Policy Implications for HIV Services
This publication was prepared by Myra Betron and Evelyn Gonzalez-Figueroa. The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the U.S. Government.
EXECUTIVE SUMMARY Background After 26 years of grappling with the HIV/AIDS epidemic, providers, researchers, and policymakers understand that social discrimination is connected to HIV risk, vulnerability, and access to care and prevention. Unfortunately, around the world, men who have sex with men (MSM) and transgender persons (TG) often face stigma, discrimination, poverty, violation of human rights, homophobia, and heterosexism. Negative attitudes and violence toward gay men, MSM, and TG commonly are condoned by the State and society in many countries. In such environments, MSM often face arrest if they overtly state their sexual orientation, and expressions of same-sex behavior can be punished by imprisonment. Law enforcement and healthcare providers often perpetrate widespread corruption, intimidation, and harassment against gay men, MSM, and TG, thus hindering them from accessing services. Similarly, the rates of violence among MSM and TG, particularly those engaging in sex work, are alarming.
This violence and stigma and discrimination (S&D) faced by MSM and TG often find their roots in homophobia, or fear of homosexuality, as well as a general fear of those whose gender identity does not adhere to traditional gender norms. Violence against MSM and TG often is a manifestation of stigma and discrimination due, at least in part, to the fact that they do not fit into traditional gender categories. Those who enact violence against MSM and TG may feel a sense of entitlement to greater power and control based on perceptions that his/her gender is of a higher social status than that of the victim. Moreover, evidence points to the fact that intimate partner violence (IPV) faced by MSM and TG mirrors intimate partner violence that women experience—the perpetrator uses violence as a way to maintain power and control over the victim, and often the victim takes on the more effeminate role in the relationships. In these ways, violence against MSM and TG can be considered a form of gender-based violence (GBV).
According to the literature, violence against MSM and TG increases their vulnerability to HIV and AIDS. The most direct documented link is the high level of sexual coercion—often without condoms—that MSM and TG suffer. Evidence also shows a correlation between IPV and having sex without condoms. Likewise, violence against MSM and TG may also further degrade their self-esteem, leading to other high-risk behavior, including substance abuse, transactional sex, or forcing sex themselves. More overtly, violence or fear of violence by health professionals prevents MSM, TG, and sex workers—those with and without HIV—from accessing critical health services, and sex workers often are harassed if they are found carrying condoms, which denotes being a sex worker (SW) in many cultures.
Despite the fact that MSM and TG face numerous vulnerabilities related to violence, stigma, and discrimination based on their gender identity, health-related services are limited to a handful of pilot programs that only touch upon the problem of violence as it emerges as a key issue for MSM and TG. On the whole, however, MSM and TG are so marginalized that they do not access health services, whether due to poverty, discrimination, or a general lack of knowledge.
As this review has identified, there is still much to be learned about how gender-based violence affects the lives of MSM and TG, including HIV vulnerability. Through evaluation of the above interventions and additional studies, the following information should be collected:
Different types of violence and abuse by subcategory of MSM and TG;
Perceptions of MSM as to whether IPV is violence and to what extent they think it is gender based;
The full complexity of the links between violence against MSM/TG and HIV, especially as revealed through qualitative research; The help-seeking behavior of MSM and TG to identify whom they are most likely to approach when in need of emotional or physical health services;
Attitudes of health professionals toward MSM and TG to understand how open they are toward those individuals;
Discovery of whether screening for violence in HIV or other health services is an effective entry point to address violence against MSM and TG; and
Ways that HIV and/or other health interventions can address violence within their programs.
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