Awareness and Sensitivity in the Promotion of Sexual Health among Men who have Sex with Men

Participant Handbook

Foreword
In 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 HIV infections in the country, Family Health International (FHI) and its partners, the Thai Red Cross AIDS Research Centre (TRC/ARC) and the Bangkok Metropolitan Administration Health Center Number 28 (BMA 28), have participated in the Demonstration HIV Counseling and Testing Project, targeting MSM. The goal of this project has been to identify service provider site and programming barriers as well as personal barriers to accessing HIV counseling and testing among this population and to use this information to improve counseling and testing services in order to increase uptake of services among MSM. Service provider attitudes toward men who have sex with men was one of the barriers identified in the first phase of the project. This handbook was has been specifically adapted to provide information on and build sensitivity and awareness of the sexual health of men who have sex with men in Thailand. The handbook may be used together with the Awareness and Sensitivity in the Promotion of Sexual Health among Men who have Sex with Men: Trainers Manual, as part of a training package, or it may be used separately as an information resource.

Acknowledgements
This 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 training package, Awareness and Sensitivity in the Promotion of Sexual Health among Men who have Sex with Men. Funding for this work was provided by USAID.

Contents
Page Section 1: Who are MSM? Section 2: Conceptualizing MSM in the Thailand Context Section 3: Risk and Vulnerability to HIV Infection Section 4: Multifaceted Risks for HIV in Thailand Section 5: Need for Health Services and Access Strategies Section 6: Special Sexual Health and Psychosocial Needs of MSM Section 7: Safer Sex Strategies Section 8: Challenges of Counselling Positive MSM Section 9: Reorienting the Clinical Environment Section 10: Concluding Note for Health Care Providers References 1 4 7 10 12 14 16 20

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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 sex behaviour self-define as gay, bisexual or homosexual but may more aptly self-identify using local social and sexual identities and behaviours. They do not consider their sexual encounters with other men in terms of sexual identity or orientation. Many men who have sex with men self-identify as heterosexual rather than homosexual or bisexual, especially if they also have sex with women, are married, only take the 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 variables such 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 used because it addresses behaviours that put men at risk for infection. It has been argued that the term is too focused on sexual behaviour and not enough on other aspects, such as emotions, relationships, and sexual identity. Some organisations and individuals prefer the term males who have sex with males because it indicates a broader group of individuals engaged in sex with members of the same sex. In particular, it does not have the age limitation implied by the term men, and therefore includes boys who are 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 cultures to describe and/or medicalise sexual acts between men. Also, the emergence of gay culture in Western th societies 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 sexual identity. Some MSM may be highly visible in the community and can include men who dress as women or wear some items of womens clothing. However other MSM may be completely indistinguishable from non MSM. Where homosexuality is not visible it is sometimes thought not to exist, however this is probably not the case. In fact sex between men happens in most, if not all, societies. Public discourses that deny the existence of same sex activity do not reflect what happens in real life.

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Possibly the largest group of MSM in most countries in Asia is men who do not accept their nonmainstream sexual behaviour, do not openly self-identify as gay or homosexual, and who have either casual anonymous sexual encounters or highly clandestine relationships with other men. Some of these men may be married and/or also have sex with women. A few may self-identify as bisexual. Some men who self-identify as heterosexual or bisexual occasionally have sex with men for pleasure, usually because women are less accessible. Some men may have sex mainly with transgender MSM without self-identifying as gay or homosexual, primarily because transgender MSM are not considered men in their cultural context.

Transgender and intersex persons

Understanding terminology Transgender 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 sometimes referred to as gender variant. The term transsexual refers to an individual who feels that their gender identity does not match the biological 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 are further 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 may be used in reference to both transsexuals and cross dressers. Cross dressers (also known as transvestite) is a term usually reserved for individuals who like to cross-dress but who do not experience any discord between their physiological appearance or their gender identity. Most cross-dressers are heterosexual men who cross-dress for purposes of amusement, role-playing, stress relief, or sexual gratification. Usually biological women are not called cross dressers as society allows a broader range of dressing 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 be of the opposing gender. Transitioning commonly refers to the process of moving from one gender to the opposite one. Transitioning is likened to a developmental process with the process of transitioning involving many steps. Increasingly you may hear the term intersex. This term tends to be used by health professionals working in gender orientation. A variety of conditions that lead to atypical development of physical sex characteristics are collectively referred to as intersex conditions. These conditions can involve abnormalities of the external genitals, internal reproductive organs, sex chromosomes, or sex-related hormones. 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.

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Inability of the body to respond normally to sex related hormones.

Intersex conditions are not always accurately diagnosed, experts sometimes disagree on exactly what qualifies as an intersex condition, and government agencies do not collect statistics about intersex individuals. Some experts estimate that as many as 1 in every 1,500 babies is born with genitals that cannot easily be classified as male or female. The sexuality of intersex individuals Most people with intersex conditions grow up to be heterosexual, but persons with some specific intersex conditions 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 restricted access to women. This can be due to conservative societies which encourage strict social segregation of men 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. Denied access to women, men have to gratify their sexual urges with other men, without leading to selfidentification as gay or homosexual. Many male sex workers across Asia often self-identify as heterosexual and have sex with men mainly to support themselves and their families. They are often married or have girlfriends or female sex partners. There are, however, some male sex workers who do self-identify as gay or homosexual and only have sex with men. Some men prefer to have sex only with men but pressure to get married and start families results in them having sex with women. Some have a preference for men but are not averse to women and vice versa. Others prefer to have sex only with women but end up having sex with men for money or because they cannot get access to women. The ambivalent 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 attracted to the same sex. There are some theories which stress biological differences between heterosexual and homosexual adults, suggesting that people are born with their sexuality predetermined. Though experiments and tests have been undertaken to measure differences in hormone levels, genetic makeup, and brain structures of homosexual and heterosexual people the findings of these have, for the most part been unclear. One psychological explanation stresses the importance of life experiences, childhood and relationships with other people, particularly with parents. A persons assumptions about sexuality and their behaviour is influences by their family environment, their experiences and their sense of themselves. Beliefs about sex are initially shaped by family values. Later on these beliefs may be challenged and shaped by pleasant and unpleasant experiences of sex which also shape their choice of sexual activities and partners. Throughout their life a persons sense of whom and what they are has a strong impact on their sexual development and experience. Another theory suggests that preferring your own sex is a matter of willpower, and that a man who has sex with men does so out of a wish to deviate from established gender roles. However, there is little evidence for either of these theories. Other researchers think that it may be possible that sexual orientation is a mixture of both biology (nature) and social conditioning (nurture).

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Male and transgender sex workers

Who are sex workers? Sex workers encompass a diverse group of people, so it is therefore difficult to generalise about their behaviours and attitudes towards HIV prevention and care. For example, they may be injecting drug users, married women or men, indentured workers (i.e. they are coerced into the work and even taken to other 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 care interventions need to recognise these individuals not only as sex workers, but as partners, wives or husbands, and as parents.

Section 2: Conceptualizing MSM in the Thailand Context

The 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 of men who have sex with other men, regardless of the situation or sexual orientation. The term men who have sex with men was introduced in Thailand during the 1980s along with the HIV epidemic so it is difficult to find an equally suitable term in Thai. It is translated literally into Thai as phuchai tee mee phetsamphan gap phuchai. This term had little meaning to many Thai people. The term commonly used for MSM was katoey. However, this terms does not encompass the broad spectrum of MSM in relation to their 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 different meaning in relation to a persons living environment and socioeconomic status.

M SM Subtypes

In Thailand male-same sex is not new, but this behavior has been hidden and underreported because of its nature as a sensitive subject regarding social norms and values. Since those who are involved in male-same sex are likely to be stigmatized by the society, MSM have manifested themselves in varied sexual identities. In rural areas, terminology for MSM sexual behavior is limited to the extremes of katoey and man. Katoey is 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 Thai male is effeminate, he many be stereotyped into the role of katoey. The katoey are, for the most part, not shunned in rural areas and may actively participate in both family and village life. This tacit acceptance
1

Excerpts from: HIV and Men Who Have Sex with Men : HIV/AIDS and Human Rights in Southeast Asia. Expert Meeting on HIV/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 in relation to MSM and HIV/AIDS

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may be based of the belief among many rural villagers that the state of being a katoey is a punishment for sexual indiscretions in a previous life. It is therefore considered natural for a katoey to express sexual interest in persons of the same sex. The role of a man is more difficult to identify. It generally means a male who is heterosexually identified and is the sexually active partner with either a male or female. The idea that good women remain untouched until marriage still prevails. Rather than suppressing the male sex drive, Thai society has channeled it. One option as a sexual outlet is the female sex worker and another is the katoey. If a male takes the active role in sexual relations with a katoey, his masculinity and sexuality do not come under question. Yet another sexual outlet is the notion of friends helping friends. Two males with a good understanding between them or residing in close proximity in a same-sex institutional environment make use of each others bodies in order to meet physical needs while preserving the chastity of women. The action is not considered homosexual in nature, but as a purely physical act because it is not seen to involve the emotions or heart . When emotions do come into play it is difficult to understand why or how a man is attracted to someone of the same sex without filling the traditional roles and stereotypes of the katoey. 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 has become more common. In some more remote areas, gay is synonymous with katoey. In more developed areas, the term gay has taken on the meaning of men who are sexually attracted to men but are not transvestite or transsexually identified. While the new term provides greater opportunities for emotional attachment, the label of gay king or gay queen indicates an individuals role in a relationship and sexual role. In urban areas, the term gay is in common use along side of the terms man and katoey; however, the labeling of sexual roles has become blurred and insignificant. In the report, The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand , the data suggest no association between the role in sex acts and sexual identification of MSM. Therefore, it cannot be assumes that a person who identifies himself as a gay king takes only the insertive role in sex and a person who identifies himself as a gay queen takes only the receptive role in sex. The term bi has also become blurred as well. For some it means that they have sex with both men and women. For others, it means they take both the insertive and receptive role in sex with men. On account of the rural to urban drift of MSM and the blurred terminology, it is essential that service providers clearly identify sexual behaviors that place clients at risk and not make assumptions based on labels.
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Use of term s and potential discrim ination

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Lyttleton C: Framing Thai sexuality. TAJA 1995, 6:135-139. The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand, Australian Research Centre in Sex, Health and Society and La Trobe University, 2006.

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While homosexual behavior between consenting adults is not a criminal offence in Thailand, MSM are still bound by social and cultural norms and sanction. Social discrimination against MSM increases their vulnerability to HIV infection and compromises the health of MSM as they may avoid contact with health and social services. The result is that those most needing information, education and counseling are driven underground . Social discrimination can often be apparent in the terms or labels that are used to address MSM. Beyond the preferred terms, there are terms or labels considered as discriminatory and demeaning by MSM. For example toot [adopted term from the movie, Tootsie for effeminate male, transvestite or transgender person]. Other terms are boy [English adopted term for general MSM but also denotes status in a relationship], lady boy [English term adopted for transvestite, transgender], and money boy [English term adopted for male sex worker]. These terms are commonly used to describe self and others in very close relationships 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 someone outside the relationship uses this label. Service providers should not use terms for MSM loosely but should determine how clients wish to be identified. Remember that sexual identification may not always reflect sexual practice. In addition, some service providers may encounter clients from neighboring countries who have come to Thailand for testing because same sex behavior is a criminal offence in these countries. These clients may be hesitant to identify themselves sexually so that determining sexual practice is obligatory.
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Disclosure of Sexual Orientation and Identity

Thailand is fairly tolerant of same-sex activity compared to many societies but this does not mean that it accepts homosexuality. There is little active intervention to prevent or punish same-sex activity. Tolerance does not equate to social acceptance. Some MSM have expressed fear that if their sexual behavior should 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 MSM . While outward discrimination is not apparent, there is a fear of social sanction with disclosure.Disclosure is most often limited to a group of people with whom a MSM has a close relationship. 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-gaykatoey or MSM-MSW) rather than behavior specific. Thus, vulnerability to HIV infection increases as this fear may prevent MSM from accepting their same-sex behavior, seeking information on HIV/AIDS and STI prevention, and seeking appropriated medical services.
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Sexual Networks of M SM
4

McCamish M, Storer G, Carl G, Kengkanrua K: Why should more attention be given to male-male sex encounters in Thailand. IV International 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 Care 1993, 5:261-271

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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 both heterosexual men and women. In the report, The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand , sexual networking is facilitated through social networks. The study found that the social networks of MSM in Thailand are generally formed along the lines of their sexual identification, degree of openness in revealing ones 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 the interaction of once social network with another.
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The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand, Australian Research Centre in Sex, Health and Society and La Trobe University, 2006.

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Section 3: Risk and Vulnerability to HIV Infection

Risk There are important differences between male to male behaviours and MSM identities. Not all men who have sex with other men are equally vulnerable to HIV. Men who only have sex with a regular, long-term partner 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. Anal intercourse with out a condom is the primary way in which HIV and other sexually transmitted infections are passed on in sex between men. Many of these men may also have women partners. This means that anal intercourse without a condom between men also places the mens female partners and their future children at risk of infection. Likewise, vaginal or anal intercourse without a condom between a man and a woman may place the mans male partners at risk of infection. The risk of HIV transmission through anal intercourse (and anal sex can also be practised between a man and a woman), is especially high when condoms are not used. The lining of the rectum is thin and can easily tear, and even only small lesions in the lining are enough to allow the virus easy access. Even without such lesions, it is thought that they may be a lower immunity in the cells of the rectal lining to resist HIV. The risk to the receptive partner in unprotected anal sex is several times higher than a woman having unprotected vaginal intercourse with an HIV-infected man. Some men may practice fist-to-anus intercourse (fisting) before penetrating the partner with their penis. Such practices may increase risk of tearing the lining of the anus. Unprotected anal sex also poses a risk to the penetrative partner when HIV is present in the other person. The presence of other, untreated sexually transmitted infections such as syphilis, 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 of HIV 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 in the mouth is more likely to cause infection. Withdrawing from the mouth before ejaculation will reduce the risk. 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 less risky, though the presence of STI may increase the risk. The range of practices varies according to region, country and region within the country, as does the extent to which safer sex practices are adopted.

Vulnerability The relative lack of MSM friendly programming and services contributes to MSM vulnerability to infection. Many countries are still unwilling to acknowledge the existence of male-to-male sexual behaviour 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 often condemned. Condom Use Stigma and discrimination have rendered MSM invisible, and the result is that the unique prevention and treatment needs of MSM are not being met. Discrimination can result in the absence of condoms and lubricant in places where male-male sex takes place. Consistent condom use is generally low as many MSM believe that they are low risk. Many also have sex with women and can thus serve as a bridge population for HIV transmission.

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Risk perception Information resources are seldom produced that highlight same sex behaviour. HIV/AIDS prevention programs in Asia have been focused on heterosexual transmission and transmission through injecting drug use. This has led many MSM to conclude that their own behaviours do not place them at risk or they see sex with women as an HIV risk and male-male sex as a safer option. Number and type of partners Stigma and discrimination have made it difficult for MSM develop and maintain relationships, which may contribute to a high level of sex partners and, for some, high levels of transactional sex. A mans ability to negotiate for safer sex may be determined by gender identity and poverty. Sexual assault Non-consensual forms of male-to-male sex also occur, in particular with younger males. Victims of malemale sexual violence seldom report the incident out of fear of being identified as person involved in sexual relations with other men. Untreated STI Unprotected sex also means that MSM may be exposed to other sexually transmitted infection of the mouth and anus, increasing the risk of HIV infection. Symptoms may go undetected or are disclosed, and thereby not treated, out of fear of revealing same sex behaviour. Doctors and other medical care providers are not always properly trained in the diagnosis and treatment of infections in the mouth and anus. Men who have sex with men, like other people, have the right to information about behaviours that place them at risk for infection and how to protect themselves during sex; to services related to HIV prevention and care, including counselling and testing. STI services, and other health services; and, to freedom from discrimination on the grounds of sexual orientation. When these rights are not respected, MSM have less control over their behavioural risks and are there more vulnerable to HIV infection. Protecting their rights can increase the likelihood that they will be able to access and use prevention messages, skills and services.

Principles that Hinder HIV Prevention It is sometimes argued that HIV transmission between men could be stopped if men were prevented from having 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 be achieved 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.

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These strategies have been widely practised in many societies, both before and after the advent of HIV/AIDS. However, they have consistently failed to prevent sex between men and consequently they 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 the dynamics of transmission among men who have sex with men in the local context, specific risk behaviours practised, and what increases MSM vulnerability to risk in that location. Establishment of linkages to organisations which work directly with men who have sex with men or that are involved in behavioural 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.

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Section 4: Multi-faceted risks for HIV in Thailand

Although sub-populations of MSM may differ in the levels of risk for HIV infection they are engaging in the same types of risk-taking behaviors, such as unprotected anal and oral sex. Levels of risk behavior are determined by inter-linked factors, i.e., individual and contextual factors. The individual factors include a lack of knowledge about HIV/AIDS, the self-efficacy of condoms and lubricants, and the misconceptions related to personal risk assessments and preventive measures. The contextual factors consist of social and cultural contexts, in which MSM interact and engage in risk-taking behaviors, such as presence of different forms of stigma and discrimination, absence of community with social norms and rules, absence of rights protecting minorities. On an individual level, an individuals risk taking behavior may also be influenced by their own acceptance of their sexual orientation.

HIV Prevalence and Risk Factors am ong M SM

In 2003 and 2005, the Thailand Ministry of Public Health U.S. Centers for Disease Control and Prevention Collaboration and its partners conducted surveillance of HIV prevalence and risk factors among populations of MSM in Thailand. A comparison of the results of both studies indicated a significant increase in HIV infection among MSM in Bangkok from 2003 to 2005. In 2003, the overall HIV prevalence among MSM in Bangkok was 17.3%. This increased to 28.3% in 2005. The increase was observed among MSM at entertainment venues and saunas and in all age groups. The 2005 findings also indicated that HIV infection was widespread among MSM, MSW, and TG in Bangkok, Chiang Mai and Phuket. The following factors were significantly associated with HIV prevalence among MSM in 2005: older age drug use, homosexual or bisexual self-identification, both insertive and receptive anal intercourse, selfreported genital ulcer or discharge, and drug use. Sex with women during the preceding 3 months was inversely associated with HIV infection. Among male sex workers the factors significantly associated with HIV prevalence included: recruitment from park or street location, self-identification as homosexual or gay, receptive or both insertive and receptive anal intercourse, and self-reported genital ulcer or discharge. Sex with women during the preceding 3 months was inversely associated with HIV infection. The risk factors among transgender individuals included: older age, recruitment from park or street location, lower education, history of selling sex, and a higher number of sex partners in the preceding 3 months.

Drug Use and M SM

The data from the 2005 study indicates that lifetime use of any non-injected drug (mostly smoked methamphetamine) was reported frequently by MSW (38.5%), TG (24.1%), and MSM (15.5%). 8 Increasingly, drug use is viewed as an occupational tool by MSW , potentially increasing their vulnerability to infection with HIV and STI.
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HIV Prevalence Among Populations of Men Who have Sex with Men Thailand, 2003 and 2005. Morbidity and Mortality Weekly Report, August 11/2006, Vol. 55, No. 31. 8 Conversation with Outreach workers, 21 December 2008

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Only limited data is available on the use of other drugs, particularly those that are injected or enhance or prolong sexual pleasure among MSM, MSW, and TG in Thailand and needs further monitoring.

Beliefs, Knowledge and Perception

Unprotected anal and oral sex is quite frequent among MSM because many were not informed about the risks and preventive measures for HIV infection. And, although condoms are available, accessible and affordable in the market, many MSM do not use condoms or used them inconsistently for both anal and oral sex because a number of obstacles to condom use still exist. These include reduced pleasure, the bad smell, unavailability of condoms when needed, the embarrassment associated with buying and carrying condoms, the size of condoms, the lack of power to request condom use from a partner, and the difficulty 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 Contexts of Male-to-Male Sex in Indonesia and Thailand , identifies that sexual relationships among MSM in 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 more than one male partner at anyone time generally across these relationship categories. Sexual partners may 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 the less perceived risk. Condom use appears to be most common and consistent with casual partners. For partners, such as a boyfriend (faen) or somebody who is treated as a spouse or husband, a condom is often not used; or it is used but not consistently. Case I I: What do you think is you level of risk for HIV? R: Risk. I think I have high risk. I: Why do you think so? R: Because I and my faen dont use condoms. I: Do you use them with giks? R: I use condoms with all gik. I never fail to use one. I: Why dont you use a condom with your faen? 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 = respondent The high prevalence among MSM, MSW, and TG in Thailand highlights the need for more effective behavioral 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 HIV
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Case II I: Suppose you and I meet in a sauna R: If I meet you there and you like me, I would use a condom with you. But if I like someone as a special one like a farang, sometimes I dont use. I: Why? Is it because you want to have a real touch of him as much as possible? R: That too. Also, I want to test his heart. More than that, I want to win his heart.

The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand, Australian Research Centre in Sex, Health and Society and La Trobe University, 2006.

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counseling and testing, and improves services for diagnosis and treatment of sexually transmitted infections.

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Section 5: Need for Health Services and Access Strategies

The situation for men who have sex with men highlighted in the previous section can be characterised by a relative lack of programming, lack of knowledge and high prevalence of unsafe sex. In many countries in Asia MSM are already becoming disproportionately affected by the HIV epidemic. In countries where such information is now available, HIV infection rates among MSM are often higher than in the general population. Voluntary counselling and testing services that are sensitive and responsive to the needs of men who have 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 provides an opportunity to provide appropriate information on HIV/STIs and safer sex for MSM. It also provides an opportunity for clients to learn about community-based and other organizations and services that work with men who have sex with men. Where a client tests positive for HIV, he can also be given details of organisations of people living with the virus. Strategies to Access MSM Some may socialise with MSM friends and identify with MSM communities, others may not have any such affinities. For all MSM it is important to have appropriate or friendly HIV/AIDS or STI services where they can obtain accurate information about HIV (and STI) transmission and prevention. Because many health services have traditionally not been welcoming of MSM it may be important to reorient health services so that they are MSM friendly. Some of these adjustments may be subtle, such as including paintings of posters of attractive men on the walls of waiting rooms and in rooms where clients are interviewed. Other strategies 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 be linked into a broader network of services. Moreover, the drop-in centres can provide important services to introduce and refer MSM to voluntary counselling and testing services as well as appropriate psychosocial support programming as a follow up to VCT. Where it is possible, drop-in centres and outreach services targeting MSM can provide pre-test counselling and possibly testing through mobile VCT services. Clients are then referred to a formalized counselling and testing centre to receive post-test counselling and the test results in order to ensure confidentiality.

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A lot can also be said for the provision of quality service. If clients consider the service MSM friendly then word 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

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Section 6: Special Sexual Health and Psychosocial Needs of MSM

Men, whether they have sex with men or women, generally do not use sexual health services, even if they are available. Mens lack of awareness that they may be at risk of HIV and STI and the cost of testing (and cost of possible treatment) are likely to be some of the reasons. For men who have sex with men, the fear of disclosing or being identified as a man who has sex with other men is also a consideration. Thus, men who have sex with men have specific health needs that can only be met by counselling 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 and recognise that they may also have sex with women. However, counsellors often fail to ask about male-to-male sexual behaviour due to negative attitudes toward same sex behaviour, preconceived notions about a clients behaviour and identity, or out of fear of asking 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 for HIV 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 clients sexual history. Moreover, the client must be assured that confidentiality will be maintained, respecting their right not to divulge their sexual behaviour and gender/sexual identity, along with the results any testing, to others Although many of the issues surrounding HIV are similar for men who have sex with men to the rest of the population there are other issues that may arise during health care visits. These can include: Beliefs about masculinity: Healthy and strong men dont get sick or cannot get infected. These beliefs may be supported by previous experiences of non-condom use. It is important that you acknowledge the difficulties the client experiences with these issues and challenge these beliefs. This indicates to the client that no matter how strong and healthy they are, that they are susceptible to HIV and other infections if they do not protect themselves. Diagnosis and treatment of STI: Ideally, all health care providers need to recognise genital, oral and/or anal symptoms of STI that may be disclosed by the client during the HIV risk assessment. When STI are suspected, 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 and anus, as well as the sexual organs. Internalised homophobia: This is when a client feels uncomfortable about their sexual identity and sexual behaviour. When the client is unwilling to admit same sex behaviour and is therefore unwilling to take protective measures it is important that you explore the reasons for the discomfort and unwillingness to protect themselves. Clients who have significant difficulties with their sexuality may find it beneficial to see a counsellor or to review some of the information for clients available on the websites or in the references 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 use prevention 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-tomale behaviour.

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Sexual dysfunction: Issues of sexual identity fear of infection, and/or HIV status may prevent the client or his partner from maintaining an erection, affecting the ability to use condoms. Similarly men may experience difficulties with reaching sexual climax (known as retarded ejaculation) and a typical response to this is to remove a condom or avoid the use of condoms in the first place in order to maximise stimulation. It is important that you normalise the possibility of these difficulties by saying, Many men I see report that they have difficulties maintaining an erection or reaching sexual climax and this often results 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, or ways to increase stimulation whilst the condom is in place; a referral to a doctor who may be able to assist the client can also be made. Often sex worker peer counsellors or educators can assist in these situations. Sexual violence: More men than we would like to believe are victims of rape or coercive sex. This is seldom discussed out of fear of being emasculated. If sexual violence is disclosed or suspected then sexual assault protocols should be followed; Suicide ideation: MSM are at higher risk of suicide due to double stigmatisation from same sex behaviour and HIV positive status. If the client discloses thoughts about suicide, protocols in suicide risk assessment should be followed. All MSM and especially those who indicate they are having difficulties accepting their sexuality, difficulties with forming relationships, and those who experience rejection by partner, families or who use significant quantities of drugs and alcohol may be at heightened risk of suicide.

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Section 7: Safer Sex Strategies

Strategies 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 and psychological issues of men who have sex with men may prevent some men from succeeding in some of these. Therefore, counsellors need to assist the client in assessing safer sex strategies, namely condom use and non-penetrative sex. In particular, the counsellor will need to assess the clients access to condoms 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 both pragmatic and effective. Counselling sessions will need to explore a range of options to fit the behaviours that 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. Thicker condoms have been recommended for use in anal intercourse, but recent studies suggest that thickness of 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 anal intercourse. 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 not require 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 act may cause the condom to tear. While the use of appropriate water-based lubricant is recommended the cause is beyond the reach of most men who need it. Lubricants commonly found in the home cooking oil 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 to appropriate lubricant. Safer oral sex. Although the risk of transmission of HIV and most other STIs is significantly smaller in oral sex, condoms should be used. However, many men find the taste and sensation unpleasant so they prefer not to use them. If not used, ejaculating in the mouth is more likely to cause infection. Withdrawing from the mouth before ejaculation will reduce risk. Non-penetrative sex. A menu of non-penetrative sexual behaviours may also provide some additional options for consideration. For example, intercrural intercourse (thigh sex) in which one partner places his penis between his partners thighs, usually directly under the groin, creating friction and pressure that provides pleasure to both partners. These behaviours may provide occasional alternatives to intercourse rather than replacing it. Knowledge and skills in condom use and in the negotiation for their use are still a necessity. Negotiation / refusal skills. The client needs the ability to communicate with a partner or partners about using condoms or non-penetrative sex, identify barriers they may face in discussing these issues, and develop or strengthen the skills needed to negotiate for safer behaviour. The client may also need to have refusal 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 sex strategies for MSM and to refer clients to organisations which conduct workshops on issues of concern to

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MSM, including HIV/AIDS; STI diagnosis and treatment; condoms and lubricant and negotiation for their use; modifying risk behaviours; sexual identities and gender; marriage and families; wives and other female sexual partners; legal and human rights issues; discriminations and stigmatisation; and, sex work.

Risk reduction among MSM with female partners When men present for HIV testing they may not volunteer their sexual identity. When conducting a risk assessment 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 are heterosexual, homosexual or bisexual is asking about sexual identity rather than sexual practice. It is also important to understand that men who identify as homosexual may not disclose that they also have sexual relationships with women unless explicitly asked. If you only ask questions related to sexual identity you may miss discussing specific exposure risks. Men who are in relationships with female partners and who engage in sexual activities with male partners and who cannot introduce the use of condoms into their heterosexual relationships should be advised to have 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 who have female partners. It is important that during HIV counselling associated with HIV testing that men who have indicated that they are either at risk of HIV infection or who test positive consider ways to reduce infecting female partners. Furthermore you should ask if the partner is pregnant, if they indicate that they are, and then men should be offered advice on preventing unplanned pregnancy and offered referral for family planning. It should be reinforced that condoms can not only reduce HIV and STI transmission but that they can also prevent unplanned pregnancies. Men who test positive should be offered support in disclosing their HIV status to their partners, even if they do not wish to fully acknowledge that they contracted HIV through same-sex behaviour. All men irrespective of their status should be warned explicitly about the risks of transmitting HIV through unprotected sex whilst their partner is breastfeeding. To understand more about counselling MSM it is important that you follow-up the materials cited as references at the end of this handbook.

Specific risk reduction strategies for transgender clients Whilst 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 natural vagina 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 removes friendly bacteria and mucous, exposing the porous membranes (surface skin lining) and increasing the risk of HIV transmission. The practice of douching is generally discouraged by health workers. Clients

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should be reminded that douching and gels are not an alternative for safe sex, and that only condoms can offer protection from the HIV virus and other sexually transmissible infections during intercourse. If clients should douche because they are concerned about vaginal odours, they should see a doctor as these odours may indicate an infection. Advice on precautions following gender reassignment surgery. If clients are thinking of, or have recently undergone, any gender reassignment surgery involving areas of their body that may be exposed to body fluids 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 during intercourse it may not be enough for comfortable sexual activity. You should counsel clients regarding the use of water based lubricants such as Wet stuff and KY Jelly. These will help avoid breaks or tears in the vaginal lining which occur naturally during intercourse but which also increase the risk of the virus being transmitted. Hair Removal. Your clients should be advised that when they shave or wax the body or pubic hair they must be careful of creating cuts and scraping the skin. They should be advised to cover any cuts and abrasions before sex and never allow anyones body fluids (blood, semen or vaginal fluids) to touch damaged skin. They should be especially careful if they shave their pubic hair, legs, chest or armpits and then 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 dangerous viruses including Hepatitis can be found in a shared needle or syringe. If you clients inject their own hormones or help friends with theirs, they should be advised to keep a clean supply and never share needles or syringes. Taping, Strapping and Tucking. Taping, strapping or tucking the genitals could create a warm, moist area leading to skin disorders, chaffing and dermatitis. Removing tape roughly could result in damaged or broken skin. Any of these increase the risk of the virus penetrating skin during sex. Clients should generally be advised to remove tape carefully and remove any traces of adhesive with something gentle and soothing oil.

Sex workers and HIV risk Sex workers are especially vulnerable to HIV transmission due to their large number of sexual partners and often high rates of other sexually transmitted infections. Sex workers often feel disempowered to negotiate safer sex practices with clients on whom they rely for income. In some cases, sex workers may accept 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 sex and this depends according to the extent of the emotional relationship. While with new clients sex workers may use condoms, with their regular clients or lovers to whom they have developed an emotional relationship, they do not think about using a condom. In some situations, there is an overlapping risk for sex workers between injecting drug use and commercial sex work. This requires the simultaneous implementation of prevention strategies from two separate disciplines - harm reduction for IDUs 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 interventions should be tailored specifically to ensure effectiveness. It is crucial that HIV testing and counselling

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services reach this vulnerable population, both to protect the sex workers from HIV and other STI infections and to prevent transmission to their clients and partners. Some key prevention interventions with sex workers Teaching 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 more extreme symptoms. Of course, it must be stressed that there are many infections which have no visible symptoms, including HIV and hepatitis. Advising against the practice of douching and cleaning. Male, transgender sex workers use a number of personal hygiene methods. Unfortunately these often include the use of harsh chemicals and detergents which are not suitable for use in the anus or vagina because they break down the natural protection against infection. The same is true of vaginal drying agents. Both sex workers and their clients need to be made aware that these practices may actually cause tissue damage that places them at increased risk of HIV and other STI. Advising and referring for advice on microbicides and spermicides. Microbicides are chemicals which kill germs or viral material, including those that may cause many sexually transmitted diseases. Spermicides are 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 that N9 does not reduce the risk of HIV transmission. Many people have reported that N9 irritates the skin in the anus or vagina; it might therefore increase the risk of HIV transmission. Most services discourage routine use of N9 because its harmful effects may outweigh any benefits.

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Section 8: Challenges of Counselling Positive MSM

Everyone diagnosed with HIV faces a range of concerns, which may include ongoing health, whether to disclose their status to partners, and HIV/AIDS-related stigma and its consequences, such as loss of employment or home. Men who have sex with men who learn they are HIV positive face additional difficulties, 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 to health, in particular whether the individual has tested positive to HIV or an STI, and to behaviour and gender/sexual identity, i.e. respecting the individuals right not to divulge their sexual behaviour and identity to others. Confidentiality around HIV should be respected whatever the result, particularly since willingness to disclose a clients negative status may suggest that those whose statuses are not disclosed are HIV positive. Men who have sex with men, like other clients who have tested positive for HIV, will need information on health, rest, exercise, diet, safer sex and infection control. Follow-up counselling visits may be necessary to answer further questions and to assess the impact of the diagnosis on the clients relationships, occupation, sexual behaviour and living situation. Special attention should be given to problem solving in each of these areas, but in particular to the disclosure of HIV status to partners and others. Telling a current partner or an ex-partner that they are HIV positive will be probably one of the hardest situations the client must face. The difficulty may be compounded if same sex behaviour is revealed at the same time 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. Counsellors need 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 place in the clients life. A single counselling session will not be sufficient to explore all the issues. Ongoing counselling is idea but, where it is not possible clients should be referred to groups and organizations that can provide the needed support and assistance.

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Section 9: Reorienting the Clinical Environment

10

This chapter provides guidelines for the development of a health care environment that is welcoming and friendly for MSM and transgender people. It is a basic principle of health promotion to make health services accessible and acceptable to the community they serve.1 Many MSM and transgender people experience ridicule, humiliation, violence and imprisonment as a result of disclosing their sexual behavior to health care providers. Research has shown that fear of discrimination and stigma cause many MSM and transgender people to postpone or decline seeking medical care. Others, once in care, withhold personal information that may be critical to their care. It is therefore no surprise that a clinical environment can be very threatening to MSM and transgender people when 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 and poor health outcomes for the patient.2 Some 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 transgender issues 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 arrive or speak to a member of staff. For example, the location of the service (is it easy to get to?), the opening hours (are they convenient for the staff or the clients?), service signage (is it discreet, or confronting by revealing the intentions of those who enter?), the availability of community newspapers (do they reflect the values of the readers?) and clinic decoration (does it reflect community issues or tastes?) all provide correct or incorrect impressions of the service. New clients may already have spoken to other clients of the service about how friendly the staff are or what happens to you when you attend. The client will also be sensitive to language and manners that suggest discrimination against them when they approach reception staff or complete registration forms. While waiting, the client may hear staff speaking to new clients at the reception area or on the telephone and note how much personal or identifying information is discussed publicly. Are there client brochures availableabout the service and how it operates-about sexual health problems-and are they written in an easily understood manner? All of this happens before the 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 MSM and transgender communities during service development will demonstrate that your service seeks and values the views of the communities and that there is a commitment to their health care. By contributing their knowledge to the clinic operations, MSM and transgender community members also develop a sense of ownership of the success of the service and therefore share the rewards and help to seek solutions 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 of new staff. During service delivery, many specific issues arise that are beyond the scope of these guidelines; these issues will require local solutions. Most challenges to service delivery can be overcome by a process of adequate consultation and negotiation between affected parties. Solutions in one service cannot always be duplicated exactly in another clinic but can provide ideas and directions. An example of a specific service challenge is when male-to-female transgender clients in a general STI clinic wish to use the womens toilet or sit in the womens waiting room in a clinic where there are separate rooms for men and women.
10

Excerpt from IUSTI Asia Pacific Branch [ Bangkok.

], Clinical Guidelines for Sexual Health Care of Men who have Sex with Men, IUSTI,

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It may be a female sex worker clinic session during which transgender sex workers also attend, or an MSM clinic session for which there is only a male toilet. Some clinics and clients have no problem with this arrangement; in others, both the female and male clients complain about it. Consultation with the affected parties usually reveals the true problem (is it a specific individual or a larger issue?), a solution and/or a compromise that will work for most clients most of the time. Solutions include having separate mens, womens and other (or unisex, meaning any sex) toilets and having separate clinic times. Notices should inform clients and the affected communities about the agreement reached during consultation and staff should be prepared to revisit the decision at any time. Staff will also need to be prepared for the times 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:2 1. Clinic staff 2. Client rights 3. Client reception 4. Service planning and delivery 5. Confidentiality 6. Community relations Within each key area there are two or more applicable standards. These offer minimum standards for the conduct of a clinic. It would be unrealistic to expect that all of these policies could be adopted and implemented immediately. Therefore, a step-by-step approach should be explored with the full inclusion of staff and clients alike. Examples are provided of quality indicators within each area to assist with fulfilling the standard. Key area 1: Clinic staff Standard 1: Employment of qualified MSM and transgender staff at the clinic where possible The strongest indicator of a non-discriminatory, welcoming workplace for MSM and transgender clients is the employment of MSM and transgender staff. Even when it is not obvious to clients that these staff belong to these communities, the staff possess unique knowledge and skills that will not only benefit the clients but also assist with training other staff in behavioral and cultural issues. MSM and transgender staff should be visible to clients and not employed only on hidden tasks. Their visibility is one of the key assets of the service. Standard 2: A workplace free of discrimination and harassment for MSM and transgender staff Once employed in the service, MSM and transgender staff must have the same workplace and employment conditions as other staff. This may be viewed as special treatment by heterosexual and non-transgender staff who are familiar with the usual discrimination, harassment and abuse of MSM and transgender people in their community. However, equal terms and conditions of employment must be vigorously enforced for MSM and transgender staff. Without the safety of this equality, the service will simply reinforce the destructive aspects of MSM and transgender peoples lives rather than serve as an environment in which staff can work effectively for their communities. If a service is unsafe for MSM and transgender people to work in, it will be seen by their communities as a clinic that is also unsafe to attend as a client and it will be counterproductive to the promotion of MSM and transgender health. When a service is reorienting towards the MSM and transgender community, non-MSM and transgender staff need to be included in workplace changes to ensure they can voice their views and acquire the necessary skills and attitudes. Further, it should not be assumed that MSM understand transgender issues or vice versa. Key area 2: Client rights Standard 3: Policies for non-discriminatory service delivery High-quality sexual health care cannot be delivered to MSM and transgender people in a discriminatory clinical environment. A high-quality service has comprehensive policies prohibiting discrimination in the

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delivery of services to MSM and transgender clients. Staff need to learn and use culturally appropriate language when dealing with MSM and transgender clients. Written forms and policies will also need to use such language. Information brochures about the policies should be provided to clients when they attend and posters clearly outlining the anti-discrimination policies of the service should be prominently displayed. The policies will need to be discussed regularly during clinic promotion to the MSM and transgender communities. Examples of unacceptable discriminatory practices by clinics and doctors include requiring male-to-female transgender clients to wear male clothes in the waiting room, staff leaving early from or arriving late to an MSM clinic; rushing examinations; and not asking MSM or transgender people about sex with women. Standard 4: Complaints procedures for anti-discrimination policies Once anti-discrimination policies are written and implemented it is important to know whether they are effective. The effectiveness of policy implementation can be assessed in several ways, such as observing interactions between staff and clients in the clinic, seeking the views of clients or having a clear process by which clients can complain about the service. Criticism or complaints are often viewed negatively because they are often delivered with strong emotion and are about something that has gone wrong. But it need not be this way. Criticism is an opportunity for the service to reflect on a staffclient interaction in detail and to review the expectations of the service and community. Community members must feel that they can provide feedback (or criticism) and staff must respect this right. On the other hand, managers must ensure that staff members are not victimized in the process but are supported so that they can learn from a complaint. Services should have comprehensive and easily accessible procedures in place for clients to file and resolve complaints alleging violations of anti-discrimination policies. Key area 3: Client reception Standard 5: MSM and transgender sensitive clinic reception procedures and staff The first person to greet a client in most clinics is a receptionist or administration clerk who will need to adopt an open, welcoming and non-judgmental manner. Commonly, the clerks main task during reception is to gather identifying information to create a unique client record (usually with a unique record number) 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 brief questionnaire. Clients should not be asked to show official identification papers. This reassures them that there is no link between the clinic and official (usually government) agencies. Clients with low literacy skills 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 by creating confusion between clinic records. However, when clients are hesitant, they should be offered the option of providing a minimum of three pieces of identifying information such as a first name, a birth date and sex, for example Mohamed, 10/12/1970, male. If the information appears to be false, the client should be told to remember the information because it will be used to confirm the medical record and number for any subsequent visits. Providing an other option for sex in addition to male and female shows a sensitivity to transgender clients who do not wish to identify as either male or female. Reception staff also need to be familiar with culturally appropriate language, behavior and manners of MSM and transgender people. Registration forms should allow optional self-identification of gender identity and marital or partnership status. Clients should have an opportunity for further written or verbal explanation about the registration procedure The role of the reception clerk is pivotal to the smooth operation of the clinic, so a strong investment in cultural 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

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 Investing in skill development for reception staff Key area 4: Service planning and delivery Standard 6: Culturally competent in MSM and transgender issues services An effective reorientation of a clinic to meet the needs of the MSM and transgender community can occur only if all staff members have a basic familiarity with MSM and transgender cultures and manners. This should include an understanding of the issues affecting their lives including discrimination, harassment, poverty, victimization, rejection by families, and unemployment. External members of management boards should also undertake such training. Some staff will have greater skill than others in managing MSM and transgender issues and an early referral to these staff will ensure the best health care outcome for the client. Key area 5: Confidentiality Standard 7: Confidentiality as a cornerstone of sexual health care Confidentiality is a cornerstone of high-quality sexual health clinical care. Clinics need clear confidentiality policies that are vigorously enforced and publicized. Staff orientation and regular training need to cover confidentiality of client data, including information about sexual behavior and transgender issues. MSM and transgender clients should be informed about data collection that includes references to sexual behavior 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 be disclosed, 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 any identifying information about a client without the written consent of the client. De-identified, aggregate data is commonly used for service planning and evaluation and should not pose a serious threat to a persons confidentiality. However, if there are very few people with a specific condition or behavior from a defined location, care will be needed as a community and individual members of the community may then be identifiable within aggregate data. There are many ways to maintain confidentiality within the clinic. For example, when discussing cases or calling a patient from the waiting area, some clinics use only the clients first name (although when the patients name is common, their identity will need to be confirmed once in a private space, say by asking them for their family name), while others use only the clients registration number when referring to patients. Care will also be needed when discussing a patients sexual health care with colleagues to ensure that names, diagnoses, behaviors or gender issues are not linked, if the discussion can be overheard by others. Standard 8: Privacy Another important aspect of patient confidentiality is privacy. Many clinics have space restrictions and struggle to provide a quiet, private and comfortable space for sexual health consultations. A flimsy curtain on a doorway is a poor sound barrier and is open for people to walk through without warning, even if this is accidental. A consultation cannot be confidential if it is not private. Patients are asked to disclose intimate personal details about their lives and then to undress, exposing the most personal part of their body to a person they do not know. A screen between the interview desk and the examination couch allows patients some privacy while they undress. For a comfortable and effective consultation, the basic requirements are a room in which the consultation cannot be heard or seen by others (preferably with a door and, when the door is closed, a sign alerting outsiders that a consultation is in progress), and where there will not be any interruptions (except in emergencies). Knocking on doors should be standard clinic practice to alert room occupants that someone wishes to enter. The occupants can then provide their permission if it is convenient. Also, the patient must provide their consent to other people being in the room, including chaperones. Standard 9: MSM and transgender youth and children issues In some countries and states, the sexual health care of MSM and transgender youth who are children or minors (as defined by local laws) may be complicated by a clinics legal obligations to report child sexual

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abuse to government agencies. The clinic should be familiar with country and state laws on whether minors can give consent for care and treatment. Staff should be trained and clients of the service who are minors informed of various mandated reporting laws and their implications. Key area 6: Community relations Standard 10: MSM and transgender community input to protocols and procedures Just as employing MSM and transgender staff helps to reorient a clinic, opportunities for representation from MSM and transgender communities on the clinic board of directors and other institutional bodies should be encouraged. This representation demonstrates transparency in the procedures required to operate clinics and will, for example, allow for early input from community members to policy changes affecting them and ensure support for the implementation of the policies. References
1. 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 Transgendered Clients. Boston, MA: Gay, Lesbian, Bisexual, and Transgender Health Access Project, 2001. At www.glbthealth.org. Accessed January 14, 2004.

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Section 10: Concluding Note for Health Care Providers

Men who have sex with men have specific health heeds that can only be met by health service providers who are fully aware of and sensitive to the issues involved. This includes an ability to deal with men who have sex with men in a non-judgmental way (using neutral or supportive language an mannerisms) that elicits their sexual history. It also includes a familiarity with and an ability to treat infections in the anus as well as the genital area and mouth. When working with men who have sex with men, confidentiality must be maintained. This applies to behaviour and gender/sexual identity (respecting the individuals right not to divulge their sexual behaviour and identity to others) and to health, in particular when the individual has contracted HIV or a STI. Ideally, all health care providers should be aware that some men have sex with other men, but health services are seldom targeted at this group. Skilled and sympathetic counsellors and staff should be trained to provide such services. Although many issues surrounding HIV are similar for men who have sex with men to the rest of the population, there are many others, such as safer sex, becoming HIVpositive after rape, partner notification, and care within the family, that require a different approach by both the service provider and client. Health care providers and others who work specifically with men who have sex with men must recognize that most men who have sex with men also have sex with women. Programs should ensure that men are also informed of the need to protect their women partners.

If a client tells you they have sex with the same sex.

Dont criticize the person for being different. Listen and learn. Find out about his/her experiences. Understand issues that are important to him or her. Dont Strive to develop trust and openness with you rather than conformity. Dont discriminate against or oppress the person. Dont demand that he/she try to change. Dont 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.

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References

Family Health International (2002), HIV/AIDS Interventions With Men Who Have Sex With Men (MSM) http://www.fhi.org/en/aids/impact/briefs/msm.htm Family Health International (2002), HIV/AIDS Interventions With Men Who Have Sex With Men (MSM) http://www.fhi.org/en/aids/impact/briefs/msm.htm Family Health International, et al. (2007) Peer and Outreach Education for Improving the Sexual Health of Men 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 in Vietnam. 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. Background paper prepared for Expert Meeting on HIV/AIDS, Organized by Asia-Pacific Regional Office of the United Nations of the High Commissioner for Human Rights (OHCHR), 23 24 March 2004 International HIV/AIDS Alliance (2003), Between Men: HIV/STI Prevention for Men Who Have Sex With Men. Key Population Series. International HIV/AIDS Alliance. IUSTI Asia Pacific Branch [ Men, IUSTI, Bangkok. ], Clinical Guidelines for Sexual Health Care of Men who have Sex with

Malcolm McCamish, Graeme Storer, Greg Carl. 'Refocusing HIV/AIDS interventions in Thailand: the case for male sex workers and other homosexually active men'. Culture, Health and Sexuality, Vol 2 No 2 AprilJune 2000. Naz Foundation (India) Trust (2001) Training Manual: An Introduction to Promoting Sexual Health for Men Who Have Sex With Men and Gay Men, Samrat Offset Pvt, Ltd. Shivanandra Khan (1996) Bisexualities and AIDS in India, Bisexualities and AIDS International Perspectives, ed Peter Aggelton, Taylor and Francis: London, p 163 Shrivananda Khan (2004) MSM, HIV/AIDS and Human Rights in South Asia. Background paper prepared for Expert Meeting on HIV/AIDS, Organized by Asia-Pacific Regional Office of the United Nations of the High Commissioner for Human Rights (OHCHR), 23 24 March 2004 Treat Asia (2006). MSM and HIV/AIDS Risk in Asia: What is Fueling the Epidenic Among MSM and How Can It be Stopped? The Foundation for AIDS Research [amfAR] UNAIDS (2000) AIDS and men who have sex with men, Technical Update, Geneva: UNAIDS UNAIDS (2006), HIV/AIDS and Men who have Sex with Men in Asia and the Pacific. Best Practice Collection. Geneva: UNAIDS

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