NGO Delegate for Asia and the Pacific, Attapon Ed Ngoksin, shares his experiences and lessons learned from taking part in a consultation on HIV and young MSM and transgender women in his region.
‘Self-issues’ and their linkage with sexual risk-taking in the context of HIV is a topic not well known to public health practitioners and policy makers. To explore these issues, a 3-day consultation, organized in October 2012 in Bangkok by Youth Voices Count, brought together young men who have sex with men (MSM) activists and transgender women below the age of 30 from 14 countries in the Asia and the Pacific region..
‘Self-issues’, as these youth put it, is a term to describe 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 constitute barriers to provision of and access to HIV and other health services, self-issues, including self-stigma, are much harder to deal with: it involves the knowledge, skills, perceptions and experience of young people that ultimately influence individual choices of the type of sexual activity they decide to perform with their partners – be it protected or unprotected.
The ‘experts’ categorize young men who have sex with men and young transgenders as ‘target groups’ for programmes; a typical indicator of success in these expert interventions is the number of condoms distributed. However, their lived realities are more complex. Little is understood about their lifestyles and sexuality, particularly how the culture of ignorance and silence dominates thinking and directly impacts their psychological well-being as they grow up: that being gay, lesbian, bisexual or transgender is somehow ‘un-natural’, ‘bad’, ‘wrong’ or immoral’.
Look at the experience of a young female transgender, similar to many stories shared at the consultation, and imagine the impact these self-issues have on self-acceptance and self-esteem: to be perceived by your family and society as a person with no career prospects (apart from working in beauty parlors or the ‘entertainment’ industry); to be the subject of domestic abuse or sexual coercion; to be bullied by your peers in school and harassed by police officers; and to be ‘exclusive’ from the sexual education that only talks of heteronormativity. The World Health Organization, which is the international public health institution that is supposed to provide normative guidance to countries, even embraces the ‘abnormality’ of transgender, recognizing their identity as one form of mental and behavioural disorders.
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 associated with adoption of several ‘bridging’ habits, including alcohol drinking, substance or injecting drug use or sex work, habits that can lead to situations in which a young person may decide to perform ‘risky’ sex. Lack of self-acceptance can also lead to destructive self-coping behaviour such as substance abuse or sex addictions as a result of social anxiety, isolation, stress and feelings of helplessness or depression. 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 transgenders, it is also often seen to ‘validate’ gender identity.
What is also unique and not usually discussed is the individual perception of beauty and how it to a significant degree influences sexual risk-taking. Many young MSM and transgenders choose to perform unprotected sex with someone they have just met because they meet their ideal perception of beauty; they are ready to jeopardize their well-being for unprotected sex regardless of the health outcome. Then the desire for unprotected sex can also 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.
One thing that we learned: knowledge and practice are totally two different things. Ask HIV peer educators if they regularly use a condom with their partners and a majority of them will simply say they don’t in what they hope are or will be stable relationships.
Government responses to the complexities have been fairly simple: simple ignorance. According to a study by amfAR, governments profess “lack of data” to justify the absence of effective MSM programming. Same-sex behavior between consenting adult men is illegal in 78 countries worldwide, in seven of which is punished by death. Countries that also criminalize same-sex sexual practices 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. Condom-compatible lubricants, considered a core commodity for MSM by PEPFAR, is not accessible to MSM in all countries receiving PEPFAR funding. The situation is even more desperate 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.
The participants at this meeting called for a comprehensive response to address both psycho-social needs and sexual well-being of young MSM and young transgenders. This involves creating acceptance within the self and society of sexuality, lifestyle and identity and creating safe spaces and supportive environments in family, school and employment sectors. A set of complex issues needs multifaceted programmes that help to improve self-esteem as we realize that those who accept their sexuality and identity are psychologically healthy, more likely to disclose their HIV status if they are HIV-positive with their casual sexual partners and are less likely to engage in sexual risk-taking. Programmes 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.
Changing societal attitudes and perceptions is not easy but each of us can play our part to ensure the voices of these groups of 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 minimize the projected upsurge of HIV infections among MSM and transgenders in the region over the next decade.
 Commission on AIDS in Asia, 2008.
 Hetero-normativity 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.
 World Health Organization, International Statistical Classification of Diseases and Related Health Problems, 10th Revision (1999), F64.
 amfAR, The Foundation for AIDS Research and Johns Hopkins Bloomberg School of Public Health, Achieving an AIDS-Free Generation for Gay Men and Other MSM: Financing and implementation of HIV programs targeting MSM, January 2012.
 The Global Forum on MSM & HIV (MSMGF), An analysis of major HIV donor investments targeting men who have sex with men and transgender people in low- and middle-income countries, August 2011.
 Harm Reduction International, Global State of Harm Reduction 2012.