The Red Knob

Casting off the cobwebs in The Red Knob Coal Bunker and dusting ourselves down, it’s not often that we post a missive on the Red Knob blog in these days of The Catastrophe  brought to us by the current overlords at UK Plc – if you stick your helmet (oo’er) above the parapet too many times you’ll get pot shots taken at you, or possibly a cruise missile. Not that we don’t have plenty to say of course, but we could ask who beyond our over subscribed readership ( we do have them you know – honest!) is  listening? We can blather until we’re blue in the face, or spout words of the wisest erudition , but  there are only so many brick walls you can batter your head against until you do yourself serious damage, ie a case of let’s give it a rest. So, it comes as a very welcome surprise today amidst the ongoing pie slinging match surrounding Messrs Murdoch and co, that a headline has sneaked through about UK Plc’s stance on preventative work on health – that nudging people in the right direction on it’s own won’t do, that further incentives are required if people are to consider changing their behaviours around health. Beyond another worthy message ‘there’s no health without mental health’ – and if we don’t get that right we can forget the rest, there seems to be a welcome change in direction in terms of what needs to be applied to preventative health work – ie what we at The Red Knob have been foaming at the mouth about for an aeon or two, the appliance of the sciences of human behaviour alongside that of the social sciences. It’s extremely welcome and long overdue (although we wonder how long it will take to seep down into the Sociology smitten basement of sexual health…). So we thought we’d better put up our hands excitedly at the back of the class -  “but Miss we told you so!”

An interesting view on this can be found in The Guardian ( http://www.guardian.co.uk/commentisfree/2011/jul/19/nudge-is-not-enough-behaviour-change ); as the article points out, beyond the gaps in our knowledge of human behaviour, and ‘credible evidence bases within the social science disciplines’ ( The Guardian said it, not us… ) that there is a ‘lack of commitment to the interdisciplinary research needed to integrate perspectives on the various drivers of behaviour, including genes, neurons, thoughts, feelings, habitats, social interactions, and cultural influences.‘ The article goes on to say amongst other things that if UK Plc wants to follow this line, then we need to invest more money in the sciences and that perhaps the Research Council should invest money in interdisciplinary research. On that score we can say those folks at The Guardian obviously aren’t aware of the interdisciplinary sniping wars  that bedevil any mention of one side perhaps admitting that the other side has something valid to say after all  – put a neuroscientist in a room with a sociologist and you’ve got a good case for the TV show Celebrity Death Match – if there were any celebrities in either field of course. Ouch!

The central point of The Guardian article is about ‘nudging’ people in the right direction – and that you can’t ‘nudge’ people without incentives. Well, maybe some you can and some you can’t etc, but the greater point for The Red Knob is that finally there is the acknowledgement that the very valid sciences of human behaviour have a place in informing preventative work. That doesn’t mean to say that Dr Frankenstein is about to be unleashed – but that neuroscience or evolutionary psychology may offer other explanations about why people behave as they do. It also means that the wider application of the social sciences will be required in order to engage with populations – especially in terms of resources and media. A central tenet of The Red Knob has been since its inception that a reciprocal base of practice acknowledging both the social sciences and the sciences of human behaviour is required to address health concerns , and  at least there’s a hint now that – especially in terms of sexual health, we may not have to stick with one-size-fits all Sociology solutions ( or do we hear the sound of drawbridges being drawn up? ). We’ll have to wait and see how this one plays out – but you can be sure it’s a theme we’ll be returning to (just as long as the pen of the mighty red nib keeps a flowin’!)

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We noticed that a programme by this title is on BBC 3 tonight. A lot of sexual health professionals will be aware of the link between HPV and oral, head and neck cancers.  Watch the programme – or read about it here on a Red Knob blog post from 2008: Good Health (F)oral(l)

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Hunkier than thou? Sexual attraction? One thing leads to another, fnar fnar etc? It’s a conjecture that a straight guy’s take on ‘wimmin‘ lies somewhere between Nick Hornby’s novel  ‘High Fidelity’ and Charles Bukowski’s  semi-autobigraphical view  - ‘Women‘. Take your pick as befits the mood you’re in – or as Mr Wild Billy Childish may  ( or may not)   indicate, take  a read in eye dialect and get yerself an educashun ( although as of 9th December 2010 and Slighty Duplicitous Nick’s , Vince Cable’s, Slimy Dave’s and  Nasty George’s et alii’ verdict on increases in student fees, only their scions and the prodigy of similarly monied public school and Oxbridge educated individuals will gain a higher education; is opportunity for the rest of us again to retreat to servile obedience and ‘yes Sir I will’?  Know thy place as in Orwell’s Animal Farm . Bricks in the Wall. Etc.) But what about how women view men? This article from of all places, the Rothschild’s  banking family’s related publication ( believe what you will…) The Economist -that metronome of  Tory thinking,  makes for an interesting read – what do straight women see in men and what do they find attractive? Beats me, but here’s the article: Hunkier than thou?  ; read it? You should.

Now, considering potentially ‘attractive’ masculine attributes beyond those described in the article –  and as we’re in Economist mode alluding to E. F. Schumacher  and the theory of Buddhist Economics – ‘Small is Beautiful’ - which is something those Ancient Greek sculptors of masculine bronze statues would surely have agreed with when casting the winkie bits ( or perhaps they just ran out of bronze? )  one wonders quite what they would have made of today’s male porn stars with their 12″ King Dongs? ( and even we won’t create a link there…but you know what we’re talking about.) Attributed to the priapic Great God Pan perhaps? Attractive? If you’re a size queen quite possibly. That’s right were talking penis size.  So, how long is your piece of string and does it matter? Answers: a. a micro-penis? b. 5″?  c. 6″ – or perhaps d. 7″ on a lucky day when the wind is blowing in the right direction and the blood is going that way too?  Or if you’re a ‘real man’ –  e. all the way to the moon and back with a mighty Saturn Five Rocket. For most guys it’s about 5 to 6 inches – you can put the tape measure away now.  And you know it doesn’t matter – well, not too much. So, whilst some of us may have such attributes, we can’t all be Hector and Achilles with prominent brows, jutting jaws, and thrusting blades – the mechanistic men that myth and media have created for us to aspire to; we live in a culture which promotes such ‘virtues’ as manly and if you don’t measure up – well, you’re just not a real man are you. Hence Connell and the theory of masculinities ( and as we’re talking Greek, keeping up the references, here’s a review of Connell’s book ‘Masculinities‘ from the appropriately named  magazine Achilles Heel ).

This post isn’t the place to go into Connell’s work – but the text’s premise in an acorn is that within the cultures we live in that there are forms of hegemonic masculinity  -  masculine cultures which seek to exclude, dominate, and remain ascendant over other forms of masculinity which are either complicit ( as in go with the flow) or are different and are therefore marginalised or subordinate to the dominant masculine culture. Lost? We can see an example of hegemonic masculinity in action daily on our TV screens in the personae of the men of the Coalition Government ( and let’s not forget the big beasts of the previous administration too) –  the upper echelons of politics appears to be permeated with hegemonic types ( if we were being rude we’d say that there are some big pricks strutting around Westminster beating their hairy breastplates like they’re King Cock – but hang on, this is The Red Knob…). Is this attractive? For some possibly – it takes all sorts. But what message are these men sending out? That to be a certain ‘type’ of man is the only way to progress in this world? Heck, call us Neo-Feminists, but there’s more to being a man than being a besuited power wielder. Want to change the world? Change yourself first – and ditch the suit. And that archetypal 50s man, Charles Atlas? How does he figure in this? Apart from the fact that we just liked the naff allusion to Greek god Atlas , Charles provides (possibly unintentional at the time?) a 20th Century example of how a type of masculinity  is promoted via the media ( comic books – the boy with sand kicked in his face? See A half-naked muscleman in trunks: Charles Atlas, superheroes, and comic book masculinity )  as  the way a man should be, of what young men should aspire to be – of the way young men think women want them to be.  That only a certain type of man ‘gets the girl’. Or possibly Evolutionary Psychologists would say that men have evolved to be this way. Nature or nurture, either way it isn’t pretty and whilst there may well be ‘good’ masculine attributes which should be encouraged, other masculine attributes have the capacity to inflict much damage to indivduals, partners, children – or in the case of some of our preening politicans, much damage on society in terms of hopes,  aspirations and social progress – ie those men who have the testosterone charged balls to tough out any criticism of their policies and see them through to the end. Bitter though it may be eh Dave, George, Nick – and Vince.  Oh, and getting back to Charles Atlas, the fact that he  wasn’t afraid to sport a nifty pair of manly trunks worthy of Ernest Hemingway.  Hunkier than thou? Masculinity and The Old Man and the Sea? We’ll leave that one for another time.

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Hey kids, it’s the Dick – back again, pickin’ up the baton of sexual health, and handing over a Christmas cracker. That’s right, just a gentle reminder folks before you go wielding the turkey baster and roastin’ yer meat, that STIs ain’t just for Christmas…with a nudge to an earlier posting by the Skater, that that kiss under the mistletoe you we’re just so lookin’ forward to, may leave you with much more than a lingerin’ taste of oxytocin ( and babe, you know if you go there, well there just ain’t no goin’ back: Science finds the secret of a hot kiss ) . Nice huh: An unwanted gift at Christmas

Somethin’ to mull yer wine over. Did you want cream with that? Have a good one – be seein’ you. The Dick.

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Back in 2001 the Gloucestershire Boys and Young Men Network came together as a mulitagency/disciplinary group to facilitate health work with young men – predominantly sexual health and mental health work. The rationale for this body of work is detailed in the journal WYM – working with young men Vol 2, No 2, May 2003. The world may have changed since then and governments come and go – but ethics don’t. The basis for the Gloucestershire Boys and Young Men Network was a collective identity – or brand, working in partnership to improve amongst other things, the general well-being of young men. What it was not about was making money, competition or one-up (wo)manship. It was about partnership.

Dare we say that one of its finest achievements was a free resource entitled Know your Kit. This is a body of activities, guidance, and information around sex and relationships work with young men ( although it is entirely appropriate for use with ‘young people’ ) – made freely available as a CD-ROM resource – and as a downloadable 277 page pdf ( or 10.34mb of download for digital doodlers).

The principle behind it was that guidance and activities were being made available by third sector organisations – which cost money – as in about £30.00 per guidance booklet. This is fine and all well and good, it was sorely needed at the time – but for practitioners working on the ground, eg youth workers, school nurses, teachers etc ( ie a lot of people) a £30.00 manual on guidance and activites for all of the above people – with back-up training to boot – was never going to be available to all employees; and not every organisation or employee was aware that the guidance was available in the first place. The folk responsible for the guidance made a great effort to develop this and promote work with young men – but how work was rolled out in different areas of the country was very much on an ad hoc basis. Hence the Gloucestershire Boys and Young Men Network declared UDI and put together a free, educational body of activities, guidance, and information in the form of Know your Kit – backed up by training. It’s something the Network can be very proud of – and what’s more important it’s still available.

It can be downloaded here: http://www.gbymn.org.uk/gbymnp/KYK06.pdf 

Know your Kit is a free educational resource – it was intended to ensure that people working with boys and young men had access to freely available activities and guidance. It was not developed to be exploited – by anyone – for the purposes of making money. It had to  – and has to – be free at source to allow for maximum impact in terms of getting across sexual health information.

Sadly, the world moves on and the current evisceration of statutory providers of health and social care means that alongside established third sector ‘big boys’ such as Brook and THT, others are now setting up shop as providers of sexual health education. That’s fine ( although one could argue where’s the governance and quality control?) – there are skilled practitioners out there whose skills will be wasted otherwise ( although we fear some undoubtably will be lost ). Sex and relationships education should be provided freely if at all possible – after all wasn’t that the point of skilling up teachers etc? PSHE certification programmes? In the new financial climate – courtesy of Mr George Osborne and co – it appears that good health does cost after all. But if the State won’t pick up the tab then those who want good SRE may have to pay for it (and pity those, probably more needy schools etc that can’t afford it – ie there will still be be no ‘ base level’ of SRE) – and so people, who afterall need to have their daily crust paid for too, are going to provide it – they cannot do it for free. It’s a skilled job that not just anyone can do.

If that’s the situation we have to work with for the next five depressing years of the Demolition ( well, it’s all been pretty negative so far cuts, cuts, cuts…) , whoops, Coalition, then so be it. What we do not want to lose in all of this is the spirit of partnership – and where possible provision of freely available resources, guidance and information. The Red Knob had to be set up as a Limited Company in order to produce The Red Knob fanzine and other resources – no statutory body would touch it as it was against any previous guidance on work with young men ( although we had a well-researched rationale as to why this approach would work with some young men – and thus it proved) – however whilst we obviously have to charge for resources, training etc ( and believe us – if we were in this for the money, well, more fool us – but we are not.) we have endeavoured to make resources freely available too from our downloads section.

As a btw – if anyone has any free resources they’d like to share with others – send them to us and in the spirit of collectivism we’ll place them in the downloads section of The Red Knob website – we’ll of course credit them to you – not us.

Thus partnership working; whether you work for the statutory sector ( whilst you still have a job), a large sexual health third sector provider such as Brook or THT, or you’ve set up or are setting up as a one man in their van one-stop sexual health shop, or possibly an all-singing, dancing travelling sexual health education circus, sexual health improvement aims are achieved best if we work in partnership. Competition, ner ner ner ner ner, dog-eat-dog etc may do you financial favours – but the spirit level of sexual health will mean that work remains fragmented and patchy – great stuff for those who can afford it and tough on those who can’t. If we work in partnership we get things done to the benefit of all. Hence the need to maintain networks. If you work in competition – caveat emptor and less young people benefit etc.

The Red Knob’s satirical, theatrical, subculture driven, down in the basement humour approach may not be to everyone’s ‘serious’ taste ( who is hard-to-reach – young men – or rarefied health strategists? Depends on who you are) – possibly it only engages with the less than serious young folk, after all a lot of young men are anti-authoritarian, you may not even approve our approach ( although we’re getting a bit old hat now – best before 2004 and all that ) – but wait – our intention is never less than serious; we may be Knobs – and proud of it, but pricks, spare or not at any event we are not. Get the message – don’t be a prick. Kick against the cliques! And in the gloomy days ahead keep up the partnership working folk.

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Worth a read. Eviscerating the NHS by  Dr John Lister, Senior Lecturer in Health Journalism at Coventry University.  The implications for the delivery of sexual health and reducing health inequalities are clear: in a competetive free-for-all market run by private companies and third sector organisations where is the quality control?

Dr Lister’s article can be accessed here:

http://jrwlister.wordpress.com/2010/10/02/british-government-plan-eviscerating-the-nhs/

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Well, the folks at The Red Knob may at times appear cryptically cross with the state of health and things in general (feel our spleen over the last couple of apoplectic posts ) – we’re not exactly enamoured of the current public services pogrom and the swingeing cuts that are and will continue to disrupt health service delivery, not to mention the fallout  in terms of the health impact, especially the mental health impact on those people who have already or may be about to undeservedly lose their livelihoods, homes etc as a result of Mr Cameron’s and Young Mr Osborne’ s  zeal (Neverwhere anyone – the ‘non-people’ oppressed by Mr Vandemar and Mr Croup?) – but then neither were we that  enamoured of the previous occupants of Number 10 Rillington Place -  whoops Downing Street. But that’s what happens when you float off into the stratosphere, breathing a rarefied air – and forgetting the people below and exactly why you’re there to do the job in the first place. People as bean counters?

Ditto health, public health, sexual health, work around men’s health, restructuring, and commissioning conundrums. The tale – anecdotal, but also backed up by the Royal Society of Public Health arguing for specialised health promotion, is that health promotion departments disappeared under Mr Blair’s and Mr Brown’s  ( that’s Mr Vandemar and Mr Croup – again) aegis back in 2005; the subsequent evisceration of health promotion departments  as providers of ‘health promotion/health improvement ( or whatever title you wish to apply as befits the zeitgeist) and the advent of tiers of commissioning managers (shuffle, shuffle, shuffle…) hasn’t really set the world on fire. Surprised? Possibly it’s just the limited Weltanschauung offered by the vista from The Red Knob coal bunker; eg that we consider that the Daily Mail proclaiming in its ‘shock horror’ article that ‘Sacked NHS managers could simply move to work for GPs’ is simply stating the bleedin’ obvious. More restructuring for the sake of it? Our collective experience of ‘restructuring’ under the previous administration has not been a good one.  On a number of levels: gripe  number one is the current raison d’etre of public health practice; think we don’t know what we’re talking about? Really? We may not appear to know the difference between a quintile and the Mighty Quinn (“oh come on without, come on within…” ) Well, but guess what we do! The problem of perspective is yours – not ours. The problem is that current public health practice is built upon a hierarchy of evidence where Evidence Based Medicine/practice/public health and the Randomised Control Trial is King Emperor – lost already? Basically, public health initiatives, are guided by a hierarchy of evidence. Top of the unassailable grand pyramid of evidence is the Randomised Control Trial – below this are further tiers of evidence, with ‘expert opinion’ , consigned to the bottom of the pile, or jettisoned down the rubbish shute as befits the model you follow. Elucidating further, the problem is that this pyramid of evidence only takes into account the ‘objective’. Fine, that’s how it should be, you may splutter over your smooth espresso, however what the current hierarchy of evidence does not acknowledge is that sometimes the ‘subjective’, that which you cannot account for in a RCT, is the defining factor as to why an intervention is successful – thus it is not evidence by degree that should be taken into account – but evidence by kind. This great revelation is evidenced in a paper by one Mark Tonelli published in the Journal of Evaluation in Clinical Practice ( 2006). Use your Athens account and take a peek: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2004.00551.x/full  – it makes for interesting reading and a challenge to the current state of clinical and public health practice.

An example in terms of public health work:  one local sexual health clinic is more successful at attracting and engaging with young people than sexual health clinics elsewhere in an area – because the receptionist has built a up a very friendly rapport with a group of young people  ( pleeeease – forget the ,” well it might be the particular group of young people – it’ll only work with that group,  the time of day, the colour of their shoes”)…really, the ‘expert opinion’, and that of the young people is that it’s the receptionist’s friendly and welcoming manner that’s the catalyst for engagement.  It’s the defining factor in the clinic’s success in attracting young people. But, in terms of the hierarchical evidence by degree diktat adhered to within public health circles, the anecdotal, the ‘subjective’ – the personal (i.e. why we’re all human beings) gets lost. Evidence by kind, rather than evidence by degree would address this; challenging an entrenched public health status quo is going to take a long time (we’ve been wearing our tin helmets in The Red Knob coal bunker for quite a while).

The second problem is that (being subjective) that some commissioners may not know what they’re talking about. Ouch! How dare we! No, we’re not really being personal, it’s the fact that commissioning leads may not be ‘experts’ in the field they are commissioning. Possibly, they need ‘experts’ to guide them  – although cynics have validly queried if this is the case why are they in the job in the first place, and shouldn’t the work be led by experts supported by data crunchers – yet hang on, isn’t that the point of GP commissioning? (but not in public health, coming to a local authority somewhere near you very soon – but that’s another argument…). So back to the contention of commissioning leads requiring expert guidance; worryingly  – in terms of any field of health, but we’re talking sexual health, men’s health and work with young men here, is that services may be commissioned by commissioning leads who ‘go with the flow’ without digging deeper into the services they’re commissioning. Mentioning no names ( as if…) but in terms of the aforementioned fields there are few large third sector organisations out there to be commissioned to deliver specific services. Nationally, sexual health work is likely to be commissioned ( ie also meaning the defacto breaking up of current tiers of NHS sexual health services) out to these organisations. Mr ‘one man and his van’ sexual health services, made redundant from statutory services and now setting up in the ‘new financial situation’  – despite a cornucopia of local expertise and knowledge, will not get a look in, when  – if they haven’t done it already, those commissioning managers who are giving the Daily Mail palpitations by their move to GP Consortia, commission those large third sector sexual health organisations to deliver sexual health work ( and who will conveniently forget that they’re sticking the boot into the supine form of the NHS  ) . What are we talking about? Take work in schools – who is more likely to be commissioned to do this; Mr one man and his van with local knowledge  – or a large third sector organisation? Sadly ‘expert opinion’ and skills and knowledge of local schools won’t come into it. Commissioning as it stands isn’t flexible enough to acknowledge this – the ‘non-expert in their fields’ commissioning leads have eyes bigger that their collective bellies in terms of who they commission to deliver the work; ie they see ‘ major national organisation/charity’ writ large  – and commission.  Choice? There will be no choice at all.

The final and deepest gripe is that in commissioning large third sector organisations to deliver work, that NHS/LA/GP Consortia commissioners do not dig deep enough into the ethics, ‘politik’, and research that drives the practice delivery of these organisations. That they produce wonderful guidance on ‘what works’ and ‘this is the way to do it’ cannot be doubted, and it’s appropriate to use it in work with many men – but there is an ingrained inflexibility of practice driven by an adherence to certain tenets of academic discipline that has become an unchallenged mantra in sexual health work with men ( but interestingly not in other fields of health work with men – we wonder why?) over the years – that we have to ‘challenge and change men’, that work which attempts to work with men ‘as they are’ via subculture of whatever form is somehow wrong. It is not. Sometimes we have to acknowledge that we cannot always challenge and change men – that sometimes the ‘challenging’ creates barriers and that to address immediate health concerns( such as STI inflation ) we need to engage with men in ways which they are comfortable and not just what we as professionals are comfortable with…Yes Maam, this is The Red Knob and we don’t espouse comfortable conformity and tugging the forelock here. Tugging the todger maybe – but  this is not the place for going off at a tangent on good prostate health.

Back in December of last year there were a series of roadshows around the UK that considered updating the guidance on sexual work with young men. The concern of some practitioners following this was that we would be presented with a version of the same guidance as before in shiny new covers. Whether that has come to pass we’re not sure – we haven’t seen it…however, a ‘social marketing base of practice’  – acknowledging that for some young men subculture is a ‘real lived life’ and that we sometimes have to engage with young men through subculture and the mediums familiar to them – the social marketing base of practice as advocated by The Red Knob won’t get a look in that’s for sure. That said, the evidence base of this type of work  – of engaging with men as they are through subculture, whether it’s via sports outreach projects, comedy nights, festivals, Harley Davidson weekends, barbers shops and so on being built up and advocated by The Men’s Health Forum is very welcome. The sad thing is, that from what we know, that this will not be reflected in the new guidance on sexual health work with young men. Why? Because of the research base that drives that guidance ( take a look in the references section if you want to go into why – surely not that old discourse on applied feminism, we’ve laboured this one more than a bit…). We don’t necessarily disagree with the evidence driving the new guidance – in fact much of the time we’ll go along with the notion of changing men (e.g. around domestic violence concerns)  – but not all men, and this is where the guidance falls down. It’s not realistic to challenge and change all men, it cannot work, and it’s foolish to think that we can – yet this is the doctrine that has been peddled out over preceding years and implemented in the course of sexual health work with young men. However, commissioners will continue to blithely commission third sector organisations who develop and deliver this type of guidance and train their staff to use it ( without the staff questioning why)  without exploring the rationales behind the delivery of their work – and if it actually works. We can all be suckered into going along with the new thing – personally I’d rather stick with the local expert opinion driving the one man and his sex and relationships van, after all isn’t localism the new spirit of the age?

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