Troubling complaint: Addressing hepatitis C-related stigma and discrimination through complaint mechanisms.

The need to grapple with hepatitis C-related stigma and discrimination in Australian health-care settings has been recognised in public policy, and work is underway to address it. But how likely are people to raise a complaint when they experience stigma or discrimination? And how effective and accessible are complaints mechanisms? Given complaint procedures are considered important parts of the delivery of safe and ethical health care, these are important questions that have yet to be substantially explored. Drawing on interviews with people with lived experience of hepatitis C (n = 30), this article considers how affected people feel about complaints processes and the act of complaining. Alongside these perspectives, we discuss complaint mechanisms, and the views of stakeholders who work with hepatitis C-affected communities in policy, health, legal and advocacy roles (n = 30) on the institutional and cultural dynamics of complaint. We draw on Sara Ahmed's Complaint! and Fraser et al.'s work on drug-related stigma to analyse these concerns that have yet to be researched, and argue that the (unlikely) prospect of successful complaint is a key part of the network of forces that perpetuate stigma, discrimination and disadvantage among people who have (lived with) hepatitis C. Although people with lived experience are often powerful advocates and acutely aware of the deficiencies in the quality of their treatment, our interviews suggest that the obstacles they face to accessing health care are seen as commonplace, intractable and insurmountable; and, that mechanisms for addressing them-where they exist at all-treat complaints in narrowly individualising terms and expose complainants to dismissal. Following Ahmed, we call for a 'troubling' of complaints-responding to them not as individual problems but rather as collective, structural concerns, necessitating new approaches.

'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.

Shifting solutions: tracking transformations of drugs, health and the 'human' through human rights processes in Australia.

Global drug policy is in a period of change. Human rights can play an important role in such change, but more work is needed to understand the how rights work and why they might come to matter. Drawing on insights from a major study on drug policy and human rights, I argue that important new dynamics in respect of how drugs are thought to relate to health are emerging, including a conceptualisation of some drugs as capable of generating or improving health, rather than undermining it. Drugs are in some cases coming to be understood not as the origin of social problems but as the solution for them. I introduce the concept of 'solutionisation' as a tool for understanding the mechanisms by which human rights shapes ontologies, positioning 'solutionisation' as corollary and counterpart to Carol Bacchi's work on policy 'problematisation' (Bacchi [2009]. Analysing Policy: What is the Problem Represented To Be? Pearson). I argue that both 'problematisation' and 'solutionisation' have value for sociological analyses of human rights and that we need to pay careful attention to the co-constitutive dimensions of drugs and human rights, to understand how norms about health, self and subjects are made, sustained, and brought under pressure.

'I'm not hep C free': afterlives of hepatitis C in the era of cure.

Since the advent of more effective, new-generation treatment for hepatitis C, immense resources have been devoted to delivering cure to as many people with the virus as possible. The scale-up of treatment aims to prevent liver disease, liver cancer and onward transmission of hepatitis C, but social research shows that people also approach treatment with its social promises in mind, including the hope that it might reduce or eradicate stigma from their lives. Such hopes reflect broader ideas about medical cure, which is seen as an end point to illness and its effects, and capable of restoring the self to a (previous) state of health and well-being. But what does cure mean among people for whom treatment does not produce an end to the social effects of a heavily stigmatised disease? While new treatments promise to eliminate hepatitis C, accounts of post-cure life suggest that hepatitis C can linger in various ways. This article draws on interviews with people who have undergone treatment with direct-acting antivirals (n=30) in Australia to explore the meanings they attach to cure and their experiences of post-cure life. We argue that dominant biomedical understandings of cure as an 'ending' and a 'restoration' can foreclose insight into the social and other effects of illness that linger after medical cure, and how individuals grapple with those afterlives. Drawing on recent conceptual re-framings of cure from medical anthropology and disability studies, we suggest that thinking at the limits of 'curative reason' helps to better address the afterlives of chronic illness. In the case of hepatitis C, reconceptualising cure could inform improved and less stigmatising ways of addressing people's post-cure needs. And in the era of hepatitis C elimination, such reconceptualisation is increasingly important as the cohort of people undergoing treatment and cure expands worldwide.

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.

Making addicts: critical reflections on agency and responsibility from lawyers and decision makers.

Various activities are increasingly characterised as 'addictions', including within the law, and raise important questions. Do 'addicts' have agency? Do addictions shape social problems such as family and sexual violence? And how do those involved in legal systems perceive addictions? This paper explores these questions. Drawing on qualitative interviews with lawyers and decision makers (N = 48), it explores addiction in law. Lawyers and decision makers see themselves as playing important roles in making addiction and 'addicts'. Addiction is an effect principally of legal strategy, and other forces. Legal processes bring differing conceptions of agency and responsibility into being, problematising understandings of agency as an 'effect' of addiction, or as pre-existing legal processes. There are also important variations in approach regarding different addictions. Alcohol or other drug addiction is seen as 'genuine', and a major factor in family violence, while sex addiction lacks credibility. I explore some implications of these approaches.

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.

Between Public and Private: Electronic Health Record-sharing, Health Privacy Principles, and Hepatitis C.

People with (a history of) hepatitis C have concerns about privacy and the confidentiality of their health information. This is often due to the association between hepatitis C and injecting drug use and related stigma. In Australia, recent data breaches at a major private health insurer and legislative reforms to increase access to electronic health records have heightened these concerns. Drawing from interviews with people with lived experience of hepatitis C and stakeholders working in this area, this article explores the experiences and concerns of people with (a history of) hepatitis C in relation to the sharing of their health records. It considers the potential application of health privacy principles in the context of hepatitis C and argues for the development of guidelines concerning the privacy of health records held by health departments and public hospitals. Such principles might also inform reforms to legislation regarding access to health records.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.

OF RECOMMENDATIONS AND LEVELS OF EVIDENCE: Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity-frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient's needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the "teach-back" technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A). SUMMARY OF KEY RECOMMENDATIONS AND LEVELS OF EVIDENCE: Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

Becoming posthuman: hepatitis C, the race to elimination and the politics of remaking the subject.

Hepatitis C has long been a public health problem in Australia. 'Revolutionary' new drugs with the potential to cure hepatitis C have now emerged. The Australian government has invested heavily in them, and has an ambitious goal to eliminate hepatitis C by 2030. Numerous shifts in policy and practice are required if the elimination agenda is to be realised. This paper explores the significance of these shifts. We ask: what is the race to elimination doing with the subject? We argue that the race to elimination can be understood, simultaneously, as a product of posthuman forces, capable of being analysed using the theoretical tools made available via the posthuman turn; producing an intervention in what it means to be human; and generating a dilemma for people who use (or used) drugs, people with hepatitis C, and posthuman scholarship. In drawing out these issues, we aim to: trace the significant developments underway in hepatitis C medicine and raise awareness of them; encourage reflection on the consequences of these developments; and invite reflections on what might be lost when the human is remade by hepatitis C medicine.

Beyond a 'post-cure' world: Sketches for a new futurology of hepatitis C.

Australia's recent investment in, and optimism about, direct-acting antivirals to treat hepatitis C brings with it the promise of new drug futures, including the possibility of a post-hepatitis C world and a revolution in the lives of people affected by the disease. But is the situation more complicated than we might assume? What expectations are being produced about post-cure lives? And what is being overlooked along the way? We argue that hepatitis C policy, practice and research can instantiate a problematic orientation towards medicine and 'the future' and explore ways of moving beyond these orientations. The essay then proceeds into two main stages. First, combining critiques from existing research with preliminary insights from a new study on hepatitis C 'post-cure' lives, we outline some of the key logics regarding cure and post-cure, and explain why such logics are problematic. We argue against the assumption that the availability of a medical cure will alone reverse the entrenched social, political and structural dynamics that drive infections and limit service access. To do so, we note, is to overlook the net of meanings and power relations that co-constitute hepatitis C and injecting drug use and render those associated with them marginalised and disenfranchised. Such optimism erases the legacy of laws and policies devised in a pre-cure world, and their role in generating and limiting new ways of being. Second, we introduce new ideas to the field and articulate a vision for what we call a 'futurology' of hepatitis C, designed to counter these assumptions and take us beyond problematic temporal logics. Our futurology is inspired by the work of Cuevas-Hewitt (2011) on the 'futurology of the present'. Cuevas-Hewitt's approach discards linear temporalities, expectations of revolution and reform, and instead pays attention to multiplicities of becoming in the perpetual present. Taking up ideas from Cuevas-Hewitt, we introduce our own sketches for a 'futurology of hepatitis C'. This is a set of practices for thinking, researching, writing about and otherwise engaging with hepatitis C, characterised by attention not to what an imagined, singular future might look like, or to assumptions about treatment as revolutionary, but to what Cuevas-Hewitt (2011) calls the multiple 'perpetual presents' already with us, and aims to foment hope for change.

A highly charged field: Mapping energies, currents and desires for reform in Canadian expert responses to drug law.

While many experts consider major changes to legal approaches to drug use necessary, achieving such change has proven to be difficult. The political process is often seen as integral to bringing about change, largely due to orthodox understandings of the 'nature' of law, in which law is made by parliaments and capable of revision in only limited instances. In recent years, theorists such as Bruno Latour (2009, 2013), Andreas Philippopoulos-Mihalopoulos (2015) and Serge Gutwirth (2015) have taken a more expansive view of the nature of law and its effects. According to these theorists, law also emerges from outside the political process, including through various practices such as those of professionals working within legal systems, and those engaged in resistance, navigation and subversion (Seear, 2020). This article explores these processes using Karen Barad's (2015) work on lightning. As we will explain, Barad presents lightning as a 'queer', non-linear, uncertain and indeterminate phenomenon, using it to understand causation in new ways. Along with Barad's ideas, the article draws on interview data (N = 35) collected for two research projects in Canada. These interviews were conducted with senior drug use-related policy makers, service providers, advocates and lawyers based in British Columbia and Ontario, Canada. The interviews explore how key Canadian experts view drug law, debates about law and policy and whether they support reform. We also explore how these experts navigate the criminalisation of drugs and whether any insights can be drawn from their practices, including their attempts to navigate, subvert or change the law. First we consider experts' concern about current prohibitionist legal frameworks, finding it widespread, along with appetite for change. Second, we examine experts' accounts of strategies used for working around or challenging punitive frameworks. We find that change, like lightning, is complicated and messy; simplistic approaches to changes are not always possible, and may in fact make matters worse. There are multiple, unpredictable effects in engaging and resisting law, and thus difficulty in tackling criminalisation in any clear and simple way. Practices and processes of responding to and resisting drug-use criminalisation can thus be understood in terms that reflect the 'queer', indeterminate, unpredictable and multidirectional nature of Barad's lightning. In concluding, we note that this way of understanding legal processes and resistance has implications for the future of Canadian drug policy, including debates about whether it is possible to work within a framework of overarching criminalisation.

Decriminalising public drunkenness: Accountability and monitoring needed in the ongoing and evolving management of public intoxication.

In light of the recent announcement from the Victorian (Australia) state government that they are moving to decriminalise public drunkenness and replace it with a 'health-based response', it is timely to reflect on a number of important considerations identified from the academic literature on this topic. We briefly review a number of models of health-care delivery that have been utilised in other jurisdictions, and suggest there are opportunities at a more principled level to respond more adequately to the decriminalisation of public drunkenness in Victoria (and elsewhere). First, embedding research and evaluation, particularly that draws on the needs, views and experiences of those who are deemed to be drunk in public, is essential from the outset, and must be ongoing to enable the continual refinement of models of care. Second, significant funding and intersectoral support are needed to ensure that the laws are not tokenistic and do not remain the responsibility of police. Third, there are opportunities to put policies and principles in place to ensure that police do not use more coercive powers to address concerns around public drunkenness. Most importantly, state-wide education and training efforts are needed alongside the repeal of the law to ensure that emergency services and health-care workers (as well as the community), have a good understanding of the contexts and needs of people who are considered drunk in public, and consequently treat them with care and respect.

Consumption in contrast: The politics of comparison in healthcare practitioners' accounts of men who inject performance and image-enhancing drugs.

In recent years, Australian researchers' interest in the use of performance and image-enhancing drugs (PIEDs) has grown, in part because PIEDs use is thought to be on the rise. In much existing research, PIED consumers are described as a new and unique cohort of service users, with distinct needs, expectations and views regarding service provision, harm reduction and risk. There is some evidence that policymakers and service providers have been unsure of how best to support this seemingly distinct cohort. Are their needs different to those of people who use other illicit drugs, or the same? How so? And how might we design services with these similarities and/or differences in mind? As these questions suggest, understandings of PIED use and our efforts to address it are often heavily reliant on comparisons, including between people who consume different kinds of drugs. This article engages with the central role of these comparisons in shaping understandings of PIED-related service delivery and design, and considers what is at stake in the drawing of comparisons. We explore these issues through an analysis of 20 interviews with Australian healthcare professionals conducted for a major research project on PIEDs. As we explain, comparison was a tool commonly used by many of our participants - a way of thinking through who PIED consumers 'are' and what they need. Drawing on the work of philosopher of science Isabelle Stengers (2011) and an application in research on the politics of comparison in drug treatment (Fraser & Ekendahl, 2018), we argue that such comparisons can work to reproduce normalising ideals and flawed hierarchies, with PIED consumption positioned as less desirable than 'mainstream' ways of being and living, but more desirable than other forms of drug use. The comparisons we identify may also concretise or naturalise differences between consumers, positioning difference as somehow linked to the individual attributes or capacities of people who use different kinds of drugs, thus foreclosing questions about the political contexts in which comparisons are made and which give them their meaning. In concluding, we encourage other ways of thinking about difference, including whether the differences identified by our participants might be shaped by forces beyond those raised in their accounts, and what this means for both future policy responses to PIED consumption and future PIED research.

Is another relationship possible? Connoisseurship and the doctor-patient relationship for men who consume performance and image-enhancing drugs.

Consumption of steroids and other performance and image-enhancing drugs (PIEDs) is thought to be on the rise in Australia. Along with the benefits experienced by consumers come a range of health risks. This article draws on interviews conducted for an Australian research project on men who inject PIEDs to consider the ways in which information about managing these risks can be provided, the sources of information men use and value, and the professional relationships most effective for securing the best outcomes for them. As we will show, the men in our project expressed a very strong desire for reliable, credible information about risks and how to manage them, but also described often having to rely on information gleaned from sources of questionable reliability such as online forums and friends and acquaintances. Among the sources of information, advice and monitoring they expressed a desire to access were general medical practitioners (GPs), but high-quality interactions with GPs were, they argued, rarely possible. Using the recent work of Isabelle Stengers, particularly the notions of connoisseurship and symbiosis, we argue that new modes of engagement need to be developed that might allow men who consume PIEDs to access the information and support they need, including through their GPs. Following Stengers, we characterise the men in our project as 'connoisseurs' of PIEDs, and we consider what might be at stake and made possible were GPs and PIED connoisseurs to enter into more collaborative relationships to manage PIED-related health issues. In conducting our analysis, we argue for greater recognition of the complexities GPs face when encountering people engaged in illegal forms of consumption and call for new symbiotic models of engagement beyond both zero tolerance-style refusals to help and narrowly focused harm reduction approaches.

Masculinities, practices and meanings: A critical analysis of recent literature on the use of performance- and image-enhancing drugs among men.

The use of performance- and image-enhancing drugs (PIEDs) has been a topic of considerable research interest since the 1980s, with the vast majority of PIED consumers being men. In this article, our departure point is a 2005 article by Helen Keane, in which she critically analyses 'the discursive constitution of male steroid users' as psychologically disordered subjects. We extend Keane's insightful feminist analysis by examining the constitution of masculinity in post-2005 social science research on PIEDs. We ask (1) to what extent do the discursive trends identified by Keane persist in the more recent literature on PIED use among men? (2) how have her insights been taken up in the post-2005 literature, and (3) to what extent does this work attend to the specificity and varied meanings of steroid practices? We argue that men who use PIEDs continue to be pathologised as insecure, inadequate and vulnerable, and marked by 'obsession', 'compensatory behaviours' and crisis. In some of the analysed texts, the male steroid user becomes doubly disordered as both insecure in his masculine body and at risk of drug dependence. Of the articles that engage with Keane's work, only two recognise the value of her insights. The others misinterpret or apply Keane's argument in inconsistent or incoherent ways. Finally, in some of the post-2005 texts, we begin to see attention to the wide variety of practices and meanings encompassed by the term 'PIED use' although much remains to be learned.

"A spray bottle and a lollipop stick": An examination of policy prohibiting sterile injecting equipment in prison and effects on young men with injecting drug use histories.

BACKGROUND: Australian young male prisoners with histories of injecting drug use are more likely to report injecting in prison, to do so more frequently, and to be involved in more un-safe injecting-related practices than their older counterparts. Despite international evidence that prison needle and syringe programs are both feasible and effective in reducing the harms associated with injecting drug use in prison, these young men do not have access to such equipment. METHODS: We critically analyse the interview transcripts of 28 young men with histories of injecting drug use who were recently released from adult prisons in Victoria, Australia, and prison drug policy text. We use Bacchi's 'What's the problem represented to be?' approach to examine how the 'problem' of injecting drug use in prison is represented in prison drug policy, including the assumptions that underpin these problematisations, and the subjectification and lived effects that are produced for the young men in our study. RESULTS: Our analysis reveals how prison drug policy enables the creation and re-use of homemade injecting equipment crafted from unsterile items found in prison, and that in doing so the policy produces a range of stigmatising subjectification effects and other harmful material effects (such as hepatitis C virus transmission and injecting related injury and harms). Findings highlight, how injecting drug use is represented in policy silences other ways of understanding the 'problem' that may have less harmful effects for incarcerated young men who inject drugs. CONCLUSION: We argue that somewhat paradoxically, the approach of prohibiting access to sterile injecting equipment in prison-which is constituted as a solution for addressing such harms-in fact helps to produce them.