Regional feature: ‘Self-issues’: HIV and the psychosocial side of sexual risk-taking

HIV Australia | Vol. 11 No. 1 | March 2013

ATTAPON ED NGOSKIN explores links between HIV, self-esteem and risk taking among young men who have sex with men and transgender people in Asia and the Pacific.

Public health practitioners and policy makers generally do not possess a deep understanding of ‘self-issues’ and their links with HIV-related sexual risk-taking.

To explore these issues, Youth Voices Count organised a three-day consultation in Bangkok in October 2012, bringing together young men who have sex with men (MSM) and transgender women from 14 countries throughout Asia and the Pacific.

Youth Voices Count (YVC) is a regional network of young MSM and transgender people in Asia and the Pacific that supports responses to HIV in the region through community mobilisation and capacity building, and advocates for meaningful participation of young MSM and transgender people in policy and decision making processes.

‘Self-issues’, describes a specific set of issues that positively or negatively impact self-acceptance, self-esteem and confidence.

While HIV and human rights experts understand how laws and legal environments create barriers to the provision of and access to HIV and other health services,¹ self-issues – including self-stigma – are much harder to deal with.

Tackling these issues involve understanding the knowledge, skills, perceptions and experiences of young people that ultimately influence individual choices of the sexual activities they decide to perform with their partners – be it protected or unprotected.

In Asia and the Pacific, young men who have sex with men and young transgender people are most at risk of acquiring HIV, making them the so-called primary ‘target group’ for HIV prevention programs; a typical indicator of success in these expert interventions is the number of condoms distributed.

However, the lived realities of these young people are complex. Little is understood about their lifestyles and sexuality, particularly how cultures of ignorance and silence permeate thinking and directly impact upon young people’s psychological wellbeing as they grow up: that being gay, lesbian, bisexual or transgender is somehow un-natural, bad, wrong and immoral.

Consider the typical experience of a young female transgender – similar to many stories shared at the three day YVC consultation – and imagine the impact that ‘self-issues’ have on self-acceptance and self-esteem: Imagine being perceived by your family and society as a person with no career prospects (apart from working in beauty parlors or the entertainment industry); being the subject of domestic abuse or sexual coercion; being bullied by your peers in school and harassed by police officers; and being excluded from the sexual education that only talks of heteronormativity.²

The World Health Organization, the international public health institution that is supposed to provide normative guidance to countries, even embraces the ‘abnormality’ of transgender, recognising their identity as ‘one form of mental and behavioural disorders’.³

How then do these self-issues relate to risk-taking?

Regrettably, it is very common in Asia and the Pacific to be disowned by your family once you have disclosed your gender identity or your HIV status.

Homelessness and financial instability are very common among MSM and transgender individuals. This extreme marginalisation leads many people to undertake sex work out of financial necessity.

Lack of self and societal acceptance can also lead to destructive self-coping behaviour such as substance abuse as a result of anxiety, isolation, stress and feelings of helplessness or depression; these are scenarios in which a young person may engage in ‘risky’ sexual activities.

One thing that we have learned: knowledge and practice are totally two different things. Circumstances create power imbalances and complacency with HIV risks despite a person’s knowledge about protection.

A power dynamic between insertive and receptive partners can make it difficult to negotiate condom use. Unprotected penetration may be seen by people as a sign of trust or desire for love, relationships and connectedness. For some young transgender people, it is also often seen to validate gender identity.

Another influencing factor – and one not usually discussed – is the individual perception of beauty and how it can influence sexual risk-taking to a significant degree.

Many young MSM and transgender people choose to perform unprotected sex with someone they have just met because they meet their ideal perception of beauty; they are ready to jeopardise their wellbeing for unprotected sex regardless of the potential consequences.

The desire for unprotected sex can then lead to feelings of shame and consequently low self-esteem, as it goes against the socially accepted perception of safe sex. Low self-esteem and depression can prevent people from taking basic care of or protecting themselves.

Government responses throughout Asia and the Pacific to deal with the complexities influencing sexual risk-taking among MSM and transgender communities are sorely lacking, and shockingly, are in part due to simple ignorance of the issues.

According to a study by amfAR, governments profess a ‘lack of data’ to justify the absence of effective MSM programming.⁴

Same-sex behavior between consenting adult men is illegal in 78 countries worldwide, in seven of which is punished by death.⁵Countries that criminalise same-sex sexual practices also spend fewer resources on HIV-related health services for MSM and do less to track and understand the epidemic in their nations.

A review across 42 low and middle-income countries, conducted by the Global Forum on MSM and HIV (MSMGF) in 2010, revealed that less than 2% of national HIV prevention spending is dedicated to MSM.⁶

Condom-compatible lubricants, considered a core commodity for MSM by PEPFAR, are not accessible to MSM in all countries receiving PEPFAR funding.

The situation is even more desperate for young MSM, as no services are officially able to provide harm reduction and or housing support to people under the age of 18 due to the parental consent policy still imposed by many countries in Asia and the Pacific.⁷

The participants at the YVC Consultation called for a comprehensive response to address both psycho-social needs and sexual wellbeing of young MSM and young transgender people.

This involves creating acceptance of sexuality, lifestyle and identity, both among ‘the self ’ and within broader society, and creating safe spaces and supportive environments within families, schools and employers.

This set of complex issues needs multifaceted programs that help to improve self-esteem to respond to the evidence that those who accept their sexuality and identity are psychologically healthy, more likely to disclose their positive HIV status with their casual sexual partners and are less likely to engage in sexual risk-taking.

Programs and policies must at the same time address other social vulnerabilities and structural or legal environments that might encourage sexual risk-taking and that drive youth away from health and other support services.

During 2013, Youth Voices Count and its members will undertake action research in 10 countries in Asia. The findings from the research will be used to develop advocacy campaigns in those countries on self-stigma for young men who have sex with men and transgender people.

AFAO is supporting the action research component of the project in five countries (Indonesia, Laos PDR, Mongolia, The Philippines and Sri Lanka.)

Changing societal attitudes and perceptions is not easy, but Youth Voices Count believe that each of us can play our part to ensure the voices of at-risk young people are heard and that they are meaningfully engaged in policy decisions that affect their lives.

Unless this happens, we are unlikely to find a perfect solution to minimise the projected upsurge of HIV infections among MSM and transgender people in the region over the next decade.

A version of this article, written by Amy Coulterman, originally appeared on the NGO Delegation to the UNAIDS Program Coordinating Board site at: http://unaidspcbngo.org/?p=19266

References

1 Commission on AIDS in Asia, 2008.

2 Heteronormativity is the cultural bias in favor of opposite sex relationships of a sexual nature and against same-sex relationships of a sexual nature. Because the former are viewed as normal and the latter are not, lesbian and gay relationships are subject to a heteronormative bias.

3 World Health Organization. (2010). International Statistical Classification of Diseases and Related Health Problems, 10th Revision, F64.0. In October 2012, An online petition was started at change.org demanding that the World Health Organization (WHO) eliminate the diagnosis ‘transsexualism’ from the mental disorders section of the International Classification of Diseases (ICD). The current edition, ICD-10, was endorsed in 1990 and is being revised. The ICD-11 is expected to be complete by 2015. For further information see: www.who.int/classifications/icd/en

4 amfAR, The Foundation for AIDS Research and Johns Hopkins Bloomberg School of Public Health. (2012). Achieving an AIDS-Free Generation for Gay Men and Other MSM: Financing and implementation of HIV programs targeting MSM. amfAR. Retrieved from: www.amfar.org

5 Bruce-Jones, E., Itaborahy, L. (2012). State-Sponsored Homophobia: A world survey of laws criminalising same-sex sexual acts between consenting adults. ILGA. Retrieved from: www.europarl.europa.eu (PDF)

6 The Global Forum on MSM and HIV (MSMGF). (2011). An analysis of major HIV donor investments targeting men who have sex with men and transgender people in low- and middle-income countries. MSMGF. Retrieved from: www.msmgf.org

7 Harm Reduction International. (2012). Global State of Harm Reduction 2012. Retrieved from: www.ihra.net

Attapon Ed Ngoskin is a Core Working Group Member of Youth Voices Count.