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

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

Countering 'the moral science of biopolitics': Understanding hepatitis C treatment 'non-compliance' in the antiviral era.

Although new hepatitis C treatments are a vast improvement on older, interferon-based regimens, there are those who have not taken up treatment, as well as those who have begun but not completed treatment. In this article, we analyse 50 interviews conducted for an Australian research project on treatment uptake. We draw on Berlant's (2007, Critical Inquiry, 33) work on 'slow death' to analyse so-called 'non-compliant' cases, that is, those who begin but do not complete treatment or who do not take antiviral treatment as directed. Approached from a biomedical perspective, such activity does not align with the neoliberal values of progress, self-improvement and rational accumulation that pervade health discourses. However, we argue that it is more illuminating to understand them as cases in which sovereignty and agency are neither simplistically individualised nor denied, and where 'modes of incoherence, distractedness, and habituation' are understood to co-exist alongside 'deliberate and deliberative activity […] in the reproduction of predictable life' (Berlant, 2007, p. 754). The analysed accounts highlight multiple direct and indirect forces of attrition and powerfully demonstrate the socially produced character of agency, a capacity that takes shape through the constraining and exhausting dynamics of life in conditions of significant disadvantage.

Remaking the 'angry Narcanned subject': Affording new subject positions through take-home naloxone training.

Naloxone is a medication used to reverse opioid overdose. Alongside its lifesaving effects, it also has a reputation for producing distress, aggression and occasionally violence upon administration. This article analyses how take-home naloxone (THN) training initiatives address naloxone's reputation for producing aggression and conflict, and how new subject positions emerge in the context of this training. While the role of naloxone in producing aggression has been discussed in a range of research, this work emphasises that such conflict is neither inevitable nor even likely because it is contingent on several other issues such as administration practices. Building on this scholarship, we work with Bruno Latour's theorisation of technological 'affordances' to analyse THN as a socially co-produced technology that, rather than either determining or neutrally communicating actions and effects, 'affords' possibilities, capacities and subjects. Analysing data drawn from observations of THN training in Victoria, Australia, and in-depth interviews with training participants, we argue that the issue of conflict upon revival affords a subject position we term the 'angry Narcanned subject'. This subject, we note, has come to hold a powerful position in understandings of naloxone, not least because it tends to accord with stereotypes of antisocial drug users. From here, we argue that a much of THN training is focused on challenging and reframing naloxone's reputation for conflict and questioning related subject positions, especially that of the angry Narcanned subject. We argue that this process of challenging and reframing affords two new subject positions for consumers: the 'capable administrator' and the 'calmer revivee'. We conclude that while THN training affords multiple, potentially positive, subject positions, unless these initiatives are accompanied by broader interventions such as decriminalisation campaigns, they may inadvertently responsibilise people who consume opioids for addressing overdose and erase the role of prohibition, criminalisation and stigmatisation in producing overdose events.

'We've got a present for you': Hepatitis C elimination, compromised healthcare subjects and treatment as a gift.

With the advent of highly effective and tolerable direct-acting antiviral treatments for hepatitis C, widespread optimism for and investment in the project of disease elimination now informs the public health response. In Australia, the Commonwealth government has invested heavily in elimination by universally subsidising treatment, promising access for all. Reflecting concerns that commonly accompany ambitious public health projects, cost for governments supporting access to the treatment and cost for individuals consuming it have emerged as central issues. Drawing on 30 interviews with people who have been cured of hepatitis C with direct-acting antivirals, this article examines how cost shapes experiences of hepatitis C treatment and cure in Australia. Drawing on Lauren Berlant's (2011) influential work on 'cruel optimism', we analyse three interconnected ways that notions of cost shape participants' views of treatment as a beneficent gift from the state: (1) understandings of treatment access as a form of 'luck'; (2) conceptions of the cost of treatment; and (3) criticisms of others who are seen to waste state resources by not taking up treatment or by re-acquiring hepatitis C. We argue that, together, these dynamics constitute people affected by hepatitis C not as citizens worthy of public investment and fundamentally entitled to care, but as second-class citizens less deserving of treatment and of the health care to which they might otherwise be considered entitled. It is within this dynamic that the compromised quality of elimination optimism takes shape, binding people affected by hepatitis C to an inequitable relationship to health care, reproduced through the very things that promise to free them of such inequality - investments in access to treatment and cure.

Optimism and eternal vigilance: Gathering disease, responsible subjects and the hope of elimination in the new hepatitis C treatment era.

The advent of direct-acting antiviral hepatitis C medications has reshaped experiences of hepatitis C treatment and cure. Positioned as a treatment revolution, the new medications mean a world without hepatitis C has become imaginable, and this optimism is reflected in Australia's commitment to the WHO's target of 'eliminating' the virus as a public health threat by 2030. Alongside optimism about new treatments, Australia's current National Hepatitis C Strategy also emphasises the importance of partnerships with, and the 'meaningful involvement' of, priority populations for elimination to be achieved. We draw on Fraser and Seear's (2011) work on hepatitis C as a 'gathering' to examine these developments, and to approach hepatitis C as a disease in-the-making. Analysing 50 interviews conducted with people affected by the virus, we identify three key articulations that combine to trouble the distinction between old and new treatments: (1) the new treatment constitutes the disease as readily curable; (2) nevertheless, those who have been cured are responsibilised against acquiring it again by managing and monitoring their conduct; and (3) in the process, hepatitis C becomes re-constituted as an ongoing threat requiring continual post-cure medical and other monitoring. We argue that while treatment experiences have dramatically improved, responsibilising people affected by hepatitis C to attain cure in the context of an elimination agenda constitutes cure as valuable as much for the greater good as for self-care. This raises pressing ethical and political questions. Overall, we shed light on how, even in a context shaped by the availability of highly effective treatment, the hepatitis C-free body is never hepatitis C-free, but must be continually reproduced through regulatory practices.

The trouble with normalisation: Transformations to hepatitis C health care and stigma in an era of viral elimination.

Modern health-care systems have customarily approached hepatitis C in ways that resemble the public health approach to HIV/AIDS known as 'HIV exceptionalism'. HIV exceptionalism describes the unusual emphasis on privacy, confidentiality and consent in approaches to HIV and was partly developed to address HIV/AIDS-related stigma. In the case of hepatitis C, exceptionalist approaches have included diagnosis and treatment by specialist physicians and other 'boutique' public health strategies. The recent availability of highly effective, direct-acting antivirals alongside goals to eliminate hepatitis C have heralded dramatic changes to hepatitis C health care, including calls for its 'normalisation'. The corollary to exceptionalism, normalisation aims to bring hepatitis C into routine, mainstream health care. This article draws on interviews with stakeholders (n = 30) who work with hepatitis C-affected communities in policy, community, legal and advocacy settings in Australia, alongside Fraser et al.'s (2017, International Journal of Drug Policy, 44, 192-201) theorisation of stigma, and Rosenbrock et al.'s (1999, The AIDS policy cycle in Western Europe: from exceptionalism to normalisation. WZB Discussion Paper, No. P 99-202) critique of normalisation to consider the perceived effects of hepatitis C normalisation. Stakeholders described normalisation as a stigma-reducing process. However, they also expressed concerns about the ongoing stigma and discrimination that is not ameliorated by normalisation. We suggest that in centring normalisation, changes in health care may exaggerate the power of technological solutions to transform the meanings of hepatitis C.

Embarrassment, Shame, and Reassurance: Emotion and Young People's Access to Online Sexual Health Information.

Introduction: Research suggests that embarrassment and shame are significant barriers to young people's access to sexual health information. In this article, we analyse the relationship between emotion and young people's engagement with online sexual health information. Methods: Drawing on the work of Ahmed on the performativity of emotion and Probyn's theorisation of shame, we analyse interviews conducted in 2020 with 37 young people in Australia on sources of sexual health information. Results: Based on themes emerging from the data, our analysis considers the role of embarrassment and shame in shaping young people's access to sexual health information, the sources they seek, and the forms of information provision they prefer. Overall, we find that shame, embarrassment, and judgement shape our participants' access to sexual health information in four key ways: (1) by enacting suitable sources of information; (2) by propelling curiosity in different directions; (3) by constituting 'normal' bodies, sexuality, and sexual health; and (4) by constituting desired forms of communication. Conclusions: As part of these dynamics, our participants use a range of strategies to avoid potential embarrassment or judgement when seeking sexual health information. The article concludes by exploring the implications of these practices and dynamics. Policy Implications: Our analysis suggests the need for research, policy, and public health initiatives that are open to the multiple effects of emotion, including those traditionally thought of as negative, and their role in materialising encounters with sexual health information.

Proper distance in the age of social distancing: Hepatitis C treatment, telehealth and questions of care and responsibility.

During the COVID-19 pandemic, telehealth has played a prominent role in the treatment of hepatitis C. As part of a qualitative study on the accessibility and effectiveness of telehealth for hepatitis C treatment during this period in Australia, this article considers how health-care practitioners and patients experience and manage their proximity to each other in telehealth encounters of care. Comparisons between telehealth and in-person health-care tend to focus on measures of patient satisfaction rather than qualitative changes in treatment relationships. Media scholar Silverstone (Digital media revisited: Theoretical and conceptual innovations in digital domains, MIT Press, 2003) uses the term 'proper distance' to theorise how ethical relationships are mediated by technology. Drawing on this concept, we explore how patients and health-care practitioners understand telehealth as affecting distance and proximity. We find that both groups express some ambivalence about the impact of telehealth on relationships, on the one hand expecting and privileging simple, transactional relationships, and on the other hand, expressing concerns about the loss of more intimate relationships in health care and about 'missing something' while providing health care. Given that proximity is important to the development of ethical relationships in health care, we conclude with some considerations for establishing and sustaining attentive and responsive relationships in telehealth.

Complicating cure: How Australian criminal law shapes imagined post-hepatitis C futures.

In recent years, highly tolerable and effective drugs have emerged promising a radical new 'post-hepatitis C' world. Optimism about medical cure potentially overlooks discrimination and stigma associated with hepatitis C and injecting drug use. Legal frameworks are especially relevant to hepatitis futures, since the law has the potential to reinforce or alleviate stigma and discrimination. This article explores how hepatitis C figures in Australian criminal law and with what potential effects. Drawing on Bruno Latour's work on legal veridiction, Alison Kafer's work on futurity and disability and case law data collected for a major study on hepatitis C and post-cure lives, we explore how the criminal law handles hepatitis C in the age of cure. We find that law complicates cure, constituting hepatitis C as disabling despite the advent of effective cures. The law steadfastly maintains its own approach to disease, disability and illness, untouched by medical and scientific developments, in ways that might complicate straightforwardly linear imaginaries of cure, transformation and progress of the kind that dominate biomedicine. We explore the implications of these tensions between law and medicine.

'It's a different way to do medicine': Exploring the affordances of telehealth for hepatitis C healthcare.

While the use of telehealth was common in hepatitis C healthcare in Australia in remote and regional areas prior to the COVID-19 pandemic, it has been used more broadly to improve access to hepatitis C heathcare during the pandemic. Despite its widespread uptake, little research has explored how telehealth shapes hepatitis C healthcare. In this article, we draw on the concept of affordances (Latour, 2002) and interviews with 25 healthcare practitioners to explore the emergent possibilities for hepatitis C care that take shape through telehealth. Despite suggestions that telehealth is comparable to in-person care, healthcare practitioners' accounts suggest that telehealth significantly changes the nature of their experience of providing healthcare for hepatitis C. According to these service practitioners, while it increased access to hepatitis C healthcare during the pandemic, it also afforded narrower, less personal healthcare encounters, with a focus on simple and singular issues, and reduced opportunities for communication and rapport. These affordances also discouraged the use of interpreters and by extension the inclusion of patients from non-English speaking backgrounds. However, the data collected also suggest that telehealth has the potential to afford more informal and relaxed healthcare environments and dispositions between healthcare practitioners and patients, potentially disrupting classic practitioner-patient power dynamics. In concluding, the article considers how telehealth models of care might better afford quality hepatitis C healthcare and care beyond COVID-19 pandemic conditions.

Exhausted practical sovereignty and lateral agency: Non-uptake of treatment for hepatitis C in the antiviral era.

With the advent of highly effective antiviral treatment for hepatitis C, many people have undergone treatment and been cured. Others, however, have not undergone treatment, even where it is free and readily available. Australia's aim of eliminating the disease by 2030 means this group is of concern to researchers, health professionals and policymakers. This article draws on 50 interviews conducted for a research project on treatment experiences to examine treatment non-uptake in Australia. Informed by Berlant's (2007) work on 'slow death', it analyses experiences of non-uptake to explain the dynamics at work in such outcomes. The analysis is divided into three parts. First, participant Cal describes a lifetime in which hepatitis C, homelessness and prison have shaped his outlook and opportunities. Second, Evan describes intergenerational drug consumption, family contact with the prison system and an equally long history with hepatitis C. Finally, Rose also describes a long history of hepatitis C, complex struggles to improve life and contact with the prison system. All three accounts illuminate the dynamics shaping treatment decisions, calling to mind Berlant's slow death as a process of being 'worn out by the activity of reproducing life' under conditions that both demand self-management, and work against it. In concluding, the article points to Berlant's distinction between 'epidemics' and 'endemics', arguing that its politics apply directly to hepatitis C. In doing so, it highlights the need to address the criminalising, pathologising, capitalist context of 'attrition' (Berlant) that wears out lives even as it fetishises autonomy, responsibility and choice.

UNDERSTANDING PREFERENCES FOR TYPE OF TAKE-HOME NALOXONE DEVICE: INTERNATIONAL QUALITATIVE ANALYSIS OF THE VIEWS OF PEOPLE WHO USE OPIOIDS.

Background: Take-home naloxone (THN) is provided to non-medically trained people to reverse potential opioid overdoses. There is an increasing range of effective intramuscular (IM) and intranasal (IN) naloxone devices and this paper explores the types preferred by people who use opioids, using consumer behaviour literature to interpret the findings. Methods: Data derive from two unconnected qualitative studies involving audio-recorded semi-structured interviews. Study 1 was conducted in the United States (n=21 users of non-medical/illicit opioids). Study 2 was conducted in Australia (n=42 users of non-medical/illicit or prescribed opioids). Findings: Most participants preferred IN naloxone. Preferences were based on the ease, speed, safety and comfort of each device and underpinned by accounts of overdose revivals as being very rushed and frightening situations. Preferences related to complex interactions between the naloxone device ('product'); the knowledge, skills, experience and attitudes of the lay responder ('consumer'), and when, where and how naloxone was to be used ('usage situation'). Conclusions: THN programs should offer choice of device when possible and nasal naloxone if resources permit. Asking people which devices they prefer and why and treating them as valued consumers of naloxone products can generate insights that improve future naloxone technology and increase THN uptake and usage.

Hepatitis C cure as a 'gathering': Attending to the social and material relations of hepatitis C treatment.

Since the advent of direct-acting antiviral hepatitis C treatments, widespread enthusiasm about disease elimination has emerged. This article examines experiences of hepatitis C treatment and cure in this period. Mobilising Fraser and Seear's (Making disease, making citizens: The politics of hepatitis C, Ashgate, 2011) approach to hepatitis C as a 'gathering', we analyse cure not as a biomedical phenomenon but as a social and material event. To do so, we take a Science and Technology Studies-inspired approach to analyse three complementary cases drawn from an Australian project on experiences of hepatitis C, treatment and cure. First, we analyse the ways a friendship between two women combines with adjustments to treatment access to produce a gathering that makes cure possible. Second, we analyse the forces that gather and distribute responsibility when a cure does not occur in a context shaped by oversimplified treatment logics. Third, we analyse a gathering of relations in which hepatitis C lingers, thereby limiting the cure's possible transformative effects. We argue that, even in an era defined by highly effective medicines, the hepatitis C cure is not necessarily straightforward, but an unpredictable gathering constituted by a fragile coalescing of social and material forces.

Heavy drinking as phenomenon: gender and agency in accounts of men's heavy drinking.

Alcohol consumption is a significant public health concern in Australia, with men disproportionately represented in treatment for health issues related to heavy drinking. Despite this, little is known about the experiences of these men or the gender dynamics that may shape heavy drinking. Increasingly, the treatment of alcohol and other drug-related issues, including those related to heavy drinking, is based on a biopsychosocial approach. Within this framework, heavy drinking is understood as a symptom of individual pathology in the context of various social 'factors' that influence individual capacity to exercise agency. Following the work of Karen Barad, this article employs a feminist science studies account of agency to formulate heavy drinking as a gendered 'phenomenon': enacted and sustained through the 'intra-action' of other phenomena. Drawing on interviews with men who drink heavily, our analysis explores how the phenomenon of men's heavy drinking materialises through the intra-actions of gender, isolation and healthcare. We argue that heavy drinking is not a sign of failed individual agency but an expression of entangled agencies. In concluding, we suggest it is possible to enhance the well-being of men who drink heavily by addressing specific gendered intra-actions in the making of heavy drinking.

Addiction stigma and the production of impediments to take-home naloxone uptake.

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for all opioid consumers, not just those who consume opioids illicitly. Second, we explore how stigma may limit the scale-up and expansion of programmes and access points. From here, we focus on how stigma co-constitutes the politics of overdose and prevention, rendering take-home naloxone ill-suited to many social settings of overdose. In closing, we point out that stigma is not just a post hoc impediment to access to and use of take-home naloxone but is central to opioid overdose production itself, and to effective prevention. While take-home naloxone is an excellent life-saving initiative, uncritically valorising it may divert attention from broader goals, such as the de-stigmatisation of drug consumption through decriminalisation, and other ambitious attempts to reduce overdose.

Holding 'new recovery' together: Organising relations and forms of coordination in professional sociomaterial practices of addiction recovery.

Questions about what addiction recovery is and the mechanisms by which people 'recover' have long animated alcohol and other drug research and policy. These debates became even more intense following the advent, and increasing influence in some quarters, of the 'new recovery'. Starting from the position that recovery is ontologically multiple (Mol & Law, 2002), we trace how alcohol and other drug professionals attempted to make sense of 'new recovery' as a concept and set of professional practices during a period of Australian drug treatment system reform. Drawing on Annemarie Mol's (2002) account of organising relations and forms of coordination (addition, translation and distribution), we explore how the new recovery was enacted and coordinated in alcohol and other drug professionals' sociomaterial practices, and highlight the ontological work involved in holding such an unstable object together. First, we argue that the addition of multiple enactments of addiction and recovery contributed to the formation of a singular and serviceable problem (that was simultaneously heterogeneous and complex), making the 'disease-to-be-treated' amenable to diverse treatment approaches, including new recovery. Second, we analyse the role of metaphor in translating authoritative logics and obligations into an enactment of new recovery suitable for application in clinical settings. Lastly, we track how incompatible enactments of recovery, both new and old, were kept apart through distribution. Although new recovery ultimately failed to gain policy traction in the Australian context, we focus on the ontological work undertaken by professionals in response to its introduction as such case studies can be useful for analysing other powerfully governing policy objects and their operations.

Basic care as exceptional care: addiction stigma and consumer accounts of quality healthcare in Australia.

The discrimination faced by people understood to have alcohol or other drug addictions has been the subject of extensive research, with many studies documenting experiences of stigma within healthcare services. Building on this literature, we examine the role of stigma in shaping the healthcare expectations of people seen as affected by alcohol and other drug addictions. Our analysis draws on recent theorisations of stigma as a process of social production to analyse in-depth, qualitative interviews with 20 people who had recently attended an inpatient withdrawal management service. Participants describe as exceptional forms of care that are often taken for granted by other members of the community. We argue that routinised experiences of discrimination work to constitute basic care as exceptional. This finding is significant for two reasons: (1) people who consume alcohol and other drugs often have complex healthcare needs and already encounter obstacles to accessing the care they need, and (2) by positioning people who consume drugs outside the purview of healthcare, this dynamic obstructs their fundamental right to care. We conclude by reflecting on the implications of these findings for those who are often positioned as not entitled to high quality healthcare.

The "Be All and End All"? Young People, Online Sexual Health Information, Science and Skepticism.

In this article, we investigate young people's trust in online sexual health resources. Analyzing interviews with 37 young people in Australia using Irwin and Michael's account of science-society relations and Warner's conceptualization of "publics," we explore the processes by which they assess the credibility of online sexual health information. We suggest that when seeking medical information, young people opt for traditionally authoritative online sources that purport to offer "facts." By contrast, when seeking information about relationships or sexual practices, participants indicated a preference for websites presenting "experiences" rather than or as well as "facts." Regardless of content, however, our participants approached online sexual health information skeptically and used various techniques to appraise its quality and trustworthiness. We argue that these young people are productively understood as a skeptical public of sexual health. We conclude by exploring the implications of our analysis for the provision of online sexual health information.

Making epistemic citizens: Young people and the search for reliable and credible sexual health information.

The 21st century has seen the proliferation of technologies and sources of information on issues of all kinds, including sexuality. Amid debates about the role of social media and the internet in mediating sexuality, questions about credible, reliable and objective sources of information have also arisen, particularly in relation to young people's knowledge-seeking. Drawing on theorisations of sexual citizenship, Foucault's notion of the 'episteme', and the work of science and technology studies scholar John Law, this article examines a 'collateral reality' produced by contemporary demands on young people to source, assess and act on sexual health information. Using interviews with 37 young people living in Australia, the analysis identifies a range of approaches to sexual health-seeking practices, key dynamics in the construction of reliability and fact, and the extent and nature of the accommodations young people report making to navigate incomplete and unreliable information. With the contemporary self increasingly framed through the ability to discern truth from falsehood, reality from fake news, these demands and choices have significant implications for qualification as the proper modern citizen. Accommodating information weaknesses and gaps in sexual health information, we argue, produces what we call contemporary 'epistemic citizens'; young people explicitly aware of the limits of official knowledges about sex and sexualities, and of the expectation that individual citizens must either content themselves with officially constituted sexual selves or else seek and enact marginal or unofficial alternatives using sources generally denigrated as unreliable. As we will conclude, current forms of sexual health information and related calls for youth literacy operate as a mechanism for generating a specific modern form of epistemic citizenship. Future sexuality education might consider ways to support even more literate, sophisticated epistemic citizens relieved of the responsibility to piece the truth together on their own, and who in turn feel more included.