On Easter Saturday in 1979, three bored men decided to dress in nun’s habit and outrageous white facial makeup¹⁠. Carrying a toy machine gun, they took a walking tour across San Francisco. One of the trio, Ken Bunch, likened the effect on bystanders to a “psychological car wreck”¹. Realising they had a “stick of dynamite” with which to fixate crowds, they decided to sustain the spectacle as a tool for social change¹.

Incorporating as the Sisters of Perpetual Indulgence (SPI), they busied themselves with bingo/disco benefits for gay Cuban refugees, charity dog shows, political activism, and chasing away fundamentalist demonstrators^1⁠. With sexually transmitted infection running rampant in the gay community, an SPI committee including two public health nurses (Sister Roz Erection R.N. and Sister Florence Nightmare, R.N.) produced Play Fair! in 1982, a pamphlet to promote safer sex practice^2⁠. Sister Titania Humperpickle reported 84 active affiliated orders of SPI across the world as of 2016, many of which adapt Play Fair! for modern times and local audiences¹⁠. Here, we describe the original campaign, relate it to the Health Belief Model and Social Cognitive Theory of behavioural change, and consider its relation to harm reduction theory.

Prior to 1979, sexual health messaging in the United States exclusively targeted heterosexuals. It promoted monogamy, contraception and prevention of venereal disease in men – particularly those in the military³⁠. Meanwhile, homosexual men were flocking to San Francisco to find not only sexual liberation but a culture where, as SPI founding Grand Mother Vish-Knew said, “if you didn’t get laid every other day, oh my God, something’s wrong with you.”¹⁠.

In 1980, the National Coalition of Gay Sexually Transmitted Disease Services published sex-positive Guidelines⁴⁠ without moral judgement for gay men. Bay Area Physicians for Human Rights (BAPHR) adapted and circulated these guidelines in order to raise awareness about STDs and reduce transmission in the local community³⁠. While the Guidelines made several advances (like acknowledging the existence and culture of gay men), the clinical language didn’t cut through with the community and STD cases continued to rise³⁠. With the same objective, Play Fair! adapted the Guidelines with culturally appropriate language, added cheeky cartoons, and in a pastoral sense, advocated for a culture of care towards others. Compare the following translation:

“When you do go to bed with someone, undress in a lighted area and casually inspect for growths, sores, or rashes, especially around the genitals”
— BAPHR Guidelines⁴

“Check out your man before you lay hands on one another. One sister even carries a flashlight for those all-too-frequent encounters in the darkness”
— Play Fair!^2⁠

The ethos is best summarised in a prayer released alongside Play Fair!: “Let us spread affection without infection”¹⁠.

Play Fair! was first distributed at San Francisco Gay Freedom Day in June 1982, and is now often accompanied with free condoms and lubricant¹⁠. By this stage, the Sisters were highly credible insiders within the gay community, with a reputation for care and advocacy. They quickly found that their high camp appearance was key to cutting through to sensitive topics in their street ministry. One reason was that people felt more comfortable talking to a theatrical persona than, say, a health worker in street clothes¹⁠. Another was the appeal to pastoral tradition almost universally recognised by Americans: despite the parody aspect of their presentation, Sister Agnes Dei'Afta Tamara maintains that Sisters see themselves as legitimate nuns who work in the same spirit of service as their Catholic counterparts⁵⁠. Sister Unity Divine described the fun and artifice as “...the lure [with which] you hook them, and then you give them the real”¹⁠. It draws an audience, entertains them, and allows delivery of a sincere message. Leveraging humour, costume and existing brand credibility meant that Play Fair! was read and shared widely.

The Health Belief Model (HBM) traces its roots to the 1950s, as a way of interrogating why people don’t access health services⁶⁠. For this reason, it may have influenced the design of Play Fair!, perhaps if indirectly. One HBM construct is perceived threat – a combination of susceptibility and risk. While the target population was aware of susceptibility to venereal disease, the threat was widely dismissed because it was considered easily treatable¹⁠. This was not true in the case of Hepatitis B, the severity of which Play Fair! addressed by noting the possibility of chronic, possibly fatal, consequences. The term “AIDS” was coined within days of Play Fair!’s initial distribution⁷⁠, but at initial publication, Kaposi’s sarcoma (“gay cancer”) and pneumocystis pneumonia were early proxies for the condition. The severity of AIDS quickly became evident and uncontested¹⁠.

Perceived barriers – the negative consequences of acting in the interests of health – are the most powerful single predictor in studies employing HBM⁶⁠. Given the extent to which gay men in San Francisco valued and prioritised frequent casual sex, a key innovation of Play Fair! was to present risk-reducing recommendations that did not depend on meeting unacceptable barriers such as abstinence or monogamy. In fact, Play Fair! was partly funded by benefits from a sex party and sale of ashes from a bath house lost to fire⁸⁠.

Clover’s 2006 study⁹ of barriers to older gay men accessing health services is illuminating if we presume the attitudes are rooted in experiences from when the men were younger – perhaps in the early 1980s⁠. Barriers included negative experiences or expectations of poor treatment from healthcare providers based on their sexuality, or a reluctance to talk openly about sexuality with providers. Play Fair! addresses this by endorsing 15 “gay-sensitive” local medical providers²⁠.

HBM’s construct of benefits concerns the upside of behaviour change. An obvious upside to a sexual encounter is the possibility of making a friend with benefits; Play Fair! presents an obvious benefit to doing so responsibly in not experiencing the effects of venereal disease, like having to declare human-size crabs as dependents on one’s income tax²⁠. With religious overtones, it presents another benefit as a virtue: be responsible, and protect your community.

Self-efficacy is conceived the same way in HBM as it is in Social Cognitive Theory (SCT): that individuals should feel empowered to take the steps necessary to improve their health¹⁰⁠. Glanz et al.⁶⁠ report that self-efficacy was a significant predictor of condom use; Kadden¹¹⁠ reports the same for a wider range of behaviour. Of the four ways to increase self-efficacy identified by Bandura, quoted by Snelling¹⁰⁠, the Sisters employ three. They offer social modelling (observational learning) as credible community insiders who endorse safer sexual behaviour, perhaps even simulating what it might look like to an audience. They improve emotional state by employing sex-positive language and the demand doing away with guilt, and their street ministry efforts incorporate verbal persuasion. Hinyard and Kreute, quoted in Glanz et al.⁶⁠, say that “storytelling in the form of a narrative may be more effective than the presentation of directly didactic or persuasive messages” for promoting observational learning; Play Fair! opens with a tale of infection within the convent²⁠.

SCT’s construct of impediments is distinct from HBM’s barriers in that a barrier is an unwanted effect of a change, whereas an impediment is more of an external influence that makes behaviour change harder – and The Sisters confront several. Play Fair! calls out guilt surrounding homosexuality as a problem, and places blame on widespread religious sentiment (a longitudinal Gallup Poll showed that almost 90% of Americans were either Protestant or Catholic in 1980, with similar figures over the preceding 20 years¹²⁠). Such guilt can present an impediment to seeking treatment, or as a barrier to those who consider infection as “punishment”.

Other impediments are addressed too: promoting a culture or habit of responsible sexual practice makes better decisions easier when impaired by drugs or alcohol; quips about using appropriate lubrication or carrying a flashlight also underscore the importance of preparation. Blair mentions that negotiational and transactional idioms borrowed from the sadomasochism community provided language to talk about safer sex practices^3⁠.

Alfred Bandura was based just 30 minutes south of San Francisco at Stanford University, but we can only guess whether or not he was influenced by the Sisters at a charity dog show prior to publishing his Social Cognitive Theory in 1986. SCT introduces the construct of reciprocal determinism: “that individuals are not simply products of their environments but help to create those environments”¹⁰⁠. Blair credits the success of the Sisters’ early initiatives to “amphibious activists” such as the public health nurses on the Play Fair! committee, who were members of both the queer and health professional communities³⁠. They were well positioned to respond to the needs they saw and advocate for themselves.

More broadly, the experience of AIDS in early 1980s San Francisco was conveyed to the Mersey Regional Health Authority, who eventually produced the Mersey Model of Harm Reduction in response to drug use in Liverpool¹³⁠. In terms of the Transtheoretical Model’s stages of change10⁠⁠, this meant motivating behaviour change in people beyond those contemplating quitting drugs outright. Stimpson¹⁴ formalises the key components of harm reduction as ACME: raise Awareness; make Contact; provide Means for behaviour change; gain Endorsement⁠. Play Fair! can be described in terms of ACME, but can also be seen as the foundational work in formulating it.

Play Fair! was an iconic and influential campaign in terms of behaviour change. It demonstrated the power of “amphibious actors” in developing an effective campaign; the benefits of plain, insider language; and how to build and leverage street credibility. It is well-grounded in both HBM and SCT, and can be considered an early influence on harm reduction theories. In secular life as Bobbi Campbell, Sister Florence Nightmare became the first publicly disclosed case and “poster boy” of the AIDS crisis, appearing on the cover of Newsweek on August 8th, 1983¹⁵⁠. May we all, like Bobbi, “expiate stigmatic guilt and promulgate universal joy,” per the Sisters’ mission¹⁠.

References.