines. My own research program includes elements that look pretty odd together – like using cultural studies to think about markets as complex systems, or using legal theory to think about what counts as evidence in public health.


This lists my interests rather than discrete bits of work, and they look pretty divergent – yet these are themes that come up repeatedly in my work on very diverse topics. For example, I draw on similar theory when thinking about community-based HIV prevention as I do when thinking about market stewardship. In both cases, I’m thinking about the limitations on our ability to understand and influence complex systems.


When dealing with complex systems, you’re always operating under conditions of uncertainty – complexity makes it impossible to know, in a timely or comprehensive fashion, what the system is doing now (or will do in future). Under those conditions, all you can do is try something and see what happens. Instead of knowing and then doing – which is the paradigm that informs most academic research and deeply misguided efforts at ‘knowledge translation’ – it’s a matter of knowing-by-doing.

Theory comes to play a particularly important role in this epistemology of practice. Social and cultural theory can be sensitising devices, suggesting where to look and what to look for. We are also constantly engaged in theory-building about our contextual environment – and our implicit theory (sometimes described as ‘mental models’) can be an important source of data to elicit in research seeking to build explicit theory.


Community-based health promotion is a site where practices have emerged for working effectively and ethically under conditions of uncertainty. For example, workers in a peer-based needle exchange might identify a change in street-based drugs markets that has implications for safe injecting. It could take a couple of years to launch academic research into the change – but the program needs to respond now. It may convene an action group to get different perspectives on the shift – which helps reduce the changes of being wrong, but also diffuses the political risk. Practitioners have their own epistemology that is grounded and embedded in practices for dealing with the uncertainty that is ever-present when dealing with complexity.

Right now there are two main pathways in my research program – one focused on communities and the other on markets. 


Because I see practice as such an important site for learning and theorising, I’ve worked to maintain my own skills and investments as a facilitator, writer, activist and health promotion practitioner. Given the time and energy this takes, this isn’t always an easy balance to negotiate – but I learn as much from this involvement as more formal research ‘methods.’


Early on in my PhD I wanted to conduct an ethnography of campaign-making from within health promotion agencies in HIV and cancer prevention. After a year of trying to recruit partner organisations, I shifted my focus to emerging, ‘interstitial’ organisations – working in the gaps left by more-established, government-funded agencies. Because they are new and operating with a startup-like ‘move fast and break things’ approach, my two case studies are an incredibly rich source of knowledge about the complexities of community organisation and mobilisation.

But I still regretted not having that inside perspective on campaign-making. Earlier this year, in my practice as an activist and communication strategist, the opportunity came up to develop a campaign of my own – featuring a short film and digital resource focused on event-based PrEP. The campaign launched last week, right before I jumped on a plane to Montréal for six months. (Ooft, timing.) And while it’s not part of my PhD research, it still provided an opportunity to think about engagement from that inside perspective.

You can watch the film below and visit the website to view the end result. (Warning: it’s NSFW AF!)

Postscript — under no circumstances should you buy me little platypus figurines. (Plushies are acceptable.)

‘Your normality stinks of blood’: writing the aftermath of a killing

About five weeks ago, as I was walking home through the drizzle after a date, my friend Zoe Mavroudi, producer of the must-watch documentary Ruins, got in touch to ask if I could help in translating a piece from French. The piece, by Dimitris Alexakis, concerned the killing of the queer and HIV activist Zak Kostopoulos in Athens a few weeks prior. Even with my high-school French I could tell it was spare and powerful writing, and I offered to ask around. I posted a request on Facebook and went to bed. 

“The sole fact that Zak was probably seeking safety in the place where he found death is enough to cry for the rest of one’s life,” writes V.

Two days after his death, stenciling appears on walls throughout the city: “Your normality stinks of blood.”

‘Like a prayer’: In memory of Zak Kostopoulos

Next morning there were two offers to help – one from Darren Russell, a Cairns sexual health doctor who is a fluent French speaker, and another from Rose Peach, currently studying literary translation in Paris. Darren offered to do a first draft the same day and Rose offered to follow up, and so I created a FB chat with Dimitris and Zoe, and we were away. 

Zak Kostopoulos

The translation came together quickly, thanks to Darren and Rose. Finding a home for the piece took longer. It was finally published, today, in full. I’d love for you to read it. Trigger warnings for homophobic violence. 

There are a couple of words and images in the French and that first draft that will stay with me forever. One is the hard-to-translate s’acharner. It translates as ‘to hound’ in English, but if you can hear the Latin echoing through the French, the stem is a word meaning meat, or flesh – as in charnel house, i.e. a chamber for human remains. In my head I translate s’acharner as ‘to reduce to meat’ — referencing the single-minded obsession of a dog pack on the hunt; a hunger that obliterates humanity. 

The second describes the owner of a jeweller’s where Zak sought refuge, going in for one last kick at his head, like a footballer taking a penalty shot.

At one point we were pitching the piece to a well-known Left publication, and they wanted to cut it down to a couple of thousand words of straight (ahem) reportage. That misses the point of the piece. It’s not just a bad thing happened. It’s about how you know what happened and how you tell that. 

We considered splitting the piece into two – one with the first half, describing the media circus and the farcical investigation, the other with the second half, describing the communities organising in response and struggling to make sense of the attack and its aftermath.

I wrote the words below as a kind of foreword to the second piece – an attempt to translate queer politics into a form that straight Left scholars might be able to recognise as politics. I am glad it wasn’t needed, because the piece was published in full in e-Flux Conversations. 

Exiled in time: mourning and protest

Cathy Caruth describes trauma as ‘unclaimed memory’ – the experience that refuses to be encoded in memory as a narrative with a beginning, a middle and an end. Instead, traumatic experience demands to be be relived in the present, in the form of flashbacks, and it registers in the body and in dislocations of time and place.

In the aftermath of Zak’s killing, the imperative is to resist narrative closure. There has not yet been a credible, independent investigation. Almost as soon as it happened, the usual suspects – the police, the media, the juridical establishment – went to work to wrap the event in a containing narrative. Nothing to see here: just a robbery. For Zak’s loved ones, the most immediate task was to unpick that shroud of counter-narrative, to let the body be seen, to let the event register in the community body assembled in protest and mourning.

Trauma, in this sense and on this occasion, is analogous to Raymond Williams’ description of structures of feeling as ‘social experience which is still in process, often indeed not yet recognised as social but taken to be private, idiosyncratic, and even isolating’ but which has emergent, connecting and dominant characteristics that, on analysis, yield important insights into social transformation.

The piece that follows is not easy reading. The writing marks the temporal dislocation characteristic of trauma: recollection in the continuous present tense, current events in the past tense. It is a fragmentary and multivocal account, reflecting the diverse perspectives that cohere in the community experience of grief and loss. For their safety, speakers are identified only by first initials. Even pseudonyms could mark out innocents for targeted harassment. This, as much as the text, speaks to the intensification of an incipient fascism in Europe.

Alexakis carefully describes the negotiation of tensions arising between queer and anarchist people and groups in organising action in response to the killing. Some are predictable: disagreement over the use of violence; conflicts over the language of protest and critique. He highlights, as well, the way queer politics are so often unrecognised as politics within the broader Left and autonomous movement.

Writing in ROAR about the Gezi Uprising in 2014, Cagla Aykac notes ‘Minorities were present from the start — they already knew how to think, write and talk about all this.’ Others, she argues, ‘had to learn a new language, and many still struggle to declassify their tongue,’  and integral to this language is ‘splashing color, joy and pleasure.’

Using this language, Alexakis vividly evokes a queer politics that is geared not only to social transformation but also to preserving space for tenderness and celebratory gesture amid protest and mourning.

Adventures in policy advocacy: challenging the proposed ‘poppers’ ban

In progressive politics there’s an age-old split between reformists and revolutionaries, and this shows up in the HIV response as well – LGBTIQ health advocates and policy-makers don’t always get along with queer activists and researchers. But as the HIV response demonstrates, you always need both. At the onset of the AIDS crisis, there was a sizeable homosexual contingent in the public service, and there were unionists, gay liberationists and feminists with skills in organising people to protest. And while they fought with each other, they were effective in combination – media pressure stirred up by protestors and radicals created political problems that reformists and policy-makers could offer to solve. You’d better believe there was quiet informal coordination over beers, especially when organisers like Phil Carswell became public servants, working with political allies like Neal Blewett and policy entrepreneurs like Bill Bowtell.

The great scholar of how policy changes happen, John Kingdon, argued that major change happens when three main systems that operate in very different ways coincidentally align – the problem stream (researchers and advocates), the policy stream (policy-makers who compare solutions) and the politics stream (politicians and the media). There are no solutions without first having a clear sense of a problem and political pressure to fix it. I’ve worked in a few different sectors – not just HIV but viral hepatitis, sexual and reproductive health, migrant and refugee health, and cancer screening. And nearly all the non-HIV sectors try to work quietly and politely within the process. (And often complain about why HIV gets all the attention.) But increasingly, that’s how HIV funded organisations work as well. It’s a recipe for declining relevance.

When the TGA announced a proposal to reschedule alkyl nitrites – the volatile ingredient in ‘poppers’ – there was outcry among gay men and queer people. There was community and mainstream media coverage. Steve Spencer got himself pictured shirtless in the newspaper showing off his tattoo of an amyl bottle, and quickly started a petition with help from Nic Holas, creating a focal point for community anger. Prof Kane Race crowdsourced a quick and dirty cultural history of amyl using his Facebook page and the Unharm Queer Community Forum, before developing a nuanced account of its historical and contemporary cultural significance. It even became an issue in Reason Party candidate Jarryd Bartle’s campaign for the Victorian seat of Albert Park, currently held by Minister for Mental Health and Equality Martin Foley.

At the same time I was working on a joint submission with public health researcher Julien Tran, sexual health physician Dr Vincent Cornelisse, Prof Kane Race and LGBTQIA+ health and human rights advocate Paul Kidd. You can read the submission here. Our goal was to write in language the TGA decision-makers might be able to hear – technical, evidence-based, paying attention to the legislative constraints on the decision-making process and considerations. This is the most basic principle of health promotion: meet your audience where they’re at. But at the same time, we wanted to shift the issue off the fairly narrow ‘track’ it was on, into a forum where it might be possible to talk about the benefits and purposes of ‘poppers’ use.

By conducting a review of the medical literature, we were able to show that cases of maculopathy and vision loss only emerged after an EU decision to ban the most common ingredient in ‘poppers’ (on the flimsiest of evidence). It made for a pretty striking graph:

adverse events (1979-2017)3.png

A couple of weeks ago, Vincent called to say the TGA had asked him to come and present to a joint session of the two committees that advise the Department of Health on scheduling decisions – specifically to talk about the clinical experience and community perspective. As a paid-up member of the Australian ‘partnership’ approach to HIV, he encouraged the TGA to invite me along to speak from the community perspective. So today, at the frankly homophobic hour of 9AM, we’re presenting for ten minutes – arguing for a regulatory approach that acknowledges cultures of care and harm reduction among queer people and partygoers, along with a more limited ban on the one chemical (isopropyl nitrite) that causes vision loss, and accurate instructions on product packaging – no more ‘do not inhale’!

Click to view our presentation:

Screenshot 2018-11-08 11.26.29

Also, here’s a media release we’ve put out, in which we acknowledge the work of queer advocates like Steve and Nic in drawing media and public attention to the proposal to ban poppers. (A side note from my perspective as a PhD researcher studying engagement: it’s interesting how quiet the funded HIV and LGBT health organisations were about the ban.) Let’s hope the TGA advisory committees and decision-maker are open to considering alternatives to prohibition that address all the risks without criminalising up to 90,000 gay men and countless other queer people and partygoers. And if not – our community knows how to fight.

Not your political football: queer kids and ‘religious freedom’

This is about queer* kids in religious schools.

I went to law school wanting to change the world, and I remember the exact moment when I realised I’d need to find some other way. It was a subject on Victorian human rights and anti-discrimination law (ADL for short.) It became clear that the arena in which most discrimination is practiced – everyday life, between private individuals – just isn’t covered by anti-discrimination protections, as those protections are configured in liberal democracies like our own.

The configuration of ADL regimes enshrines a distinction that is fundamental to liberalism: a distinction between public and private life. So, for example, you can believe whatever you like, because belief is defined as private. In theory, according to the harm principle advanced by liberal thinkers like JS Mill, the moment you act on your beliefs in ways that harm another person, your conduct is legitimately the target of regulation – in the name of protecting public order and the very same rights and freedoms that are held by others.

ADL prohibits discrimination in public life. In practice, this means it marks out certain aspects of everyday life as public. You can see the full list in Part 4 of the Equal Opportunity Act 2010 (Vic). It includes employment, corporations, industrial organisations and qualifying bodies, educational institutions, provision of goods and services, accommodation, access to public premises, clubs and societies, local councils and sporting activities.

All other domains of everyday life are defined, by implication, as private.

I’ve worked on numerous projects over my working life that tackled stigma and discrimination in one form or another. Stigma towards people with HIV, or sexual racism, which is race-based stigma in sexual contexts. Discrimination towards international students. Many of those projects said something like this: discrimination is illegal, contact the Victorian Equal Opportunity and Human Rights Commission for advice and assistance. But in the vast majority of cases, that was not truthful or helpful advice.

If a person, let’s call them Peter, experiences the most vile HIV stigma from a dating partner, Norman, that’s a private relationship; ADL does not apply. If Norman goes around telling his friends Peter’s HIV status, there’s no legal remedy against that. It’s the truth, so it’s not defamation. There’s no legal right to interpersonal privacy. Peter might be able to get an apprehended violence order, but the damage will be done. The harm in this case is extreme, and it’s a clear-cut case of discrimination, but ADL does not apply because it occurs within a private relationship.

Likewise, if I offer an apartment for lease on the public market and refuse to lease it to tenants of a particular ethnicity, ADL provides some recourse to rejected tenants (if they can prove it was racially motivated). But if I’m leasing a room in my apartment, to live with me, that’s a private relationship and I can discriminate all I want without fear of legal consequence.

There’s another less recognised consequence of the ADL regime: it makes anti-discrimination protections themselves the dividing line between public and private life. That’s why anti-discrimination law is currently a political battleground. Religious conservatives are borrowing tactics from the United States in their fight to remake our country as a Christian nation.

This time last year, Australia had a plebiscite on same-sex marriage. Religious conservatives were fighting to preserve a public statement of discrimination against queer people in legislation, the law of the land. They lost, and a commission on religious freedom was established. A leak this week revealed that the report recommends legislation to allow religious schools to fire queer teachers and expel queer kids.

Now, as David Marr wrote in The High Price of Heaven way back in 1999, it was already legal to fire queer teachers and expel queer kids. Religious institutions were exempted  from having to comply with anti-discrimination protections from the very beginning. (The only exceptions are Queensland and Tasmania; WA has announced it plans to join them.) This included religious schools, hospitals, homelessness and family violence refuges.  

As soon as the recommendation leaked, there was a counter-leak claiming that really, the recommendation aims to constrain the right of religious schools to expel queer kids, by requiring them to disclose upfront to prospective students and parents that their policy is to expel any student found to be queer.

There are a few things I want to note about that.

The proposal represents an attempt to get permission to discriminate against queer people and relationships into public law. That violates the harm principle: the government does not regulate conduct that does not cause harm to another person. Queer people and relationships don’t cause anyone harm. The peaceful existence of people and conduct of whom or which you disapprove is not harm.

Now, if you want to create a club for straight people to get together and talk about how terrible queer people are, I’m fine with that. I’m not harmed by that exclusion: your clothes are ugly, your haircuts are bad, your cakes and biscuits are made with margarine and your music is terrible.

ADL already provides so-called negative rights to such groups and institutions, in the form of exemptions from ADL. But the ‘religious freedom’ report demands official recognition of a positive right to discriminate, granted by government. This wouldn’t change the rights of religious institutions, but it would change the character of the law.

Let’s come back to the harm principle. There’s a particular problem with this proposal: it involves kids.

Some kids know they are same-sex attracted or sex and gender diverse from a young age. I certainly didn’t; I didn’t work it out until I was 13 yo. That’s not uncommon, and it highlights a particular problem with the proposal to permit the expulsion of queer kids, so long as their parents have been warned upon their enrolment that this is a possibility. The problem is that a child may only come into the realisation they are same-sex attracted at a point in their personal development some time after enrolment.

The proposed recommendation contemplates severing the child from their friendship network, from supportive relationships with teachers, from their own religious beliefs and community. It is beyond question that such an experience will do permanent psychological damage to that child. Similar damage will be done if a same-sex attracted child sees a teacher fired for the teacher’s own attraction or relationships.

Religious people have the right to their own beliefs, and to teach those beliefs. They have the right, granted under the harm principle, to constrain their own lives in the name of those beliefs. They have the right to teach young people those beliefs, and to invite those young people to constrain their own lives in similar ways.

But they don’t have the right to act in ways that will cause lifelong psychological damage to children and young people.

Apparently, the Ruddock report recommends that, ‘In relation to students, the school must have regard to the best interests of the child as the primary consideration in its conduct.’ But religious schools understand same sex attraction as a contagious and voluntary form of transgenderism, from which it is in the best interests of the child to cease and desist.

Rather, the harm principle should guide a legislative response by the state itself. From the earliest days of liberal democracy, it was recognised that the state has a special responsibility for the welfare of children, and the obligation to intervene if those children are being neglected or harmed. That’s reflected in the parens patriae jurisdiction, where any person can apply to a court for an order in the best interests of a child. It’s the basis of child protection law, truancy officers, indeed, the emergence of the profession of social work.

I was recently diagnosed with PTSD, caused by anti-gay bullying in a Catholic secondary college, twenty years ago. Let me be clear: it is child abuse. Research evidence describes its longterm effects for mental health and a range of outcomes including metabolic disorder and cardiovascular risk. It violates the harm principle, and it has no place in a liberal democracy, even one as imperfect as our own.

* Note about terminology: I personally identify as queer and have done for nearly two decades, but this piece initially referred to ‘gay kids’. That’s because I was writing from my own experience of having been a gay kid – although that doesn’t become explicit until the closing paragraph. It was pointed out that the ‘gay’ identifier doesn’t include trans people or lesbian and bisexual women and girls. Neither does my own lived experience of this issue, but as a result of the PTSD I write about, I’m not in any position to have an argument over terminology, so I’ve changed it to queer. 

Last opportunity to challenge poppers ban!


The TGA has published an interim decision on moving nitrite inhalants, also known as amyl or poppers, onto Schedule 9 of the Poisons Standard — a move which would make the sale, possession, use or administration of poppers a criminal offence under controlled substances legislation in Australian states and territories.

These laws are different in each state and territory, making the full exposure to criminal liability a bit difficult to predict. Under the relevant law in the Australian Capital Territory, for example, a person who purchased a poppers product from overseas, held it in their possession, used it themselves and offered it to a sexual partner could be guilty of four separate offences. (See Vic | NSW | ACT laws.)

The interim decision on nitrite inhalants can be viewed here.

Submissions open!

You can make submissions on the interim decision by e-mail until 11 October 2018.

See the instructions on how to respond and my own draft response below

There’s work underway on a public document with key messages and evidence that you can draw on to write your own submissions.

Update 18 Sept – 


My own (draft) response

To whom it may concern,

Re: Including a group entry for nitrite inhalants in Schedule 9 of the Poisons Standard

I am a gay man – a member of the community most affected by the proposed changes. I have worked as an educator in HIV prevention since 2004 and as a researcher in the same field since 2013. In addition to undergraduate qualifications in Law and Arts, I hold a Graduate Diploma in Public Health and I am currently a PhD candidate at the ANU School of Regulation and Global Governance.

I have used inhaled nitrites, popularly known as ‘poppers’, on occasion since 2009. The effects of poppers use are extremely short-acting. They play an important role for many gay men in making sexual intercourse less painful, due to their principal effect of relaxing smooth muscle. Indeed, a topical nitrite product, glyceryl trinitrate, is available for the same purpose as a pharmacist-only medication.

In the United Kingdom, the Conservative Party MP Crispin Blunt spoke publicly about the benefits that nitrite inhalants offer gay men, during debate over legislation to ban legal highs. A Home Affairs Select Committee report found the use of poppers was ‘not seen to be capable of having harmful effects sufficient to constitute a societal problem.’[i]

Poppers have been used by gay men for sexual purposes since the 1970s. The medical literature shows a smattering of case reports documenting injuries attributed to poppers use. Only recently have there been reports of retinal injuries subsequent to poppers use. This trend needs to be understood in a regulatory context.

In the EU in 2007 and in Canada in 2013, regulatory action was taken to ban the sale of the chemical formulations commonly included in poppers products. This in turn caused some manufacturers to include different formulations in poppers products. Users have reported the reformulated products often cause an intense headache, ‘blue lips’ and a characteristic chesty cough in the days after use. The Lancet attributes ‘poppers maculopathy’ to the reformulated product.[ii]

This highlights the risk of product substitution posed by any ban. Following the EU and Canadian regulatory action, alternative products have been brought to market. These are packaged in aerosol cans. These are not nitrite inhalants and their mechanism is effectively the same as paint-sniffing. These products would not be captured by the proposed ban, and indeed the proposed ban is highly likely to increase the market for such products.

Poppers have been in use for nearly five decades with very few reports of serious harm, and recent case reports describe a previously undocumented form of harm. This suggests the harm is the result of the reformulated products, which were only adopted due to regulatory action. Banning nitrite inhalants as a class will have a significant impact on the capability of many gay men to achieve sexual pleasure and intimacy without pain and discomfort. In addition, it will expose a historically marginalised, stigmatised and criminalised community to a new vulnerability to criminal prosecution.

A more targeted ban, leaving long-standing formulations legal, would reduce the risks of rare but serious clinical harms, and prevent the import and widespread uptake of copycat products whose risks are substantially unknown.

Yours sincerely,

Daniel Reeders BA LLB (Melb) Grad Dip Pub Hlth (Flin)

[i] Home Affairs Committee, Psychoactive Substances (report), London: Stationery Office, 23 Oct 2015, p. 14

[ii] Gruener, Anna M., Megan A. R. Jeffries, Zine El Housseini, and Laurence Whitefield. “Poppers Maculopathy.” The Lancet 384, no. 9954 (November 1, 2014): 1606.