Working with vulnerable males and HIV in Pakistan A one day seminar Shivananda Khan Naz Foundation International

Assumption That participants have knowledge on HIV and AIDS. That we understand dynamics and frameworks of male-male sex in Pakistan

Goals Process Level Personnel/Capacity Level Institutionalise knowledge and understanding within NACP/PACP regarding male-to-male sexualities, masculinities, sexual behaviours, risk and vulnerabilities. Personnel/Capacity Level A deeper understanding of differing frameworks of male-to-male sex, risks and vulnerabilities in Pakistan, and towards developing knowledge-based interventions within a framework of agreed good practice principles in regard to HIV prevention, care and support programming amongst a range of highly vulnerable MSM sub-populations.

Learning Outcomes Have a better understanding of male-male masculinities and sexualities in Pakistan. Have a better understanding of male-to-male sexual behaviours, genders and identities, along with risks and vulnerabilities in Pakistan. Be able to integrate this knowledge into progamme planning and design for MSM sexual health interventions Have access to a range of knowledge resources

We will be exploring: Current epidemiological knowledge Why work with MSM and HIV Who is MSM Why males have sex with males Risk and vulnerability Issues, needs and concerns Changing Behaviours Building an enabling environment Developing a response

Personal sensibilities We will be discussing male-male sexualities and sexual practices. There needs to be an open discussion. How do you feel about talking about sex, particularly stigmatised sex.

HASP Presentation

Why work with ‘MSM’ Why we should work with male-to-male sex and HIV prevention, care and support? Because: It is the right thing to do on humanitarian grounds. It is the right thing to do epidemiologically. It is the right thing to do from a public health perspective.

Males who have sex with males (MSM) whether their self-identity is linked to their same sex behaviour or not, have: The right to be from violence and harassment; The right to be treated with dignity and respect; The right to be treated as full citizens in their country; The right to be free from HIV/AIDS; MSM who are already infected with HIV have the right to access appropriate care and treatment equally with everyone else, regardless of how the virus was transmitted to them.

Who are MSM?

Who is involved in male-to-male sex? Feminised males Masculine males Teachers Students Relatives Street males Prisoners Males in a occupational groups: truck drivers, boatmen, fishermen, taxi drivers, etc. Politicians Bureaucrats Labourers Farmers Male sex workers Males in uniformed services Male friends Foreigners Adolescent males What distinguishes these men from each other?

Who are hijras? To often there is a major confusion between hijras and zenanas, with both sub-populations being grouped as one. But this is not so. Hijras represent a specific community with its own rules, regulations and order. To become a hijra is not only about dress code, behaviour and language. They have adopt the hierarchy absolutely. There are rituals to perform (Reet) which is a ritual where a young male (and sometimes not so young), primarily zenana identified, who enters a hijra household through ritual offerings made to the guru/nayak, who have absolute authority over the new chela. Thus the hierarchy is chela - guru - nayak.

Chelas must get permission from their gurus, and gurus must get permission from their nayak - head of a particular hijra household (not a dehra) to be involved in any activity. Hijras have specific beliefs relating to their spiritually given powers over fertility, which are granted following the castration ritual. Not all hijras are castrated, but this is the end goal. Not all zenanas are hijras unless they adopt the rituals and authority of the hijra community.

Who are zenanas? Hijras and some zenanas are not the same, even though they make look alike in terms of dress and gender performance. Zenana is a term that identifies a particular male who is feminised both in behaviour and sexual preference and practice, that is receptive anal and oral sex. Not all zenana-identified males cross dress either full-time or part-time, and many are only situationally zenanas. Some zenana’s imitate hijra households by having a guru and chela system, but they don’t conduct the Reet rituals nor belong to a specific hijra household. It needs to be noted that it is not unknown for zenana identified males (as well as some hijra chelas who sell sex) to also penetrate other males.

Questions What do we mean by the words: Sex Gender Sexuality Masculinity Need to think in terms of genders, sexualities, masculinities

Masculinities A term used to think about men/males and how it is expected that they should behave. What does it mean to be a male? What does it mean to be a man? What does it mean to be masculine? What does it mean to be an “effeminate” man?

Why males, and not men? The word MAN is a culturally loaded term, and carries significant beyond that of biological age and performance. It also is host to concepts of adulthood and personhood, social obligations and family duty. A zenana does not define himself as a man. An adolescent male is not defined as a man.

Why do males have sex with males?

Desire for other males – gender/orientation Desire for specific acts – anal/oral Pleasure and enjoyment from discharge – “body heat” – also play and curiousity Wives do not do anal or oral sex – ashamed to ask

Males are easier to access –females are more socially policed and can be more difficult to access Protecting a girls virginity – maintaining chastity For money, employment, favours Anus is tighter than vagina and gives more pleasure No marriage involvement Its not real sex

Feminine males who desire other males - receptive Masculine males who desire other males - penetrative Males who both penetrate and get penetrated Males who just want anal or oral sex - discharge, ‘body heat’ Situational male-male sex behaviours

Frameworks of male-to-male sex Gendered framework Male to male desire based on feminised gendered roles an identification - sexual acts based on gender roles, i.e. man/not-man Discharge framework Male to male sexual behaviours arising from immediate access, opportunity, and “body heat”. They involve males/boys/men from the general male population

Many males from the general male population will also access feminised-identified males or boys for anal/oral sex . These males do not see themselves as “homosexuals”, or even their behaviour as “homosexual”, since they take on the “manly” penetrating role in male to male sex. Nor do their partners see themselves as homosexuals because they either see themselves as “not men”, or they are involved in play - not sex.

Emergent gay framework Male to male desire framed by sexual orientation. Primarily used by middle and upper classes. Such gay identified men usually seek other gay identified men as sex partners.

And of course not to forget, males/men in all male institutions, such as prisons, the uniformed forces, colleges, university, schools, religious institutions, as well as a range of occupational groups and situations.

Most male-to-male sexual behaviours are invisible and not gay/homosexual/kathoey/apwint identified Sexual/gender identities tend to be based on class, education, and sex roles Many males involved in male-to-male sex will also often have sex with wives/other women Male-to-male sex is not uncommon and involves males across the economic and social spectrum, rural and urban MSM then is no an exclusive category or “target group” – it reflects a behaviour which may be relatively common The issue is risk and vulnerability

Thus in Pakistan MSM can be categorised as: Hijras Zenanas Chawas/murwasi “college boys” Gay/homosexual identified men Male sex workers, including malaishes who sell sex And there sexual partners

Who should we focus on? Identity/groups or behaviour? Why?

Identities and/or behaviour Various types of self-identified zenanas Real men who penetrate - called giryas by zenanas/hijras

Identities and/or behaviour Two male sex workers - chavas and one self-identified zenana who also sells sex A malaisha who also sells sex to males and females - will penetrate and be penetrated

Risks and vulnerabilities Multiple partners Anal sex as primary sexual activity Low condom use Significant levels of STIs Sex with both male and female partners Marriage Stigma and discrimination Invisibility and denial Myths and misconceptions

Risks and vulnerabilities Gendered framework Sexual violence Illegality and conflict of state policies Poor access to treatment Low coverage of appropriate sexual health services Poverty Low levels of knowledge and understanding

Issues, needs and concerns

Issues, needs and concerns Significant levels of male-to-male sex Anal sex the predominate behaviour Multiple partners Significant levels of commercial sex work High rates of STIs Low levels of health seeking behaviours

Issues, needs and concerns Inadequate STI services: anal and oral STIs No water-based lubricant Stigma and discrimination Violence and harassment Low level of condom use

Issues. Needs and concerns Female partners including wives Psychosexual issues and myths Legal, police, judiciary Very low service coverage Low technical skills and capacity

Issues Environment Understanding and knowledge Services social exclusion Legal and policy advocacy sensitization Understanding and knowledge epidemiology ethnographic/anthro behavioral Meaningful Involvement of the affected Populations Group interface Effectiveness and impact assessment Services Appropriateness Delivery environment availability accessibility

There are only 2 main strategies for promoting sexual health THE MORAL STRATEGY – DON’T DO IT THE PRAGMATIC STRATEGY – DO IT SAFELY WHICH STRATEGY WOULD BE THE MOST EFFECTIVE?

Frameworks for prevention Identity/behavioural based interventions through self-help organising and peer pressure Including unprotected anal sex as high risk behaviour in any HIV prevention programme for occupational and situational populations, i.e. truck drivers, prisoners

Changing behaviours

What I feel DESIRE What I believe THINK What I do BEHAVIOUR CONSEQUENCE

Changing behaviour requires Knowledge Desire to change Will to change Skills to change practice Power Access to sexual health services and products An enabling environment

Sexual Health Sexual health is the integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love. WHO, 1975

Developing responses that address the needs that arise from the: This means: Developing responses that address the needs that arise from the: Physical Emotional Intellectual Social

Building an enabling environment

A disempowering environment What does this mean? Stigma, discrimination and social exclusion affects the ability of vulnerable populations to protect themselves from HIV/AIDS. It disempowers them from support and care. It disenfranchises them from accessing what services may be available. It reduces opportunities to develop appropriate services.

An enabling environment What does this mean? To enable: Authorise, empower, supply with means to take action. To provide with adequate power, means opportunity, or authority. Equity: A system of justice founded on principles of natural justice and fair conduct. Thus to develop an enabling environment means to create systems of empowerment, social justice, and equity for the most marginalised populations.

An enabling environment What does this involve? To empower affected and infected populations to develop and deliver their own self-help services. To increase the technical skills of service providers and those that deliver services To ensure appropriate resources are easily available.

Empowerment Address low self-esteem and self-worth Provide skills and knowledge Provide resources, technical, financial, institutional Advocate on their behalf Create and enabling environment Assist in self-help organising What other steps can be taken?

Developing a response

Education, clinics and products alone will not build sustainable risk reduction.

Addressing the HIV prevention, care and support needs of Hijras & self-identified MSM and male sex workers Need separate outreach strategies and implementation for hijras/zenanas and other sub-populations Community development and mobilising Clinical services providing VTC, STI (also addressing anal and oral STIs), rectal issues, castration and hormonal intake concerns as well as general health

Advocacy Empowerment and self-esteem activities Access to sexual health products such as condoms and lubricant IEC and IPC resources for literate and non-literate populations self-help organising and skills and capacity building

These services will need to be appropriate Access to safe spaces for socialising and community building Outreach specific to the needs of various sub-populations Clinical Services Access to condoms, lubricant and education materials These services will need to be appropriate

advocacy & technical support Field services Outreach and friendship building Community development and mobilisation Education and awareness BCC resource/condom distribution Referrals advocacy & technical support Clinical services STI management HIV testing and counseling Access to ARVs Psychosexual counseling General healthcare Center based activities Socialising and support groups Vocational training and skills building Drop in services Community building activities

Principles of good practice Most key stakeholders (international, national and local), including UNAIDS, based on their global experience, now recognise that for an effective, appropriate, and sustainable, HIV and AIDS prevention programme that focuses on any marginalised and socially excluded population, certain key indicators are required. These are:

Focused participatory interventions Strategic focusing of participatory prevention programmes for MSM populations most at risk. Need 80% coverage of these sub-populations Ownership of the issue Those most at risk will also need to acknowledge their own risk and own the issues involved.

Self-help community-based organising To ensure involvement of, and management by, beneficiaries, key individuals within marginalised populations should be recruited, provided training and skills building, and empowered to develop their own service organisation. Access to appropriate and affordable STI treatment services It is essential that clinicians providing STI treatment services are sensitised to the specific sexual health needs of vulnerable MSM, which includes providing STI management in regard to anal STIs and symptoms. Such services should be confidential, not only around STI status, but also with regard to sexuality and behavioural choices.

Access to appropriate HIV voluntary testing and counselling Ensuring that confidential testing along with pre-test and post-test counselling appropriate and sympathetic to the needs of MSM is essential. Access to appropriate HIV treatment and care services Many MSM living with HIV/AIDS are not only stigmatised by their positive status, but also by the route of infection and their feminised sensibilities. Treatment, care and support programmes need to be sensitised to these different frameworks of stigmatisation and address them appropriately.

Access to affordable condoms and water-based lubricants Reducing the risks of STI/HIV infection is central to any effective HIV/AIDS prevention programme. The most significant risk is through anal sex, both for the penetrated as well as for the penetrator. Regular use of condoms for anal sex is an essential component for any risk reduction strategy. However, in addition to this, ready access to appropriately packaged water-based lubricant is also an essential component of this, since anal sex by its nature increases the stress on condoms itself as well as reduces rectal damage.

Access to appropriate BCC materials These materials need to be appropriate to the issues and concerns of MSM in languages, terminologies and imagery that are meaningful and understandable to them.

Long-term technical and financial support It is most likely that the level of technical knowledge to develop, implement and manage an HIV/AIDS prevention and care programme for peer beneficiaries will be low if existent at all. Developing these skills and knowledge will require a sustained effort to share such information with those developing the service. At the same time, these self-help initiatives must also en ensured of appropriate levels of funding over a sustained period of time in order to develop these skills and continuity of service provision.

Advocacy on legal, judicial and social impediments to promoting HIV/AIDS prevention and sexual health for MSM Along with advocacy on the above signifiers, advocacy on addressing the legal, judicial and social impediments to HIV/AIDS prevention and care programmes focusing on MSM is an essential requirement towards developing an empowering environment so that affected populations can reduce their risks to HIV/STI infections and modify their sexual practices in order to achieve this.

Thank you