1. Venkatesan Chakrapani - Consultant Physician, Social Welfare Association for Men (SWAM), India - Policy & Research officer, Indian Network for People living with HIV/AIDS (INP+), India cvenkatesan@hotmail.com www.indianGLBThealth.info METHODOLOGICAL & ETHICAL ISSUES IN CONDUCTING BEHAVIORAL RESEARCH AMONG MEN WHO HAVE SEX WITH MEN (MSM) IN INDIA

2. ISSUE In India, men who have sex with men (MSM) might have indigenous identities/labels based on gender expression & sexual role (Kothi- feminine/receptive, Panthi- masculine/penetrative, DoubleDecker- penetrates/receives); “western” identities – gay/bisexual; or no specific identity. Presence of these diverse populations of MSM poses unique challenges in conducting research.

3. DESCRIPTION: 1. Getting ‘representative sample’ in a survey research - One does not know the proportions of the different subpopulations of MSM. Thus one cannot recruit a ‘representative sample’ of MSM. (Also, “MSM population” is NOT static, in that sexual behaviors can change in an individual over time) - Need for inclusion of different subpopulations of MSM means need to recruit MSM from different venues and with different identities (or no specific identity) or behavior

4. 1. Getting ‘representative sample’ in a survey research: (Contd.) This poses some problems since –Recruiting some subpopulations of MSM is difficult. –The proportion of a particular subpopulation enrolled in a study depends on many factors – venue type, who is recruiting the participants (identity of the recruiters), type of MSM served by the community agency that assists in recruitment.

5. 2. Identities and Labels: Sampling issues Kothi-identity is shared by feminine homosexual males & Aravanis/Alis (male-to-female transsexual/transgendered persons). ‘Panthi’ is a label given by kothis to their masculine partners with no specific identity. ‘DoubleDecker’ is the term used by kothis to denote MSM with any/no identity who inserts & receives. Some could identify as both kothi & gay. These point out the difficulties in asking the ‘identity’ of MSM in surveys & in recruiting MSM belonging to mutually exclusive categories (‘identities’).

6. 3. Recruiting MSM from cruising area Some subpopulations may not be recruited since the recruiter may tend to approach those MSM who have a particular identity and who “appear” to be homosexual men. The safety of the recruiters is also a concern if we are going to screen all the males coming to the cruising area for same-sex/bisexual behavior (to assess their eligibility to participate in the study).

7. 4. Practical problems in adhering to a specific sampling technique Example: to recruit every third MSM who comes to the cruising area from 6 to 8 pm. –Among the males coming to the cruising area it is not possible to know who are MSM. –Since the cruising area may have several entrances/exits there will be a problem in choosing “every third MSM” coming to the cruising area. –Need for adequate research staff: one ‘clicker’ and two or three recruiters/interviewers

8. 5. Cruising area as the site of interview poses some issues Is it safe to administer questionnaire in the cruising area? Does the interviewee accept that a questionnaire is used? Will his apprehension or distraction in using the questionnaire in a public venue affect the accuracy of his responses? Is the participant comfortable in talking about intimate sexual practices and condom use in a cruising area? Is the participant interested in only looking for partners in the cruising area and not in answering to the questions so that the accuracy of the answers is questionable?

9. 5. Cruising area as the site of interview poses some issues (Contd.) Does the length of the questionnaire need to be reduced to facilitate quick interviews in the cruising area? (If so, will this result in not getting adequate information?) How can the questionnaire be made discreet so that others don’t notice that a survey is being done? Should the questionnaire not be administered in the cruising area but the interviewer has to memorize the questions (and answers!) and then fill up the questionnaire in a safe place?

10. 6. Advantages and disadvantages of having a ‘community’ interviewer The dynamics between the interviewer and the interviewee may depend upon their self-identities. Kothi-identified participant may not reveal their “high- risk’ behaviors since the “non-community” interviewer [“Panthi”] could be a potential sexual partner. Gay- identified participant may face a similar situation with a gay-identified interviewer. Embarrassed to talk about condom use and sexual history since the community interviewer is known to the participant and he may be seeing the interviewer again later in the cruising areas. Interviewee may be afraid that the community interviewer might tell others or knows all his secrets and can blackmail him.

11. 7. Issues in offering and not offering monetary incentives a. Concerns of community leaders if participants are offered monetary incentives –It will become a habit to ask money for participating in research –Monetary imbursement inhibits volunteerism and the feeling that ultimately their community is getting benefited. –“Non-MSM” may want to participate in the survey –Problems from some MSM if systematic random technique is employed –Concerns of the management about corruption among the recruitment staff if money is given.

12. 7. Issues in offering and not offering monetary incentives (Contd.) b. Concerns if monetary incentives are not offered: –A feeling that ‘MSM’ population is being used for research but they are not ‘benefited’. –MSM from lower class would appreciate if their time is compensated for and if their travel expenses (if any) are reimbursed.

13. 8. Informed consent & confidentiality Some subpopulations of MSM (example: MSM from lower socioeconomic status) may not participate if we insist on signature or finger imprint. Oral consent (verbal) should be ok in certain situations. Interviewer can sign on behalf of interviewee to imply that consent has been given and the participant can put ‘x’ sign to indicate that he consents. Can a copy of informed consent be given to the participant, if that poses the risk that others come to know about his behavior?

14. LESSONS LEARNED Different sampling & recruitment strategies are needed to gain access to diverse populations of MSM. Cultural & local context need to be considered when following “standard” ethical guidelines.

15. RECOMMENDATIONS Appropriate methodologies need to be developed to do quality research among MSM in India. Community members need to be involved in solving research ethical dilemmas. Acknowledgements: SWAM Team: Sekar Balasubramaniam, Reginald Watts, Timothy Ebenezer, EC Gnanasundari, P Nalini, P Mahalingam and all the field staff of SWAM