It is evident in the practices of sexual health assessments that health care providers are plagued by the landmines of sexual and gender politics. Even the most attentive and mindful health care provider will inevitably and awkwardly ask questions that are extraneous, immaterial, inappropriate, and often offensive of ‘queer’ people during these encounters. Heteronormativity and homonormativity underscore sexual health assessments even though these practices are touted as being universally appropriate. Where do health care providers turn for further clinical guidance on how to be more inclusive of sexual and gender minorities? In an effort to provide practitioners with the resources they need and to establish Canadian practice standards, the state consolidates academic literature and evidence-based research. In 2006 the Public Health Agency of Canada (PHAC) revised the Canadian Guidelines on Sexually Transmitted Infections (referred to hereafter as Guidelines) to provide recommendations on how best to prevent and manage “STIs [sexually transmitted infections] across a diverse patient population” (5). In an appendix in the Guidelines, more specific concerns and questions are raised to help health care providers serve men who have sex with men (MSM) and women who have sex with women (WSW). Essentially, from the government’s perspective, this is the prescriptive manner in which to deal with all sexual minorities. However, the appendix does not address the sexual health needs of people who challenge hegemonic gender and sexual dichotomies; instead, it reinforces dominant understandings of sex, gender, and sexuality.

I examine this policy and speculate about its effect on the health of queer people. I highlight the forces influencing this policy, including heteronormativity within health care and an emerging homonormative agenda put forward by dominant lesbian, gay, bisexual, and transgender (LGBT) organizations that produce their own sexual health best practices and evidence-based research. These homonormative tendencies within identity politics contribute to the general sexual health policy discourse. Although the predominantly gay and lesbian experiences put forward by LGBT organizations expose a way of being that is not heterosexual, they do not often challenge hegemonic categories within sex, gender, and sexuality. By not problematizing binary systems of understanding perpetuated in homonormativity, LGBT organizations render queer people invisible and deviant. I argue that a homonormative agenda is taken up and becomes complicit in validating heteronormativity within the dominant health care system. I expose how the Guidelines effectively render queers invisible and degenerate through homonormativity.

Queer: Front and Not So Centre

I use the word ‘queer’ in this article both as a verb and a noun. To queer something is to question normalcy by problematizing its apparent neutrality and objectivity. Britzman suggests that ‘queer’ as a practice “is not an affirmation, but an implication. Its bothersome and unapologetic imperatives are explicitly transgressive, perverse, and political” (82). I use a queer methodology to expose how normal is constructed via sex, gender, and sexuality. For me, this means I ask specific questions that deconstruct binary ways of thinking to make visible queer existences. As a noun, I also use ‘queer’ to refer to people who challenge or exist beyond dualistic and constructed categories within gender, sex, sexuality, and so on. Typically, this includes transgender, bisexual,[1] Two-Spirit,[2] transsexual, transvestite, intersex, pansexual, and questioning people. I see ‘queer’ as a term that encompasses people whose experience, place, or identity defies what is clearly defined, contained, or seen as normal. Queer complicates the binaries of gender, sex, and sexuality. Queer is more than just a category or identity, it is a way of being and thinking. So although ‘queer’ is predominantly understood to mean gay or lesbian, I do not use this term in what I see as a reductive and exclusionary form. Although I use ‘queer’ as shorthand to describe a group of people who may or may not consider themselves queer, I do this with reservation and hesitation, because I do not want to reify queer as a category or suggest that this imposition is uniformly accepted. And I acknowledge the contradiction I present in doing so. These are the ways in which I take up queer for the purposes of this article – as a non-normative sex, gender, and sexual identity; as a disruptive way of thinking and questioning; and as a perversely political stance.

Homonormativity: Its Emergence and Effects

The concept of homonormativity is useful to explore when examining sexual health policies and practices because it highlights another development of heteronormativity at work. The new homonormativity is a set of “neoliberal sexual politics […] that does not contest dominant heteronormative assumptions and institutions, but upholds and sustains them, while promising the possibility of a demobilized gay constituency and a privatized, depoliticized gay culture anchored in domesticity and consumption” (Duggan 50). I see homonormativity, within a Foucauldian understanding, as a reverse discourse of heteronormativity. That is, homonormativity is a way of thinking that certain (namely, white middle – and upper-class) gay men and lesbians can take up to situate themselves as normal and, thus, respectable. To expand further on this concept, I propose that it positions gay and lesbian experiences above, and at the expense of, other queer experiences – an idea upon which I elaborate later.

There have always been conservative and assimilative forces within the LGBT movement such as the homophile organizations of the 1950s and 1960s. Arguably, the “new” Mattachine Society revised the radical politics of the original group, which was rooted in Communist ideologies, to reflect a more respectable and conservative agenda that suggested to fellow gay men and lesbians that they should adjust to heterosexual ideals and norms to be accepted by dominant society (Meeker 79).[3] This air of conservatism still exists in the current LGBT liberation movement as neoliberal projects of assimilation, consumerism, and respectability. Just as dominant society makes queers deviant, so too do neoliberal lesbians and gay men who claim that queers are too radical, too immoral, and too queer. Sapphistry: The Book of Lesbian Sexuality, a highly critiqued and contentious piece of work, was appalling to many lesbians in the ’80s and early ’90s because it included sadomasochism, butch/femme relationships, dildo sex, and casual lesbian sex (Califia xv-xvi). Although many of these topics may seem now commonplace in the LGBT community, this is an example of how the gay/lesbian community (and press) regulate which sexual acts are socially acceptable. Califia criticizes the moralizing attitude taken by conservative, gay liberationists and orthodox lesbians towards sex acts that are often carried out by those on the margins (158). To gain credibility, several notable LGBT organizations and publications, such as the Gay and Lesbian Medical Association (GLMA) and the Advocate (Califia xxiii-xxvi), have put forward a specific LGBT agenda that is more palatable to dominant society. This agenda is put forward at the expense of queers. Ostracizing queers from dominant LGBT discourse inevitably marks them as deviant, abnormal, and perverted.

Gay marriage is an excellent example of a homonormative agenda that fails to question the binary systems of male-female by accepting and perpetuating the idea of ‘same-sex’ marriage to further gay and lesbian rights. ‘Same-sex’ reads as gay or lesbian and, therefore, posits same- sex’ and ‘opposite-sex’ relationships as being intrinsically and inherently the only kind of relationships. Thaemlitz (182) asks, “Within a binary heterosexual/homosexual paradigm, what is a transgendered person’s gender opposite?” What about the committed relationships of other queer relationships (such as transgender people’s love relationships or queer polyamorous relationships [LaSala])? The gay-marriage movement is pushing for the acceptance of couples composed of a man and a man (or a woman and a woman) as normal. Same-sex marriage erases the visibility of those people who live outside the traditional constructs of sex and gender. For example, how does a committed relationship between a cisgender person and an intersex person get classified? Although an intersex person can share the same biological sex classification as a partner, does that classification erase and ignore both parties’ gender identity? Queer intrinsically questions this kind of normative thinking.

Significance of Sexual Health Assessments

Sexual health risk assessments help health care professionals assess the risks posed to patients as a result of engaging in various sexual activities. The broader purpose of these assessments is to provide effective management and prevention of STIs (PHAC). In clinical settings these assessments result in the provision or absence of specific health services that educate about harm reduction measures, provide services or treatment regarding pregnancy or STIs, and provide other follow-up health services such as contact tracing. Health professionals, mostly physicians and nurses, generally conduct these assessments within the context of sexual and reproductive health care. In theory these assessments are to be conducted as part of routine primary health care visits.

Health professionals and government health authorities consider STI risk assessment a valued practice because it saves lives and controls communicable diseases (Dattilo and Brewer; PHAC). Early detection of STIs, including HIV, is key in both management and treatment and can prevent untimely death and unnecessarily prolonged illness (PHAC 14). Although there have been some recent developments that shape these practices in ways that make them more appropriate for and accessible to LGBT people (GLMA; Human Rights Campaign Foundation and GLMA), health care providers often find conducting sexual health assessments challenging and awkward (Dattilo and Brewer), more so with queer people (GLMA 24). Medicine has a long history of homophobic practices and the pathologizing of queer people (Foucault; Somerville; Hellquist; GLMA). As a result, the medical profession is often unfamiliar with the specific sexual health needs of queers, making access to sexual health services challenging for this population (Anderson et al.; Ryan; Hellquist; GLMA; Human Rights Campaign Foundation and GLMA). Some theorists, as well as many racialized or queer individuals, posit that the specific lack of attention to STIs, mainly HIV, is a tool of colonization and genocide that perpetuates bigotry (Herek and Capitanio; Guinan; Quinn; Gilley and Keesee; Thomas and Crouse Quinn).

Embedded Forces in Sexual Health

Numerous underlying forces affect sexual health assessments, including homophobia, heterosexism, heteronormativity and positivist approaches in health care. But health care providers and policy-makers rarely acknowledge that “sexual health problems are systematically shaped by multiple forms of structural violence – institutionalized poverty, racism, ethnic discrimination, gender oppression, sexual stigma and oppression, age differentials, and related forms of social inequality – in ways that typically harm and negatively affect groups and populations already marginalized or oppressed” (Parker 973). These multiple and compounding underlying forces have an impact on policy development, language and discourse, AIDS phobia and the absence of queers in health literature. Although these forces have a significant impact on sexual health discourses and practices, I focus on homonormativity as a primary site of investigation. This focus is necessary because homonormativity’s influence on sexual health discourse is just as dangerous as heteronormativity’s, even though heteronormativity’s effects on health care are more widely acknowledged. Nonetheless, it is important to stress how these forces function in interlocking and interconnected ways. To highlight how heteronormative forces compound the effects of homonormativity on sexual health and the provision of sexual health services, I examine the manner in which health care providers view sexual health assessments, gender, and sexuality.

Health care providers are not immune to dominant society’s homophobic and heteronormative dispositions (see GLMA). Several studies expose the impact that medical professionals’ biases have on the sexual health care they provide. One example is a study conducted by Dattilo and Brewer in which they assert that nursing students “were even more reluctant to discuss sexual health matters and concerns with an individual that they believed might live a homosexual lifestyle or was HIV positive” (215). The fear of discussing sexual practices, especially when a patient is suspected of being non-heterosexual, is not only rooted heteronormative beliefs, it also maintains heterosexism within this clinical setting. A student from the same study displays a set of heteronormative assumptions commonly held within the medical profession.

Given medicine’s history of pathologizing queer people, it is not surprising that health care providers create additional barriers by imposing homophobic and heteronormative assumptions and asking uninformed questions. Although asking close-ended questions can be used for reasons of efficiency, they often reflect binary thinking. Typically, STI assessment forms are composed of questions that require a yes or no response, which makes evaluating gender, sexuality, and sexual activities challenging (Dattilo and Brewer 214). From my own experience as a health care provider, an extension to this critique would be that asking mainly close-ended questions during STI assessments limits discussion of sex, gender, and sexuality because it requires respondents to answer with a framework of limited possibilities. For example, boxes on sexual health intake forms often ask people to define themselves in heteronormative terms. Questions about gender and martial status often reinforce binary, neoliberal, and heterosexual understandings of the world, a practice that makes people with non-normative sexes or sexualities invisible. Namaste discusses the erasure of transsexual and transgender people in public institutions such as AIDS organizations. She argues that research regarding the impact of HIV/AIDS on transsexual and transgender people is essential to develop appropriate programs and services for this population (Namaste 238). I propose that addressing access to appropriate sexual health services is a way to combat discrimination and work towards social inclusion.

In addition to these effects, homonormativity greatly shapes sexual health discourse and often functions to exclude certain people. Welle and colleagues, commenting on the invisibility of queer youth in public health research, note that

Although there are numerous authors who attest to the absence of queer sexual health policy, I echo that this silence within sexual health literature contributes to homonormativity. Brotman and Ryan argue that

Sexual Health Policy History and Context

There is an array of policies that influence queer sexual health assessment. First, clinical texts such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) pathologize queer people and establish a basis for homophobia, transphobia, heteronormativity, and heterosexism within health care. Second, the federal government, through PHAC, issues inadequate guidelines for clinical and public health professionals that establish prescriptive methods on how to manage STIs across diverse populations (PHAC 5). Third, many LGBT organizations have created clinical assessment tools to meet the particular needs of LGBT people in response to historical oppression. By promoting inclusive sexual health policy, LGBT advocacy groups are key producers of professionalized knowledge that “makes some queer realities real at the expense of others” (Grundy and Smith 299).

There exists a body of work outlining how medicine, specifically psychiatry, exerts negative effects on various queer people through pathologizing practices (Bayer; Anderson et al.; Laizos; Somerville; Flowers and Langdridge). Produced by the American Psychiatric Association, the DSM greatly influenced and currently influences health care providers’ conceptions of queer people. With the removal of homosexuality from the DSM in 1973, some perceptions shifted. However, Gender Identity Dysphoria and Transvestic Fetishism are still considered clinical psychiatric diagnoses. The DSM is a significant piece of mental health policy and protocol that pathologizes trans people as people with mental health conditions. The effects of this definitive psychiatric reference manual on queer people are still visible within health care and health policy today.

The federal government’s clinical sexual health assessment guidelines have produced overarching effects similar to those of the DSM. The Canadian Guidelines on Sexually Transmitted Infections (2006) was, according to the Preface, updated the 1998 edition “in an effort to develop updated, evidence-based recommendations for the prevention, diagnosis, treatment and management of STIs in Canada. The content reflects emerging issues and highlights changes in the STI literature” (PHAC 5, my emphasis). These guidelines provide direction to health care providers and exemplify best practices for the prevention and clinical management of STIs in primary care settings as well as suggesting recommendations for STI assessment, counselling, and screening (PHAC 7). The Preface conveys the message that certain practices are the definitive way to provide sexual health risk assessments in Canada.

LGBT advocacy groups contest the notion that guidelines such as those issued by the Canadian government meet the needs of all sexual minorities, despite the addition of sections that focus on specific populations such as “Men Who Have Sex with Men (MSM)/Women Who Have Sex with Women (WSW)”[4] (PHAC 262–72). In opposition, many national organizations in Canada and the United States such as the Rainbow Health Coalition, the Gay and Lesbian Medical Association (GLMA), and the Human Rights Campaign Foundation call for the inclusion of LGBT or create their own guidelines to assist health care providers (Hellquist; GLMA; Human Rights Campaign Foundation and GMLA). These organizations, and several others like them, have successfully created tools that can be used easily by service providers and can potentially be taken up by governments. While LGBT organizations use positivist methods of social science to derive statistical and evidence-based determinants of certain gays and lesbians, these actions inevitably involve rendering others invisible (Grundy and Smith 303).

The GLMA Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients (referred to hereafter as Guidelines for Care) provide an example of how homonormativity plays out in sexual health assessment policy. In Guidelines for Care, a patient is asked, “Do you have sex with men, women, or both?” (26). Aimed at including bisexual people, this additive model, embedded within this one-word-answer question, falls short of addressing queer sex. First, queers’ use of language is localized and the meanings are varied (Welle et al. 66), which complicates what is meant by ‘men’ and ‘women.’ Queer bodies vary even within specific gender/sex identifications. Second, and more importantly, this question assumes several critical pieces of information: (1) that the health care provider can deduce what kind of physiology the person sitting in front of them has; (2) that the health care provider can presume from the one-word answer what kind of physiology their sexual partners have; and (3) that the sex of this person can be inferred from the gender/sex of their sexual partners. A more appropriate question would be, what kind of sex do you have? This question sidesteps assumptions about gender or sex and instead focuses on sexual behaviour – in my mind, the most important information in a sexual health assessment. Moving away from close-ended questions opens up multiple possibilities for gathering information from queers regarding their sexual health.

Feinberg warns health care providers that the “crisis for trans patients won’t be solved by creating 2 more boxes: female-to-male and male-to-female” (898). The GLMA Guidelines for Care illustrate what this homonormative assumption leaves out. The section titled “Caring for Gay and Bisexual Men: Additional Considerations for Clinicians” (37–52) fails to acknowledge that someone who identifies as male might not have (all of the) biological/scientific male sex organs. Without this explicit acknowledgment, someone who identified as a gay man but was born a genetic female and has female reproductive organs is unlikely to be offered contraceptives to protect against pregnancy. The implicit assumption is that if you identify as a man or as a woman, then you have the specific biology strictly associated with the respective (and respectable) male or female sex. As Butler argues in Gender Trouble, ‘woman,’ as a gender category is only stable within heterosexuality.

In this section, I have highlighted two examples of how LGBT organizations render queers invisible in sexual health care policy and thus promote a homonormative agenda. When LGBT organizations do not represent queers, their message becomes consistent with a reverse discourse. Yet, their loud message is validated and heard by dominant society and governments thus presenting it as the only respectable one.

A Disruptive Queer Analysis of the Guidelines

Policy History and Development

At 370 pages, the PHAC Guidelines set the national standard for conducting sexual health risk assessments to prevent and manage STIs in Canada (5). The story of how these guidelines came about provides some insight into how queer exclusion was accomplished. A fourteen-member ‘expert’ working group revised each chapter in the 1998 edition, which involved literature reviews to assist authors and facilitate ‘evidence-based revision,’ four rounds of internal and external blind expert reviews, and working group approval (PHAC 12). The working group included physicians, professors, and health policy analysts. Although their academic credentials are clearly laid out in the introduction (PHAC 4), it is impossible to know if any of the group’s members were LGBT or queer. Regardless of how the experts identified, they reproduced hetero-homonormative thinking. These experts should have self-identified because it is dangerous for people outside the trans community to define and make health policy regarding trans people (Feinberg 898–99), and this argument can certainly be extended to sexual health policy development and queer people. Very little information other than that provided in the Preface and Introduction of the Guidelines is available about the development process. I would suggest that the Guidelines are situated as authoritative and hegemonic through the devices I have noted: the writers are positioned as experts by their academic credentials and the exclusion of personal information, such as their membership in the communities that the Guidelines addresses; the phrase ‘evidence-based’ positions the work as scientific; and the use of blind expert review positions the work as neutral and objective.

The Guidelines’s Ontology, Values, and Goals

As noted, the PHAC Guidelines reflect dominant positivist and dichotomous understandings and normative values that are aligned with Western medicine. Evidence-based research “uses expert and neutral facts and evidence in making policy decisions and implementing government policies [….] and is consistent with advanced liberal governmentality” (Grundy and Smith 296–97, my italics). Heather Campbell argues further that this form of policy making is “seen as a more pragmatic non-ideological mode of governance, ‘based on what works best, rather than an ideological position’” (qtd. in Grundy and Smith 298). In other words, “The values and interests of ruling groups are more or less successfully promulgated as the values and interests of all” (Brock xix). This line of thinking draws us back to the authoritative and normative nature of the policy by simply reinforcing the values and interests of the ruling class while assuming that it actually speaks for and benefits all Canadians.

The Guidelines position gender, and to a lesser extent sexuality and sexual orientation, as a binary system. The absence of any discussion about the gender(s) of the patient implies that the gender(s) of the patient can be identified visually upon meeting – an assumption that perpetuates a dominant and dichotomous view of sex and gender. These silences and abstentions exclude many queer people. Although there may have been some LGBT experts in the working group, it appears that a conservative and homonormative approach was taken to further the health of a specific and privileged group of LGBT people. The MSM/WSW Appendix is evidence that the policy predominantly focuses on the unstated, dominant, normal heterosexual (and ironically exemplifies my argument that queer health is often applied as an appendage). MSM and WSW are the acceptable Others that are in need of a special section at the end of the universal (read heterosexual) guidelines. There is no mention of trans or intersex people and no mention of those for whom sex and gender is not a binary system.

Regardless of who constituted the working group and what material was incorporated, the Guidelines take up a homonormative agenda. Even if the dominant LGBT literature was adopted into the Guidelines and the process included LGBT people, the recommendations and practice guidelines do not disrupt dominant understandings of sex, gender, and sexuality. Grundy and Smith refer to the use of evidence-based research to prove the existence of homophobia, and their conclusions are useful because they highlight the allure of positivist research methods in examining LGBT and queer issues. These findings also reveal the homonormative tendencies within evidence-based research. Inevitably, quantifying LGBT people and making visible some existences renders others invisible. Who gets counted, who does not, and why are important questions to probe with regard to evidence-based research and its effects on sexual health policy (Manning 2009). Grundy and Smith’s claim reinforces the temptation of illusory visibility and the dangers of exclusion when using “the master’s tools” (Lorde 112).

Benefits, Costs, and Slightly Visible Forces

Although the revised Guidelines, with the addition of MSM/WSW Appendix, demonstrate the influence some LGBT organizations have had on sexual health policy development, the recommendations primarily reflect the needs of heterosexuals. The MSM/WSW Appendix only includes those sexual minorities who have so far been heard by the government. Assuming this addition was either written or informed by gay men or lesbians, its challenge is that it was done at the expense of all other queers and depoliticizes sexual health policy. Enforcing ‘male’ and ‘female’ as binary and exclusive categories alienates everyone who challenges those categories or exists outside or on the fringes of them. Sara Cooper and Connor Trebra state that lesbian communities have had an “awfully bad reputation of defining what is authentically female or lesbian, restricting access to the small range of rights and privileges won by the gay and lesbian movement, and making negative judgments on non-conformity” (quoted in Aragón 3). This illustrates how lesbians and other sexual minorities often subscribe to dominant understandings of gender and sexuality and how this privileging benefits only a narrowly defined section of the LGBT and queer communities. Welle and colleagues suggest that adding transgender health to existing LGB health falls short of meeting the unique primary care and sexual health needs of people who identify as queer, because it does not “disrupt the notion of the unified body” (44). The complexity queer people intrinsically present to the pervasive LGBT agenda places them on the sidelines of dominant LGBT sexual health discourse.

One may argue that PHAC has removed itself from identity politics by using terms that refer to who people have sex with rather than how they identify themselves. However, caution is needed if sexual identity is to be removed from the equation: it does not mean that all the gender connotations and assumptions or politics will also be removed, it merely recognizes those inside of clearly defined identities. In fact, PHAC’s Guidelines make explicit the “prior experiences of MSM and WSW with discrimination, homophobia, and heterosexism” and links these experiences with a possible “effect on health care–seeking behaviour and disclosure of sexual behaviour in consultations” (265). It is commendable that this current federal government can acknowledge the historical and contemporary effects that homophobia has had on MSM/WSW, but what about the rest of us queers?

At this point, one may ask, what is the difference between the identity politics of MSM/WSW and LGBT and queer? I suggest that the two aforementioned categories exist within engendered, respectable, and neoliberal understandings of gender, sex, and sexual orientation. Conceptualizing sexuality within an ethnic identity model (see Hicks) reifies non-heterosexual people as knowable objects within an unexamined heteronormative framework. I also propose that queer is a particular way of being and thinking that challenges these dichotomous, contained, and stable categories and works against an assimilative neoliberal agenda. Butler incites the politicization of queer and emphasizes how critical it is in “creating a kind of community in which surviving with AIDS becomes more possible [and] in which queer lives become legible, valuable, worthy of support” (Bodies that Matter, 21). The project of politicization of queer is necessary, although some may deem it unnecessary, intolerable, and undignified.

The depoliticization of gender and sexual identity likely occurred prior to PHAC’s governmental consciousness. When LGBT organizations involve themselves in their own projects of evidence-based research to push a specific LGBT agenda and gain credibility, they constrain their “options by closing off political spaces to forms of representation that may be unconventional or deemed too politicized” (Rachel Laforest and Michael Orsini, qtd. in Grundy and Smith 298). This homonormative act is done specifically and intentionally at the expense of queer people.

Guidelines and Practice

In theory the nature of the Guidelines lends itself to directly affect the practice of sexual health risk assessments because it is designed to provide advice and recommendations to clinical and public health care professionals regarding the prevention, diagnosis, treatment, and management of STIs in Canada (5). The implication for practice is obviously practical in nature. However, there is little information available regarding the consequences of not following the recommendations. The document does appeal to health care providers’ sense of duty as a reason to apply these new recommendations: “Primary health care providers and public health practitioners can be strategically placed to apply relevant and complementary individual and community-based education and patient services” (PHAC 14). In theory physicians, nurses, and other licensed health practitioners who conduct STI risk assessments are bound by ethical and legal obligations. However, that is little assurance to queer people who have experienced homophobia, heterosexism, transphobia, AIDS phobia, and heteronormativity in health care interactions. Unfortunately, queer people must rely on the good nature and academic diligence of health care professionals to read these Guidelines, its appendices, other documents produced by LGBT organizations, and queer-specific material. Clearly, even the most diligent health care provider would have to spend a great deal of time and energy attempting to education themselves on this complex and challenge area of practice.

From a pessimistic standpoint, the Guidelines do little, if anything, to meet the complex needs of queers already on the margins of lesbian and trans communities (Welle et al.). Queer identities are not understood, and their sexual activities and bodies are unfamiliar. The policy alludes to sexual activities that queers may participate in; however, little detail about what the activity is and what risk it presents to those who engage in it is presented. Activities such as sharing sex toys and manual-anal or manual-vaginal intercourse are mentioned, but numerous other activities are absent, such as sadomasochistic activities, felching, scissoring, and so on.[5] The absence of a discussion about STI and HIV risks associated with these activities is dangerous and striking. Practically speaking, if service providers are unaware of sexual activities and their associated risks, queers who are defined by their sexual activities will disproportionately end up being more susceptible to infection.

When the experiences of sexual minorities are depoliticized and homogenized through the application of categories such as MSM and WSW, it is unlikely that health care providers will accept those who challenge gender and sexuality binary systems in a political manner. In my own experience, practitioners cling to what they already understand and assume they know all the intricacies of LGBT and queer communities. I have also witnessed queers being stuffed into the boxes that health care providers already recognize; therefore, health care providers take up a hetero-homonormative agenda.

However, an optimist may suggest that these Guidelines are the first step to bringing the unique needs of gender and sexual minorities into dominant sexual health discourse. In terms of this policy’s ability to affect the practice of sexual health assessments, there is some potential. First, the existence of the Guidelines highlights the need for STI risk assessment as part of routine health care (8). Given the earlier example of the nursing student quoted by Dattilo and Brewer, the policy does stress the essential need for sexual health assessments and emphasizes the broad range of situations and populations that would benefit from this kind of assessment. The Guidelines also provide service providers with specific questions to pose in order to conduct an assessment – a development that is, again, directly applicable to practice (12, 14–15, and 19). Second, it offers practitioners a basic primer on how to conduct a STI risk assessment with MSM and WSW. Queer people may marginally benefit from this practice-oriented advancement because it raises health care providers’ awareness that not everyone is heterosexual.

Conclusion

Sexual health risk assessments, as valued practices, help to prevent and control STIs. The Canadian Guidelines on Sexually Transmitted Infections produced by the Public Health Agency of Canada established recommendations and protocol for conducting this practice. The 2006 edition of the Guidelines include an appendix to address the specific sexual health needs of MSM and WSW. A critical and queer analysis of this policy reveals its intrinsic dichotomous understanding of gender, sex, and sexuality and it highlights an additive model as well as the advancements gay men and lesbians have made in promoting a specific homonormative LGBT agenda. I argue that the exclusion of queer people is a homonormative trend that privileges the needs of a select group of gay men and lesbians. Governments may not be aware of the identity politics at play; however, federal policy-makers follow the persuasive arguments put forward by dominant LGBT voices and their evidence-based research, thereby developing sexual health policies that omit the needs of queers. The effect of the policy on practice is unknown, but the implementation of the practice of the Guidelines suggests, at best, marginal benefits to those defined outside of the hegemonic MSM and WSW categories. Prevailing LGBT discourses on sexual health dominate and exclude queers, rendering them invisible in policy and practice. This homonormative movement privileges those LGBT people who subscribe to strict gender and sexual dichotomies and a don’t rock the boat mentality and are respectable enough to be heard. Thus, the movement insinuates that those of us queers who are pushed and kept to the margins are “not like them.”

The task now is not only to challenge the dominant voices within LGBT organizations but also to queerly disrupt homonormativity within the practices, discourse, and literature on sexual health. Examining assumptions embedded within sexual health assessment questions is crucial work. Questioning how sex and gender are conflated is one place to start. What can be surmised from the words ‘men’ and ‘women’ with regard to physiology? What theories and discourses have informed those ideas? How can queer theory shift the practices of sexual health assessments? One way is to explore how sex, gender, and sexual identities are political. While I argue that it is important to focus on the sexual activities one is engaged in, I propose that it is essential to not dismember the person from the politics of sexual health. For those who are made invisible and degenerate through heteronormativity and homonormativity, it is essential that queers be recognized and treated with respect. Asking questions such as what kind of sex do you have? opens the door to explore sex, gender, and sexual activities in ways not possible through questions such as do you have sex with men, women, or both? The elusive, non-normative, perverse, and transgressive qualities of queer offer a unique disruption to the dominant world of binary systems in sexual health.