Sexual healthcare to meet the needs of sexuality and gender diverse aboriginal young people: imagined possibilities.

In Australia, Aboriginal young people who are lesbian, gay, bisexual, trans, queer or otherwise sexuality and gender diverse (LGBTQ+) are recognised within several overlapping priority populations in state and federal sexually transmissible infection and HIV strategies. However, limited research has documented their unique sexual health experiences, needs and preferences. In this qualitative study, semi-structured interviews were conducted with 10 LGBTQ+ Aboriginal young people aged 16-24 years in New South Wales. Interviews incorporated questions about service access, positive and negative experiences and self-determined healthcare priorities. We conducted a strengths-based thematic analysis to understand the issues of greatest importance in sexual healthcare for participants. Using the framework of 'imaginaries', we explored how participants imagined sexual healthcare that would meet their individual and cultural needs. The dominant imaginary centred on respect, representation and the as-yet-unrealised possibility of sexual healthcare designed by and for people who shared the intersection of Aboriginal and LGBTQ+ experience. We identified individual-level, service-level and societal-level factors influencing this imaginary, including relationships, accessibility and experiences of racism. Analysing the imaginaries constructed by LGBTQ+ Aboriginal young people of empowering, culturally safe sexual healthcare that is 'for them' provides insight into potential service design to improve sexual health outcomes for this population.

Yarning as a method for building sexual wellbeing among urban Aboriginal young people in Australia.

This paper describes the strategies used by Aboriginal young people to build positive relationships and sexual wellbeing. It does so to counter the risk-focussed narratives present in much existing research and to showcase the resourcefulness of Aboriginal young people. We used peer-interview methods to collect qualitative data from 52 Aboriginal young people living in western Sydney, Australia. Participants reported a strong desire to stay safe and healthy in their sexual relationships and to achieve this they relied heavily on oral communication and yarning strategies. Participants viewed communication as a way to gain or give advice (about bodies, infections, pregnancy, relationships); to assess the acceptability and safety of potential partners; to negotiate consent with partners; to build positive relationships; and to get themselves out of unhealthy relationships. Participants also discussed 'self-talk' as a strategy for building sexual wellbeing, referring to narratives of self-respect and pride in culture as important in establishing Aboriginal young people's positive views of self and as deserving of respectful and safe sexual relationships. These findings suggest that future programmes and interventions based on yarning could be well-regarded, given it is a cultural form of pedagogy and a strategy Aboriginal young people already use to build positive relationships and identities.

Aboriginal young people's perspectives and experiences of accessing sexual health services and sex education in Australia: A qualitative study.

Aboriginal and Torres Strait Islander (Aboriginal) young people seek information and access health services for their sexual health needs. This study examined Aboriginal young people's perspectives on sexual health services and sex education in Australia. Overall, 51 Aboriginal people aged 16-26 years were interviewed by peer researchers in Sydney, Australia in 2019-2020. The findings suggest that the internet was used to assess information quickly and confidentially, but Aboriginal young people questioned its reliability and accuracy. Family, Elders and peers were seen as sources of advice because they had real-life experience and highlighted intergenerational learning that occurs in Aboriginal communities. School-based sex education programmes had mixed reviews, with a preference for programmes delivered by external specialists providing anonymity, clear and accurate information about sex and relationships and positive approaches to sex education, including how to gain consent before sex. There was a need identified for school-based programmes to better consider the needs of Aboriginal young people, including those who identified as LGBTQI + . Aboriginal Medical Services were highly valued for providing culturally safe access to services, while sexual health clinics were valued for providing specialised confidential clinical services with low levels of judgement.

Beyond deficit: 'strengths-based approaches' in Indigenous health research.

Health research concerning Indigenous peoples has been strongly characterised by deficit discourse-a 'mode of thinking' that is overly focused on risk behaviours and problems. Strengths-based approaches offer a different perspective by promoting a set of values that recognise the capacities and capabilities of Indigenous peoples. In this article, we seek to understand the conceptual basis of strengths-based approaches as currently presented in health research. We propose that three main approaches exist: 'resilience' approaches concerned with the personal skills of individuals; 'social-ecological' approaches, which focus on the individual, community and structural aspects of a person's environment; and 'sociocultural' approaches, which view 'strengths' as social relations, collective identities and practices. We suggest that neither 'resilience' nor 'social-ecological' approaches sufficiently problematise deficit discourse because they remain largely informed by Western concepts of individualised rationality and, as a result, rest on logics that support notions of absence and deficit. In contrast, sociocultural approaches tend to view 'strengths' not as qualities possessed by individuals, but as the structure and character of social relations, collective practices and identities. As such, they are better able to capture Indigenous ways of knowing and being and provide a stronger basis on which to build meaningful interventions.

Men and masculinities in qualitative research on vasectomy: perpetuation or progress?

Although vasectomy is a safe and highly effective method of contraception, uptake is variable globally, with scope for increased engagement in high income nations. Very little qualitative research has been published in recent years to explore men's perspectives on vasectomy, which represents a key opportunity to better understand and strengthen men's contribution to reproductive and contraception equality. This paper takes a scoping review approach to identify key findings from the small but important body of qualitative literature. Recent masculinities research argues that, despite some expansion in ways of being masculine, an underpinning ethos of masculinist dominance remains. Extant research on men's attitudes to vasectomy supports this ambivalent picture, indicating that while there are extending repertoires of masculinity for men to draw on in making sense of vasectomy, many remain underpinned by masculinist narratives. There remains scope for education and health promotion ensuring vasectomy is viewed as a suitable and safe option by more men of reproductive age. Increased uptake of vasectomy may also help shift the longstanding social expectation that women take primary responsibility for contraceptive practices, challenging gender discourses on contraception.

Stigma as understood by key informants: A social ecological approach to gay and bisexual men's use of crystal methamphetamine for sex.

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities.

Priorities and practices of risk reduction among gay and bisexual men in Australia who use crystal methamphetamine for sex.

Crystal methamphetamine (hereafter crystal) is associated with deleterious health outcomes, such as drug dependence and physical and mental health disorders. While some harms from crystal use can affect all users, there may be additional risks for people who combine the use of drug with sex. Compared with the broader population, gay and bisexual men in Australia report a higher prevalence of methamphetamine use, and crystal is the most commonly injected illicit drug among this population. The Crystal, Pleasures and Sex between Men research project was conducted between 2017 and 2019 and examined gay and bisexual men's crystal use in four capital cities in Australia, with the aim of identifying how to best support men who use crystal for sex. In this article, we examine how risk is understood and prioritised by gay and bisexual men who combine crystal use and sex and identify the range of risk reduction practices that they used. We classified these risks as those associated with the transmission of HIV, HCV and STIs, and those associated with dependence on either crystal or the sex it facilitated. Gay and bisexual men overwhelmingly prioritised the risk of dependence over any other risks associated with crystal-enhanced sex, and this prioritization was reflected in the risk reduction practices they employed. While some of the strategies that gay and bisexual men have adopted may contradict anticipated public health principles, they derive from a carefully considered and shared approaches to the generation of pleasure, the maintenance of a controlled form of feeling "out of control", and the negotiated reduction of risk. The consolidation of these strategies effectively constitutes a "counterpublic health" underpinned by forms of "sex-based sociality", which gives primacy to the priorities and practices of gay and bisexual men in Australia who combine crystal and sex.

Interface between biomedical and traditional systems of treatment and care among HIV positive fisher folk in two fishing communities on Lake Victoria, Uganda.

BACKGROUND: Fisherfolk have been identified as a key population in the HIV response in Uganda due to high HIV prevalence and low engagement in HIV services. While studies have examined lifestyles and risk, much remains to be understood about help and health seeking experiences, including the combined use of biomedical and traditional health care. OBJECTIVE: To examine the use of biomedical and traditional health care in two fishing communities around Lake Victoria in Uganda. METHODS: Exploratory, in-depth qualitative study involving semi-structured interviews with 42 HIV positive fisherfolk. RESULTS: Prior to HIV diagnosis, participants who described becoming ill sought different forms of help including biomedical treatment prescribed by health workers or self-prescribed; biomedical and herbal medicines together; herbal medicines only; or no form of treatment. Following HIV diagnosis, the majority of participants used ART exclusively, while a smaller number used both ART and traditional care strategies, or reported times when they used alternative therapies instead of ART. Prior to HIV diagnosis, fisherfolk's health care seeking practices inhibited engagement with HIV testing and access to biomedical HIV treatment and care. After HIV diagnosis, most resorted only to using ART. CONCLUSION: Study findings provide insight into how fisherfolk's use of biomedical and traditional care prior to diagnosis influences subsequent engagement with HIV treatment. Efforts are needed to reach fisherfolk through everyday health seeking networks to ensure HIV is diagnosed and treated as early as possible.

Working with Aboriginal young people in sexual health research: a peer research methodology in remote Australia.

In a context of ongoing colonization and dispossession in Australia, many Aboriginal people live with experiences of health research that is done "on" rather than "with" or "by" them. Recognizing the agency of young people and contributing to Aboriginal self-determination and community control of research, we used a peer research methodology involving Aboriginal young people as researchers, advisors, and participants in a qualitative sexual health study in one remote setting in the Northern Territory, Australia. We document the methodology, while critically reflecting on its benefits and limitations as a decolonizing method. Findings confirm the importance of enabling Aboriginal young people to play a central role in research with other young people about their own sexual health. Future priorities include developing more enduring forms of coinvestigation with Aboriginal young people beyond data collection during single studies, and support for young researchers to gain formal qualifications to enhance future employability.

Enhancing HIV Prevention: Social Support, Access to, and Use of HIV Testing, Treatment, and Care Services in Fishing Communities Around Lake Victoria, Uganda.

In-depth interviews were conducted with 42 HIV-positive fisherfolk and 15 health care providers to identify experiences of social support and its influence on access to and use of HIV testing, treatment, and care. Fisherfolk participants reported receiving support at some point. Prior to HIV diagnosis, this usually took the form of advice on what illness they were dealing with and remedies to use. After HIV diagnosis and disclosure to friends or family, emotional support enabled fisherfolk to come to terms with an HIV diagnosis, informational support offered guidance on how best to live with HIV, while instrumental support enabled access to relevant HIV services. Finally, affiliative support, in the form of new friends met through HIV clinic visits, provided a sense of belonging. Each of these different kinds of support assisted fisherfolk to respond positively to HIV with important consequences for secondary and tertiary prevention.

Young Aboriginal people's sexual health risk reduction strategies: a qualitative study in remote Australia.

Background Surveillance data indicate that Aboriginal and Torres Strait Islander young people are more likely than their non-Indigenous counterparts to experience sexually transmissible infections (STIs) and teenage pregnancy. Despite increasing emphasis on the need for strengths-based approaches to Aboriginal sexual health, limited published data document how young Aboriginal people reduce sexual health risks encountered in their everyday lives. METHODS: In-depth interviews with 35 young Aboriginal women and men aged 16-21 years in two remote Australian settings were conducted; inductive thematic analysis examining sexual health risk reduction practices was also conducted. RESULTS: Participants reported individual and collective STI and pregnancy risk reduction strategies. Individual practices included accessing and carrying condoms; having a regular casual sexual partner; being in a long-term trusting relationship; using long-acting reversible contraception; having fewer sexual partners; abstaining from sex; accessing STI testing. More collective strategies included: refusing sex without a condom; accompanied health clinic visits with a trusted individual; encouraging friends to use condoms and go for STI testing; providing friends with condoms. CONCLUSION: Findings broaden understanding of young Aboriginal people's sexual health risk reduction strategies in remote Aboriginal communities. Findings signal the need for multisectoral STI prevention and sexual health programs driven by young people's existing harm minimisation strategies and cultural models of collective support. Specific strategies to enhance young people's sexual health include: peer condom distribution; accompanied health service visits; peer-led health promotion; continued community-based condom distribution; enhanced access to a fuller range of available contraception in primary care settings; engaging health service-experienced young people as 'youth health workers'.

Playing Recognition Politics: Queer Theoretical Reflections on Lesbian, Gay, and Queer Youth Social Policy in Australia in the 1980s and 1990s.

This article provides a queer theoretical reflection on the emergence of lesbian, gay, and queer (LGQ) youth as subjects of policy attention in Australia in the late twentieth century. In particular, it focuses on the ways in which specific forms of social, bureaucratic, and organizational recognition have given shape to LGQ youth as categorical policy objects. To this end, this article critically interrogates social policy related to the provision of funding for LGQ youth support during the 1980s and 1990s in two Australian states: New South Wales and Western Australia. More specifically, it focuses on some of the ways in which LGQ youth have been discursively shaped and materially supported in three different organizations, two of which continue to be strongly associated with support of LGQ youth in Australia. This study of the emergence of these organizations, resourced by three different sectors-the state, the church, and the LGQ community itself-necessarily draws on ephemeral resources, reflecting the conditions of possibility in which this work was being enacted. We conclude with an analysis of the necessity for situating policy recognitions within specific contexts to examine the implications for LGQ youth as the subjects such recognitions simultaneously seek to constitute and serve.

Practical justice as an innovative approach to addressing inequalities facing gender and sexually diverse people: a case example from Papua New Guinea.

Cultural values and practices influence many aspects of sexual and reproductive health and rights - from access to and quality of health education and services, to gender roles and responsibilities, to family planning and sexual freedoms. Culture is frequently marginalised in epidemiologically driven analyses of sexual and reproductive health and rights yet remains central to the ways in which inequalities within these fields manifest themselves and are engaged with in society. Using Papua New Guinea (PNG) as a case example, this paper sheds light on the enabling and restrictive role of culture in efforts to work towards equity and justice for gender and sexually diverse people. Drawing on four case stories, we offer insight into where culture can and has been deployed to redress serious inequalities in what is often a hostile environment. In these stories we illustrate how practical justice provides an innovative way to approach issues to do with sexual and reproductive health, particularly as they relate to enhancing the lives of people in visible, grassroots ways. In this way, given evidence, good normative judgement and the opportunity to do good and be fair, practical justice may be seen to be taking place.

Young Aboriginal people's engagement with STI testing in the Northern Territory, Australia.

BACKGROUND: Australian surveillance data document higher rates of sexually transmissible infections (STIs) among young Aboriginal people (15-29 years) in remote settings than non-Aboriginal young people. Epidemiological data indicate a substantial number of young Aboriginal people do not test for STIs. Rigorous qualitative research can enhance understanding of these findings. This paper documents socio-ecological factors influencing young Aboriginal people's engagement with clinic-based STI testing in two remote settings in the Northern Territory, Australia. METHODS: In-depth interviews with 35 young Aboriginal men and women aged 16-21 years; thematic analysis examining their perceptions and personal experiences of access to clinic-based STI testing. RESULTS: Findings reveal individual, social and health service level influences on willingness to undertake clinic-based STI testing. Individual level barriers included limited knowledge about asymptomatic STIs, attitudinal barriers against testing for symptomatic STIs, and lack of skills to communicate about STIs with health service staff. Social influences both promoted and inhibited STI testing. In setting 1, local social networks enabled intergenerational learning about sexual health and facilitated accompanied visits to health clinics for young women. In setting 2, however, social connectedness inhibited access to STI testing services. Being seen at clinics was perceived to lead to stigmatisation among peers and fear of reputational damage due to STI-related rumours. Modalities of health service provision both enhanced and inhibited STI testing. In setting 1, outreach strategies by male health workers provided young Aboriginal men with opportunities to learn about sexual health, initiate trusting relationships with clinic staff, and gain access to clinics. In setting 2, barriers were created by the location and visibility of the clinic, appointment procedures, waiting rooms and waiting times. Where inhibitive factors at the individual, social and health service levels exist, young Aboriginal people reported more limited access to STI testing. CONCLUSIONS: This is the first socio-ecological analysis of factors influencing young Aboriginal people's willingness to undertake testing for STIs within clinics in Australia. Strategies to improve uptake of STI testing must tackle the overlapping social and health service factors that discourage young people from seeking sexual health support. Much can be learned from young people's lived sexual health experiences and family- and community-based health promotion practices.

Destabilising the 'problem' of chemsex: Diversity in settings, relations and practices revealed in Australian gay and bisexual men's crystal methamphetamine use.

In Australia, the crystalline form of methamphetamine ("crystal") is a commonly used illicit substance associated with sexual activity among gay and bisexual men. Attention to psychoactive substance use among this population is the subject of increasing global concern regarding the intentional and simultaneous combination of sex and drugs, often referred to as "chemsex". While not all gay and bisexual men who use psychoactive substances report problematic use, those who do often become representative of chemsex practices more generally, and the harms they experience become attributable to all men who use drugs for sex. The way in which these practices have been framed over the past few decades contributes to the rise of a narrow set of understandings of chemsex defined by the circumstances and behaviours presumed of drug-enhanced sexual activity. In effect, these understandings now align recognisable combinations of sexual and drug-using practices with assumed correlates of risk. The Crystal, Pleasures and Sex between Men study conducted 88 interviews with gay and bisexual men in four Australian cities between 2017 and 2018. Findings from the project revealed that men used crystal in a variety of settings and relations, which mediated their sexual practices and patterns of use. In looking at the wider context in which practices were associated with the combination of sex and drugs, we identified experiences that the contemporary discourse of chemsex-in its rhetorical proposition of at-risk behaviours and circumstances-may leave out of consideration. Our findings indicate that researchers should remain open to the variability and contingency of settings, relations and practices in gay and bisexual men's different networks when recommending public health responses to their engagement in drug-enhanced sexual activity. Accordingly, we seek to destabilise the definition of chemsex that precludes consideration of the influence of experiences beyond pre-determined risk parameters.