HIV Prevention and Singaporean MSM – What is Desperately Needed?
Introduction
The number of infections transmitted through Men Who Have Sex With Men (“MSM”) has been rising since 2000. More alarmingly, there is a sharp rise in HIV infection numbers from both homosexual and heterosexual modes of transmission in 2004. The increase rate is a worrying trend that requires sincere collaboration from all stakeholders to address.
In response to these trends, Senior Minister of State for Health, Dr Balaji Sadasivan highlighted in his speech of 23rd March 2005 the increase of HIV infection, especially among MSM. On the one hand, while the content of his speech has been rightly critiqued locally and internationally for increasing stigmatization of gay Singaporeans as was indicated by the subsequent news reports which sensationalized the issue to give voice to homophobic segments of the wider community. On the other hand, however, the intent of his speech, as Dr Balaji subsequently clarified, is very much welcomed by Oogachaga as the speech has brought HIV/AIDS into mainstream discussion.
The fact is sex between men exists in all societies. It frequently involves anal sex which, when unprotected, carries a high risk of HIV transmission, especially for the receptive partner. Nearly everywhere, sex between men is a significant and interconnected part of the epidemic. It cannot be ignored. Further, due to societal and personal homophobia many men who have sex with other men, whether occasionally or frequently, do not regard themselves as "homosexual" or "bisexual", hence the medical term “MSM” i.e. Men Who Have Sex With Men. MSMs who do not identify as gay are very often married. Even if they are not, they may have sex with women as well. This applies particularly to those societies wherein marriage is strongly promoted by society and the family. This contributes to the fact that much of the sex between men is covert.
In order to develop programs that deal with HIV amongst MSM generally and the gay community particularly, Oogachaga is in broad agreement with the views of UNAIDS on this issue (http://www.thebody.com/unaids/wac/msm.html).
Integrated Prevention Programs Needed
UNAIDS proposes that effective societal responses to dealing with HIV amongst MSM must include a combination of the following:
• breaking down social and cultural barriers against the discussion of male-to-male sex;
• educating health staff, including those in sexually transmitted infection (STI) clinics, to overcome ignorance and prejudices about men who have sex with men (MSM);
• ensuring the commitments of national AIDS programs and donor agencies to include the issue of MSM in their programs and funding priorities;
• scaling up peer education among MSM;
• promoting high-quality condoms and water-based lubricants, and ensuring their continuing availability; and
• formulating laws that protect the rights of MSM.
Barriers To Having Integrated Prevention Programs
The reasons that stop societies from having integrated prevention programs amongst MSM and the gay community include:
Denial
Strong social negativity towards, and misconceptions about, sex between men have resulted in inadequate HIV prevention measures. Some governments refuse to support prevention programs for men who have sex with men or if they support such programs are constantly concerned about being viewed negatively by homophobic segments of the wider community that go under the guise of a moral majority. As a result, these men and their partners are at increased risk of HIV infection. Denial is an enormous obstacle to AIDS prevention efforts and care among MSM.
Inadequate Epidemiological Data
A lack of or unreliable, epidemiological data are an obstacle to HIV prevention work. In some places, surveys do not include a category for MSM, and data pertaining to this group are therefore often not available.
Lack of Knowledge or Awareness
When HIV education amongst the wider community emphasizes only heterosexual transmission, men who may not identify as gay or who have not yet come out as part of a gay community, may be ignorant of the risks of male-to-male sex, or consider that the risks do not apply to them. They may therefore be less likely to protect themselves. This is particularly true for youth.
Lack of Appropriate Programs
Many countries lack AIDS programs for MSM. At the same time, existing programs may be inappropriate. Educational material that is suitable for people in a self-identified gay bar may not appeal to those men who do not self-identify as "gay," but who nevertheless have sex with other men. Similarly educational materials that do not address the concerns of youth will miss out a major high risk segment in society.
Difficulty in Reaching Many of the Men Who Have Sex with Men
Many MSM engage in fleeting and anonymous sexual encounters because they are closeted. Unable and not permitted to come to terms with their own sexuality without stigmatization, they often lead double lives. Thus they may also not identify themselves as "gay" or think that they belong to the group of men who have sex with men. The combination of these factors makes them difficult to reach for prevention work. Male sex workers (yes they do exist in Singapore too) can be particularly difficult to access, especially where the work is clandestine.
Stigmatization and Difficulty in Sustaining "Safer Sex" Practices
The fact is a community will only take care of itself if its members feel that they are worthwhile and of value. The constant negative images that MSM and gay people are bombarded with is bound to take an adverse psychological toll on the community generally and individuals particularly. This is turn has often led to a sense of hopelessness which in turns fuels risky sexual behavior. The Center for AIDS Prevention Studies at University of California, San Francisco found that low self esteem due to stigmatization can lead to increased sexually risky behavior (http://www.caps.ucsf.edu/MSMrev.html)
Inadequate, Inaccessible or Inappropriate Health Facilities
MSM seeking attention for sexual or medical matters, or tests for HIV or other STIs, may find such facilities to be lacking. Alternatively, the facilities may exist, but the men may find access to them difficult, due to negative attitudes on the part of health staff towards same-sex behavior, lack of discretion or anonymity for clients, inconvenient location/opening hours, or cost.
Criminalization
Societies can be hostile towards men who engage in same-sex behavior, stigmatizing it and treating it as sinful or criminal -- with severe penalties. Men will then often choose not to be honest about the fact that they have had sex with other men. Afraid of being questioned, they will be reluctant to report symptoms of STIs, including HIV. Because of this, HIV and safer sex education, the provision of condoms, and appropriate STI and other medical care are made extremely difficult. Hostility on the part of society also hinders effective HIV prevention efforts aimed at adolescents and young men who have sex with other men.
Under the law in Singaporea, those who actively participate in safe sex education with MSM populations are constantly faced with the possibility that their actions are abetting a criminal act.
UNAIDS has found that a key measure towards combating HIV amongst MSM is the “abolition of laws criminalizing consenting sexual behavior between men”. It has further asserted that continued criminalization is a hindrance to HIV prevention work amongst this group.
Most other Asian countries do not have any statutes that criminalize homosexual activity, e.g., China, Taiwan, Japan, Thailand, Cambodia, Indonesia, South Korea, Vietnam and the Philippines. As a direct result of the AIDS epidemic, a number of other ex-British colonies, such as Hong Kong and New Zealand, have taken the pragmatic approach and repealed their archaic laws many years ago.
What Can Be Done?
• Firstly explore your own prejudices:
• What are your own reactions towards a man who has sex with men?
• Do you discriminate? How would you react if your father, son, brother or close friend disclosed to you that he was having sex with other men?
• Why is sex between men a criminal act in your country? How might it impede MSM coming forward for assistance? Should sex between consensual adult men be a criminal act?
• Help parents and teachers better understand the development and psychology of their children and young people. Teach parents how to adjust to the development of their child's sexuality.
• Train peer educators to talk to men who have sex with men about HIV prevention in bars and other places where they meet socially or for sex.
• Urge male celebrities to speak openly about men who have sex with men and the need for men to change their behavior. Also provide these celebrities with simple messages on these topics to be used in public forums or media interviews.
• Encourage open discussions about sex between men in the community as well as in male-only institutions, including discussions on the possibility of HIV transmission between men within and outside these environments.
• Encourage networking and information exchange between MSM organizations in different countries.
• Train doctors and other health workers to talk with, and listen to, their male patients about sexual behavior, sexuality and safer sex.
• Invite representatives of groups of men who have sex with men to talk to AIDS service organizations and to other forums where HIV prevention is discussed.
• Include a component on men who have sex with men in the planning and implementation of AIDS prevention and care programs.
• Remove legal impediments that obstruct the work of HIV prevention amongst MSM.
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