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Studies attempt to understand MSM behavior
By Gus Cairns
July 30, 2004
Several studies presented at the World AIDS Conference documented gay life in
India, China and other parts of the globe, and in many cases showed that gay
men are missing out on HIV-prevention messages.
The first thing to sort out, however, appeared to be what to call men with
same-sex attraction. The acronym "MSM," for Men who have Sex with Men, seemed
to be the usual conference term, in deference to societies that don't view
homosexuality through the lens of modern "gay" culture, or to men who only had
sex with other men in certain situations, such as in prison.
But this abbreviation was criticized as dangerous and demeaning by
HIV-prevention campaigners from the developed world, such as San Francsco's
Frank Strona, who came to the conference to present his Web site
SafeSexCity.com, a riposte to sites like Barebackcity.com. Strona had to fund
Safesexcity with $10,000 of privately raised capital after U.S. funding for gay
men's HIV information dried up.
"HIV funders and providers need to start looking at us as men who have sex with
men who love men," he said. Sexual behavior always includes the emotions, and
concentrating exclusively on sex would miss out on the psychological drivers of
much unsafe sexual behavior, Strona argued.
Alex Carballo-Diéguez of Columbia University in New York is currently
investigating the motivation of men who seek out bareback sex.
He described how he and a team of racially diverse researchers posed as
"regular guys" over a three-month period in the most popular chatrooms online
to compile what he called a "cybercartography" of the use of the Internet to
contact men for bareback sex. Having mapped the most popular sites, his team
now intends to interview users to find out why they seek out condomless
encounters.
Whatever they are called, while "men who make love to men" seem to be
discarding prevention messages in the developed world, they are missing out on
them altogether in the developing world.
There were several alarming studies from India, the Asian country where
epidemiologists most fear an Africa-style HIV epidemic may take off in the next
few years.
There was much talk at the conference of the fact that married, monogamous
women were now among those most vulnerable to HIV, and that they needed
female-controlled prevention methods like microbicides.
But there was less talk about where the men who infected them were getting HIV
from. The answer, certainly in some countries, seems to be that they are
getting it more often from other men than from women sex workers.
A study of 6,661 MSMs contacted through parks and cruising areas in Hyderabad
in central India showed that the vast majority of them (87 percent) had had
unprotected anal sex, nearly half had had it in the last two weeks and 20
percent in their last sexual encounter. Although 85 percent had heard of AIDS
and 70 percent knew condoms could prevent it, nearly a quarter of them had
never even heard of condoms.
The study gave fascinating insights into how the men regarded themselves. 46
percent described themselves as "Kothis," that is, bottoms; 43 percent were
"Panthis," or tops; and only one in nine, 11 percent, called themselves "double
deckers," the local term for what we would call "versatile."
Thirty-one percent had never been to school, and less education, an income
under U.S. $22 a week, being under 30 and, worryingly, being a Kothi were all
predictive of not using condoms and/or not knowing about them. On the other
hand, those who said they didn't use condoms because they couldn't get them
were more likely to be "double deckers" and to be better educated.
Evidence that their man/man sex could be a source of infection to women was
provided by the fact that 41 percent of the men were currently married (though,
intriguingly, 2.3 percent said "to a man"), and that half of them had had sex
with a woman in the last three months, mostly without condoms.
Another survey from Mumbai added another term to the list: MSHs, or Men who
have Sex with Hijras, Hijras being the religiously castrated transsexual caste
in India.
This was a survey of 1,901 men presenting at several STD clinics in Bombay.
Of these men, 431 (23 percent) said they had sex with men, and 185 (10 percent)
said they had sex with Hijras but not other men. Nearly all of them had sex
with women too, and though 55 percent used condoms with female sex workers,
only 15 percent did so with regular female partners. The men who were what we
would call "bisexual" were also more likely to have anal sex with women.
The answers about who were "tops" and who were "bottoms" differed completely
from those of the Hyderabad study, however. Ninety-eight percent of the MSMs
said they'd had "insertive" anal intercourse, but only 13 percent admitted to
having been penetrated. Whether this reflects a different population or just
different questioning is a moot point.
A final study from India stirred intravenous drug use into the potentially
deadly mix, looking at men in the southern city of Chennai who were intravenous
users (IVDUs).
By Indian standards, there was a horrifyingly high HIV prevalence of 34 percent
in men who were current IVDUs and 22 percent in men who had been. Twenty-two
percent said they had sex with both men and women.
Most were married, but so far the HIV prevalence in their wives was only 5
percent, which the researchers somewhat optimistically described as a "window
of opportunity" to get HIV messages across to this group.
A study from China showed a totally different take on homosexuality again, with
Chinese men studied in Beijing apparently more likely to use westernized terms
like "gay" (59 percent) or "bi" (34 percent) to describe themselves.
The men were recruited in bars and via gay friendship networks rather than in
cruising areas. And unlike the Indian men, they were much less likely to be
married; 86 percent were single. This may have more to do with the current high
rates of internal migration and migrant labor in China than the adoption of gay
lifestyles, though; two-thirds of the men had no legal residence status in
Beijing.
Only 15 percent considered themselves at high risk for HIV, and only one of the
482 men already knew he had HIV. When blood samples were taken, it turned out
that 15 of them were HIV-positive, or 3.1 percent -- a rate comparable with
that of provincial areas of the U.K. So, although HIV has clearly found its way
into the gay population in China, its potential to cause a generalized epidemic
is less immediate than in India.
In one reminder of the isolation and stigma endured by many gay men in the
developing world, the Beijing man were "out" as gay to an average of two other
people. None were out to more than 10 other people, and many kept their
homosexuality a secret from everyone.
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