1 SECTION ONE: BASIC ISSUES

This section covers why men have sex with men, how men have sex with men,
social and personal issues.

WHO?

Peter, a 17-year-old in a boarding school in South Africa, sometimes crawls late at night
into the bed of his 16-year-old friend Daniel. They play with each other. Peter talks about
girls and so does Daniel, although the younger boy is more interested in his friend.

Vladimir, a 20-year-old Russian, has been in prison for a year. He had a girlfriend before
he was arrested for drug dealing, but he doesn’t think he will see her again. Every night
he has sex with Boris, a large, violent man in his forties, because Boris protects him from
other, more violent men.

Twenty-three-year-old Lal is a rickshaw driver in Dhaka, Bangladesh. Some nights he

goes to one of the big parks in the city where he can meet men who are attracted to
other men.

Thirty years ago, Julia was born a boy in a small town in Costa Rica, but since the age of
16 she has dressed as a woman and taken hormones to develop her breasts. She makes
a little money as an entertainer in bars in San José, the capital, but most nights she
stands on a street corner and waits for customers to drive by.

Shen-Wah is an unmarried 33-year-old in Shanghai, China. He has just discovered the

city’s latest gay bar, where he goes two or three times a week, hoping to
meet a man to fall in love with.

Jorge and Hideki are two men in their forties

in São Paulo, Brazil. They have lived together
for 16 years. Very occasionally they have sex
together, but more often each has
“adventures” with other men.

Sunil, 35, and his partner Raj, 50,

consider themselves lucky to share
a large house near the ocean in
Mumbai, India. They have just
celebrated ten years of living
together and being faithful to
each other.

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BASIC ISSUES

René is a 55-year-old businessman in Abidjan, the Ivory Coast. He is married and has
three children. At night he sometimes drives down one of the main avenues in the city
looking for the young men who wait under the trees for men like René to stop and call
them over.

A universal phenomenon
Sex between men is found in every stratum of every society: among the young,
middle-aged and old; rich and poor; married and single; educated and illiterate;
the ethnic majority and ethnic minorities; criminals and honest men; singers and
sportsmen; beggars and businessmen; postmen and politicians.

It is a phenomenon as old as history. In ancient China, it was called the ‘Love of the
Cut Sleeve’, after an emperor who cut off the sleeve of his robe rather than wake his
male partner who was sleeping on it. In ancient Greece and medieval Japan, warriors
took teenage boys as lovers. In many North American tribes, men who dressed and
lived as women spent their lives with other men. Medieval Arab literature contains
many examples of men who made love to younger men.

Social attitudes change over time, but men continue to have sex with other men,
regardless of whether society approves or disapproves. In Western Europe in the
nineteenth century, sex between men was a criminal offence; today it is fairly widely
accepted. In many parts of Africa before colonisation, some forms of sex between
men were accepted; today some people claim it is “un-African”. Classical Indian
sculpture and art shows men embracing,
yet Indian law, drafted by the British
colonisers, penalises sex between men.

Men who have sex with men are not

a discrete group, somehow set
apart from the rest of society.
Most also have sex with women;
many – perhaps the majority –
are married. That means any
epidemic of HIV/AIDS or another
sexually transmitted infection
will not be confined to that
sector of the population.

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How many?
How many men have sex with other men is not known. Research is difficult,
particularly in countries where sex between men is taboo. And where research has
been undertaken, the methods and results are sometimes uncertain. Respondents
may be unwilling to answer the question “have you had sex with a man?” or they
may interpret the question differently from the questioner.

Recent statistics from around the world suggest that at least 3 per cent, and perhaps
as many as 16 per cent, of men have had some form of sex at least once with another
man. That suggests a global figure of anywhere between 45 and 240 million men.

How old?
Some boys are sexually active before they reach sexual maturity – usually defined by
the appearance of pubic hair and the ability to ejaculate. This may be with children
of their own age, or as the result of abuse by older children or adults. Sexual abuse of
children – when adults have sex with children – can cause severe mental and physical
trauma and is condemned by every society.

Irrespective of the legal age of consent, many sexually mature boys are sexually
active, sometimes with girls or women, sometimes with boys or men and sometimes
with both sexes. This may be with both partners’ consent or it may be the result of
psychological or physical coercion, either by the boy or by his partner, particularly if
the partner is older.

Because there is often no clear legal, social or physical boundary between sexually
mature boys and adult men, and because sexual activity can start at an early age,
unless otherwise specified, the word “men” in this booklet includes boys who have
reached sexual maturity.

WHY?

Men have sex with other men for many different reasons. Most men do so from
desire, but others do so for money or some other reward, or because women are not
available, or because they are forced to.

In every society a minority of men are sexually attracted to other men. Many have
wives or girlfriends and children, but they prefer sex with men. Some are single and
only occasionally have sex with women. Some never have sex with women.

Some men have sex with other men for money or gifts. They may prefer men or they
may prefer women, but need or want the rewards that other men give them for sex.

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Some men have sex with men because no women are available. Teenage boys in
boarding school or adult men in single-sex situations, such as prison or the military,
may seek other men for sexual release. “Men need to use their dick to feel like men, and
if they don’t have a woman, then they screw a guy”, explains Enrique, a prisoner in
Costa Rica.

Most sexual acts between men are consensual. However, some men are raped or
otherwise forced into sex, especially if they are young or weak, by other men, for
sexual release, as punishment or to establish power. This is common in prison, but
can occur anywhere. Some men use psychological rather than physical coercion to
oblige other men to have sex with them.

When two men have sex, they don’t always do so for the same reason. In a commercial
exchange, for example, the client probably prefers men, while the man he is paying
may prefer women.

We don’t know why most people are sexually attracted to the opposite sex, but
some men and women prefer their own sex. Some people suggest that sexual
attraction is influenced by a child’s relations with other people, in particular their
parents. Others suggest that preferring your own sex is a matter of willpower, and
men who have sex with other men do so from a wish to be “perverse”. However,
there is little evidence for either of these theories. The most likely explanation is
that sexual attraction, whether to one’s own or the opposite sex, is like right – or
left-handedness; it is inborn and cannot be explained or predicted.

Social constructs
Although men have sex with other men for different reasons, the words used to
describe them usually refer to what they do rather than why they do it. These words
reflect social constructs – the way in which societies think about sexual behaviour
and social relations.

In western countries, such as North America, much of Europe and Australia, and
New Zealand, sexual behaviour is defined according to the sex of one’s partner:
to prefer one’s own sex is to be “homosexual”; to prefer the opposite sex is to
be “heterosexual”; and to have more or less equal preference is to be “bisexual”.
Other words used include “gay”, which means to be homosexual and to demand
the same legal and social rights as the rest of society.

In many other parts of the world, however, sexual identity (who you are) and sexual
behaviour (what you do) is often defined according to whether you penetrate or
are penetrated. In many parts of Latin America, for example, a man who takes the
penetrative (also known as active) role in sex, whether with a woman or another

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man, is described as macho, while a man who allows himself to be penetrated (takes
the passive role) is maricón (Spanish-speaking countries) or bicha (Brazil). In South
Asia and elsewhere, similar distinctions are made: in Hindi and related languages a
kothi is a man who is penetrated, a panthi is a man who penetrates men and double-
deckers may take either role.

Even within a culture, social constructs and definitions may

vary. For example, most middle-class Costa Ricans would not
recognise the distinctions drawn in the
country’s prisons between cacheros, who
perform active anal sex, guilas, young men
who are penetrated, travestis, who are
men dressed as women, and others.

Masculinity and other genders

Definitions of sexual behaviour often
reflect definitions of sexual identity or
gender – the social roles that men and
women are expected to play. These social
roles vary from society to society and are not
always defined by an individual’s physical sex.
Not everyone with a penis considers
himself – or is considered by others – a man.

Masculinity – the social role associated with boys and men – is a

cultural, not physical, phenomenon. Some attributes of masculinity, such as a
willingness to take risks, appear to be common all over the world, but others vary.
In parts of India, for example, a young man who appears effeminate in western eyes
but who has a wife and child, is considered more masculine than a more aggressive
older man who is unmarried and childless.

Preference for the passive role in sex is often associated with a measure of
femininity, such as dressing as women and using speech and mannerisms associated
with women – although it should not be assumed that all effeminate men prefer to
be penetrated.

Some men take hormones to develop female breasts, and some also undergo such
operations as removal of the testicles and penis, creation of a vagina, removal of
their Adam’s apple or enlargement of the hips to become women. In English, such
people may describe themselves as transvestite (wearing women’s clothes) or
transsexual (undergoing some or all body changes). Words in other languages
include: yan daudu in northern Nigeria, travesti in South America, bencong in

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Indonesia, fa’afafine in the Pacific Islands and hijra (also known as ali or eunuch)
in South Asia. And while many of these terms imply a degree of femininity, some
individuals reject labels of both masculinity and femininity, calling themselves
“not-men” or a third sex.

All these categories are fluid and not determined by physical or biological features
alone.They are included in the word “transgender”, which covers the many identities
and behaviours that cross gender norms.

In other words, many individuals referred to as men in this booklet do not think of
themselves as such and are not seen as men by their sexual partners or the society in
which they live. Not only is it important to recognise and respect different identities,
but those identities must determine the nature of HIV/STI prevention activities.

Behaviour and desire, activity and identity

Sexual behaviour is not the same as sexual desire. Some men who want
to have sex with other men never do so, while some who prefer sex with
women have sex with men. A few men are asexual;
they have no sexual desire at all.

Similarly, sexual activity is not the same as sexual identity.

In the West, men who claim to be heterosexual may
have sex with men, and men
who say they are
homosexual sometimes
have sex with women.
Elsewhere, men who
appear highly feminine
may take the penetrative
role in sex, while men
who appear to be the
active partner may enjoy
being penetrated.

Sometimes society’s taboos are so strong that men will not admit even to
themselves where their true preference lies. For example, a young man who sells
sex may tell himself he is only doing it for money, when the real reason is that he
is attracted to men more than women.

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Sexual identity is not fixed but changes over time according to an individual’s
perception of themselves and changing values in society. As cultures come into
contact with each other, words and ideas are exchanged and sometimes used
differently. Thus “homosexual” is sometimes used to refer to any man who has sex
with another man, irrespective of his sexual preference, while in many parts of the
world “gay” has come to mean men who are effeminate or transgendered.

Worldwide, there is a growing tendency to use western definitions of sexual

behaviour, particularly among the middle classes. However, millions of men who
have sex with men still categorise their sexuality according to the culture in which
they live, and those who work with them must conform to their perspectives
and needs.

Sex, love and emotion

The emotions experienced by two men in a relationship cannot always be easily
categorised. The meaning of the word “love” varies not only from culture to culture
but from individual to individual. And some men who have sex with other men are
afraid to fall in love with them because of the social and psychological problems
that it would cause. Others are aware of their strong feelings but are unable to
express them.

For many people, sex is an essential part of love, although love may not be
essential for sex. Most men who prefer sex with other men often experience a
deeper emotional attraction for their partner. Many wish that they could spend
their lives with another man rather than with a wife and children. Such relationships
are common in the West, but are found everywhere, even in countries where sex
between men is highly taboo. All kinds of arrangements can be made, such as
meeting regularly in a hotel or hired room, frequent travelling together, or one
partner marrying the other’s sister.

It is important to recognise the emotional element of sex between men. Not only
is it a key aspect of self-respect, but love can significantly affect attitudes towards
protecting oneself and one’s partner from sexually transmitted infections.

HOW?

The commonest sexual acts between men are anal intercourse, oral intercourse,
intercrural intercourse (thigh sex) and mutual masturbation. Many of these acts
are also practised by male and female partners, but throughout this booklet it is
assumed that both partners are male.

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It can be difficult to find the most appropriate words to discuss sex. This chapter
uses formal expressions, but gives alternatives commonly used by English speakers
in everyday speech. Each language, of course, has its own formal and informal words
for sex.

Foreplay
Every part of the body can be sexually stimulating and play a part in sexual
activities. In sex between men, attention is usually given to the penis (dick, cock,
prick), the anus (ass, asshole), the mouth, the testicles and scrotum (balls) and the
nipples (tits).

Sexual desire and/or rubbing, or other friction, causes the penis to become erect.
Friction against the head of the penis stimulates the prostate gland to ejaculate
semen (to come or cum) – an essential part of the male orgasm.

Sexual foreplay can arouse both partners. Examples of foreplay include mouth-to-
mouth kissing, caressing or kissing the partner’s body, playing with his nipples,
scrotum and testicles, and penetrating his anus with a finger. Some men find that
prolonged manipulation of their nipples makes them ejaculate.

Sex
The goal of most sexual acts between men is to stimulate the penis until orgasm.
In anal intercourse (fucking), the erect penis penetrates the anus. Anal intercourse
can be performed in many positions, including standing or lying, and with the
recipient facing away from his partner or with both partners facing each other.

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Anal intercourse gives the penetrating partner (also known as the “top”) pleasure
because it produces friction against the penis. It also gives the recipient
partner (also known as the “bottom”) pleasure because
the penis stimulates the prostate gland, located
alongside the rectum (the area
inside the anus). It can
sometimes be painful for
the recipient partner,
particularly when the
recipient is being
penetrated involuntarily,
when there is no lubrication
and when penetration does
not allow time for the muscles in
the anus and rectum to relax.

Because the anus does not have natural

lubrication, some form of lubricant is needed.
This can be spit, which tends to dry quickly, and
various oils, which should not be used with condoms because they
destroy latex. Water-based lubricants, such as K-Y jelly, are ideal.

In intercrural intercourse (thigh sex), one partner places his penis between his
partner’s thighs, usually directly under the groin. The recipient partner receives
pleasure from pressure against the testicles and along the perineum (the area of
skin between the testicles and anus).

Oral intercourse (fellatio, sucking, blowing) is inserting the penis in the partner’s mouth.
Some recipient partners find it uncomfortable, but most enjoy it. Mutual fellatio (sixty-
nine) – when each man takes the other’s penis in his mouth – is also practised.

Masturbation (wanking) is using the hand to bring oneself or one’s partner to

orgasm. Mutual masturbation is when each performs the act for the other.

Some men practise other sexual acts, including sadomasochism (the inflicting of
pain on a consenting partner) and insertion into the anus of objects (dildos,“toys”)
or the hand (fist-fucking). Such acts are more common in cultures where men
have the freedom to explore their sexuality, but can be dangerous when practiced
without getting specialised knowledge of safe practices and techniques.

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Sexual roles and pleasure

Some men prefer to take only one sexual role, as either the penetrator or the
recipient. Others are happy to be versatile, taking either role depending on their
mood or the needs of their partner. Like any human activity, sex can and should be
creative, and sexual roles can change several times during sex. One partner may
fellate (suck) the other, then penetrate him and then be penetrated before either
achieve orgasm.

Both anal intercourse and fellatio can be explicitly and implicitly associated with
power and domination. Anal rape, in particular, is a means of establishing power over
another man. And in many acts of consensual intercourse, one man intentionally
dominates his partner, while his partner is willingly submissive. Other men, however,
see anal intercourse and fellatio as means of giving and receiving pleasure or as acts
of love, where ideas of domination and submission are irrelevant.

Sexual acts which some men find pleasurable are distasteful to others, and men
may find some acts pleasurable on one occasion and distasteful on another.
Pleasure in sex derives as much from an individual’s attitude as from the physical
act he performs. Many factors, including his psychological state, whether he has
been drinking or taking other drugs, and his emotional and physical attraction to
his partner all influence a man’s enjoyment of sex.

The limited research that has been carried out in this area shows that men who
have strong inhibitions about sex with other men – either because they live in a
culture where there is a strong taboo against such sex, or because they have strong
religious or other convictions – are less likely to derive great pleasure from it, are
less likely to explore their own sexuality and are less likely to consider their partners’
sexual needs. They are also less likely to be aware of HIV/STI prevention messages
relating to sex between men. On the other hand, men who are truly at ease with
their sexual preference are more likely to enjoy sex and to give their partner
pleasure – and to be receptive to prevention messages for men who have sex
with men.

Sex work
In some societies, sex work provides an opportunity for poor young men, including
boys who live on the streets, to make money, irrespective of whether they are
primarily attracted to men. Some men find sex work both financially and
psychologically rewarding, and find that it enables them to explore their sexuality.
Men who are aware of what they are doing, at ease with their sexual preference and
accustomed to dealing with clients, are not only more likely to be able to protect
themselves and their partners from infection, but can be role models for their

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colleagues and clients. Many such men form the backbone of groups working
with men who have sex with men across the world.

Sex work also has many disadvantages.

It may be practised unwillingly by boys
and young men who see no other way of
earning an income. Those with very
effeminate behaviour or who dress
as women often find it difficult to
make money in any other way. It
can be dangerous, with violence
from potential clients, the public
and the police, and it may pose a
severe health risk.

WHERE?

Men seek and find sex with other

men in many different places.
Teenage boys and younger men often find it by chance – two
friends talking together and the conversation moves to sex, or sleeping together
and finding they are both aroused. Sometimes an older family member or friend
makes suggestions that lead to sex; depending on status, power and age difference,
this may be welcomed by the younger partner or may constitute abuse.

Men who are aware of their sexual needs often “cruise” – look for other men.
This may be anywhere: in the streets, on buses, in shops and restaurants, or places
where men spend time together, such as bars and sports and gym associations.

In some countries there are bars, nightclubs and bathhouses that specifically cater
to men who are attracted to men. But even where sex between men is taboo, almost
every large town has a park or beach or other public place where men meet. And
almost everywhere men find other men in public toilets. Bars and nightclubs are
more likely to attract wealthier, more educated men; while poorer, less educated
men are more likely to cruise public parks and cinemas. There may be little contact
between the two groups, except in situations where one is paying the other.

As mentioned earlier, single-sex institutions may also enable sex between men.
Sometimes men’s work gives them access to sex; for example, hotel workers may
offer or sell sex to hotel customers and masseurs to their clients. This may not always

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be consensual; the Blue Diamond Society which works with men who have sex
with men in Nepal, for example, reports that feminine men are sometimes
forced to have sex with their employers
in these situations.

Sex does not always occur where men meet, particularly if it does not offer privacy.
It may take place in the home where one partner lives if there is no one there to
object. Where most men live with their families, sex is more likely to take place in the
park or public toilet where they meet, in a massage parlour, a car, a hotel room or
elsewhere. Some men who could take a partner home do not do so because it is too
far, because they do not want to take a stranger home or because they are excited
by the risk of being seen.

Sometimes sex occurs in full view of others. This may be where sex between men is
common, such as in prison, public parks after dark, and nightclubs and bathhouses
frequented only by men. Others may join in the sexual activity, sometimes against
the wishes of one or both of the original participants.

Places that are well-known for cruising can be dangerous if thieves and violent men
go there pretending to offer sex but in reality want to steal from or attack their
victims. And the police may stage raids, which can lead to blackmail or arrest and
trial, or they may attack or even rape the men they find. On the other hand, cruising
places can also be havens for men who have no other opportunities to meet others
who share their preference. They are social spaces where friendships and love affairs
are made and fostered, and communities formed.

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BASIC ISSUES

MEETING IN BELARUS

Vstrecha (“Meeting”) is an NGO in Minsk, Belarus, working with

young gay men, men who do not call themselves homosexual but
who have sex with other men, male sex workers and men who
both have sex with men and inject recreational drugs.

In 2001, funding from the Open Society Institute (Soros Fund)

allowed Vstrecha to undertake research among 300
men who sell sex to other men, identifying their
activities, risks and needs. As a result of the
research, male sex workers have been offered
anonymous testing for HIV, condoms and
lubricants, as well as opportunities to build social
support with Vstrecha and other men in the same position.

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SOCIAL AND PERSONAL ISSUES

As noted above, sexual activity and attitudes towards sex are strongly influenced
by the society in which we live. Attitudes are not monolithic, but are composed of
several strands that may complement or contradict each other. For example,
legislation may penalise sexual activity between men, but public attitudes in large
cities, particularly among the educated, younger middle classes, may be relatively
tolerant. Or the law may not discriminate against sex between men, but public
attitudes are hostile.

Legislation
According to the most comprehensive survey of relevant legislation, undertaken by
the International Lesbian and Gay Association,1 at least 84 countries and territories
specifically outlawed sex between men in 1999. These include nine where such acts
are theoretically subject to the death penalty, although only three countries are
known to have executed men who had sex with other men in the previous ten years.

In most countries where sex between men is legal, it is on the same basis as sex
between men and women, but in some the age limit is higher than the age at which
men can have sex with a woman.

In some countries there is no specific legislation against sex between men, but other
laws, often referring to public morality, may be used to prevent nightclubs or
commercial establishments opening, associations forming or the issue being raised in
public discussion.

Religion
Religious beliefs are a strong and integral part of many people’s identity, including
men who have sex with men. Religious attitudes are highly influential in forming
social, community and legal attitudes towards all aspects of sexual behaviour.

Religious teachings can be interpreted in many different ways, and those

interpretations change over time. Although a large minority of Christians, Jews and
Muslims believe that the scriptures of all three religions permit consensual sex between
men – and there is evidence that it was much more acceptable to Christians and
Muslims several centuries ago – today, most leaders of these three faiths condemn it.

Other religions, such as Buddhism, Hinduism and Shintoism, are less hostile to sex
between men, but are still likely to imply that sex between men is less significant or
important than sex between men and women.

1. This is an ongoing survey published on the web at: http://ilga.org/Information/Legal.survey/ilga.world.legal.survey%20introduction.htm

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Homophobia
In most countries there is a strong current of homophobia – disapproval or hatred
of sex between men (or between women) – which is expressed in stigma and
discrimination and, in extreme forms, violence. Homophobia often has its roots in
law, religion and social attitudes.

Social attitudes partly reflect and partly influence legislation and religious attitudes.
The origins of homophobia are not always clearly understood and are too complex
to discuss here. One theory is that it stems from the insecurity that some men
(particularly those who don’t have sex with other men) feel in their own sexual
identity. Another theory is that power is an essential element of men’s control of
women’s lives, and men who have sex with men or who appear effeminate
challenge that power.

In most parts of the world, a combination of legislation and religious and social
attitudes threaten men who have sex with men with arrest and imprisonment,
dismissal from work and expulsion from the family home, name-calling and public
humiliation, blackmail, violence and even death. The Blue Diamond Society reports
that blackmail, extortion and the threat of exposure are common experiences for
men who have sex with men in Nepal. The Grupo Gay da Bahia in north-east
Brazil estimates that over 100 gay men are killed each year as a consequence
of homophobia.2

Homophobia forces most men who have sex with men to hide their sexuality
from their colleagues, friends and family, and sometimes to deny it to themselves
– sometimes known as “internalised homophobia”. Although some men are
unaffected, for many others it creates patterns of secrecy, fear and shame, which
may lead to depression, abuse of alcohol and violence towards others.

Even those men who do not directly experience violence or discrimination can
suffer from homophobia, since they are likely to suppress aspects of their behaviour
in order to conform to society’s demands. That may include marrying when they
would prefer not to, not showing affection in public and having sex in dangerous
places rather than in the comfort of their own home.

Homophobia also makes it difficult to provide information on health risks and safer
sex behaviour, partly because so many men hide their sexual activity and partly
because individuals and organisations involved in HIV prevention may be unwilling
to work with them.

2. Grupo Gay da Bahia has an ongoing project monitoring anti-gay violence in Brazil. See: http://www.ggb.org.br/ftp/artigo1.rtf

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Recognising one’s true preferences, meeting others who share those preferences
and recognising the harm caused by society’s taboos on sex between men is
liberating for most men. While it does not resolve all their problems, such as pressure
from family to get married, it provides a positive foundation for life, leading to
greater enjoyment and greater likelihood of protecting their health.

Women, marriage and family

Many men who have sex with men also have sex with women on a casual basis, in a
long-term relationship or in a marriage. In some cultures marriages are arranged by
the family, while in others continual questions and pressure from family, neighbours
and friends force many men to find a wife. Some enter these relationships willingly
and consider women their primary sex partners; some prefer men but marry under
compulsion from family and society; while others are unaware of or deny their
preference for men. In such circumstances, sex with one’s wife is often seen as duty
rather than as a source of mutual pleasure.

Some women discover that their partners have sex with men, which can place great
strain on the marriage. Some women accept the situation, but both husband and
wife, and sometimes the children, can be severely stigmatised if there is divorce or
if his sexual behaviour becomes known – although a wife’s family may consider
divorce a preferable solution. A few women welcome the situation, particularly if
they have little interest in sex with men.

Whether or not men tell their woman partners about their sexual activities, they
usually face a range of ethical issues around HIV and other STIs. These include
concerns about personal responsibility, possible infection of their wife and future
children, notifying their partners if they contract an infection, and economic issues
brought on by long-term illness and/or death.

Community and support

Despite this often negative picture,
social attitudes are changing in many
countries as men who have sex with
men become more visible. Underlying
this visibility is a growing sense of
community among men who have
sex with men and the dedication of a
small number of men willing to
challenge society’s taboos.

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BASIC ISSUES

Even in the most hostile societies, many men who have sex with men consider
themselves part of a community, which may meet in parks, bars, people’s homes or on
the internet. Such communities give rise to formal and informal support groups that
may offer psychological, physical, economic or legal support.

Formally established groups may be involved in a wide range of activities, including

campaigning for equal rights, providing legal support for men with problems created
by their sexual preference, and offering a safe place for men to discuss the implications
of their sexuality. Health promotion, particularly around HIV, is almost always an
essential element of their work. Hundreds of such groups exist across the developing
world, yet they meet the needs of only a small proportion of the millions of men
everywhere who have sex with other men.

Informal groups consist of friends who can provide support during difficult times.
They may be able to meet in each others’ homes, but more often it will be in public
spaces where they can talk but are unlikely to be able to offer each other professional,
long-term support for problems that arise from their sexuality. And millions more,
particularly the young, the old and those who live in small towns and rural areas, are
isolated by their sexuality. Informal groups may provide information about health
issues, but without links to wider networks, they cannot always ensure that such
information is comprehensive and correct.

GAYS AND LESBIANS ASSOCIATION

OF ZIMBABWE
Since 1990, Gays and Lesbians Association of Zimbabwe (GALZ), a
membership-based organisation, has been a focus of information,
help and advice for lesbians, gay men, bisexual and
transgendered people (LGBT). The GALZ drop-in centre
provides members with information on HIV and other STIs
and pre- and post-test counselling, while GALZ Positive
not only helps members living with the HIV virus but
has also achieved much by lobbying for the
normalisation of homosexuality within the national
HIV/AIDS network.

The GALZ Affinity Group Programme encourages LGBT communities

across Zimbabwe – and soon to be across Africa – to use HIV/AIDS as
a focus for developing an understanding of their sexualities.

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2 SEX BETWEEN MEN AND HIV/STI PREVENTION

This section looks at sexual health, HIV prevention issues for men who have sex
with men, how to identify risk and vulnerability and what to consider when
designing HIV/STI prevention programmes.

SEXUAL HEALTH AND HIV INFECTION

Across the world, over 40 million people are currently living with HIV. Three million
died of AIDS-related illnesses in 2001. Every day one million people contract an STI
other than HIV. The extent to which these infections result from sex between men is
not known, because in many communities few or no surveys are undertaken and
many men are reluctant to admit that they have sex with men.

In addition to HIV, over 20 infections can be transmitted through sexual activity,

whether between a man and a woman or between two men. These include
gonorrhoea, syphilis, chlamydia, herpes and hepatitis. Some infections are
transmitted more easily than others, and the presence of one infection can increase
the likelihood of transmission of another; for example, HIV is transmitted more easily
when one or both partners has another STI that results in an ulcer or open sore.

Effective HIV/STI prevention depends on individuals understanding their level of

risk, being motivated to reduce that risk and living in an environment that allows
them to take steps to reduce risk. It also depends on their understanding of sexual
matters – how their own body, and their partner’s body, functions.

Unfortunately, many people are ignorant about sex, and where sex education does
exist, it often ignores sex between men. In order to be effective, HIV and other health
programmes for men who have sex with men should include basic information
about sex as well as means of preventing transmission of STIs. Furthermore, because
many men who have sex with men also have sex with women, women’s anatomy
and reproductive health should also be covered.

Varying risk
Risk of infection with HIV or STIs depends on physical, epidemiological and
socio-economic factors.

The extent of physical risk depends on the sex act practised. Vaginal and anal
intercourse without a condom are highly risky, in particular if one partner has
another STI which causes sores or lesions. Oral sex carries much less risk, although
that risk rises if the recipient partner has mouth ulcers or bleeding gums.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

Epidemiological risk depends on the number of partners an individual has

unprotected sex with and the overall extent of infection in the community.
Different factors make people vulnerable or more likely to behave in ways that put
them at risk of infection. Socio-economic vulnerability factors can include a
reluctance to discuss sexual behaviour, as well as such issues as poverty, illiteracy
and homophobia. For example, poverty reduces access to condoms, illiteracy
reduces the options of learning about the risk of infection and homophobia results
in limited or non-existent prevention programmes.

Viruses and bacteria

HIV and other infections are transmitted when infected body fluids – usually vaginal
fluid, semen and blood – from one person enter another person’s body through
broken skin or across mucous membrane (the moist tissue that lines some organs
and body cavities).

Some STIs, such as HIV and herpes, are caused by viruses. Others, such as chlamydia
and gonorrhoea, are caused by bacteria. STIs are present in the bloodstream, semen
and/or vaginal fluid. Transmission usually occurs through vaginal and anal
intercourse. Tiny blood vessels can rupture unseen on the head of the penis, in the
vagina and in the anus, allowing the infection to pass from one person to the other.
Because the tissues of the rectum are relatively fragile, HIV is more easily transmitted
during unprotected (without a condom) anal intercourse than in unprotected
vaginal intercourse.

Some infections, such as herpes and human papilloma

virus, which leads to warts and may
cause cancer, are relatively easily
transmitted through oral intercourse.
However, the risks of transmitting
other infections, such as HIV, in oral
intercourse are considerably smaller
than in unprotected vaginal or anal
intercourse.

Drug use
Some men who have sex with
men also take recreational
drugs such as heroin, cocaine,
ecstasy, other chemical compounds
or alcohol. Injection of recreational drugs
using shared injecting equipment can result in

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transmission of HIV. Recreational drugs that are smoked, drunk or eaten can lower
men’s inhibitions and make them less likely to practise safer sex. Some men take
drugs because they help them to overcome the social and psychological taboos
against having sex with men.

Symptoms and treatment

The symptoms men experience from STIs range from a burning sensation while
urinating (gonorrhoea), to a painless sore (syphilis), to symptoms so vague that they
are not always noticed. HIV can cause flu-like symptoms in the first 12 weeks after
the virus has been contracted, but these symptoms then disappear. Some infections,
including HIV, syphilis and hepatitis, are fatal if untreated. Others, such as herpes,
may only cause persistent discomfort, although they also have long-term
health consequences.

STIs caused by viruses such as herpes and HIV, can be controlled but not cured –
scientists have not discovered a way to eradicate viruses from the body. Infections
caused by bacteria, such as syphilis and gonorrhoea, can be cured by antibiotics.
In both cases, however, the treatment can be lengthy and expensive, and many
people who begin treatment do not complete it. As a consequence, many drug-
resistant forms of STIs are emerging, making them increasingly difficult to treat.

HIV weakens the body’s immune system, making it vulnerable to opportunistic

infections such as tuberculosis. HIV may not present serious symptoms for up to ten
years after infection, but once symptoms of AIDS appear it is usually fatal within two
years. Antiretroviral treatment keeps HIV under control and allows most people
living with the virus to lead healthy lives. Antiretroviral treatment must be taken for
life and although still too expensive for most people in the developing world, access
is increasing, and there is evidence that treatment has a role to play in prevention.

PREVENTION

The best treatment for any STI is prevention – not to become infected in the first
place. This subsection looks at the actions that individuals can take to protect
themselves and their sexual partners. However, it is also necessary to consider social
and psychological issues which may prevent many people from acting in these ways.

Safer sex
Prevention can be accomplished in four ways: abstinence, mutual fidelity, condom
use and non-penetrative sex. Penetrative sex without a condom is very risky.
Consistent use of a condom and non-penetrative sex are known as safer sex,
because they substantially reduce the risk of infection with HIV and other STIs.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

Although abstinence guarantees complete protection from STIs, it is a viable option for
very few men. Sex fulfils many needs. It is a unique and usually free source of pleasure,
which often provides an emotional bond between partners, and for many men it is
validation of their identity.

Mutual fidelity – where both partners have been tested for HIV and know they are
infection-free and neither has sex outside the relationship – is an option available to
very few men who have sex with men. Many do not have regular partners or they live in
societies that make it difficult to find and keep a regular partner. Many are married and
have sex with their wives out of duty, and with one or more other men for pleasure.
Those who are not married but have a regular male partner may not be able to meet
that partner as often as they wish, with the result that frustration may lead one or both
partners to resort to sex with others.

Non-penetrative sex means stimulating the penis by hand or between the legs, or some
other method that does not involve insertion in the mouth, vagina or anus. It affords
protection because when infected semen lands on unbroken skin the infection cannot
enter the bloodstream. Mutual masturbation and other forms of non-penetrative sex
are commonly practised by men who have sex with men, but as occasional alternatives
to intercourse rather than replacing it.

Because few people want to or can restrict themselves to abstinence, mutual fidelity
and non-penetrative sex, all men who have sex with men should be aware of the need
to use condoms consistently and efficiently when these other options are unavailable.
Where condoms are not used or not available, withdrawing the penis from the anus or
the mouth before ejaculation reduces but does not eliminate risk.

Condoms and lubrication

Unless both partners can prove they are HIV-negative, which requires a blood
test and no sexual or drug-injecting activity that might lead to infection for three
months, condoms should be used in every act of anal and vaginal intercourse.
When used properly, male condoms prevent transmission of STIs 99 per cent of
the time. Thicker condoms have been recommended for use in anal intercourse,
but recent studies suggest that the thickness of the condom makes no difference
as long as lubrication is used.

Condom use appears simple, but it requires practice.When not used properly – for
example, if air is left in the tip or if the condom is not rolled down the length of the
penis – condoms can break or fall off.When with a partner, men are often rushed and
do not put the condom on properly. Men should first practise putting on a condom on
their own, ejaculating and taking it off; condom use with a partner will then be easier.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

Because the anus does not produce lubrication, friction may cause the condom to tear.
To overcome this, many men use saliva, but that can dry quickly and is not advised.
A water-based lubricant is preferable, but this may be unavailable or too expensive
for many men. Oil-based lubricants, such as Vaseline
or cooking oil, must not be used as they
destroy the latex. A key activity
in working with men who
have sex with men is
ensuring easy access to
appropriate lubricant.

Although the risk of

transmission of HIV
and most other
STIs is significantly
smaller in oral sex,
some authorities
recommend that
condoms are used.
However, many men find
the taste and sensation so
unpleasant that they prefer not to
do so. Studies suggest that ejaculating
in the mouth is more likely to cause infection.
Withdrawing from the mouth before ejaculation will reduce the risk.

There are significant variations in penis size. Male condoms are made in different sizes;
wearing the wrong size can lead to discomfort or to the condom coming off during sex.
Organisations responsible for distributing condoms should make those different sizes
available to their clients. It should also be recognised that male condoms cause loss of
sensation for some men.This can be remedied by applying saliva to the inside of the
condom where it will rub against the head of the penis.

Condoms may be available free, at subsidised prices or commercial prices from many
different sources, including health clinics, shops and NGOs. Means of ensuring that men
who have sex with men have access to condoms, demonstration of their use and to
how to negotiate condom use with partners, are vital areas for programming with MSM.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

ASSESSING RISK AND VULNERABILITY

Before HIV/STI programmes can be developed by men who have sex with men, it is
important to understand the dynamics of transmission in the location (who, how
many, how, where etc.), specific risk behaviours practised and what makes men who
have sex with men vulnerable to risk. In addition, existing interventions need to be
assessed to see where there are gaps. This subsection gives general information on
assessment of this kind, but does not provide a “how to” guide for assessment since
this is available elsewhere.

Understanding the dynamics of HIV transmission

Understanding the dynamics of HIV transmission in communities at high risk is the
first step to devising appropriate prevention programmes for those who are
vulnerable to HIV and STIs. Many different types of assessment methodologies
currently exist to do this.3 General objectives of such assessments include analysing
the sexual and social networks in which people live, the patterns of behaviour that
enable or prevent HIV transmission and the priorities on which prevention
programmes should be built.

The following lists the types of issues that are important to consider in order to
design prevention programmes for and with men who have sex with men. Work
should be carried out predominantly with men who have sex with men in the
location, but also with service providers, policymakers, the police etc. This list is not
intended to be exhaustive; rather to give an idea of the types of things people look
for during participatory assessments:

• Categories and subgroups of men who have sex with men, including
transvestites, transgenders
• An estimation of numbers of men who have sex with men
• Patterns of mobility of men who have sex with men (within the location
and to other sites)
• Types, location and quality of existing clinical service providers for men
who have sex with men (STI diagnosis and treatment that includes anal
and oral STIs, voluntary counselling and testing, AIDS care)
• Types, location and quality of other services for men who have sex with
men (including informal mutual support and social/cultural groups)
• Access to and quality of commodities such as condoms and lubricant
• Types of risk and also risk reduction behaviour practised
• General and location – specific factors that influence HIV/STI transmission
between men (including violence, stigma, the law etc.)

3. For examples of the Alliance’s experience in assessments see the Alliance website: www.aidsalliance.org

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SEX BETWEEN MEN AND HIV/STI PREVENTION

• Levels of motivation, knowledge and skills for prevention amongst men who have
sex with men, including knowledge of rights
• Categories or types of men who are most at risk of contracting or transmitting HIV
• Priority gaps that exist in services/interventions/self-help and support
• Change that needs to happen to reduce HIV/STI transmission and infection
amongst men who have sex with men and their partners
• Suggestions for how change can happen and who should be involved
• Barriers and opportunities which help or hinder change.

Assessment findings can be used as baseline information, a starting point with which
to compare how well projects and interventions are doing and to review whether or
not they are on track to achieving their goals.

Participatory assessment
While the concept of assessment is widely understood, it is important to stress the
importance of participation in assessment.This ensures that assessment is undertaken
by men who have sex with men and with men who have sex with men, and not for
them. In most situations, the only people who can successfully access a wide
representative selection of men who have sex with men will be their peers – other
men who have sex with men.

Sometimes men who have sex with men are used as “resource” people and their job is
to help find their peers so that “trained” researchers can then carry out the assessment.
Experience shows that you do not necessarily need to be a researcher to do a
participatory assessment. In some cases it can even be a drawback. What is important
is to have a wide range of men who have sex with men from the location who have
good knowledge of the location, an ability to listen, good interpersonal skills, who are
organised and have everyday analytical skills. So long as some of the team can read
and write, this is not important for everyone to be able to do so.

Transparent and fair recruitment processes are important, and full training, fair
payment and support should be offered to those recruited to carry out the
participatory assessment. Often, a group which carries out participatory assessment
becomes well bonded and can go on to be an integral part of prevention and other
subsequent programmes for men who have sex with men.

It is important to take steps to make sure that the assessment itself does not increase
stigma and discrimination against men who have sex with men. It should be very clear
how the information will be used, who will have access to it and how information will
be kept secure and confidential. What people can expect as a result of participatory

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SEX BETWEEN MEN AND HIV/STI PREVENTION

assessment should also be made very clear. When people are told that programmes
and services will result and then nothing happens, it makes them reluctant to
participate in anything further.

The participatory assessment should use language and vocabulary appropriate to the
participants. Academic language, such as “penetrative anal intercourse” should always
be avoided. In some communities explicit sexual language such as “fucking (in the
ass)” is preferred, while in others locally-accepted euphemisms are better, such as “be
the man/woman”.

In order to be very clear about what is happening in the location, participatory

assessments often make use of visual tools. Participants are asked to draw maps
or diagrams, or make drawings to better communicate the context of their lives.
Simple recording tools can be devised to organise information in a logical and
helpful way. Verification meetings with a larger group of participants can be held
towards the end of the assessment to see if the information accurately reflects the
local situation and to highlight any information gaps.

Participatory assessments are not just about “extracting” information for someone
else to analyse. Analysis can be done on the spot by individuals and groups.
These discussions can result in men making changes to their lives to reduce risk.
It can also catalyse positive action by service providers in the area. In this way,
participatory assessment can be an intervention in itself. Condoms, lubricant and
referral information should be provided to participants in the assessment. Safer and
non-penetrative sex techniques can also easily be shared during the assessment.

Participatory assessments must also make a clear distinction

between actual risk and men’s perceptions.The many myths
about HIV transmission and prevention lead some people to
overestimate and others to underestimate the risk they
face. In communities where there has been little or
no information about the risk of sex between
men, individuals may believe that they face
no risk at all. Alternatively, some people
who are aware that sex between men
can lead to HIV transmission may
believe that even non-penetrative
sex between men is risky.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

Interpreting statistics
Participatory assessments also use secondary sources, or other sources of
information that do not come directly from men who have sex with men, such
as national and local statistics. Often it is not straightforward to interpret
these statistics.

The rate at which HIV spreads depends on several interacting factors, including the
sexual acts individuals practise, the numbers of partners they have, whether either
partner has an STI that assists transmission, and how infective the HIV-positive
partner is – for instance, people are often more infectious when they have just
contracted the virus.

Not all men who have sex with men are at high risk of infection. Those who only
have sex with a regular, long-term partner who is equally monogamous, and those
who consistently practise safer sex are at little risk. However, large numbers of men –
and their women partners – are at risk from frequent, unprotected anal sex with
other men.

Identifying current HIV infection rates among men who have sex with men is an
essential but often difficult task. National or local statistics may not include sex
between men as a risk category or, where it is recognised as a transmission route,
men may be reluctant to admit to doctors or researchers that they have sex with
men. The picture may be further obscured by out-of-date statistics, national statistics
not distinguishing between infection rates in different parts of the country, and a
high percentage of “unknown risk behaviour” responses, which on further research
often prove to be mostly men who have sex with men.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

While HIV statistics indicate how many people have already contracted the virus,
STI rates give some indication of how many are at risk. Where national statistics do
not exist, some information may be available from STI clinics. While clinics should
never release information on individual patients, they may be able to provide
statistics on overall rates of infection in their clients. To gauge the accuracy of such
figures, clinic personnel should be asked whether male patients are questioned,
even if not directly, about sex with men and whether doctors routinely investigate
potential infections in the mouth or anus. Clinics which do not actively consider sex
between men are likely to miss some infections and attribute others, wrongly, to sex
with women.

Even where information on HIV/STI among men who have sex with men is available,
it must be analysed with care. Rates of infection may be exaggerated where only
men at high risk are researched, or underestimated when the extent of sex between
men is unknown.

DESIGNING PROGRAMMES

Once participatory assessment has identified the men at greatest risk of contracting
and transmitting HIV and other STIs, appropriate prevention programmes can be
devised. Before looking at different types of interventions (see Section 3), this
subsection outlines overall goals and strategies, the principles that should underlie
interventions and good practice guidelines.

Goals and strategies

Whether or not an individual adopts safer sex strategies depends as much on his
social and psychological circumstances as on his knowledge of HIV transmission
and prevention. This means that the goals and strategies of interventions must be
equally broad.

Interventions should therefore always aim to achieve the following goals:

• Increased awareness of HIV transmission and prevention

• Increased condom use
• Increased use of water-based lubricants
• Increased use of HIV/STI services
• Increased social capital (the ability to secure benefits through membership
in networks and other social structures), solidarity and self-esteem
• Reduced unprotected anal penetrative sex
• Reduced stigma and discrimination (of sex between men and of HIV).

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SEX BETWEEN MEN AND HIV/STI PREVENTION

Ideally, other outcomes of interventions will include:

• Increased understanding of male sexual health

• Increased access to primary health care
• Increased use of primary health care services
• Increased capacity to minimise consequences of violence and abuse
• Increased ability to communicate about sex and health issues
• Increased involvement by men who have sex with men in public policy
structures and forums
• Reduced violence and abuse
• Reduced risk-taking with female partners
• Reduced shame, fear of exposure and embarrassment.

The priority strategies should be:

• Appropriate STI and HIV services

• Peer outreach and support
• Adequate and sustained supply of appropriate condoms and lubricants
• Skills-building in the use of condoms and lubricants
• Provision of information, in appropriate formats, on HIV and male sexual health
• Social, cultural and community development activities
• Appropriate training of health workers and treatment providers
• Provision of information on recreational drugs, if appropriate.

Other strategies may include:

• Focused anti-discrimination activities

• Leadership training
• Advocacy on issues that affect men who have sex with men
• Programmes for new arrivals in site, people “coming out” or new to sexual
activity between men
• Community development and capacity-building for self-help, advocacy,
social and cultural activities
• Referrals to primary health care services and to social, legal and
economic assistance
• Information and treatment referral on tuberculosis
• Information on HIV/AIDS opportunistic infections and treatment options.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

More than sex

People’s sexual behaviour and attitudes towards sex are motivated by much more
than knowledge. Behaviour change is a complex process motivated by several
factors, including awareness of the need for change and of its benefits, practice in
new skills such as condom negotiation, and confidence in one’s ability to maintain
new behaviour in changing circumstances and despite setbacks or failures.

HIV/AIDS prevention must therefore address not only the physical aspects of
prevention but the social and psychological contexts in which sex occurs. For men
who have sex with men, these contexts may include issues of sexuality, culture,
gender, health, social status, religion, politics, law, self-esteem and power. For many
men, the most pressing issues are poverty and basic needs such as food and
clothing and also the obligation to get married and to care for one’s wife and
children. Broader social attitudes, such as stigmatisation of sex between men and
abuse of men who practise it, are also key issues. Interventions that do not place
these concerns at the heart of prevention strategies will not succeed.

Working with CBOs

Prevention strategies are most effective when “owned” by the people they are
intended to benefit. As with the assessment process, men who have sex with men
must participate in all stages of planning and implementation of interventions.
Often this can be through an existing group or CBO run by and for men who have
sex with men. The CBO can then take responsibility for certain interventions.
Such an organisation may already exist; if not it should be encouraged.

Creating a CBO of men who have sex with men requires time and careful support.
Care should be taken to recognise the autonomy of such organisations and the
need for them to make their own decisions if they are to be sustainable. Often they
start informally, with committed individuals slowly taking on leadership roles.

The concept of leaders is closely allied to that of CBOs. Leaders are those individuals
in a community who are recognised as representing the community and/or whose
sexual or social practices are admired by the community. Leaders have critical
influence: in one study in the United States, risky sexual behaviour among men who
have sex with men fell by 30 percent in small towns where the most recognised
clients in bars were trained in HIV prevention and encouraged to promote safer sex
with their acquaintances. Leadership training is increasingly recognised as a means
of maximising leaders’ potential to build the solidarity necessary amongst men who
have sex with men for a variety of HIV/STI prevention strategies.

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SEX BETWEEN MEN AND HIV/STI PREVENTION

Other types of capacity-building to support

emerging CBOs can include administrative
and strategic skills; partnership-building
and development of referral services;
quality assurance, especially for
health services; and assistance in
developing and implementing
advocacy strategies. Equally important
are financial systems development;
strengthening of governance and
accountability systems; development of
documentation, monitoring, evaluation and
communication functions; and resource mobilisation.

Because CBOs are usually small and have relatively few resources, and because
collaboration provides additional strength and resources, mechanisms for networking
with NGOs and other CBOs should also be developed.

Working with gatekeepers

Gatekeepers are men or women who indirectly or directly control access to a target
audience.They include the owners of commercial venues where men who have sex
with men meet, the police, who control access to public spaces where men cruise
(seek sexual partners), and prison officers, who permit or prohibit HIV and other
interventions in prisons.

Working with gatekeepers is an essential aspect of any prevention

strategy. Interventions that have the approval and assistance of
gatekeepers will reach many more men than those where
gatekeepers are hostile. In negotiations with
gatekeepers, however, it is important
to ensure that control over the
intervention is retained by the CBO
and that inappropriate messages
that may be suggested by
gatekeepers are not accepted.

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Working with health care providers

Men who have sex with men have specific health needs that can only be met by
medical personnel who are fully aware of and sensitive to the issues involved.
This includes an ability to deal with men who have sex with men in a non-
judgemental way (using neutral or supportive language and mannerisms) that
elicits their sexual history. It also includes a familiarity with and an ability to treat
infections in the anus as well as the genital area and mouth.

When working with men who have sex with men, confidentiality must be
maintained. This applies to behaviour and gender/sexual identity (respecting the
individual’s right not to divulge their sexual behaviour and identity to others) and
to health, in particular whether the individual has contracted HIV or an STI.

Ideally, all health care providers should be aware that some men have sex with other
men, but voluntary and confidential counselling and testing for HIV and STIs are
seldom targeted at this group. Skilled and sympathetic counsellors and staff should
be trained to provide such services. Although many issues surrounding HIV are
similar for men who have sex with men to the rest of the population, there are many
others, such as safer sex, becoming HIV-positive after rape, partner notification, and
care within the family, that require a different approach by both counsellor and client.

Health care providers and others who work specifically with men who have sex with
men must recognise that most men who have sex with men also have sex with
women. Programmes should ensure that men are also informed of the need to
protect their women partners.

Principles that hinder HIV prevention

It is sometimes argued that HIV transmission between men could be stopped if men
were prevented from having sex with each other. Instead of providing services such
as STI clinics and condoms and lubricants, prevention programmes should focus on
reducing the frequency of sex between men. This can be achieved theoretically by:

• Religious prohibitions
• Social stigma
• Legislation outlawing sex between men, with punishments such as
imprisonment, fines and, in a few countries, execution
• Police actions closing commercial establishments and preventing sex
between men in public spaces
• Reducing the number of locations where men who have sex with men meet
• Discriminating against men who have sex with men or encouraging social,
economic or legal sanctions against sex between men

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• Reducing the availability of, or demand for, sexual services offered by men
• “Cures” for homosexuality.

These strategies have been widely practised in many societies, both before and
after the advent of HIV/AIDS. However, they have consistently failed to prevent
sex between men and consequently they have failed to prevent HIV
transmission between men.

Furthermore, by depriving men of appropriate prevention programmes, in many

communities such strategies have actually contributed to the spread of the virus
among men and to their women partners. In addition, stigmatising sex between
men not only denies many men the ability to lead happy and fulfilling lives, but
can cause significant psychological and social problems for the men, their wives
and children.

Because this approach to HIV prevention is both counter-productive and a denial

of human rights, it is not recommended and not supported by the International
HIV/AIDS Alliance. However, the high profile of such strategies in many communities
cannot be ignored and it is essential that NGOs and CBOs discuss them in order to
respond appropriately to institutions and individuals who propose them. In order
to provide an appropriate response, it is often important to work with allies such as
human rights organisations, sex worker organisations, politicians and others who
understand the need to reject inappropriate strategies.

36