MSM Awareness Handbook Thailand

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MSM Awareness Handbook Thailand

  1. 1. Awareness and Sensitivity in the Promotion of Sexual Healthamong Men who have Sex with Men Participant Handbook
  2. 2. ForewordIn the context of recently documented high HIV prevalence among men who have sex with men(MSM) in Thailand, and their projected increasing contribution to the proportion of total new HIVinfections in the country, Family Health International (FHI) and its partners, the Thai Red CrossAIDS Research Centre (TRC/ARC) and the Bangkok Metropolitan Administration Health CenterNumber 28 (BMA 28), have participated in the Demonstration HIV Counseling and TestingProject, targeting MSM. The goal of this project has been to identify service provider site andprogramming barriers as well as personal barriers to accessing HIV counseling and testingamong this population and to use this information to improve counseling and testing services inorder to increase uptake of services among MSM.Service provider attitudes toward men who have sex with men was one of the barriers identifiedin the first phase of the project. This handbook was has been specifically adapted to provideinformation on and build sensitivity and awareness of the sexual health of men who have sexwith men in Thailand. The handbook may be used together with the Awareness and Sensitivityin the Promotion of Sexual Health among Men who have Sex with Men: Trainer’s Manual, aspart of a training package, or it may be used separately as an information resource. AcknowledgementsThis handbook was adapted by Dr. Kathleen Casey, FHI Asia and Pacific Regional Office(APRO), and Greg Carl, Thai Red Cross AIDS Research Centre, from the FHI-Vietnam trainingpackage, Awareness and Sensitivity in the Promotion of Sexual Health among Men who haveSex with Men.Funding for this work was provided by USAID.
  3. 3. Contents PageSection 1: Who are MSM? 1Section 2: Conceptualizing MSM in the Thailand Context 4Section 3: Risk and Vulnerability to HIV Infection 7Section 4: Multifaceted Risks for HIV in Thailand 10Section 5: Need for Health Services and Access Strategies 12Section 6: Special Sexual Health and Psychosocial Needs of MSM 14Section 7: Safer Sex Strategies 16Section 8: Challenges of Counselling Positive MSM 20Section 9: Reorienting the Clinical Environment 21Section 10: Concluding Note for Health Care Providers 26References 27
  4. 4. Awareness and Sensitivity in the Promotion of Sexual Health Among Men Who Have Sex With Men Section 1: Who are MSM?The term men who have sex with men or MSM is meant to address all men who have sex with men,regardless of their sexual identities. It is used because only a minority of men involve in same sexbehaviour self-define as gay, bisexual or homosexual but may more aptly self-identify using local socialand sexual identities and behaviours. They do not consider their sexual encounters with other men interms of sexual identity or orientation. Many men who have sex with men self-identify as heterosexualrather than homosexual or bisexual, especially if they also have sex with women, are married, only takethe penetrative role in anal sex, and/or have sex with men for money or convenience.MSM includes various categories of men who may be distinguished according to the interplay of variablessuch as: • their sexual identities, regardless of sexual behaviour (gay, homosexual, heterosexual, bisexual, and transgender, or their equivalents, and other identities); • their acceptance of- and openness about- their non-mainstream sexual identities (open or closeted); • their sexual partners (male, female, and/or transgender); • their reasons for having these sexual partners (natural preference, coercion or pressure, commercial motivation, convenience or recreation, and/or being in an all-male environment); • their roles in specific sexual practices (penetrative, receptive, or both); and • their gender-related identities, roles and behaviour (male or female, masculine or feminine/effeminate, cross-dressing or gender-concordant dressing).What do health care providers need to know about sexual identity and sexual behaviour?Men who have sex with men has become a popular term in the context of HIV/AIDS where it is usedbecause it addresses behaviours that put men at risk for infection. It has been argued that the term is toofocused on sexual behaviour and not enough on other aspects, such as emotions, relationships, andsexual identity. Some organisations and individuals prefer the term males who have sex with malesbecause it indicates a broader group of individuals engaged in sex with members of the same sex. Inparticular, it does not have the age limitation implied by the term “men,” and therefore includes boys whoare having sex with each other and also sexual relationships between men and boys.In part the term MSM can be seen as a reaction to the language that has developed in Western culturesto describe and/or medicalise sexual acts between men. Also, the emergence of ‘gay culture’ in Western thsocieties during the 20 century has encouraged the belief that people are either ‘gay’ (homosexual) or‘straight’ (heterosexual). This may be true for some people in some parts of the world, but for many men,having sex with other men is just one part of their sexual life and does not determine their social or sexualidentity. Some MSM may be highly visible in the community and can include men who dress as womenor wear some items of women’s clothing. However other MSM may be completely indistinguishable fromnon MSM. Where ‘homosexuality’ is not visible it is sometimes thought not to exist, however this isprobably not the case. In fact sex between men happens in most, if not all, societies. Public discoursesthat deny the existence of same sex activity do not reflect what happens in real life. HB page 1
  5. 5. Possibly the largest group of MSM in most countries in Asia is men who do not accept their non-mainstream sexual behaviour, do not openly self-identify as gay or homosexual, and who have eithercasual anonymous sexual encounters or highly clandestine relationships with other men. Some of thesemen may be married and/or also have sex with women. A few may self-identify as bisexual. Some menwho self-identify as heterosexual or bisexual occasionally have sex with men for pleasure, usuallybecause women are less accessible. Some men may have sex mainly with transgender MSM withoutself-identifying as gay or homosexual, primarily because transgender MSM are not considered men intheir cultural context.Transgender and intersex personsUnderstanding terminologyTransgender is a broad term that designates somebody who does not fit clearly into “male and female”descriptions. The individual rejects the gender assigned to him or her at birth. Transgender is sometimesreferred to as “gender variant”.The term transsexual refers to an individual who feels that their gender identity does not match thebiological body he or she was born with and/or the gender he or she was assigned by society.Transsexuals can be referred to as male to female (MTF) or female to male (FTM). Transsexuals arefurther described in terms of whether they are “pre-operative” (“pre-op”) or “post-operative” (“post-op”)and some describe themselves as “no-operative”(“no-op”).Cross dressing refers to the act of dressing in the clothing typically worn by the opposite gender and maybe used in reference to both transsexuals and cross dressers. “Cross dressers” (also known astransvestite) is a term usually reserved for individuals who like to cross-dress but who do not experienceany discord between their physiological appearance or their gender identity. Most cross-dressers areheterosexual men who cross-dress for purposes of amusement, role-playing, stress relief, or sexualgratification. Usually biological women are not called cross dressers as society allows a broader range ofdressing behaviour for women (i.e. women can wear pants, have short hair etc).Other terms used refer to either how society perceives the individual or the gender reassignment.Passing refers to the degree to which an individual of one gender is perceived (by others in society) to beof the opposing gender. Transitioning commonly refers to the process of moving from one gender to theopposite one. Transitioning is likened to a developmental process with the process of transitioninginvolving many steps.Increasingly you may hear the term intersex. This term tends to be used by health professionals workingin gender orientation. A variety of conditions that lead to atypical development of physical sexcharacteristics are collectively referred to as intersex conditions. These conditions can involveabnormalities of the external genitals, internal reproductive organs, sex chromosomes, or sex-relatedhormones. Some examples include: • External genitals that cannot be easily classified as male or female. • Incomplete or unusual development of the internal reproductive organs. • Inconsistency between the external genitals and the internal reproductive organs. • Abnormalities of the sex chromosomes. • Abnormal development of the testes or ovaries. • Over- or underproduction of sex-related hormones. HB page 2
  6. 6. • Inability of the body to respond normally to sex related hormones.Intersex conditions are not always accurately diagnosed, experts sometimes disagree on exactly whatqualifies as an intersex condition, and government agencies do not collect statistics about intersexindividuals. Some experts estimate that as many as 1 in every 1,500 babies is born with genitals thatcannot easily be classified as male or female.The sexuality of intersex individualsMost people with intersex conditions grow up to be heterosexual, but persons with some specific intersexconditions seem to have an increased likelihood of growing up to be gay, lesbian, or bisexual adults.There are men whose natural preference is for women but who have sex with men because of restrictedaccess to women. This can be due to conservative societies which encourage strict social segregation ofmen and women, or being in all-male environments over extended periods of time, such as prisons,military establishments, male migrant labour settings, and all-male educational institutions. Deniedaccess to women, men have to gratify their sexual urges with other men, without leading to self-identification as gay or homosexual. Many male sex workers across Asia often self-identify asheterosexual and have sex with men mainly to support themselves and their families. They are oftenmarried or have girlfriends or female sex partners. There are, however, some male sex workers who doself-identify as gay or homosexual and only have sex with men. Some men prefer to have sex only withmen but pressure to get married and start families results in them having sex with women. Some have apreference for men but are not averse to women and vice versa. Others prefer to have sex only withwomen but end up having sex with men for money or because they cannot get access to women. Theambivalent position of male-to-female transgender individuals adds other dimensions to the scenario.Why do some men engage in same-sex behaviour?It is not known why most people are sexually attracted to the opposite sex and some people are attractedto the same sex. There are some theories which stress biological differences between heterosexual andhomosexual adults, suggesting that people are born with their sexuality predetermined. Thoughexperiments and tests have been undertaken to measure differences in hormone levels, genetic make-up, and brain structures of homosexual and heterosexual people the findings of these have, for the mostpart been unclear. One psychological explanation stresses the importance of life experiences, childhoodand relationships with other people, particularly with parents. A person’s assumptions about sexualityand their behaviour is influences by their family environment, their experiences and their sense ofthemselves. Beliefs about sex are initially shaped by family values. Later on these beliefs may bechallenged and shaped by pleasant and unpleasant experiences of sex which also shape their choice ofsexual activities and partners. Throughout their life a person’s sense of whom and what they are has astrong impact on their sexual development and experience. Another theory suggests that preferring yourown sex is a matter of willpower, and that a man who has sex with men does so out of a wish to deviatefrom established gender roles. However, there is little evidence for either of these theories. Otherresearchers think that it may be possible that sexual orientation is a mixture of both biology (nature) andsocial conditioning (nurture). HB page 3
  7. 7. Male and transgender sex workersWho are sex workers?Sex workers encompass a diverse group of people, so it is therefore difficult to generalise about theirbehaviours and attitudes towards HIV prevention and care. For example, they may be injecting drugusers, married women or men, indentured workers (i.e. they are coerced into the work and even taken toother countries), college students or unattached minors. Sex workers may be of all genders (i.e. male,female or transgender). They may work temporarily as sex workers or full time. Effective health careinterventions need to recognise these individuals not only as sex workers, but as partners, wives orhusbands, and as parents. Section 2: Conceptualizing MSM in the Thailand ContextThe term “Men who have sex with men” (MSM) describes a behavior rather than an identity. The term“MSM” emerged to describe all those involved in sex between men, whatever their circumstances,preferences or self-identification (Foreman, 2003). In other words, it was designed to include all kinds ofmen who have sex with other men, regardless of the situation or sexual orientation. The term “men whohave sex with men” was introduced in Thailand during the 1980’s along with the HIV epidemic so it isdifficult to find an equally suitable term in Thai. It is translated literally into Thai as “phuchai tee meephetsamphan gap phuchai”. This term had little meaning to many Thai people. The term commonly usedfor MSM was katoey. However, this terms does not encompass the broad spectrum of MSM in relation totheir sexual behavior. Other terms that come into common usage in identifying MSM behavioral roles are:gay, and man. While these terms are easy to define in general interpretation, they take on differentmeaning in relation to a person’s living environment and socioeconomic status.M SM Subtypes 1In Thailand male-same sex is not new, but this behavior has been hidden and underreported because ofits nature as a sensitive subject regarding social norms and values. Since those who are involved inmale-same sex are likely to be stigmatized by the society, MSM have manifested themselves in variedsexual identities.In rural areas, terminology for MSM sexual behavior is limited to the extremes of katoey and man. Katoeyis the traditional Thai word for someone, either male or female, who is ‘hermaphrodite’. In modern usage,the term has taken on the meanings of transvestite, transsexual, and effeminate male. If a young Thaimale is effeminate, he many be stereotyped into the role of katoey. The katoey are, for the most part, notshunned in rural areas and may actively participate in both family and village life. This tacit acceptance1 1 Excerpts from: HIV and Men Who Have Sex with Men : HIV/AIDS and Human Rights in Southeast Asia. Expert Meeting onHIV/AIDS, Organized by Asia-Pacific Regional Office of the United Nations of the High Commissioner for Human Rights (OHCHR),23 – 24 March 2004. Adapted from "HIV and men who have sex with men: Perspectives from selected Asian Countries" Roy Chan,Ashok Row Kavi, Greg Carl, Shivanada Khan, Dede Oetomo, Michael L. Tan and Tim Brown, AIDS 1998, 12 (Suppl B):S59-S68.The current article updates the situation focusing on the countries of Southeast Asia, and with an emphasis on human rights inrelation to MSM and HIV/AIDS HB page 4
  8. 8. may be based of the belief among many rural villagers that the state of being a katoey is a punishment forsexual indiscretions in a previous life. It is therefore considered ‘natural’ for a katoey to express sexualinterest in persons of the same sex.The role of a man is more difficult to identify. It generally means a male who is heterosexually identifiedand is the sexually active partner with either a male or female. The idea that ‘good women’ remainuntouched until marriage still prevails. Rather than suppressing the male sex drive, Thai society haschanneled it. One option as a sexual outlet is the female sex worker and another is the katoey. If a maletakes the active role in sexual relations with a katoey, his masculinity and sexuality do not come underquestion. Yet another sexual outlet is the notion of ‘friends helping friends’. Two males with a ‘goodunderstanding between them’ or residing in close proximity in a same-sex institutional environment makeuse of each other’s bodies in order to meet physical needs while preserving the chastity of women. Theaction is not considered homosexual in nature, but as a purely physical act because it is not seen to 2involve the emotions or ‘heart’ . When emotions do come into play it is difficult to understand why or howa man is attracted to someone of the same sex without filling the traditional roles and stereotypes of thekatoey. Therefore, same-sex relationships may continue as long as they are conducted discretely.In semi-urban/rural areas, the phenomena of man and katoey are still present but the term ‘gay’ hasbecome more common. In some more remote areas, ‘gay’ is synonymous with katoey. In more developedareas, the term ‘gay’ has taken on the meaning of men who are sexually attracted to men but are nottransvestite or transsexually identified. While the new term provides greater opportunities for emotionalattachment, the label of ‘gay king’ or ‘gay queen’ indicates an individual’s role in a relationship and sexualrole.In urban areas, the term ‘gay’ is in common use along side of the terms man and katoey; however, thelabeling of sexual roles has become blurred and insignificant. In the report, The Dynamics and Contexts 3of Male-to-Male Sex in Indonesia and Thailand , the data suggest no association between the role in sexacts and sexual identification of MSM. Therefore, it cannot be assumes that a person who identifieshimself as a “gay king” takes only the insertive role in sex and a person who identifies himself as a “gayqueen” takes only the receptive role in sex. The term ‘bi’ has also become blurred as well. For some itmeans that they have sex with both men and women. For others, it means they take both the insertiveand receptive role in sex with men.On account of the rural to urban drift of MSM and the blurred terminology, it is essential that serviceproviders clearly identify sexual behaviors that place clients at risk and not make assumptions based onlabels.Use of term s and potential discrim ination2 Lyttleton C: Framing Thai sexuality. TAJA 1995, 6:135-139.3 The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand, Australian Research Centre in Sex, Health andSociety and La Trobe University, 2006. HB page 5
  9. 9. While homosexual behavior between consenting adults is not a criminal offence in Thailand, MSM are stillbound by social and cultural norms and sanction. Social discrimination against MSM increases theirvulnerability to HIV infection and compromises the health of MSM as they may avoid contact with healthand social services. The result is that those most needing information, education and counseling are 4driven underground .Social discrimination can often be apparent in the terms or labels that are used to address MSM. Beyondthe preferred terms, there are terms or labels considered as discriminatory and demeaning by MSM. Forexample ‘toot’ [adopted term from the movie, “Tootsie” for effeminate male, transvestite or transgenderperson]. Other terms are boy [English adopted term for general MSM but also denotes status in arelationship], lady boy [English term adopted for transvestite, transgender], and money boy [English termadopted for male sex worker]. These terms are commonly used to describe self and others in very closerelationships but should not be used by others outside the relationship or social network. For example,masculine MSM may address each other as katoey in jest, but would take great offence if someoneoutside the relationship uses this label.Service providers should not use terms for MSM loosely but should determine how clients wish to beidentified. Remember that sexual identification may not always reflect sexual practice. In addition, someservice providers may encounter clients from neighboring countries who have come to Thailand fortesting because same sex behavior is a criminal offence in these countries. These clients may be hesitantto identify themselves sexually so that determining sexual practice is obligatory.Disclosure of Sexual Orientation and IdentityThailand is fairly tolerant of same-sex activity compared to many societies but this does not mean that itaccepts homosexuality. There is little active intervention to prevent or punish same-sex activity. Tolerancedoes not equate to social acceptance. Some MSM have expressed fear that if their sexual behaviorshould be revealed, there would be negative consequences in their jobs, possibly leading to dismissal.Others expressed the difficulties in having a double life among family and co-workers and among other 5MSM . While outward discrimination is not apparent, there is a fear of social sanction withdisclosure.Disclosure is most often limited to a group of people with whom a MSM has a closerelationship. This may include long-term friends from school or work, and regular partners.Services and other interventions that are provided in Thailand are often sexual identity specific (man-gay-katoey or MSM-MSW) rather than behavior specific. Thus, vulnerability to HIV infection increases as thisfear may prevent MSM from accepting their same-sex behavior, seeking information on HIV/AIDS andSTI prevention, and seeking appropriated medical services.Sexual Networks of M SM4 McCamish M, Storer G, Carl G, Kengkanrua K: Why should more attention be given to male-male sex encounters in Thailand. IVInternational Congress on AIDS in Asia and the Pacific. Manila, October 1997 [abstract C(P)082].5 Sittitrai W, Brown T, Sakonhavat C: Levels of HIV risk behavior and AIDS Knowledge in Thai men having sex with men. AIDS Care1993, 5:261-271 HB page 6
  10. 10. The sexual networks of MSM are characterized by interactions with people with varied sexual identities.MSM had sex within their own sub-population, with MSM in other sub-populations, and with bothheterosexual men and women. In the report, The Dynamics and Contexts of Male-to-Male Sex in 6Indonesia and Thailand , sexual networking is facilitated through social networks. The study found thatthe social networks of MSM in Thailand are “generally formed along the lines of their sexual identification,degree of openness in revealing one’s sexual identity, and socio-economic status.” As a general rule,sexual activity is limited within a social network. However sexual contacts may be facilitated through theinteraction of once social network with another.6 The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand, Australian Research Centre in Sex, Health andSociety and La Trobe University, 2006. HB page 7
  11. 11. Section 3: Risk and Vulnerability to HIV InfectionRiskThere are important differences between male to male behaviours and MSM identities. Not all men whohave sex with other men are equally vulnerable to HIV. Men who only have sex with a regular, long-termpartner who is equally monogamous, and those who consistently practise safer sex are at less risk.However, large numbers of MSM are at risk from frequent, unprotected sex with other men. Analintercourse with out a condom is the primary way in which HIV and other sexually transmitted infectionsare passed on in sex between men. Many of these men may also have women partners. This means thatanal intercourse without a condom between men also places the men’s female partners and their futurechildren at risk of infection. Likewise, vaginal or anal intercourse without a condom between a man and awoman may place the man’s male partners at risk of infection.The risk of HIV transmission through anal intercourse (and anal sex can also be practised between a manand a woman), is especially high when condoms are not used. The lining of the rectum is thin and caneasily tear, and even only small lesions in the lining are enough to allow the virus easy access. Evenwithout such lesions, it is thought that they may be a lower immunity in the cells of the rectal lining toresist HIV. The risk to the receptive partner in unprotected anal sex is several times higher than a womanhaving unprotected vaginal intercourse with an HIV-infected man. Some men may practice fist-to-anusintercourse (fisting) before penetrating the partner with their penis. Such practices may increase risk oftearing the lining of the anus. Unprotected anal sex also poses a risk to the penetrative partner when HIVis present in the other person. The presence of other, untreated sexually transmitted infections such assyphilis, gonorrhoea, and chlamydial infections, can greatly magnify the risk of HIV where HIV is present.Oral sex (mouth-to-penis) is also commonly practiced between men. Although the risk of transmission ofHIV and most other STIs is significantly smaller in oral sex the best protection is to use a condom,though, many men find the taste and sensation so unpleasant that they prefer not to do so. Ejaculation inthe mouth is more likely to cause infection. Withdrawing from the mouth before ejaculation will reduce therisk. The presence of STI or sores and lesions in the mouth will increase the risk.Other common sexual practices, such as inter-femoral/crural sex, and mutual masturbation, are far lessrisky, though the presence of STI may increase the risk. The range of practices varies according toregion, country and region within the country, as does the extent to which safer sex practices areadopted.VulnerabilityThe relative lack of MSM “friendly” programming and services contributes to MSM vulnerability toinfection. Many countries are still unwilling to acknowledge the existence of male-to-male sexualbehaviour together with the social stigmatisation of same sex behaviours, life styles and discrimination.Stigma of same sex behaviour is present at many levels and sexual acts between men are oftencondemned.Condom UseStigma and discrimination have rendered MSM invisible, and the result is that the unique prevention andtreatment needs of MSM are not being met. Discrimination can result in the absence of condoms andlubricant in places where male-male sex takes place. Consistent condom use is generally low as manyMSM believe that they are low risk. Many also have sex with women and can thus serve as a bridgepopulation for HIV transmission. HB page 8
  12. 12. Risk perceptionInformation resources are seldom produced that highlight same sex behaviour. HIV/AIDS preventionprograms in Asia have been focused on heterosexual transmission and transmission through injectingdrug use. This has led many MSM to conclude that their own behaviours do not place them at risk or theysee sex with women as an HIV risk and male-male sex as a safer option.Number and type of partnersStigma and discrimination have made it difficult for MSM develop and maintain relationships, which maycontribute to a high level of sex partners and, for some, high levels of transactional sex. A man’s ability tonegotiate for safer sex may be determined by gender identity and poverty.Sexual assaultNon-consensual forms of male-to-male sex also occur, in particular with younger males. Victims of male-male sexual violence seldom report the incident out of fear of being identified as person involved insexual relations with other men.Untreated STIUnprotected sex also means that MSM may be exposed to other sexually transmitted infection of themouth and anus, increasing the risk of HIV infection. Symptoms may go undetected or are disclosed, andthereby not treated, out of fear of revealing same sex behaviour. Doctors and other medical careproviders are not always properly trained in the diagnosis and treatment of infections in the mouth andanus.Men who have sex with men, like other people, have the right to information about behaviours that placethem at risk for infection and how to protect themselves during sex; to services related to HIV preventionand care, including counselling and testing. STI services, and other health services; and, to freedom fromdiscrimination on the grounds of sexual orientation. When these rights are not respected, MSM have lesscontrol over their behavioural risks and are there more vulnerable to HIV infection. Protecting their rightscan increase the likelihood that they will be able to access and use prevention messages, skills andservices.Principles that Hinder HIV PreventionIt is sometimes argued that HIV transmission between men could be stopped if men were prevented fromhaving sex with each other. Instead of providing services such as STI clinics and condoms and lubricants,prevention programmes should focus on reducing the frequency of sex between men. This can beachieved theoretically by:• Religious prohibitions• Social stigma• Legislation outlawing sex between men, with punishments such as imprisonment, fines and, in a few countries, execution• Police actions closing commercial establishments and preventing sex between men in public spaces• Reducing the number of locations where men who have sex with men meet• Discriminating against men who have sex with men or encouraging social, economic or legal sanctions against sex between men• “Cures” for homosexuality. HB page 9
  13. 13. These strategies have been widely practised in many societies, both before and after the advent ofHIV/AIDS. However, they have consistently failed to prevent sex between men and consequentlythey have failed to prevent HIV transmission between men.In the provision of effective sexual health care, it is important for providers to learn and understand thedynamics of transmission among men who have sex with men in the local context, specific riskbehaviours practised, and what increases MSM vulnerability to risk in that location. Establishment oflinkages to organisations which work directly with men who have sex with men or that are involved inbehavioural surveillance may be advantageous in this regard.• Categories and sub-groups of men who have sex with men• Organisations working with and services available to men who have sex with men (including mutual support and social/cultural groups)• Accessibility to quality condoms and lubricant• Types of risk and also risk reduction behaviour commonly practised• Specific factors that influence HIV/STI transmission between men, including violence, stigma, laws/policies.• Levels of motivation, knowledge and skills for prevention amongst men who have sex with men.• Behaviour change that needs to happen to reduce HIV/STI transmission and infection among men who have sex with men and their partners.• Practical suggestions for how change can happen and who should be involved. HB page 10
  14. 14. Section 4: Multi-faceted risks for HIV in ThailandAlthough sub-populations of MSM may differ in the levels of risk for HIV infection they are engaging in thesame types of risk-taking behaviors, such as unprotected anal and oral sex. Levels of risk behavior aredetermined by inter-linked factors, i.e., individual and contextual factors. The individual factors include alack of knowledge about HIV/AIDS, the self-efficacy of condoms and lubricants, and the misconceptionsrelated to personal risk assessments and preventive measures. The contextual factors consist of socialand cultural contexts, in which MSM interact and engage in risk-taking behaviors, such as presence ofdifferent forms of stigma and discrimination, absence of “community” with social norms and rules,absence of rights protecting minorities. On an individual level, an individual’s risk taking behavior mayalso be influenced by their own acceptance of their sexual orientation.HIV Prevalence and Risk Factors am ong M SM 7In 2003 and 2005, the Thailand Ministry of Public Health – U.S. Centers for Disease Control andPrevention Collaboration and its partners conducted surveillance of HIV prevalence and risk factorsamong populations of MSM in Thailand. A comparison of the results of both studies indicated asignificant increase in HIV infection among MSM in Bangkok from 2003 to 2005. In 2003, the overall HIVprevalence among MSM in Bangkok was 17.3%. This increased to 28.3% in 2005. The increase wasobserved among MSM at entertainment venues and saunas and in all age groups. The 2005 findings alsoindicated that HIV infection was widespread among MSM, MSW, and TG in Bangkok, Chiang Mai andPhuket.The following factors were significantly associated with HIV prevalence among MSM in 2005: older agedrug use, homosexual or bisexual self-identification, both insertive and receptive anal intercourse, self-reported genital ulcer or discharge, and drug use. Sex with women during the preceding 3 months wasinversely associated with HIV infection.Among male sex workers the factors significantly associated with HIV prevalence included: recruitmentfrom park or street location, self-identification as homosexual or gay, receptive or both insertive andreceptive anal intercourse, and self-reported genital ulcer or discharge. Sex with women during thepreceding 3 months was inversely associated with HIV infection.The risk factors among transgender individuals included: older age, recruitment from park or streetlocation, lower education, history of selling sex, and a higher number of sex partners in the preceding 3months.Drug Use and M SMThe data from the 2005 study indicates that lifetime use of any non-injected drug (mostly smokedmethamphetamine) was reported frequently by MSW (38.5%), TG (24.1%), and MSM (15.5%). 8Increasingly, drug use is viewed as an occupational tool by MSW , potentially increasing their vulnerabilityto infection with HIV and STI.7 HIV Prevalence Among Populations of Men Who have Sex with Men – Thailand, 2003 and 2005. Morbidity and Mortality WeeklyReport, August 11/2006, Vol. 55, No. 31.8 Conversation with Outreach workers, 21 December 2008 HB page 11
  15. 15. Only limited data is available on the use of other drugs, particularly those that are injected or enhance orprolong sexual pleasure among MSM, MSW, and TG in Thailand and needs further monitoring.Beliefs, Knowledge and PerceptionUnprotected anal and oral sex is quite frequent among MSM because many were not informed about therisks and preventive measures for HIV infection. And, although condoms are available, accessible andaffordable in the market, many MSM do not use condoms or used them inconsistently for both anal andoral sex because a number of obstacles to condom use still exist. These include reduced pleasure, thebad smell, unavailability of condoms when needed, the embarrassment associated with buying andcarrying condoms, the size of condoms, the lack of power to request condom use from a partner, and thedifficulty of avoiding risk (i.e., using condoms) when drunk or high.Prevention is also influenced by perception of risk and partner type. The report, The Dynamics and 9Contexts of Male-to-Male Sex in Indonesia and Thailand , identifies that sexual relationships among MSMin Thailand can be categorized into four groups: casual relationships; low-commitment relations [Gik];steady relationships [Faen]; and spousal relationships. Most of the participants in this study have morethan one male partner at anyone time generally across these relationship categories. Sexual partnersmay move from one of these categories to another. Condom use is influenced by the degree of “intimacy”or “commitment” in these relationships. The greater the intimacy or commitment in the relationship theless perceived risk. Condom use appears to be most common and consistent with casual partners. Forpartners, such as a boyfriend (faen) or somebody who is treated as a “spouse or husband,” a condom isoften not used; or it is used but not consistently.Case I Case III: What do you think is you level of risk for HIV? I: Suppose you and I meet in a sauna …R: Risk. I think I have high risk. R: If I meet you there and you like me, I would useI: Why do you think so? a condom with you. But if I like someone as a special one – like a farang, sometimes I don’tR: Because I and my faen don’t use condoms. use.I: Do you use them with giks? I: Why? Is it because you want to have a realR: I use condoms with all gik. I never fail to use touch of him as much as possible? one. R: That too. Also, I want to test his heart. MoreI: Why don’t you use a condom with your faen? than that, I want to win his heart.R: Ever since we began living together … we never use it. We talked between us that if we have something (sex) with others we must use it.I = interviewer, R = respondentThe high prevalence among MSM, MSW, and TG in Thailand highlights the need for more effectivebehavioral and biomedical interventions to prevent the spread of HIV in these populations at high risk.Interventions should include programs to reduce sexual risk behavior, promotion of more frequent HIV9 The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand, Australian Research Centre in Sex, Health andSociety and La Trobe University, 2006. HB page 12
  16. 16. counseling and testing, and improves services for diagnosis and treatment of sexually transmittedinfections. HB page 13
  17. 17. Section 5: Need for Health Services and Access StrategiesThe situation for men who have sex with men highlighted in the previous section can be characterised bya relative lack of programming, lack of knowledge and high prevalence of unsafe sex. In many countriesin Asia MSM are already becoming disproportionately affected by the HIV epidemic. In countries wheresuch information is now available, HIV infection rates among MSM are often higher than in the generalpopulation.Voluntary counselling and testing services that are sensitive and responsive to the needs of men whohave sex with men in HIV prevention can to begin to fill in the gaps in needed programming for MSM.Pre- and post-test counselling with a skilled counsellor familiar with men who have sex with men providesan opportunity to provide appropriate information on HIV/STIs and safer sex for MSM. It also provides anopportunity for clients to learn about community-based and other organizations and services that workwith men who have sex with men. Where a client tests positive for HIV, he can also be given details oforganisations of people living with the virus.Strategies to Access MSMSome may socialise with MSM friends and identify with MSM communities, others may not have any suchaffinities. For all MSM it is important to have appropriate or ‘friendly’ HIV/AIDS or STI services where theycan obtain accurate information about HIV (and STI) transmission and prevention. Because many healthservices have traditionally not been welcoming of MSM it may be important to reorient health services sothat they are ‘MSM friendly’. Some of these adjustments may be subtle, such as including paintings ofposters of attractive men on the walls of waiting rooms and in rooms where clients are interviewed. Otherstrategies include: • Outreach programs by volunteers or professional social or health workers to appropriate locations such as discos, shopping malls where MSM may congregate • Peer education among MSM – training MSM to conduct peer education • The promotion of high quality condoms and water based lubricants and ensuring their continuing availability • Education for staff from other health services to overcome ignorance and prejudice about MSM • Participation in advocacy efforts for the abolition of laws that criminalise sexual activity between men • Anonymous telephone counselling and advice – can be a first step for MSM wanting to be tested for HIV but hesitant to visit a testing centre. Can provide advice and support over the phone as well as referral to an appropriate service • Provision of specially developed IEC materials with information on safe sex for MSM that available at the service site and in venues where MSM gather.Drop-in centres which provide information, training, and social and cultural services for MSM can belinked into a broader network of services. Moreover, the drop-in centres can provide important services tointroduce and refer MSM to voluntary counselling and testing services as well as appropriatepsychosocial support programming as a follow up to VCT.Where it is possible, drop-in centres and outreach services targeting MSM can provide pre-testcounselling and possibly testing through mobile VCT services. Clients are then referred to a formalizedcounselling and testing centre to receive post-test counselling and the test results in order to ensureconfidentiality. HB page 14
  18. 18. A lot can also be said for the provision of quality service. If clients consider the service MSM friendly thenword will quickly spread through the MSM networks that do exist.Elements of an MSM Friendly Service • Is anonymous and assures confidentiality • Has staff who do not make value judgements about behaviours – this means all staff from reception through to nurses, counsellors and doctors • Provides appropriate education materials in client waiting areas as well as in counselling and doctors rooms • Is open at appropriate times such as late at night on at least some nights and on weekends • Is located in an accessible area, for example near venues or locations where MSM may go to meet each other or to look for sex • Provides free or low cost HIV and STI testing • Provides free or low cost condoms and water based lubricant HB page 15
  19. 19. Section 6: Special Sexual Health and Psychosocial Needs of MSMMen, whether they have sex with men or women, generally do not use sexual health services, even ifthey are available. Men’s lack of awareness that they may be at risk of HIV and STI and the cost oftesting (and cost of possible treatment) are likely to be some of the reasons. For men who have sex withmen, the fear of disclosing or being identified as a man who has sex with other men is also aconsideration. Thus, men who have sex with men have specific health needs that can only be met bycounselling and medical care providers who are fully aware of and sensitive to the issues involved.Counselling and clinical staff should be made aware that some men have sex with other men andrecognise that they may also have sex with women.However, counsellors often fail to ask about male-to-male sexual behaviour due to negative attitudestoward same sex behaviour, preconceived notions about a client’s behaviour and identity, or out of fear ofasking sensitive questions. Counsellors must assess all male clients for possible same sex behaviour,even if they do not identify themselves as men who have sex with men, as part of the risk assessment forHIV and STI. To do this, counsellors need an ability to deal with the issues in a non-judgmental way,using neutral or supportive language and appropriate non-verbal behaviour to elicit a client’s sexualhistory. Moreover, the client must be assured that confidentiality will be maintained, respecting their rightnot to divulge their sexual behaviour and gender/sexual identity, along with the results any testing, toothersAlthough many of the issues surrounding HIV are similar for men who have sex with men to the rest ofthe population there are other issues that may arise during health care visits. These can include:Beliefs about masculinity: Healthy and strong men don’t get sick or cannot get infected. These beliefsmay be supported by previous experiences of non-condom use. It is important that you acknowledge thedifficulties the client experiences with these issues and challenge these beliefs. This indicates to the clientthat no matter how strong and healthy they are, that they are susceptible to HIV and other infections ifthey do not protect themselves.Diagnosis and treatment of STI: Ideally, all health care providers need to recognise genital, oral and/oranal symptoms of STI that may be disclosed by the client during the HIV risk assessment. When STI aresuspected, clients need to be referred to a properly equipped laboratory for diagnosis and treatment.Doctors and other medical staff must be trained in identifying and treating infections in the mouth andanus, as well as the sexual organs.Internalised homophobia: This is when a client feels uncomfortable about their sexual identity and sexualbehaviour. When the client is unwilling to admit same sex behaviour and is therefore unwilling to takeprotective measures it is important that you explore the reasons for the discomfort and unwillingness toprotect themselves. Clients who have significant difficulties with their sexuality may find it beneficial tosee a counsellor or to review some of the information for clients available on the websites or in thereferences provided at the end of this handbook.Poverty: The inability to practise safer sex because of the cost of condoms and appropriate lubricant and,as in some cases, the need for financial reward takes precedence when a paying partner refuses to useprevention or offers a higher payment for unprotected sex.Safer sex strategies: Clients need to gain knowledge and skills in safer sex strategies specific to male-to-male behaviour. HB page 16
  20. 20. Sexual dysfunction: Issues of sexual identity fear of infection, and/or HIV status may prevent the client orhis partner from maintaining an erection, affecting the ability to use condoms. Similarly men mayexperience difficulties with reaching sexual climax (known as retarded ejaculation) and a typical responseto this is to remove a condom or avoid the use of condoms in the first place in order to maximisestimulation. It is important that you normalise the possibility of these difficulties by saying, “Many men Isee report that they have difficulties maintaining an erection or reaching sexual climax and this oftenresults in their not being to use a condom….I am wondering if you experience any of these difficulties?”.If the client informs you of these difficulties you can offer suggestions on alternate sexual practices, orways to increase stimulation whilst the condom is in place; a referral to a doctor who may be able toassist the client can also be made. Often sex worker peer counsellors or educators can assist in thesesituations.Sexual violence: More men than we would like to believe are victims of rape or coercive sex. This isseldom discussed out of fear of being emasculated. If sexual violence is disclosed or suspected thensexual assault protocols should be followed;Suicide ideation: MSM are at higher risk of suicide due to double stigmatisation from same sex behaviourand HIV positive status. If the client discloses thoughts about suicide, protocols in suicide riskassessment should be followed. All MSM and especially those who indicate they are having difficultiesaccepting their sexuality, difficulties with forming relationships, and those who experience rejection bypartner, families or who use significant quantities of drugs and alcohol may be at heightened risk ofsuicide. HB page 17
  21. 21. Section 7: Safer Sex StrategiesStrategies for prevention are the same for men who have sex with men as they are for other individuals,namely abstinence, mutual fidelity, condom use and non-penetrative sex. However, the social andpsychological issues of men who have sex with men may prevent some men from succeeding in some ofthese. Therefore, counsellors need to assist the client in assessing safer sex strategies, namely condomuse and non-penetrative sex. In particular, the counsellor will need to assess the client’s access tocondoms and the ability to use and negotiate for their use.Moreover, counsellors need to assist the clients in developing a harm reduction strategy that will be bothpragmatic and effective. Counselling sessions will need to explore a range of options to fit the behavioursthat actually take place in the clients’ lives. Some strategies for safer behaviour include:Condom use. When used properly, condoms can significantly reduce risk of HIV and STI. Thickercondoms have been recommended for use in anal intercourse, but recent studies suggest that thicknessof the condom makes no difference as long as lubricant is used.Female condom For some, the female condom may also be an alternative to the male condom in analintercourse. Usually the inner ring is removed and the condom is placed over the penis before insertion.The advantages of the female condom include greater comfort for the penetrative partner and it does notrequire a full erection before use. The disadvantages include availability and the comparatively high cost.Appropriate lubrication.Because the anus does not produce lubrication, friction cause from the sex actmay cause the condom to tear. While the use of appropriate water-based lubricant is recommended thecause is beyond the reach of most men who need it. Lubricants commonly found in the home – cookingoil and hand-lotions among others – are used. These will actually weaken and begin to dissolve condoms.Therefore a key activity in working with men who have sex with men is to ensure easy access toappropriate lubricant.Safer oral sex. Although the risk of transmission of HIV and most other STIs is significantly smaller in oralsex, condoms should be used. However, many men find the taste and sensation unpleasant so theyprefer not to use them. If not used, ejaculating in the mouth is more likely to cause infection. Withdrawingfrom the mouth before ejaculation will reduce risk.Non-penetrative sex. A menu of non-penetrative sexual behaviours may also provide some additionaloptions for consideration. For example, intercrural intercourse (thigh sex) in which one partner places hispenis between his partner’s thighs, usually directly under the groin, creating friction and pressure thatprovides pleasure to both partners. These behaviours may provide occasional alternatives to intercourserather than replacing it. Knowledge and skills in condom use and in the negotiation for their use are still anecessity.Negotiation / refusal skills. The client needs the ability to communicate with a partner or partners aboutusing condoms or non-penetrative sex, identify barriers they may face in discussing these issues, anddevelop or strengthen the skills needed to negotiate for safer behaviour. The client may also need to haverefusal skills if the partner is unwilling to comply.MSM behaviour specific information materials.The counselling session is also an opportunity to distribute information materials related to safer sexstrategies for MSM and to refer clients to organisations which conduct workshops on issues of concern to HB page 18
  22. 22. MSM, including HIV/AIDS; STI diagnosis and treatment; condoms and lubricant and negotiation for theiruse; modifying risk behaviours; sexual identities and gender; marriage and families; wives and otherfemale sexual partners; legal and human rights issues; discriminations and stigmatisation; and, sex work.Risk reduction among MSM with female partnersWhen men present for HIV testing they may not volunteer their sexual identity. When conducting a riskassessment it is best to first of all remind the client that the interview is confidential. Then ask them“When you have sex, do you have sex with men, women or both?” Asking a client if they areheterosexual, homosexual or bisexual is asking about sexual identity rather than sexual practice. It isalso important to understand that men who identify as homosexual may not disclose that they also havesexual relationships with women unless explicitly asked. If you only ask questions related to sexualidentity you may miss discussing specific exposure risks.Men who are in relationships with female partners and who engage in sexual activities with male partnersand who cannot introduce the use of condoms into their heterosexual relationships should be advised tohave regular HIV tests and to use condoms with male partners.It is also important that the risks associated with mother-to child transmission be discussed with men whohave female partners. It is important that during HIV counselling associated with HIV testing that menwho have indicated that they are either at risk of HIV infection or who test positive consider ways toreduce infecting female partners. Furthermore you should ask if the partner is pregnant, if they indicatethat they are, and then men should be offered advice on preventing unplanned pregnancy and offeredreferral for family planning. It should be reinforced that condoms can not only reduce HIV and STItransmission but that they can also prevent unplanned pregnancies. Men who test positive should beoffered support in disclosing their HIV status to their partners, even if they do not wish to fullyacknowledge that they contracted HIV through same-sex behaviour.All men irrespective of their status should be warned explicitly about the risks of transmitting HIV throughunprotected sex whilst their partner is breastfeeding.To understand more about counselling MSM it is important that you follow-up the materials cited asreferences at the end of this handbook.Specific risk reduction strategies for transgender clientsWhilst all people are at risk of contracting the HIV/AIDS virus regardless of their age, gender or sexuality.People with gender issue issues may face unique risks that general prevention literature fails to address.It is important for counsellors to be aware of these and be able to offer specific risk reduction strategies.Below are some precautions that may have particular relevance to transgender and intersex clients.Rectal douching or neo-vagina douching. If clients have a neo-vagina (created through surgery), a naturalvagina or engage in receptive anal intercourse they may practice douching to keep these passages clean.They should be informed that douching weakens the lining of the anal passage or vagina and removesfriendly bacteria and mucous, exposing the porous membranes (surface skin lining) and increasing therisk of HIV transmission. The practice of douching is generally discouraged by health workers. Clients HB page 19
  23. 23. should be reminded that douching and gels are not an alternative for safe sex, and that only condoms canoffer protection from the HIV virus and other sexually transmissible infections during intercourse. If clientsshould douche because they are concerned about vaginal odours, they should see a doctor as theseodours may indicate an infection.Advice on precautions following gender reassignment surgery. If clients are thinking of, or have recentlyundergone, any gender reassignment surgery involving areas of their body that may be exposed to bodyfluids during sex, then they should be sure to cover the area until they are completely healed.Water based-lubrication and neo-vaginas. Although a neo-vagina may produce some lubrication duringintercourse it may not be enough for comfortable sexual activity. You should counsel clients regardingthe use of water based lubricants such as “Wet stuff” and “KY Jelly”. These will help avoid breaks ortears in the vaginal lining which occur naturally during intercourse but which also increase the risk of thevirus being transmitted.Hair Removal. Your clients should be advised that when they shave or wax the body or pubic hair theymust be careful of creating cuts and scraping the skin. They should be advised to cover any cuts andabrasions before sex and never allow anyone’s body fluids (blood, semen or vaginal fluids) to touchdamaged skin. They should be especially careful if they shave their pubic hair, legs, chest or armpits andthen engage in “trick sex” (having intercourse between closed thighs or under armpits etc.).Needles. Some people may use syringes/needles for hormone injections. HIV and other dangerousviruses including Hepatitis can be found in a shared needle or syringe. If you clients inject their ownhormones or help friends with theirs, they should be advised to keep a clean supply and never shareneedles or syringes.Taping, Strapping and Tucking. Taping, strapping or tucking the genitals could create a warm, moist arealeading to skin disorders, chaffing and dermatitis. Removing tape roughly could result in damaged orbroken skin. Any of these increase the risk of the virus penetrating skin during sex. Clients shouldgenerally be advised to remove tape carefully and remove any traces of adhesive with something gentleand soothing oil.Sex workers and HIV riskSex workers are especially vulnerable to HIV transmission due to their large number of sexual partnersand often high rates of other sexually transmitted infections. Sex workers often feel disempowered tonegotiate safer sex practices with clients on whom they rely for income. In some cases, sex workers mayaccept a higher price with a client refuses to use a condom.Research in some countries has shown that there is a difference in how sex workers negotiate safer sexand this depends according to the extent of the emotional relationship. While with new clients sexworkers may use condoms, with their regular clients or ‘lovers’ to whom they have developed anemotional relationship, they do not think about using a condom. In some situations, there is anoverlapping risk for sex workers between injecting drug use and commercial sex work. This requires thesimultaneous implementation of prevention strategies from two separate disciplines - harm reduction forIDUs and sexual transmission reduction – in recognition of the two sources of risk among this population.Sex workers have particular needs and HIV testing and counselling and psychosocial interventionsshould be tailored specifically to ensure effectiveness. It is crucial that HIV testing and counselling HB page 20
  24. 24. services reach this vulnerable population, both to protect the sex workers from HIV and other STIinfections and to prevent transmission to their clients and partners.Some key prevention interventions with sex workersTeaching sex workers to recognise visible symptoms of STIs is important. Photographs can be helpful.They should depict conditions which sex workers are most likely to see rather than pictures of moreextreme symptoms. Of course, it must be stressed that there are many infections which have no visiblesymptoms, including HIV and hepatitis.Advising against the practice of douching and cleaning. Male, transgender sex workers use a number ofpersonal hygiene methods. Unfortunately these often include the use of harsh chemicals and detergentswhich are not suitable for use in the anus or vagina because they break down the natural protectionagainst infection. The same is true of vaginal drying agents. Both sex workers and their clients need tobe made aware that these practices may actually cause tissue damage that places them at increased riskof HIV and other STI.Advising and referring for advice on microbicides and spermicides. Microbicides are chemicals which killgerms or viral material, including those that may cause many sexually transmitted diseases. Spermicidesare chemicals designed to kill sperm. Nonoxynol 9 (N9) is the most commonly used spermicide.Research has been carried out to see if it also has a microbicidal effect. So far, research has shown thatN9 does not reduce the risk of HIV transmission. Many people have reported that N9 irritates the skin inthe anus or vagina; it might therefore increase the risk of HIV transmission. Most services discourageroutine use of N9 because its harmful effects may outweigh any benefits. HB page 21
  25. 25. Section 8: Challenges of Counselling Positive MSMEveryone diagnosed with HIV faces a range of concerns, which may include ongoing health, whether todisclose their status to partners, and HIV/AIDS-related stigma and its consequences, such as loss ofemployment or home. Men who have sex with men who learn they are HIV positive face additionaldifficulties, including potential disclosure of their sexual activity and in maintaining a relationship.Counselling can help MSM identify and work through some of these issues.Whatever the situation, confidentiality should always be maintained by VCT services. This applies both tohealth, in particular whether the individual has tested positive to HIV or an STI, and to behaviour andgender/sexual identity, i.e. respecting the individuals’ right not to divulge their sexual behaviour andidentity to others. Confidentiality around HIV should be respected whatever the result, particularly sincewillingness to disclose a client’s negative status may suggest that those whose statuses are not disclosedare HIV positive.Men who have sex with men, like other clients who have tested positive for HIV, will need information onhealth, rest, exercise, diet, safer sex and infection control. Follow-up counselling visits may be necessaryto answer further questions and to assess the impact of the diagnosis on the client’s relationships,occupation, sexual behaviour and living situation. Special attention should be given to problem solving ineach of these areas, but in particular to the disclosure of HIV status to partners and others. Telling acurrent partner or an ex-partner that they are HIV positive will be probably one of the hardest situationsthe client must face. The difficulty may be compounded if same sex behaviour is revealed at the sametime – or, conversely, when relationships with the opposite sex are revealed to same sex partners.After the client has learned their HIV positive status, a range of risk behaviour may continue. Counsellorsneed to assist the client in developing a harm reduction strategy that will be both pragmatic and effective.Counselling sessions will need to explore a range of options to fit the behaviours that actually take placein the client’s life. A single counselling session will not be sufficient to explore all the issues. Ongoingcounselling is idea but, where it is not possible clients should be referred to groups and organizations thatcan provide the needed support and assistance. HB page 22
  26. 26. Section 9: Reorienting the Clinical Environment 10This chapter provides guidelines for the development of a health care environment that is welcoming andfriendly for MSM and transgender people. It is a basic principle of health promotion to make healthservices accessible and acceptable to the community they serve.1Many MSM and transgender people experience ridicule, humiliation, violence and imprisonment as aresult of disclosing their sexual behavior to health care providers. Research has shown that fear ofdiscrimination and stigma cause many MSM and transgender people to postpone or decline seekingmedical care. Others, once in care, withhold personal information that may be critical to their care. It istherefore no surprise that a clinical environment can be very threatening to MSM and transgender peoplewhen presenting with anogenital symptoms or being asked questions related to sexual behavior.Undisclosed behavior, especially anal sex and symptoms lead to poor clinical care by the clinician andpoor health outcomes for the patient.2Some health care providers believe they have no MSM or transgender clients or staff in their facilities;many are unsure about what their role should be in identifying and addressing MSM and transgenderissues and few have policies to guide staff or clients.Using external cues, clients will have formed views about the friendliness of a service before they arriveor speak to a member of staff. For example, the location of the service (is it easy to get to?), the openinghours (are they convenient for the staff or the clients?), service signage (is it discreet, or confronting byrevealing the intentions of those who enter?), the availability of community newspapers (do they reflectthe values of the readers?) and clinic decoration (does it reflect community issues or tastes?) all providecorrect or incorrect impressions of the service. New clients may already have spoken to other clients ofthe service about how friendly the staff are or what happens to you when you attend. The client will alsobe sensitive to language and manners that suggest discrimination against them when they approachreception staff or complete registration forms. While waiting, the client may hear staff speaking to newclients at the reception area or on the telephone and note how much personal or identifying information isdiscussed publicly. Are there client brochures available–about the service and how it operates-aboutsexual health problems-and are they written in an easily understood manner? All of this happens beforethe new client has even seen the doctor!One basic approach to service development maximizes the success of any reorientation initiatives.Actively seek the views of the MSM and transgender communities. An active engagement with the MSMand transgender communities during service development will demonstrate that your service seeks andvalues the views of the communities and that there is a commitment to their health care. By contributingtheir knowledge to the clinic operations, MSM and transgender community members also develop asense of ownership of the success of the service and therefore share the rewards and help to seeksolutions to any failures.MSM and transgender community input can help with decisions about the scope of services, location,times and signage for the clinic, what decorations are in the clinic (and even creating the decorations),pilot testing the client sexual health literature and registration forms and participating in the recruitment ofnew staff.During service delivery, many specific issues arise that are beyond the scope of these guidelines; theseissues will require local solutions. Most challenges to service delivery can be overcome by a process ofadequate consultation and negotiation between affected parties. Solutions in one service cannot alwaysbe duplicated exactly in another clinic but can provide ideas and directions. An example of a specificservice challenge is when male-to-female transgender clients in a general STI clinic wish to use thewomen’s toilet or sit in the women’s waiting room in a clinic where there are separate rooms for men andwomen.10 Excerpt from IUSTI Asia Pacific Branch [ ], Clinical Guidelines for Sexual Health Care of Men who have Sex with Men, IUSTI,Bangkok. HB page 23
  27. 27. It may be a female sex worker clinic session during which transgender sex workers also attend, or anMSM clinic session for which there is only a male toilet. Some clinics and clients have no problem withthis arrangement; in others, both the female and male clients complain about it. Consultation with theaffected parties usually reveals the true problem (is it a specific individual or a larger issue?), a solutionand/or a compromise that will work for most clients most of the time. Solutions include having separatemen’s, women’s and other (or “unisex”, meaning any sex) toilets and having separate clinic times. Noticesshould inform clients and the affected communities about the agreement reached during consultation andstaff should be prepared to revisit the decision at any time. Staff will also need to be prepared for thetimes when the arrangement does not work, to prevent escalation of conflict and disruption of the service.General guidelines for MSM and transgender health care services*There are six key areas that require attention when orienting services to MSM and transgender clients:21. Clinic staff2. Client rights3. Client reception4. Service planning and delivery5. Confidentiality6. Community relationsWithin each key area there are two or more applicable standards. These offer minimum standards forthe conduct of a clinic. It would be unrealistic to expect that all of these policies could be adopted andimplemented immediately. Therefore, a step-by-step approach should be explored with the full inclusionof staff and clients alike. Examples are provided of quality indicators within each area to assist withfulfilling the standard.Key area 1: Clinic staffStandard 1: Employment of qualified MSM and transgender staff at the clinic where possibleThe strongest indicator of a non-discriminatory, welcoming workplace for MSM and transgender clients isthe employment of MSM and transgender staff. Even when it is not obvious to clients that these staffbelong to these communities, the staff possess unique knowledge and skills that will not only benefit theclients but also assist with training other staff in behavioral and cultural issues. MSM and transgenderstaff should be visible to clients and not employed only on hidden tasks. Their visibility is one of the keyassets of the service.Standard 2: A workplace free of discrimination and harassment for MSM and transgender staffOnce employed in the service, MSM and transgender staff must have the same workplace andemployment conditions as other staff. This may be viewed as “special treatment” by heterosexual andnon-transgender staff who are familiar with the usual discrimination, harassment and abuse of MSM andtransgender people in their community. However, equal terms and conditions of employment must bevigorously enforced for MSM and transgender staff. Without the safety of this equality, the service willsimply reinforce the destructive aspects of MSM and transgender people’s lives rather than serve as anenvironment in which staff can work effectively for their communities. If a service is unsafe for MSM andtransgender people to work in, it will be seen by their communities as a clinic that is also unsafe to attendas a client and it will be counterproductive to the promotion of MSM and transgender health. When aservice is reorienting towards the MSM and transgender community, non-MSM and transgender staffneed to be included in workplace changes to ensure they can voice their views and acquire the necessaryskills and attitudes. Further, it should not be assumed that MSM understand transgender issues or viceversa.Key area 2: Client rightsStandard 3: Policies for non-discriminatory service deliveryHigh-quality sexual health care cannot be delivered to MSM and transgender people in a discriminatoryclinical environment. A high-quality service has comprehensive policies prohibiting discrimination in the HB page 24
  28. 28. delivery of services to MSM and transgender clients. Staff need to learn and use culturally appropriatelanguage when dealing with MSM and transgender clients. Written forms and policies will also need touse such language. Information brochures about the policies should be provided to clients when theyattend and posters clearly outlining the anti-discrimination policies of the service should be prominentlydisplayed. The policies will need to be discussed regularly during clinic promotion to the MSM andtransgender communities. Examples of unacceptable discriminatory practices by clinics and doctorsinclude requiring male-to-female transgender clients to wear male clothes in the waiting room, staffleaving early from or arriving late to an MSM clinic; rushing examinations; and not asking MSM ortransgender people about sex with women.Standard 4: Complaints procedures for anti-discrimination policiesOnce anti-discrimination policies are written and implemented it is important to know whether they areeffective. The effectiveness of policy implementation can be assessed in several ways, such as observinginteractions between staff and clients in the clinic, seeking the views of clients or having a clear processby which clients can complain about the service. Criticism or complaints are often viewed negativelybecause they are often delivered with strong emotion and are about something that has gone wrong. Butit need not be this way. Criticism is an opportunity for the service to reflect on a staff–client interaction indetail and to review the expectations of the service and community. Community members must feel thatthey can provide feedback (or criticism) and staff must respect this right. On the other hand, managersmust ensure that staff members are not victimized in the process but are supported so that they can learnfrom a complaint.Services should have comprehensive and easily accessible procedures in place for clients to file andresolve complaints alleging violations of anti-discrimination policies.Key area 3: Client receptionStandard 5: MSM and transgender sensitive clinic reception procedures and staffThe first person to greet a client in most clinics is a receptionist or administration clerk who will need toadopt an open, welcoming and non-judgmental manner. Commonly, the clerk’s main task duringreception is to gather identifying information to create a unique client record (usually with a unique recordnumber) to be used by staff at the clinic. This information usually includes personal and family names,date of birth, sex and contact details and is gathered by asking the client to complete a form or briefquestionnaire. Clients should not be asked to show official identification papers. This reassures them thatthere is no link between the clinic and official (usually government) agencies. Clients with low literacyskills need assistance.Clients must be reassured that their personal information is confidential (see below under Key area 5:confidentiality) and given a brief explanation why this information is gathered and how it is protected.Clients should be encouraged to provide true details because false details may jeopardize their care bycreating confusion between clinic records. However, when clients are hesitant, they should be offered theoption of providing a minimum of three pieces of identifying information such as a first name, a birth dateand sex, for example “Mohamed, 10/12/1970, male.” If the information appears to be false, the clientshould be told to remember the information because it will be used to confirm the medical record andnumber for any subsequent visits.Providing an “other” option for sex in addition to male and female shows a sensitivity to transgenderclients who do not wish to identify as either male or female. Reception staff also need to be familiar withculturally appropriate language, behavior and manners of MSM and transgender people. Registrationforms should allow optional self-identification of gender identity and marital or partnership status. Clientsshould have an opportunity for further written or verbal explanation about the registration procedureThe role of the reception clerk is pivotal to the smooth operation of the clinic, so a strong investment incultural training and technical skill is essential. In summary, the key elements of good client reception are:• Open and friendly manner• Creating a unique client record and number• Explaining why identifying information is needed• Reassuring the client about confidentiality• Gathering a minimum of three items of identifying information HB page 25
  29. 29. • Investing in skill development for reception staffKey area 4: Service planning and deliveryStandard 6: Culturally competent in MSM and transgender issues servicesAn effective reorientation of a clinic to meet the needs of the MSM and transgender community can occuronly if all staff members have a basic familiarity with MSM and transgender cultures and manners. Thisshould include an understanding of the issues affecting their lives including discrimination, harassment,poverty, victimization, rejection by families, and unemployment. External members of managementboards should also undertake such training. Some staff will have greater skill than others in managingMSM and transgender issues and an early referral to these staff will ensure the best health care outcomefor the client.Key area 5: ConfidentialityStandard 7: Confidentiality as a cornerstone of sexual health careConfidentiality is a cornerstone of high-quality sexual health clinical care. Clinics need clear confidentialitypolicies that are vigorously enforced and publicized. Staff orientation and regular training need to coverconfidentiality of client data, including information about sexual behavior and transgender issues. MSMand transgender clients should be informed about data collection that includes references to sexualbehavior and/or gender identity, including the circumstances in which such information may be disclosed,whether it may be disclosed as aggregate or individual information, whether personal identifiers may bedisclosed, and how and by whom such information may be used.A simple approach that covers most of these issues is to have a clinic policy that prevents release of anyidentifying information about a client without the written consent of the client. De-identified, aggregatedata is commonly used for service planning and evaluation and should not pose a serious threat to aperson’s confidentiality. However, if there are very few people with a specific condition or behavior from adefined location, care will be needed as a community and individual members of the community may thenbe identifiable within aggregate data.There are many ways to maintain confidentiality within the clinic. For example, when discussing cases orcalling a patient from the waiting area, some clinics use only the client’s first name (although when thepatient’s name is common, their identity will need to be confirmed once in a private space, say by askingthem for their family name), while others use only the client’s registration number when referring topatients. Care will also be needed when discussing a patient’s sexual health care with colleagues toensure that names, diagnoses, behaviors or gender issues are not linked, if the discussion can beoverheard by others.Standard 8: PrivacyAnother important aspect of patient confidentiality is privacy. Many clinics have space restrictions andstruggle to provide a quiet, private and comfortable space for sexual health consultations. A flimsy curtainon a doorway is a poor sound barrier and is open for people to walk through without warning, even if thisis accidental. A consultation cannot be confidential if it is not private. Patients are asked to discloseintimate personal details about their lives and then to undress, exposing the most personal part of theirbody to a person they do not know. A screen between the interview desk and the examination couchallows patients some privacy while they undress. For a comfortable and effective consultation, the basicrequirements are a room in which the consultation cannot be heard or seen by others (preferably with adoor and, when the door is closed, a sign alerting outsiders that a consultation is in progress), and wherethere will not be any interruptions (except in emergencies). Knocking on doors should be standard clinicpractice to alert room occupants that someone wishes to enter. The occupants can then provide theirpermission if it is convenient. Also, the patient must provide their consent to other people being in theroom, including chaperones.Standard 9: MSM and transgender youth and children issuesIn some countries and states, the sexual health care of MSM and transgender youth who are children orminors (as defined by local laws) may be complicated by a clinic’s legal obligations to report child sexual HB page 26
  30. 30. abuse to government agencies. The clinic should be familiar with country and state laws on whetherminors can give consent for care and treatment. Staff should be trained and clients of the service who areminors informed of various mandated reporting laws and their implications.Key area 6: Community relationsStandard 10: MSM and transgender community input to protocols and proceduresJust as employing MSM and transgender staff helps to reorient a clinic, opportunities for representationfrom MSM and transgender communities on the clinic board of directors and other institutional bodiesshould be encouraged. This representation demonstrates transparency in the procedures required tooperate clinics and will, for example, allow for early input from community members to policy changesaffecting them and ensure support for the implementation of the policies.References1. Ottawa Charter for Health Promotion. Adopted at the First International Conference on Health Promotion. Ottawa. November 21,1986. WHO HPR/HEP/95.1. At www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf. Accessed January 14, 2004.2. Community Standards of Practice for Provision of Quality Health Care Services for Gay, Lesbian, Bisexual and TransgenderedClients. Boston, MA: Gay, Lesbian, Bisexual, and Transgender Health Access Project, 2001. At www.glbthealth.org. AccessedJanuary 14, 2004. HB page 27
  31. 31. Section 10: Concluding Note for Health Care ProvidersMen who have sex with men have specific health heeds that can only be met by health service providerswho are fully aware of and sensitive to the issues involved. This includes an ability to deal with men whohave sex with men in a non-judgmental way (using neutral or supportive language an mannerisms) thatelicits their sexual history. It also includes a familiarity with and an ability to treat infections in the anus aswell as the genital area and mouth.When working with men who have sex with men, confidentiality must be maintained. This applies tobehaviour and gender/sexual identity (respecting the individual’s right not to divulge their sexualbehaviour and identity to others) and to health, in particular when the individual has contracted HIV or aSTI.Ideally, all health care providers should be aware that some men have sex with other men, but healthservices are seldom targeted at this group. Skilled and sympathetic counsellors and staff should betrained to provide such services. Although many issues surrounding HIV are similar for men who havesex with men to the rest of the population, there are many others, such as safer sex, becoming HIV-positive after rape, partner notification, and care within the family, that require a different approach byboth the service provider and client.Health care providers and others who work specifically with men who have sex with men must recognizethat most men who have sex with men also have sex with women. Programs should ensure that men arealso informed of the need to protect their women partners.If a client tells you they have sex with the same sex. • Don’t criticize the person for being different. Listen and learn. Find out about his/her experiences. Understand issues that are important to him or her. • Don’t • Strive to develop trust and openness with you rather than conformity. • Don’t discriminate against or oppress the person. • Don’t demand that he/she try to change. • Don’t tell the person it is a phase. • Know that the person confiding in you feels vulnerable and frightened. • Know that the person has probably spent countless hours preparing himself to come to your service and share this information with you. • Know that this person know that you have been raised in a society, like he/she has been, that despises people like him. He/she fears how you may respond. • Keep opportunities for communication open. HB page 28
  32. 32. ReferencesFamily Health International (2002), HIV/AIDS Interventions With Men Who Have Sex With Men (MSM)http://www.fhi.org/en/aids/impact/briefs/msm.htmFamily Health International (2002), HIV/AIDS Interventions With Men Who Have Sex With Men (MSM)http://www.fhi.org/en/aids/impact/briefs/msm.htmFamily Health International, et al. (2007) Peer and Outreach Education for Improving the Sexual Health ofMen who have Sex with Men: A Reference Manual for Peer and Outreach Workers. Bangkok: FHI.Family Health International (2008). Facing the facts: Men who have sex with men and HIV/AIDS inVietnam. ENCOURAGES Project-CIHP-Collected working paper. Bangkok, FHI ARPO.HIV and Men Who have Sex with Men: HIV/AIDS and Human Rights in Southeast Asia. Backgroundpaper prepared for Expert Meeting on HIV/AIDS, Organized by Asia-Pacific Regional Office of the UnitedNations of the High Commissioner for Human Rights (OHCHR), 23 – 24 March 2004International HIV/AIDS Alliance (2003), Between Men: HIV/STI Prevention for Men Who Have Sex WithMen. Key Population Series. International HIV/AIDS Alliance.IUSTI Asia Pacific Branch [ ], Clinical Guidelines for Sexual Health Care of Men who have Sex withMen, IUSTI, Bangkok.Malcolm McCamish, Graeme Storer, Greg Carl. Refocusing HIV/AIDS interventions in Thailand: the casefor male sex workers and other homosexually active men. Culture, Health and Sexuality, Vol 2 No 2 April-June 2000.Naz Foundation (India) Trust (2001) Training Manual: An Introduction to Promoting Sexual Health for MenWho Have Sex With Men and Gay Men, Samrat Offset Pvt, Ltd.Shivanandra Khan (1996) “Bisexualities and AIDS in India”, Bisexualities and AIDS InternationalPerspectives, ed Peter Aggelton, Taylor and Francis: London, p 163Shrivananda Khan (2004) MSM, HIV/AIDS and Human Rights in South Asia. Background paper preparedfor Expert Meeting on HIV/AIDS, Organized by Asia-Pacific Regional Office of the United Nations of theHigh Commissioner for Human Rights (OHCHR), 23 – 24 March 2004Treat Asia (2006). MSM and HIV/AIDS Risk in Asia: What is Fueling the Epidenic Among MSM and HowCan It be Stopped? The Foundation for AIDS Research [amfAR]UNAIDS (2000) AIDS and men who have sex with men, Technical Update, Geneva: UNAIDSUNAIDS (2006), HIV/AIDS and Men who have Sex with Men in Asia and the Pacific. Best PracticeCollection. Geneva: UNAIDS HB page 29

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