Safety in Numbers

Chapter 5

The Health Education Authority - a case study

The Health Education Authority's 'men who have sex with men' project was initiated in 1988. Its objectives were four-fold:

 

Initial advertising and promotional materials were developed; pre-testing research, however, "indicated that these were likely to be low in impact". The Authority paused, and commissioned two reviews of safer sex educational materials (92) and safer sex workshops (93).

Subsequently, new advertising was developed, and placed in lesbian and gay community publications from February until September 1989. The adverts featured photographs by Herb Ritts, with the messages "If you think safer sex sounds dull, reading this might change your position" and "They used to say masturbation was bad for you. Now it could save your life". From September 1989 to Spring 1990 two adverts featuring photography by Jean Baptiste Mondino were published, this time using the slogan "They don't have safer sex just because it's safer". During this period a line-art advert encouraging gay men to be sexually imaginative, and three adverts featuring 'safer sex situation' shots by the press photographer Caroline Mardon and the caption "Choose safer sex" were also printed.

The next six-month advertising phase began in July 1990. The Mondino advertisements were placed in a number of non-gay specific magazines, such as Arena, Time Out and The Face, while two new adverts ran in the gay press, one targeting "new entrants to the scene" using the slogan "He's into safer sex so why not give him a hand", and another "aimed at ensuring that those in relationships continue safer sex practices" with the message "If your sex life is unprotected so too is your relationship".

Another advert was aimed at "covert bisexual men". It featured a close-up photograph of a male hand wearing a wedding ring holding another male hand, and the slogan "If a married man has an affair, it may not be with a woman". This was originally published in music, style and listings magazines in Spring 1990, supported by a freephone helpline service, and was repeated in a wider range of publications, including TV Times, Angling Times, Custom Car and BBC Wildlife magazines, between July and October 1991.

A new advertising campaign began in August 1992. Advertisements providing advice on the choice of condoms and lubricants and proper condom use appeared in the gay press, and a photographic concept aimed at breaking down feelings of immortality or invulnerability among younger gay men was placed in music and style magazines. For the first time, these advertisements carried not only the National AIDS Helpline number, but also those of the Terrence Higgins Trust and London Lesbian and Gay Switchboard.

The other major strand of HEA work for gay or bisexual men was the Men Who Have Sex With Men: Action in the Community (MESMAC) project. This was a community development initiative developed on the basis of Peter Gordon's review of safer sex workshops (94), and based at four project sites reflecting a range of working situations. Newcastle Social Services hosted a project site targeting men in both urban and rural settings; Leicester Black HIV/AIDS Forum housed the Leicester Black MESMAC Project; the Terrence Higgins Trust provided a base for the London project focusing on younger gay men; and Leeds AIDS Advice agreed to host the site looking specifically at the needs of men in a large city.

MESMAC had two aims:

 

Thorough evaluation of both the processes of MESMAC work and the outcomes of the project was given high priority. During the first phase of activity between March 1990 and December 1991, the MESMAC projects undertook 49 different initiatives involving some 2,700 gay and bisexual men, while in 1992 more than this number of individuals were contacted at just one of the four sites. Despite the project's "men who have sex with men" terminology, which is discussed later, the vast majority of men involved in MESMAC activities identified as gay or bisexual. (96)

All this sounds like a most impressive body of work, and in a number of regards it is. Few other countries have seen such a body of work undertaken specifically for gay or bisexual men, and bearing the government's official stamp. But nevertheless, by 1992 the HEA had become the object of some derision in the lesbian and gay press, and its 'men who have sex with men' project Advisory Group had resigned en masse. This striking lack of support from the community had its roots in a number of concrete difficulties.

First, it is important to remember that the first government advertisement for gay men appeared in February 1989, by which time over 5,200 gay men had already tested positive and many thousands more were no doubt also infected, and the mass behaviour changes of the early to mid-1980s were already suffering the effects of subsequent neglect. Prior to 1989, government monies had been given to the Terrence Higgins Trust as a form of 'back door' funding for gay safer sex campaigns whose importance the government recognised - indeed, the chief medical officer Sir Donald Acheson met with activists as early as 1983 to express support for the Trust's initial activities in the gay community (97) - but which were far too politically sensitive for it to undertaken openly itself. After 1988, the Trust received no funding through the HEA for the educational work it undertook with gay men. (98)

As an official agency with government backing, the HEA believed that it could speak to gay men with authority and impartiality. However, this potential advantage was accompanied by a host of disadvantages. There was no theoretical or historical reason to believe that gay men would respond more favourably to the voice of officialdom than to messages clearly originating from within the gay community. The advantage of community 'ownership' of educational interventions was implicitly acknowledged in the establishment of the MESMAC projects, three of which were sited in local voluntary organisations, and which used the grass-roots community development approach to explore the self-perceived needs of gay or bisexual men and equip individuals and groups to meet those needs themselves. Advertisements, however, always face the risk that they will be rejected as unwelcome impositions from above, and this may have been particularly true of adverts bearing the logo of a statutory agency such as the HEA, as opposed to a community group.

The HEA's accountability to the Department of Health also proved to be inhibitory. In the absence of hard scientific research on effective wording for use in communicating with gay men, the Department of Health vetoed the commonsense approach of addressing the audience using the everyday language used by that audience. Thus the first edition of the Authority's leaflet Safer Sex for Gay Men employed the most tortured terminology, such as the description of fingering as 'digital intercourse', which subsequent evaluation established to have been greeted with hilarity by gay men. (99) Advertisements routinely recommended practices such as "body rubbing", "massage" and "mutual masturbation", with other, more creative non-penetrative options such as sadomasochistic sex or bondage omitted in favour of a blushing suggestion to "use your imagination". In 1991 the Department of Health requested that a 'reminder' of the discriminatory age of consent be added to the HEA's safer sex factcards for gay men (100), and again disputed the use of explicit language such as 'fuck' in a gay men's safer sex leaflet (101), despite that fact that HEA research indicated that this was the terminology used and preferred by the target audience. (102) However, these facts may be less surprising in view of the Government's description of its HIV prevention initiatives as "an equal opportunities strategy aimed at providing appropriate and adequate services sensitive to the needs of the communities regardless of age, sex, class or race". (103) Sexual orientation is notable by its absence.

Within the HEA's HIV and Sexual Health programme, just as within most other agencies undertaken HIV prevention activities, there was a striking imbalance between the pressing need for initiatives targeting gay or bisexual men, and the relative funding and priority allocated to such initiatives. At the launch of the gay press campaign in February 1989, Nick Partridge of the Terrence Higgins Trust attacked the initiative as a "wasted opportunity", pointing out that it had been allocated only 3% of the �10 million annual AIDS education budget. (104) At the time of writing, the HEA employs at least 15 staff in HIV/AIDS related posts, yet only one of these posts is concerned specifically with the projects for 'men who have sex with men'. In other words, less than 7% of HIV staff time is devoted to gay men, when about 70% of people who have been infected in Britain are gay men. (105) Furthermore, a report in the national lesbian and gay weekly newspaper The Pink Paper alleged that HEA funding for campaigns targeting gay men was actually reduced from �1.7 million in 1990/1991 - only 18% of the overall AIDS budget of �9.3 million - to a low of �700,000 in 1991/1992. (106)

In February 1992, the Advisory Group to the HEA's 'men who have sex with men' programme resigned "in protest at the Authority's failure to act upon their advice in the development of safer sex campaigns for gay men". (107) In a letter to the HEA's Chairman, Sir Donald Maitland, members of the group reported that their "detailed and, occasionally, very critical comments and advice on strategy and planning have had no discernable influence" and that "as a result there is growing and serious concern among some members of the Group about the theory and methodology underlying the HEA's approach to work in this area, doubt about the effectiveness of the work and concern that claims for effectiveness are being made in the absence of [reliable evidence]". (108)

In summary, the HEA's ability to provide useful and effective health education campaigns for gay or bisexual was hampered by a number of entirely avoidable factors. The Advisory Group, which included "internationally acknowledged experts on HIV education and prevention work amongst gay men" (109), found that they were unable to influence strategy or campaign development largely because "...despite a genuine willingness on the part of programme staff to be influenced, the organisational framework within which strategic and planning decisions are taken by the HEA are not, in practice, amenable to influence by "grassroots" representation on an internal Advisory Group". (110)

Similarly, the Authority's accountability to the Department of Health, and its obligation to act in accordance with the policies of a government not renowned for its concern with the well-being of gay men, seriously inhibited its ability to gain gay men's trust and acceptance for its messages. It was for this reason that in 1987 the Bow Group had proposed that "the best way forward is for the Health Education Authority to run no campaigns itself but to fund and support the efforts of organisations like the Terrence Higgins Trust, whose campaigns are notable for an occasional obscenity and a general effectiveness that a more august body is unlikely to be able to match". (111) Likewise, in May 1987 the Commons Social Services Committee recommended that "if the Government wishes to target information at the gay community, the Terrence Higgins Trust would be the most effective agent through which to provide the bulk of the targeted information to the whole country". (112) Both these eminently sensible pieces of advice were ignored.

More recently there have been very positive developments in the HEA's work with gay and bisexual men, particularly in the field development division which provides advice, assistance and consultancy to local prevention service providers. New materials have at last started to employ the terminology used by gay men themselves, and the now-completed MESMAC projects have clearly undertaken valuable community development work in the field. It is unfortunate, however, that these positive developments have only taken place after some years of difficulties. History now shows that the government's decision that the HEA itself should be the provider of education campaigns, rather than commissioning them from agencies with strong gay community ties, both undercut the effectiveness of the campaigns, and at the same time contributed to the 'de-gaying' of those agencies.