Little is known about the intersection of risk behaviours of MSM with substance
use in Asia. Although it is increasingly recognised that they play a
substantial role in the HIV epidemics of Thailand, Indonesia, India, China,
Pakistan, Vietnam and other Asian countries, it is becoming apparent that
traditional Western ideas of what constitutes sex between men do not often
correlate with the Asian experience.
For example, in Thai culture there are three genders: male, female and Katoey:
the latter are males who adopt female names, roles, and identities, and are
perceived as a second category of women. Men who have sex with Katoey do not
perceive themselves - and are not perceived by others in Thailand - to be
engaging in sex between men.
Aware of the need for more research in this area, the US and Thai researchers
sought to investigate MSM behaviours among populations of recovering substance
users in Thailand. Their Opiate Users Research (OUR) cohort enrolled 2005
substance-using males over the age of 13 who presented for voluntary drug
detoxification for opiate and/or methamphetamine use in northern Thailand.
Of the 2005 OUR cohort members, 1752 (84.7%) reported ever having had sex. Only
3.8% (66/1752) reported ever having sex with men. Of these, most (56/66; 84.8%)
reported sex exclusively with Katoey; seven (10.6%) reported sex exclusively
with another male-identified man; and three (4.5%) reported sex with both
Katoey and with another male-identified man.
Although the MSM were significantly younger (median 25 vs. 30 years) than the
heterosexual men, they had significantly higher numbers of lifetime sexual
partners (median 20 vs. 6; p=0.0001); reported more female sex partners in the
past year (median 2 vs. data not shown; p= 0.002); were more likely to have had
female paid sex partners (78.8% vs.46.3%; p<0.0001) and were more likely to
have been paid for sex (27.3 vs. 0.3%;p<0.0001) than the heterosexual men in
the cohort.
The MSM were significantly more likely to have HIV infection on admission for
drug detoxification than the heterosexual men in the cohort (31% vs. 16.2%; OR,
2.32; 95% CI, 1.36-3.96). Prevalence of hepatitis C infection was also greater
amongst the MSM (65.2% vs. 41.9%; OR, 2.59; 95% CI, 1.55-4.34). However there
was no difference seen in the prevalence of sexual transmitted infections.
Multivariate logistic regression analysis that compared MSM with all other
sexually active male drug users found that younger age, Thai ethnicity, greater
number of lifetime sex partners, having traded sex for money, and having a Fang
Muk (a traditional Thai penile implant) were all independently associated with
MSM behaviour. However, having been incarcerated, injection drug history, and
being HIV-infected were found not to be independent predictors of MSM
behaviour.
The authors concede that a limitation of their study is the absence of Katoey
participants. Although the majority of MSM in their cohort reported sex with
Katoey, "we do not have data on how many men (or women) self-identified as
Katoey. Studies of HIV and other health concerns among Katoey are urgently
needed to assess the prevention needs of these transgendered men."
The researchers point out that a Google search for Katoey resulted in more than
25,000 results detailing bars, clubs, dating services and chat rooms, whereas a
Medline search "yielded no scientific publications. Although HIV and sexual
health research may have overlooked Katoey, the sex and tourism industries have
not," they remark.
They go on to argue that targeted prevention strategies "must take into account
divergent cultural forms of identity, gender and behaviour", but were
encouraged by the high knowledge of HIV infection and prevention reported by
the MSM in their cohort.
In fact, MSM were more likely to have had an HIV test prior to engaging indrug
detoxification (p<0.0001), more likely to agree with the statement that
condoms were effective for HIVprevention (p<0.01), and do not often break or
leak during sex(p<0.001) than the heterosexual men in the cohort.
However, they were also more likely to agree with the statement that condoms
reduced sexualpleasure (p<0.0001) and that withdrawal before ejaculation can
prevent HIV infection(p<0.001).
The researchers conclude that "the high rates of sexual and substance use risks
[in Thai MSM] suggest that prevention remains a priority."
Reference
Beyrer C et al. High HIV, hepatitis C and sexual risks among drug-using men who
have sex with men in northern Thailand. AIDS 19 (14): 1535-1540, 2005.
