Harm Reduction

Harm reduction is a public-health strategy that acknowledges the reality of risky behavior and tries to minimize its effects on people’s lives. Although the strategy can be used to address any behavior, it is most frequently associated with drug or substance use and unsafe sex. In the LGBTQ community, harm reduction efforts have generated folk art in the form of posters and flyers for Gay venues, theatrical performances, and a semi-official folk institution of trained medical volunteers, who in turn have developed their own healthways for treating drug overdose.

Harm reduction activists in Bangkok, Thailand, 2011. Photo from Thai AIDS Treatment Action Group website (ttag.info, February 2012)

History of Harm Reduction

As early as the 1920s, Britain’s Rolleston Committee suggested that the mere prohibition of illegal drugs might not be the most effective way to control the drugs’ negative effects — that some drug users might be better served by an approach that helped them manage their own drug use toward minimizing harm. By the 1970s, this paradigm had an effect outside the United States, shaping the policy shift to limited legalization in the Netherlands of small quantities of controlled substance, the United Kingdom’s tiered classification system for drugs, and various harm reduction approaches adopted by Canada, Australia, and the World Health Organization (WHO). The paradigm spread around the world as a pragmatic way to limit the risk of HIV infection while acknowledging the futility of insisting upon total abstinence from sexual activity.

Photo from Société Canadienne du SIDA/Canadian AIDS Society (cdnaids.ca/files.nsf/pages/1280x1024home/$file/1280%20x%201024%20home.jpg, February 2012)

By contrast, the primary goal of most substance abuse programs in the United States remains the elimination of use of the substance, as exemplified in the Nixon Administration’s War on Drugs and the pervasive American law enforcement policy of zero tolerance for possession of even small quantities of recreational drugs. Nevertheless, harm-reduction theory has taken hold in some sectors. After the repeal of Prohibition, alcohol use in the United States was managed through a system of licenses, taxes, and laws intended to minimize the negative effects of alcohol without banning its use. The influence of the harm-reduction paradigm in the United States is also evident in such initiatives as methadone clinics for heroin addicts, the legalization in California, Denver, Hawai’i and elsewhere of marijuana and opiates for pain management, and needle-exchange programs designed to minimize the spread of HIV and other infections among addicts who use needles.

One problem with anti-drug campaigns is that, when people do not die from drugs, stark advertisements making the claim then become jokes. Poster from Impact publications (businesspundit.com/13-most-disturbing-anti-drugs-ads, February 2012)

Harm reduction has been influential in public-health approaches to both drug use and sex in the LGBTQ community. At the onset of the HIV/AIDS epidemic in the early 1980s, fierce debates raged, both within and outside the Gay community, over the appropriate response to a virus known to be linked to particular behaviors but far from fully understood. Those who sought temporary or permanent closure of Gay male bathhouses argued that it was irresponsible to facilitate sexual liaisons when the virus was widespread, while their opponents argued that the presence of the virus did not justify curtailing the sex-positive ethos that had evolved in the Gay community, and that bathhouses were prime locations for education campaigns. The “safer sex” approach that emerged from these debates is guided by harm-reduction principles. People are not told that they must abstain from sex but are encouraged to limit the number of their partners, to use condoms, dental dams, lubricant, and other safer sex materials, and to be periodically tested for HIV and other sexually transmitted infections.

Portion of a painting by Keith Haring, 1988 (www.haring.com/cgi-bin/art_search_lrg.cgi?id=00604&search=Sex&start=40, February 2012)

Harm Reduction Principles

As a public health philosophy, harm reduction incorporates four key principles: First, it acknowledges the effects of drugs and unsafe sex and the harm they can do, yet its goal is to reduce the adverse effects of drug use and the health risks associated with unsafe sex rather than to stop drug use or sexual behavior in itself. Second, it recognizes that drugs are used in different ways and for different reasons, and that some drug-related behaviors are safer than others. Third, its holistic approach places risky behaviors in a context that includes the individual, community, and society, and examines people’s motivations for engaging in drug use, sex, and other targeted behaviors, acknowledging the satisfactions that these behaviors can bring. Harm reduction encourages coordination among police, medical professionals, insurers, and community leaders.

Finally, harm reduction places people at the center of its strategies, encouraging clients to work with each other, to help design ways to manage their behaviors, and to minimize harm. Clients have a range of options to manage themselves – for example, getting counseling, finding ways to protect themselves and others during risky behavior, setting parameters around their behaviors (in terms of cost, time, place, and frequency), and abstaining from activities that could be dangerous.

Harm Reduction as a Gay Folkway

The harm-reduction principle has led to the establishment in some cities of public facilities dedicated specifically to treating LGBTQ people with substance abuse problems such as Stonewall Recovery Services in Seattle, The Stepping Stone in San Diego, and New Leaf Services for Our Community in San Francisco. But some LGBTQ groups have developed their own means for promoting harm reduction, for example helping in situ those who do too many drugs at Circuit events. MedEvent, an all-volunteer organization of licensed medical personnel founded by Dallas physician Chris Mann in 1997, developed its own protocol for situations that were not yet addressed by the larger medical community. Groups in Canada, such as the all-volunteer medical team for the annual Black and Blue Circuit weekend in Montreal, follow a similar protocol, which has in turn influenced standards for emergency-room treatment in some cities.

tweaker.org, a site that uses humor and real-life stories to help meth addicts overcome their addiction (tweaker.org/campaigns/popup/16.html, February 2012)

tweaker.org also uses sexy, happy men and positive messages rather than images of ruined souls (tweaker.org/campaigns/popup/19.html, February 2012)

They also have a site in Spanish: www.tweaker.org/spanish/inicio.html (February 2012)

In addition to medical personnel at events, organizations such as ACT (AIDS Committee of Toronto) and Séro-Zéro in Montreal conduct advertising campaigns with flyers, posters, and presentations designed to raise LGBTQ awareness of risk in bathhouses and in venues of festive folklife. In Boston, the Theater Offensive sponsors “A Street Theater Named Desire,” short theatrical presentations in popular Gay cruising grounds. Artists such as Straight ally Kat Coric in Montreal design posters and visual pieces geared toward the promotion of harm reduction in the Gay male community, often using drag queens, humor, and attractive male models.

Kat Coric accepting the Prix Coup de Coeur from the Council of Quebec's Gays and Lesbians. "''Kat Coric’s implication in the LGBTA community is immeasurable,' says Gary Lacasse, secretary of the CQGL who personally nominated Coric. 'She is an inspiration to anyone who believes in equal rights for all — an instigator extraordinaire, who has over the last few years instigated several fundraising initiatives for the fight against HIV and AIDS.'' (2bmag.com/2010/12/the-instigator-artist-kat-coric-wins-the-2010-prix-coup-de-coeur-2334)

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Further reading:

Coombs, Robert H., and William A. Howatt. 2005. The Addiction Counselor’s Desk
Reference. Hoboken, NJ: John Wiley and Sons.

Marlatt, G. Alan, ed. 1998. Harm Reduction: Pragmatic Strategies for Managing High-
Risk Behaviors. New York: Guilford Press.

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