British Columbia has been in the midst of a syphilis epidemic for several years. Gay, bisexual and other men who have sex with men (gbMSM) continue to be the most affected population.
In response, the Clinical Prevention Services Division (CPS) at BC Centre for Disease Control (BCCDC) led the development of a provincial syphilis action plan in collaboration with the regional health authorities. The plan included a social marketing campaign to increase health literacy around syphilis, specifically among gbMSM.
The campaign content presented unintended challenges to some parts of the gbMSM community. Here we describe these challenges, why they arose and how consideration of vulnerable communities may be improved in health-related campaigns.
BCCDC developed a print and digital campaign along with a supporting microsite (Syphistory.ca). The concept of the campaign – cartoons of famous historical figures known (or suspected) to have had syphilis, drawn in the shape of penises – was inspired by San Francisco’s well-known Healthy Penis campaign from 2002.
The intention of the campaign was to use humour and sexual innuendo to engage people, but also to promote serious messages about the transmission, asymptomatic nature, treatment and complications of syphilis.
During the campaign development, BCCDC sought input from health authorities and select community organizations, including YouthCO. Syphistory was launched in February 2017 with posters and online ads, and was later supplemented with an animated video featured on the microsite.
YouthCO perspective – Impacts of Syphistory
When we at YouthCO first saw the campaign imagery, our (primarily cisgender) team realized that by only featuring penises, these images could exclude many trans guys within gay, bi and queer men’s communities.
YouthCO’s goal was to communicate this to the BCCDC team in a constructive way, but we were cautious about calling in such an influential organization, and the power dynamic between our peer-led organization and the clinical team at BCCDC. The YouthCO Board of Directors supported our decision to provide feedback. Through email, we explained why we believed the campaign was not for all gay, bi and queer guys, but in fact, was primarily intended for cisgender gay, bi and queer guys. It became clear this was the first time during the campaign development that this feedback was being given, and we believed BCCDC needed more education about trans men within gay men’s health.
Based on our existing knowledge of trans inclusive language from working with trans youth and resources such as Primed2, YouthCO suggested revisions to the microsite, which BCCDC made. While YouthCO understood there wasn’t the capacity to modify the campaign imagery at that time, we knew that the campaign would still cause a lot of harm within our communities. Consequently, the YouthCO team decided not to promote Syphistory through our social media and personal networks, although we continued to provide information about syphilis to our communities.
Within days of the launch, we received comments from trans people in our networks expressing frustration at Syphistory, and asking if YouthCO was part of the campaign. We shared this feedback with the BCCDC team, and it was these personal accounts that deepened their understanding of the campaign impacts. From this conversation, YouthCO reached out to our networks to engage some of these young men in creating images for an updated campaign.
At the same, we were receiving feedback from trans youth within our own programs that YouthCO wasn’t as trans-inclusive and gender-affirming as we aspire to be; we weren’t doing enough to challenge the cissexism at YouthCO. While we were taking a strong position that the campaign needed to include trans people, we were also seeing that we needed to better integrate the commitment to trans youth across our own work. Over the past several months, we’ve been working to make changes within our own team to support trans youth leadership and be meaningfully trans-inclusive and gender affirming.
BCCDC perspective – Revisiting Syphistory
Through the initial feedback and ongoing discussions with YouthCO, those of us involved with the campaign at BCCDC came to realize that we had unintentionally excluded and offended part of the gbMSM audience that we were trying to reach. This was a hard lesson to learn.
As BCCDC learned more about the needs of trans men, we started to understand that this issue stemmed from the evidence used to inform the campaign. The epidemiology of syphilis shows the highest rates of infection in gay, bisexual and other men who have sex with men. In the absence of accurate and complete data, the assumption is that these are cisgender men – but that assumption is erroneous, given that our data collection systems often acknowledge only the gender binary. Not only are transgender and non-binary individuals not visible in our data, individuals also may not engage with the health care system because of past negative experiences, so the data is incomplete.
By creating a campaign based on penis imagery, Syphistory did not reflect the wide range of bodies and experiences that gay, bi and queer men have. The campaign further perpetuated the focus on cisgender men seen in other campaigns that target gbMSM. While some changes were easily and quickly made, we needed time to process the feedback from YouthCO and think about how this mistake could be addressed in a genuine and meaningful way through revision of the campaign’s visual content.
It was important for BCCDC to honor our values of respect and inclusivity, and we realized the need to engage with trans men to update Syphistory. We reached out to YouthCO, who facilitated an open and thoughtful consultation with two trans men (other trans men were invited, but were unavailable or declined), leading to the creation of new campaign posters and updates to the video.
BCCDC perspective – Moving forward
Our experience with the design of Syphistory was a powerful learning experience for our Division at the BCCDC.
- At a practical level, we learned that the use of genital-based imagery in educational and promotional materials perpetuates the exclusion of trans and non-binary individuals from our services.
- We also learned the importance of engaging community organizations in ways that facilitate dialogue early in the development process.
- Most importantly, we recognized that we had our own work to do at BCCDC to improve the cultural safety of our services and our awareness of the system barriers faced by trans and non-binary persons.
Our collaboration with YouthCO led to the creation of a new series of Syphistory posters and updates to the animated video. Not only do the revised graphics include penises and testicles of varying shapes and sizes, they also feature a penis from phalloplasty and genitals that are unique to some trans men on testosterone.
We have also worked with TransFocus Consulting to provide training sessions to increase staff knowledge around the needs of trans and non-binary individuals. We’re grateful to YouthCO for engaging with us and pointing out this opportunity for us to improve our work. There is still much work needed to affect inclusivity in the health care system and we are committed to fostering change within our organization.
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