Chi Chung Lau, "Structural factors affecting sexual rights & HIV vulnerability of gay & MSM in Muslim-dominated Malaysia"
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Chi Chung Lau, "Structural factors affecting sexual rights & HIV vulnerability of gay & MSM in Muslim-dominated Malaysia"
- 1. Structural factors affecting sexual rights & HIV vulnerability of gay & other men who have sex with men in Muslim-dominated Malaysia
- 2. Using the Malaysian context as an example, to demonstrate how a theoretical framework (i.e. the Socio-ecological model) can be applied to examine gay men’s and other MSM’s sexual rights in relation to their HIV vulnerability.
- 3. AIDS worker Health Non- Promotion religious training Research Co- creation Chinese Gay man
- 4. Location: - In Southeast Asia Population: - > 27 million Ethnic groups: -50% Malay, 23% Chinese, 11% indigenous, 7% Indian Religion: - Islam as the state religion (61% practise it) - Islamic religious law applied to Muslims in Malaysia
- 5. Founded in 1987 The largest community-based AIDS service organization in Malaysia Located in Kuala Lumpur (the capital city) Five key populations served: 1. Men who have Sex with Men 2. Sex workers (female) 3. Drug users 4. Transgenders 5. People living with HIV www.ptfmalaysia.org
- 6. Devised after a needs assessment 1. Reviewed agency documents 2. Met with individual staff members 3. Observed frontline delivery Lack of a common understanding on MSM’s risk factors for HIV infection in Malaysia (for evidence-based practice) Examining risk factors for HIV infection among MSM in Malaysia
- 7. Steps Objective 1. Review local 2. Consultations Establish an studies + PT’s with stakeholders evidence base to program data for additional inform PT’s insights program (Quantitative) development (Qualitative) Investigator’s exploration of Malaysia’s gay life
- 8. VDTS, 2009 AIMSS, 2009, 2010 PUSH, 2010 PTF’s Venue-Day- Fridae’s Asia Internet CERiA’s PLU Sexual Time-Sampling MSM Sex Survey Health Project On –site Attended to (e.g. bathhouses, clubs, designated sites massage parlors and parks) Online survey Survey + Blood Survey + Blood specimen Specimen Kuala Lumpur Malaysia-wide Penang N= 517 N=1038/1577 N=350
- 9. HIV testing service Outreach Program Year Year 2007, 2008, 2009, 2010 2010 N=653 N~ 650/year
- 10. PT’s MSM Program Staff PT’s MSM Program Volunteers MSM in general MSM business owners/operators MSM program multi-lateral partners (i.e. funders, technical support units, researchers, service organizations)
- 11. Presentation: A review on the local studies and program data Feedback: -Interpretation -Association /Explanation -Additional factors
- 12. Supranational Societal Community Organizat- ional Inter- personal Intra- perso nal
- 13. • MSM’s personal vulnerability (behavioural, emotional, physiological, and Intrapersonal psychological) level • e.g. attitudes towards condom use, sex adventurism, and age • MSM’s relationship with significant others (sex Interpersonal partners, peers, families) level • e.g. couple communications, abusive nature of relationship, disclosure of sexual identity to the family • Responsiveness and effectiveness of organizations Organizational serving MSM level • e.g. cultural competency of health providers, sensitivity of school education about homosexuality
- 14. • Cultures and norms within the gay communities Community and other MSM populations level • e.g. racism with gay communities, sex-oriented venues promoting few social consequences and obligations • Forces imposed by the mainstream societies on Societal MSM level • e.g. homophobia, heterosexism and masculinity as a norm, laws constraining MSM’s sex and relationship • National, international and global phenomena Supranational • e.g. Domestic/cross-border migration of MSM, host vs level home cultures of gay sexuality
- 15. -Not to blame the victims (i.e.MSM) -Move beyond INDIVIDUALS - “for understanding the multiple and interacting determinants of health behaviours” (Sallis et al., 2006, p.466)
- 17. 1.5- ~40% 5.3%
- 18. • A common reason for non-condom use, Organizational including in commercial -Condom availability sex settings • MSM having sex with females not necessarily practice safer sex - Sex with females Interpersonal • Do not know regular sex partners’ - UAS with regulars HIV status -Knowledge • 80% knew HIV risk vs 60% non-condom use • more non-condom use at younger ages -Age • Higher infection rate and UAS among Intrapersonal -Ethnicity Malay vs Chinese -Drug use • Meth use more common in Malaysia • Non-condom use = more fun - Fun factor
- 19. How is MSM’s HIV vulnerability related to sexual rights in Malaysia? - Consultation with stakeholders (lived experiences and observations) - Applying the Social-ecological model to go upstream and to look into deep-rooted (structural /systemic) factors.
- 21. Infection rate VDTS HIV testing service (2009) (2009) (2010) Malay 5.3%* 10.7% 17.9% MSM Chinese 1.8% 7.7% 8.2% MSM More UAS with casual partners Maly-49.4%* Chinese: 39.8% * (significantly associated)
- 22. Associated with Islamic religious beliefs Possible associations- for Muslims: In general- “Everything is written” (fated and destined) Condom use is “haram” (=“forbidden” in Arabic) MSM related- Heteronormativity: heterosexual relationships and behaviours as a norm Homosexuality as a sin (Islamic teaching)
- 23. Comparison with Chinese MSM Channels to learn about, and to be acknowledged of their homosexuality: MEDIA More coverage and positive representations of homosexuality in Chinese media Seek identifications from overseas Chinese media
- 25. “It gets better “ campaign on Youtube (Fridae.asia, 2010/10/31)
- 26. A four-day education camp for “effeminate” male students in secondary school “We are not intervening with the process of nature as we are merely trying to guide these students to a proper path in life” The director of the state education department (New Straits Times, 2011/04/08)
- 27. - Heterosexism • Restricting MSM’s - Homophobia rights to express Societal level their sexuality - Islamic beliefs -Religious institutions • Little acknowledgement -Schools Organizational • Negative /distorted -Media representation -Government (policies • Oppression and law) • Prosecution
- 28. The Socio-ecological Model: The interacting determinants of health
- 29. Mind map of risk factors in HIV transmission and their relationship among MSM in Malaysia
- 30. “We believe that such “boot camps” must be abolished on the basis that they are harmful and do not serve the best interest of the child.......Every child is entitled to protection and assistance in all circumstances without regard to distinction of any kind , such as race, colour, sex, language, religion, social origin or physical., mental or emotional disabilities or any other status.” The Women, Family and Community Development Ministry (The Malaysian Insider, 2011/04/19)
- 31. Examining HIV risk factors beyond the intrapersonal level Targeting core issues that underlie personal vulnerability Wearing a rights-based lens to address rights related (directly and indirectly) to MSM’s health. Applying the Socio-ecological model for comprehensive and dynamic understandings of health determinants.
- 32. PT Foundation, its staff and other stakeholders for their participation and inputs Dr. Suzanne Jackson, Dr. Michael Goldstadt and Dr. Ted Myers for their guidance in the field inquiry Len Tooley for being my school buddy and sharing the passion for gay men’s health promotion Will Oxford for the support in writing
Editor's Notes
- Good Afternoon everyone.Thanks to the Summit for giving me a chance to share my work that is outside the Canadian context.
- My presentation’s objective is to take you to Malaysia. showing how I used a theoretical framework, that is the Socio-ecological model, to study MSM’s sexual rights in relation to their HIV vulnerability.In this study, I am using the term MSM because you will hear more men in Malaysia encounter struggles to identify themselves as a gay man.
- Before presenting the key findings, I would like to reiterate my professional and personal backgrounds. This is because I take a study approach that acknowledges the influence of investigators’ own subjectivity in collecting data and drawing the meaning out of them. To a certain extent, investigators co-create findings and meanings with the subjects. Explicitly stating my position allows you to understand where some of the analyses come from and how they are related to my position and previous experience.So, these are my backgrounds.
- People I met in Malaysia told me that their country is not that well-known.People know Thailand, Singapore, Indonesia and Vietnam, yet many do not know much about Malaysia. Actually, Malaysia is located among all these countries, even bigger than some of them.Malay is the largest ethnic group while Chinese is the second, and then indigenous people and Indian.Islam is the state religion, and 60% of the population practice it. There are Islamic religious laws applied to Muslims in Malaysia.
- This study was conducted during my master’s program practicum.I attached to an agency, called PT Foundation, for three and a half months from Feb to May this year. PT is the oldest and largest community-based AIDS organization in Malaysia.As most AIDS organizations, PT serves the populations mostly affected by HIV. They includeMSMSex workersDrug usersTransgendersPeople living with HIVAligning with my passion, I decided to conduct a study related to MSM’s HIV situation in Malaysia.
- This presentation is based on part of the findings from a study conducted with PT Foundation.The study topic was devised after I had done an assessment on the agency’s needs in terms of what study topics would be beneficial to its program development. The assessment included these three componentsThe assessment showed that while the agency acknowledges evidence-based practice, its staff did not have a common understanding on MSM’s HIV risk factors in Malaysia. The staff focused pretty much on their own understanding to develop their programs.Therefore, I came up a rather general study topic to examine risk factors for HIV infection among MSM in Malaysia for better understanding of the situation.
- The method contained two main parts:First, to review existing local studies and program data for basic evidenceSecond, to consult stakeholders for additional insightsI also have to acknowledge that my own exploration of the gay life in Malaysia also played a part in the data collection. My observations were counted.
- In Malaysia, there is a dearth of studies related to the local situation. Only three main studies were known. These are the acronyms of the studies. Two studies included a survey on behaviours and a collection of blood specimen tested for HIV.The other one was mainly an online survey.They had samples from different geographical locations and sample sizes.
- In addition, data collected through PT’s testing service and outreach program were also looked into.
- The consultation was conducted through focus groups and these were the stakeholders consulted.The agency’s program staff and volunteersMSM in generalMSM business owners and operatorsAlso, MSM program’s multi-lateral partners. They include funders, technical support units, researchers and service providers.
- The consultation was in a format of semi-structural focus groups. A preliminary analysis of the study and program data review was presented to the stakeholders. The stakeholders were then asked whether they had feedback on interpretation, association, explanation and additional observations.Their feedback served to look for feedback which either reinforced my analysis or directed me to take a different perspective.
- The socio-ecological model is the framework to guide the data collection and analysis.The basic idea of the model is that there are different levels to look into factors related to a health issue, from focusing on individuals to larger forces existing in the society.
- What does this model mean when it is applied to the situation of MSM and HIV?Based a systematic review on MSM’s HIV situation, some guiding questions were devised to study risk factors for MSM’s HIV infection at different levels. The intrapersonal level looks into MSM’s personal vulnerability that could be in behavioural, emotional, physiological and psychological aspects.The interpersonal level looks into MSM’s relationship with significant others, such as sex partners, peers and familiesThe organizational level looks into responsiveness and effectiveness of organizations serving MSM
- The community level looks into cultures and norms within the gay communitiesThe societal level looks into forces imposed by the mainstream societies on MSMThe supranational level looks into national, international and global phenomena.
- Applying this model to guide a study can help avoid blaming the victims. It is because there is always a tendency to examine HIV risk factors related to MSM by mainly focusing MSM themselves.In fact, there could be multiple factors other than individual factors affecting MSM’s HIV vulnerability, and these factors could also be interacting with each other. This nature will be discussed in the following presentation.
- The diagram shows the key risk factors for HIV infection among MSM identified in the review of the two main studies.The HIV infection among MSM is found to be around 4%, higher than the general population’s rate at 0.5%.The studies showed an unprotected anal sex rate at 40%Some common reasons for MSM not to use condoms were concluded.In addition, some risk factors are identified to be associated with unprotected anal sex. They are related to ethnicity, knowledge level, age, the number of sex partners, drug and alcohol use, and sexual networking environments.Because of the time limit and our focus on sexual rights, I will not go into details of every factor. Instead, I will highlight some of the aspects.
- Applying the socio-ecological model, we can see most risk factors identified from the studies lie in the intrapersonal level. A couple of factors related to MSM’s sex partners exist in the interpersonal level. And, there is an issue about condom availability in MSM commercial sex venues.With this analysis, interventions would be recommended to mainly target MSM themselves, their sex partners and gay venues
- Up to this point, you may have a question: how is MSM’s HIV vulnerability related to sexual rights in Malaysia?To answer this question, I am going to highlight how stakeholders’ feedback sheds light on this issue, and how the socio-ecological model helps go upstream to look into the structural issues.
- To respond to this topic, one example is to look into the risk factor related to ethnicity.
- The studies and program data consistently show that Malay MSM have higher infection rates, and unprotected anal sex rates than Chinese MSM.
- What factors might be contributing to Malay MSM’s HIV vulnerability?Not a surprise, the stakeholders from the consultation associated this vulnerability with Islamic religious beliefs.For Muslims in general:Their belief in fatalism might make Malay MSM perceive less control over their life, including HIV prevention.Also, condom use is forbidden in their beliefs.In relation to MSM, Islam recognizes heterosexual relationships and behaviours as a norm, and homosexuality as a sin.There is no support and acknowledgement to MSM’s sexuality, which would possibly lead MSM to involve more in risky behaviours because of the stress encountered.
- Indeed, these beliefs are transformed into some structural barriers or actions that put MSM in more non-supportive or stressful situations.During the stakeholders’ consultation, there were discussions about comparisons of the situation between Chinese and Malay MSM.For Chinese MSM in Malaysia, they have more “public acknowledgement” of their sexuality, like that Chinese media have more coverage about homosexuality than Malay media. They can also look for recognitions and identifications from overseas Chinese media, like those in Hong Kong and Taiwan. There are more films about gay men, and a few actors who have come out as gay men.
- However, in Malay media, there is a stricter censorship on representations of homosexuality.During the study period, a gay film called Dalambotol, meaning `Trapped in a bottle` was in theater. However, it was criticized for perpetuating misconceptions about gay men. That is, the gay male character undergoes a sex change for the sake of establishing a heterosexual relationship with his lover, which conveys heteronormativity. The character eventually regrets the sex change and ends in a depressing ending. It is actually a film censorship guideline in Malaysia that gay characters depicted in films are required to repent their homosexuality.
- Another incident is that Malay MSM’s public representations was closely scrutinized.The youtube video of a Malay-Muslim gay man for the “it gets better” campaign in Malaysia was removed because he was threatened by a religious authority that he would be prosecuted of his homosexuality under the religious law.
- In education, there was a case that, in a Malay-dominated state schoolboys who were identified as displaying feminine qualities were sent to an “education” camp for correction.Like in this quote from the director of the state education department, the camp was trying to guide these students to a proper path in life.
- Applying the socio-ecological model, you can see that are more structural issues existing in the organizational and societal levels.Different institutions control discussions, representations and expression of MSM’s sexuality.The causes underlying all these actions are the Islamic beliefs and the dominant discourse of heteronormativity. As a result, MSM’ s sexual rights in expressing their sexuality are being suppressed.
- How are the suppressed sexual rights related to MSM’s HIV vulnerability?You might have an answer already. What I am going to show you is that how the socio-ecological model helps look into the interacting determinants of health.
- I did a mind map.Sure, you find this map very complicated at your first glance. No worries, I would not go into the details.What I want to highlight is that the map helps connect how factors at different levels may be interacting with each other.Here is the box about Malay MSM’s vulnerability about their behavioural risks and psychological state at the intrapersonal level.However, when you go deeper, you can tease out that there are some structural factors underlying, such as negative public discussions and representations of homosexuality in different institutions. Going even further, the risk is originated from the religious beliefs and the discourse of heterosexism.The implication is that while focusing on MSM’s intrapersonal risk factors, we need to reflect on how much work we have done on the deep-rooted core issues that affect MSM’s HIV vulnerability.
- What to do in relation to these structural barriers?The response has to take the religious context into consideration. Malaysia has predominately Islamic believers, and it is hard to challenge its core religious beliefs. A rather creative approach in health promotion is required to avoid direct confrontation with religious beliefs.One good example is the response to the education camp for the schoolboys. The Women, Family and Community Development Ministry asserts the camp violates the right of children who are to be protected of their mental health regardless of their background and status. This example shows how a stance can be adopted involving advocating basic human rights that relate to one’s health without directly challenging religious beliefs about homosexuality.