MSM Awareness Handbook Thailand

Awareness and Sensitivity
in the Promotion of Sexual Health
among Men who have Sex with Men

Participant Handbook

Foreword
In the context of recently documented high HIV prevalence among men who have sex with men
(MSM) in Thailand, and their projected increasing contribution to the proportion of total new HIV
infections in the country, Family Health International (FHI) and its partners, the Thai Red Cross
AIDS Research Centre (TRC/ARC) and the Bangkok Metropolitan Administration Health Center
Number 28 (BMA 28), have participated in the Demonstration HIV Counseling and Testing
Project, targeting MSM. The goal of this project has been to identify service provider site and
programming barriers as well as personal barriers to accessing HIV counseling and testing
among this population and to use this information to improve counseling and testing services in
order to increase uptake of services among MSM.

Service provider attitudes toward men who have sex with men was one of the barriers identified
in the first phase of the project. This handbook was has been specifically adapted to provide
information on and build sensitivity and awareness of the sexual health of men who have sex
with men in Thailand. The handbook may be used together with the Awareness and Sensitivity
in the Promotion of Sexual Health among Men who have Sex with Men: Trainer’s Manual, as
part of a training package, or it may be used separately as an information resource.

Acknowledgements
This handbook was adapted by Dr. Kathleen Casey, FHI Asia and Pacific Regional Office
(APRO), and Greg Carl, Thai Red Cross AIDS Research Centre, from the FHI-Vietnam training
package, Awareness and Sensitivity in the Promotion of Sexual Health among Men who have
Sex with Men.

Funding for this work was provided by USAID.

Contents

Page

Section 1: Who are MSM? 1

Section 2: Conceptualizing MSM in the Thailand Context 4

Section 3: Risk and Vulnerability to HIV Infection 7

Section 4: Multifaceted Risks for HIV in Thailand 10

Section 5: Need for Health Services and Access Strategies 12

Section 6: Special Sexual Health and Psychosocial Needs of MSM 14

Section 7: Safer Sex Strategies 16

Section 8: Challenges of Counselling Positive MSM 20

Section 9: Reorienting the Clinical Environment 21

Section 10: Concluding Note for Health Care Providers 26

References 27

Awareness and Sensitivity in the Promotion of Sexual Health
Among Men Who Have Sex With Men

Section 1: Who are MSM?

The term men who have sex with men or MSM is meant to address all men who have sex with men,
regardless of their sexual identities. It is used because only a minority of men involve in same sex
behaviour self-define as gay, bisexual or homosexual but may more aptly self-identify using local social
and sexual identities and behaviours. They do not consider their sexual encounters with other men in
terms of sexual identity or orientation. Many men who have sex with men self-identify as heterosexual
rather than homosexual or bisexual, especially if they also have sex with women, are married, only take
the penetrative role in anal sex, and/or have sex with men for money or convenience.

MSM includes various categories of men who may be distinguished according to the interplay of variables
such as:
• their sexual identities, regardless of sexual behaviour (gay, homosexual, heterosexual, bisexual,
and transgender, or their equivalents, and other identities);
• their acceptance of- and openness about- their non-mainstream sexual identities (open or
closeted);
• their sexual partners (male, female, and/or transgender);
• their reasons for having these sexual partners (natural preference, coercion or pressure,
commercial motivation, convenience or recreation, and/or being in an all-male environment);
• their roles in specific sexual practices (penetrative, receptive, or both); and
• their gender-related identities, roles and behaviour (male or female, masculine or
feminine/effeminate, cross-dressing or gender-concordant dressing).

What do health care providers need to know about sexual identity and sexual behaviour?

Men who have sex with men has become a popular term in the context of HIV/AIDS where it is used
because it addresses behaviours that put men at risk for infection. It has been argued that the term is too
focused on sexual behaviour and not enough on other aspects, such as emotions, relationships, and
sexual identity. Some organisations and individuals prefer the term males who have sex with males
because it indicates a broader group of individuals engaged in sex with members of the same sex. In
particular, it does not have the age limitation implied by the term “men,” and therefore includes boys who
are having sex with each other and also sexual relationships between men and boys.

In part the term MSM can be seen as a reaction to the language that has developed in Western cultures
to describe and/or medicalise sexual acts between men. Also, the emergence of ‘gay culture’ in Western
th
societies during the 20 century has encouraged the belief that people are either ‘gay’ (homosexual) or
‘straight’ (heterosexual). This may be true for some people in some parts of the world, but for many men,
having sex with other men is just one part of their sexual life and does not determine their social or sexual
identity. Some MSM may be highly visible in the community and can include men who dress as women
or wear some items of women’s clothing. However other MSM may be completely indistinguishable from
non MSM. Where ‘homosexuality’ is not visible it is sometimes thought not to exist, however this is
probably not the case. In fact sex between men happens in most, if not all, societies. Public discourses
that deny the existence of same sex activity do not reflect what happens in real life.

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Possibly the largest group of MSM in most countries in Asia is men who do not accept their non-
mainstream sexual behaviour, do not openly self-identify as gay or homosexual, and who have either
casual anonymous sexual encounters or highly clandestine relationships with other men. Some of these
men may be married and/or also have sex with women. A few may self-identify as bisexual. Some men
who self-identify as heterosexual or bisexual occasionally have sex with men for pleasure, usually
because women are less accessible. Some men may have sex mainly with transgender MSM without
self-identifying as gay or homosexual, primarily because transgender MSM are not considered men in
their cultural context.

Transgender and intersex persons

Understanding terminology

Transgender is a broad term that designates somebody who does not fit clearly into “male and female”
descriptions. The individual rejects the gender assigned to him or her at birth. Transgender is sometimes
referred to as “gender variant”.

The term transsexual refers to an individual who feels that their gender identity does not match the
biological body he or she was born with and/or the gender he or she was assigned by society.
Transsexuals can be referred to as male to female (MTF) or female to male (FTM). Transsexuals are
further described in terms of whether they are “pre-operative” (“pre-op”) or “post-operative” (“post-op”)
and some describe themselves as “no-operative”(“no-op”).

Cross dressing refers to the act of dressing in the clothing typically worn by the opposite gender and may
be used in reference to both transsexuals and cross dressers. “Cross dressers” (also known as
transvestite) is a term usually reserved for individuals who like to cross-dress but who do not experience
any discord between their physiological appearance or their gender identity. Most cross-dressers are
heterosexual men who cross-dress for purposes of amusement, role-playing, stress relief, or sexual
gratification. Usually biological women are not called cross dressers as society allows a broader range of
dressing behaviour for women (i.e. women can wear pants, have short hair etc).

Other terms used refer to either how society perceives the individual or the gender reassignment.
Passing refers to the degree to which an individual of one gender is perceived (by others in society) to be
of the opposing gender. Transitioning commonly refers to the process of moving from one gender to the
opposite one. Transitioning is likened to a developmental process with the process of transitioning
involving many steps.

Increasingly you may hear the term intersex. This term tends to be used by health professionals working
in gender orientation. A variety of conditions that lead to atypical development of physical sex
characteristics are collectively referred to as intersex conditions. These conditions can involve
abnormalities of the external genitals, internal reproductive organs, sex chromosomes, or sex-related
hormones. Some examples include:

• External genitals that cannot be easily classified as male or female.
• Incomplete or unusual development of the internal reproductive organs.
• Inconsistency between the external genitals and the internal reproductive organs.
• Abnormalities of the sex chromosomes.
• Abnormal development of the testes or ovaries.
• Over- or underproduction of sex-related hormones.

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• Inability of the body to respond normally to sex related hormones.

Intersex conditions are not always accurately diagnosed, experts sometimes disagree on exactly what
qualifies as an intersex condition, and government agencies do not collect statistics about intersex
individuals. Some experts estimate that as many as 1 in every 1,500 babies is born with genitals that
cannot easily be classified as male or female.

The sexuality of intersex individuals

Most people with intersex conditions grow up to be heterosexual, but persons with some specific intersex
conditions seem to have an increased likelihood of growing up to be gay, lesbian, or bisexual adults.

There are men whose natural preference is for women but who have sex with men because of restricted
access to women. This can be due to conservative societies which encourage strict social segregation of
men and women, or being in all-male environments over extended periods of time, such as prisons,
military establishments, male migrant labour settings, and all-male educational institutions. Denied
access to women, men have to gratify their sexual urges with other men, without leading to self-
identification as gay or homosexual. Many male sex workers across Asia often self-identify as
heterosexual and have sex with men mainly to support themselves and their families. They are often
married or have girlfriends or female sex partners. There are, however, some male sex workers who do
self-identify as gay or homosexual and only have sex with men. Some men prefer to have sex only with
men but pressure to get married and start families results in them having sex with women. Some have a
preference for men but are not averse to women and vice versa. Others prefer to have sex only with
women but end up having sex with men for money or because they cannot get access to women. The
ambivalent position of male-to-female transgender individuals adds other dimensions to the scenario.

Why do some men engage in same-sex behaviour?

It is not known why most people are sexually attracted to the opposite sex and some people are attracted
to the same sex. There are some theories which stress biological differences between heterosexual and
homosexual adults, suggesting that people are born with their sexuality predetermined. Though
experiments and tests have been undertaken to measure differences in hormone levels, genetic make-
up, and brain structures of homosexual and heterosexual people the findings of these have, for the most
part been unclear. One psychological explanation stresses the importance of life experiences, childhood
and relationships with other people, particularly with parents. A person’s assumptions about sexuality
and their behaviour is influences by their family environment, their experiences and their sense of
themselves. Beliefs about sex are initially shaped by family values. Later on these beliefs may be
challenged and shaped by pleasant and unpleasant experiences of sex which also shape their choice of
sexual activities and partners. Throughout their life a person’s sense of whom and what they are has a
strong impact on their sexual development and experience. Another theory suggests that preferring your
own sex is a matter of willpower, and that a man who has sex with men does so out of a wish to deviate
from established gender roles. However, there is little evidence for either of these theories. Other
researchers think that it may be possible that sexual orientation is a mixture of both biology (nature) and
social conditioning (nurture).

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Male and transgender sex workers

Who are sex workers?

Sex workers encompass a diverse group of people, so it is therefore difficult to generalise about their
behaviours and attitudes towards HIV prevention and care. For example, they may be injecting drug
users, married women or men, indentured workers (i.e. they are coerced into the work and even taken to
other countries), college students or unattached minors. Sex workers may be of all genders (i.e. male,
female or transgender). They may work temporarily as sex workers or full time. Effective health care
interventions need to recognise these individuals not only as sex workers, but as partners, wives or
husbands, and as parents.

Section 2: Conceptualizing MSM in the Thailand Context

The term “Men who have sex with men” (MSM) describes a behavior rather than an identity. The term
“MSM” emerged to describe all those involved in sex between men, whatever their circumstances,
preferences or self-identification (Foreman, 2003). In other words, it was designed to include all kinds of
men who have sex with other men, regardless of the situation or sexual orientation. The term “men who
have sex with men” was introduced in Thailand during the 1980’s along with the HIV epidemic so it is
difficult to find an equally suitable term in Thai. It is translated literally into Thai as “phuchai tee mee
phetsamphan gap phuchai”. This term had little meaning to many Thai people. The term commonly used
for MSM was katoey. However, this terms does not encompass the broad spectrum of MSM in relation to
their sexual behavior. Other terms that come into common usage in identifying MSM behavioral roles are:
gay, and man. While these terms are easy to define in general interpretation, they take on different
meaning in relation to a person’s living environment and socioeconomic status.

M SM Subtypes 1

In Thailand male-same sex is not new, but this behavior has been hidden and underreported because of
its nature as a sensitive subject regarding social norms and values. Since those who are involved in
male-same sex are likely to be stigmatized by the society, MSM have manifested themselves in varied
sexual identities.

In rural areas, terminology for MSM sexual behavior is limited to the extremes of katoey and man. Katoey
is the traditional Thai word for someone, either male or female, who is ‘hermaphrodite’. In modern usage,
the term has taken on the meanings of transvestite, transsexual, and effeminate male. If a young Thai
male is effeminate, he many be stereotyped into the role of katoey. The katoey are, for the most part, not
shunned in rural areas and may actively participate in both family and village life. This tacit acceptance

1 1
Excerpts from: HIV and Men Who Have Sex with Men : HIV/AIDS and Human Rights in Southeast Asia. Expert Meeting on
HIV/AIDS, Organized by Asia-Pacific Regional Office of the United Nations of the High Commissioner for Human Rights (OHCHR),
23 – 24 March 2004. Adapted from "HIV and men who have sex with men: Perspectives from selected Asian Countries" Roy Chan,
Ashok Row Kavi, Greg Carl, Shivanada Khan, Dede Oetomo, Michael L. Tan and Tim Brown, AIDS 1998, 12 (Suppl B):S59-S68.
The current article updates the situation focusing on the countries of Southeast Asia, and with an emphasis on human rights in
relation to MSM and HIV/AIDS

HB page 4

may be based of the belief among many rural villagers that the state of being a katoey is a punishment for
sexual indiscretions in a previous life. It is therefore considered ‘natural’ for a katoey to express sexual
interest in persons of the same sex.

The role of a man is more difficult to identify. It generally means a male who is heterosexually identified
and is the sexually active partner with either a male or female. The idea that ‘good women’ remain
untouched until marriage still prevails. Rather than suppressing the male sex drive, Thai society has
channeled it. One option as a sexual outlet is the female sex worker and another is the katoey. If a male
takes the active role in sexual relations with a katoey, his masculinity and sexuality do not come under
question. Yet another sexual outlet is the notion of ‘friends helping friends’. Two males with a ‘good
understanding between them’ or residing in close proximity in a same-sex institutional environment make
use of each other’s bodies in order to meet physical needs while preserving the chastity of women. The
action is not considered homosexual in nature, but as a purely physical act because it is not seen to
2
involve the emotions or ‘heart’ . When emotions do come into play it is difficult to understand why or how
a man is attracted to someone of the same sex without filling the traditional roles and stereotypes of the
katoey. Therefore, same-sex relationships may continue as long as they are conducted discretely.

In semi-urban/rural areas, the phenomena of man and katoey are still present but the term ‘gay’ has
become more common. In some more remote areas, ‘gay’ is synonymous with katoey. In more developed
areas, the term ‘gay’ has taken on the meaning of men who are sexually attracted to men but are not
transvestite or transsexually identified. While the new term provides greater opportunities for emotional
attachment, the label of ‘gay king’ or ‘gay queen’ indicates an individual’s role in a relationship and sexual
role.

In urban areas, the term ‘gay’ is in common use along side of the terms man and katoey; however, the
labeling of sexual roles has become blurred and insignificant. In the report, The Dynamics and Contexts
3
of Male-to-Male Sex in Indonesia and Thailand , the data suggest no association between the role in sex
acts and sexual identification of MSM. Therefore, it cannot be assumes that a person who identifies
himself as a “gay king” takes only the insertive role in sex and a person who identifies himself as a “gay
queen” takes only the receptive role in sex. The term ‘bi’ has also become blurred as well. For some it
means that they have sex with both men and women. For others, it means they take both the insertive
and receptive role in sex with men.

On account of the rural to urban drift of MSM and the blurred terminology, it is essential that service
providers clearly identify sexual behaviors that place clients at risk and not make assumptions based on
labels.

Use of term s and potential discrim ination

2
Lyttleton C: Framing Thai sexuality. TAJA 1995, 6:135-139.
3
The Dynamics and Contexts of Male-to-Male Sex in Indonesia and Thailand, Australian Research Centre in Sex, Health and
Society and La Trobe University, 2006.

HB page 5

While homosexual behavior between consenting adults is not a criminal offence in Thailand, MSM are still
bound by social and cultural norms and sanction. Social discrimination against MSM increases their
vulnerability to HIV infection and compromises the health of MSM as they may avoid contact with health
and social services. The result is that those most needing information, education and counseling are
4
driven underground .

Social discrimination can often be apparent in the terms or labels that are used to address MSM. Beyond
the preferred terms, there are terms or labels considered as discriminatory and demeaning by MSM. For
example ‘toot’ [adopted term from the movie, “Tootsie” for effeminate male, transvestite or transgender
person]. Other terms are boy [English adopted term for general MSM but also denotes status in a
relationship], lady boy [English term adopted for transvestite, transgender], and money boy [English term
adopted for male sex worker]. These terms are commonly used to describe self and others in very close
relationships but should not be used by others outside the relationship or social network. For example,
masculine MSM may address each other as katoey in jest, but would take great offence if someone
outside the relationship uses this label.

Service providers should not use terms for MSM loosely but should determine how clients wish to be
identified. Remember that sexual identification may not always reflect sexual practice. In addition, some
service providers may encounter clients from neighboring countries who have come to Thailand for
testing because same sex behavior is a criminal offence in these countries. These clients may be hesitant
to identify themselves sexually so that determining sexual practice is obligatory.

Disclosure of Sexual Orientation and Identity
Thailand is fairly tolerant of same-sex activity compared to many societies but this does not mean that it
accepts homosexuality. There is little active intervention to prevent or punish same-sex activity. Tolerance
does not equate to social acceptance. Some MSM have expressed fear that if their sexual behavior
should be revealed, there would be negative consequences in their jobs, possibly leading to dismissal.
Others expressed the difficulties in having a double life among family and co-workers and among other
5
MSM . While outward discrimination is not apparent, there is a fear of social sanction with
disclosure.Disclosure is most often limited to a group of people with whom a MSM has a close
relationship. This may include long-term friends from school or work, and regular partners.

Services and other interventions that are provided in Thailand are often sexual identity specific (man-gay-
katoey or MSM-MSW) rather than behavior specific. Thus, vulnerability to HIV infection increases as this
fear may prevent MSM from accepting their same-sex behavior, seeking information on HIV/AIDS and
STI prevention, and seeking appropriated medical services.

Sexual Networks of M SM

4
McCamish M, Storer G, Carl G, Kengkanrua K: Why should more attention be given to male-male sex encounters in Thailand. IV
International Congress on AIDS in Asia and the Pacific. Manila, October 1997 [abstract C(P)082].
5
Sittitrai W, Brown T, Sakonhavat C: Levels of HIV risk behavior and AIDS Knowledge in Thai men having sex with men. AIDS Care
1993, 5:261-271

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The sexual networks of MSM are characterized by interactions with people with varied sexual identities.
MSM had sex within their own sub-population, with MSM in other sub-populations, and with both
heterosexual men and women. In the report, The Dynamics and Contexts of Male-to-Male Sex in
6
Indonesia and Thailand , sexual networking is facilitated through social networks. The study found that
the social networks of MSM in Thailand are “generally formed along the lines of their sexual identification,
degree of openness in revealing one’s sexual identity, and socio-economic status.” As a general rule,
sexual activity is limited within a social network. However sexual contacts may be facilitated through the
interaction of once social network with another.

6

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Section 3: Risk and Vulnerability to HIV Infection

Risk

There are important differences between male to male behaviours and MSM identities. Not all men who
have sex with other men are equally vulnerable to HIV. Men who only have sex with a regular, long-term
partner who is equally monogamous, and those who consistently practise safer sex are at less risk.
However, large numbers of MSM are at risk from frequent, unprotected sex with other men. Anal
intercourse with out a condom is the primary way in which HIV and other sexually transmitted infections
are passed on in sex between men. Many of these men may also have women partners. This means that
anal intercourse without a condom between men also places the men’s female partners and their future
children at risk of infection. Likewise, vaginal or anal intercourse without a condom between a man and a
woman may place the man’s male partners at risk of infection.

The risk of HIV transmission through anal intercourse (and anal sex can also be practised between a man
and a woman), is especially high when condoms are not used. The lining of the rectum is thin and can
easily tear, and even only small lesions in the lining are enough to allow the virus easy access. Even
without such lesions, it is thought that they may be a lower immunity in the cells of the rectal lining to
resist HIV. The risk to the receptive partner in unprotected anal sex is several times higher than a woman
having unprotected vaginal intercourse with an HIV-infected man. Some men may practice fist-to-anus
intercourse (fisting) before penetrating the partner with their penis. Such practices may increase risk of
tearing the lining of the anus. Unprotected anal sex also poses a risk to the penetrative partner when HIV
is present in the other person. The presence of other, untreated sexually transmitted infections such as
syphilis, gonorrhoea, and chlamydial infections, can greatly magnify the risk of HIV where HIV is present.

Oral sex (mouth-to-penis) is also commonly practiced between men. Although the risk of transmission of
HIV and most other STIs is significantly smaller in oral sex the best protection is to use a condom,
though, many men find the taste and sensation so unpleasant that they prefer not to do so. Ejaculation in
the mouth is more likely to cause infection. Withdrawing from the mouth before ejaculation will reduce the
risk. The presence of STI or sores and lesions in the mouth will increase the risk.

Other common sexual practices, such as inter-femoral/crural sex, and mutual masturbation, are far less
risky, though the presence of STI may increase the risk. The range of practices varies according to
region, country and region within the country, as does the extent to which safer sex practices are
adopted.

Vulnerability

The relative lack of MSM “friendly” programming and services contributes to MSM vulnerability to
infection. Many countries are still unwilling to acknowledge the existence of male-to-male sexual
behaviour together with the social stigmatisation of same sex behaviours, life styles and discrimination.
Stigma of same sex behaviour is present at many levels and sexual acts between men are often
condemned.

Condom Use
Stigma and discrimination have rendered MSM invisible, and the result is that the unique prevention and
treatment needs of MSM are not being met. Discrimination can result in the absence of condoms and
lubricant in places where male-male sex takes place. Consistent condom use is generally low as many
MSM believe that they are low risk. Many also have sex with women and can thus serve as a bridge
population for HIV transmission.

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Risk perception
Information resources are seldom produced that highlight same sex behaviour. HIV/AIDS prevention
programs in Asia have been focused on heterosexual transmission and transmission through injecting
drug use. This has led many MSM to conclude that their own behaviours do not place them at risk or they
see sex with women as an HIV risk and male-male sex as a safer option.

Number and type of partners
Stigma and discrimination have made it difficult for MSM develop and maintain relationships, which may
contribute to a high level of sex partners and, for some, high levels of transactional sex. A man’s ability to
negotiate for safer sex may be determined by gender identity and poverty.

Sexual assault
Non-consensual forms of male-to-male sex also occur, in particular with younger males. Victims of male-
male sexual violence seldom report the incident out of fear of being identified as person involved in
sexual relations with other men.

Untreated STI
Unprotected sex also means that MSM may be exposed to other sexually transmitted infection of the
mouth and anus, increasing the risk of HIV infection. Symptoms may go undetected or are disclosed, and
thereby not treated, out of fear of revealing same sex behaviour. Doctors and other medical care
providers are not always properly trained in the diagnosis and treatment of infections in the mouth and
anus.

Men who have sex with men, like other people, have the right to information about behaviours that place
them at risk for infection and how to protect themselves during sex; to services related to HIV prevention
and care, including counselling and testing. STI services, and other health services; and, to freedom from
discrimination on the grounds of sexual orientation. When these rights are not respected, MSM have less
control over their behavioural risks and are there more vulnerable to HIV infection. Protecting their rights
can increase the likelihood that they will be able to access and use prevention messages, skills and
services.

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
• “Cures” for homosexuality.

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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.

In the provision of effective sexual health care, it is important for providers to learn and understand the
dynamics of transmission among men who have sex with men in the local context, specific risk
behaviours practised, and what increases MSM vulnerability to risk in that location. Establishment of
linkages to organisations which work directly with men who have sex with men or that are involved in
behavioural surveillance may be advantageous in this regard.

• Categories and sub-groups of men who have sex with men
• Organisations working with and services available to men who have sex with men (including mutual
support and social/cultural groups)
• Accessibility to quality condoms and lubricant
• Types of risk and also risk reduction behaviour commonly practised
• Specific factors that influence HIV/STI transmission between men, including violence, stigma,
laws/policies.
• Levels of motivation, knowledge and skills for prevention amongst men who have sex with men.
• Behaviour change that needs to happen to reduce HIV/STI transmission and infection among men
who have sex with men and their partners.
• Practical suggestions for how change can happen and who should be involved.

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Section 4: Multi-faceted risks for HIV in Thailand

Although sub-populations of MSM may differ in the levels of risk for HIV infection they are engaging in the
same types of risk-taking behaviors, such as unprotected anal and oral sex. Levels of risk behavior are
determined by inter-linked factors, i.e., individual and contextual factors. The individual factors include a
lack of knowledge about HIV/AIDS, the self-efficacy of condoms and lubricants, and the misconceptions
related to personal risk assessments and preventive measures. The contextual factors consist of social
and cultural contexts, in which MSM interact and engage in risk-taking behaviors, such as presence of
different forms of stigma and discrimination, absence of “community” with social norms and rules,
absence of rights protecting minorities. On an individual level, an individual’s risk taking behavior may
also be influenced by their own acceptance of their sexual orientation.

HIV Prevalence and Risk Factors am ong M SM 7

In 2003 and 2005, the Thailand Ministry of Public Health – U.S. Centers for Disease Control and
Prevention Collaboration and its partners conducted surveillance of HIV prevalence and risk factors
among populations of MSM in Thailand. A comparison of the results of both studies indicated a
significant increase in HIV infection among MSM in Bangkok from 2003 to 2005. In 2003, the overall HIV
prevalence among MSM in Bangkok was 17.3%. This increased to 28.3% in 2005. The increase was
observed among MSM at entertainment venues and saunas and in all age groups. The 2005 findings also
indicated that HIV infection was widespread among MSM, MSW, and TG in Bangkok, Chiang Mai and
Phuket.

The following factors were significantly associated with HIV prevalence among MSM in 2005: older age
drug use, homosexual or bisexual self-identification, both insertive and receptive anal intercourse, self-
reported genital ulcer or discharge, and drug use. Sex with women during the preceding 3 months was
inversely associated with HIV infection.

Among male sex workers the factors significantly associated with HIV prevalence included: recruitment
from park or street location, self-identification as homosexual or gay, receptive or both insertive and
receptive anal intercourse, and self-reported genital ulcer or discharge. Sex with women during the
preceding 3 months was inversely associated with HIV infection.

The risk factors among transgender individuals included: older age, recruitment from park or street
location, lower education, history of selling sex, and a higher number of sex partners in the preceding 3
months.

Drug Use and M SM
The data from the 2005 study indicates that lifetime use of any non-injected drug (mostly smoked
methamphetamine) was reported frequently by MSW (38.5%), TG (24.1%), and MSM (15.5%).
8
Increasingly, drug use is viewed as an occupational tool by MSW , potentially increasing their vulnerability
to infection with HIV and STI.
7
HIV Prevalence Among Populations of Men Who have Sex with Men – Thailand, 2003 and 2005. Morbidity and Mortality Weekly
Report, August 11/2006, Vol. 55, No. 31.
8
Conversation with Outreach workers, 21 December 2008

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Only limited data is available on the use of other drugs, particularly those that are injected or enhance or
prolong sexual pleasure among MSM, MSW, and TG in Thailand and needs further monitoring.

Beliefs, Knowledge and Perception
Unprotected anal and oral sex is quite frequent among MSM because many were not informed about the
risks and preventive measures for HIV infection. And, although condoms are available, accessible and
affordable in the market, many MSM do not use condoms or used them inconsistently for both anal and
oral sex because a number of obstacles to condom use still exist. These include reduced pleasure, the
bad smell, unavailability of condoms when needed, the embarrassment associated with buying and
carrying condoms, the size of condoms, the lack of power to request condom use from a partner, and the
difficulty of avoiding risk (i.e., using condoms) when drunk or high.

Prevention is also influenced by perception of risk and partner type. The report, The Dynamics and
9
Contexts of Male-to-Male Sex in Indonesia and Thailand , identifies that sexual relationships among MSM
in Thailand can be categorized into four groups: casual relationships; low-commitment relations [Gik];
steady relationships [Faen]; and spousal relationships. Most of the participants in this study have more
than one male partner at anyone time generally across these relationship categories. Sexual partners
may move from one of these categories to another. Condom use is influenced by the degree of “intimacy”
or “commitment” in these relationships. The greater the intimacy or commitment in the relationship the
less perceived risk. Condom use appears to be most common and consistent with casual partners. For
partners, such as a boyfriend (faen) or somebody who is treated as a “spouse or husband,” a condom is
often not used; or it is used but not consistently.

Case I Case II

I: What do you think is you level of risk for HIV? I: Suppose you and I meet in a sauna …
R: Risk. I think I have high risk. R: If I meet you there and you like me, I would use
I: Why do you think so? a condom with you. But if I like someone as a
special one – like a farang, sometimes I don’t
R: Because I and my faen don’t use condoms.
use.
I: Do you use them with giks?
I: Why? Is it because you want to have a real
R: I use condoms with all gik. I never fail to use touch of him as much as possible?
one.
R: That too. Also, I want to test his heart. More
I: Why don’t you use a condom with your faen? than that, I want to win his heart.
R: Ever since we began living together … we
never use it. We talked between us that if we
have something (sex) with others we must use it.
I = interviewer, R = respondent

The high prevalence among MSM, MSW, and TG in Thailand highlights the need for more effective
behavioral and biomedical interventions to prevent the spread of HIV in these populations at high risk.
Interventions should include programs to reduce sexual risk behavior, promotion of more frequent HIV

9

HB page 12

counseling and testing, and improves services for diagnosis and treatment of sexually transmitted
infections.

HB page 13

Section 5: Need for Health Services and Access Strategies

The situation for men who have sex with men highlighted in the previous section can be characterised by
a relative lack of programming, lack of knowledge and high prevalence of unsafe sex. In many countries
in Asia MSM are already becoming disproportionately affected by the HIV epidemic. In countries where
such information is now available, HIV infection rates among MSM are often higher than in the general
population.

Voluntary counselling and testing services that are sensitive and responsive to the needs of men who
have sex with men in HIV prevention can to begin to fill in the gaps in needed programming for MSM.
Pre- and post-test counselling with a skilled counsellor familiar with men who have sex with men provides
an opportunity to provide appropriate information on HIV/STIs and safer sex for MSM. It also provides an
opportunity for clients to learn about community-based and other organizations and services that work
with men who have sex with men. Where a client tests positive for HIV, he can also be given details of
organisations of people living with the virus.

Strategies to Access MSM

Some may socialise with MSM friends and identify with MSM communities, others may not have any such
affinities. For all MSM it is important to have appropriate or ‘friendly’ HIV/AIDS or STI services where they
can obtain accurate information about HIV (and STI) transmission and prevention. Because many health
services have traditionally not been welcoming of MSM it may be important to reorient health services so
that they are ‘MSM friendly’. Some of these adjustments may be subtle, such as including paintings of
posters of attractive men on the walls of waiting rooms and in rooms where clients are interviewed. Other
strategies include:

• Outreach programs by volunteers or professional social or health workers to appropriate locations
such as discos, shopping malls where MSM may congregate
• Peer education among MSM – training MSM to conduct peer education
• The promotion of high quality condoms and water based lubricants and ensuring their continuing
availability
• Education for staff from other health services to overcome ignorance and prejudice about MSM
• Participation in advocacy efforts for the abolition of laws that criminalise sexual activity between
men
• Anonymous telephone counselling and advice – can be a first step for MSM wanting to be tested
for HIV but hesitant to visit a testing centre. Can provide advice and support over the phone as
well as referral to an appropriate service
• Provision of specially developed IEC materials with information on safe sex for MSM that
available at the service site and in venues where MSM gather.

Drop-in centres which provide information, training, and social and cultural services for MSM can be
linked into a broader network of services. Moreover, the drop-in centres can provide important services to
introduce and refer MSM to voluntary counselling and testing services as well as appropriate
psychosocial support programming as a follow up to VCT.

Where it is possible, drop-in centres and outreach services targeting MSM can provide pre-test
counselling and possibly testing through mobile VCT services. Clients are then referred to a formalized
counselling and testing centre to receive post-test counselling and the test results in order to ensure
confidentiality.

HB page 14

A lot can also be said for the provision of quality service. If clients consider the service MSM friendly then
word will quickly spread through the MSM networks that do exist.

Elements of an MSM Friendly Service

• Is anonymous and assures confidentiality
• Has staff who do not make value judgements about behaviours – this means all staff from
reception through to nurses, counsellors and doctors
• Provides appropriate education materials in client waiting areas as well as in counselling and
doctors rooms
• Is open at appropriate times such as late at night on at least some nights and on weekends
• Is located in an accessible area, for example near venues or locations where MSM may go to
meet each other or to look for sex
• Provides free or low cost HIV and STI testing
• Provides free or low cost condoms and water based lubricant

HB page 15

Section 6: Special Sexual Health and Psychosocial Needs of MSM

Men, whether they have sex with men or women, generally do not use sexual health services, even if
they are available. Men’s lack of awareness that they may be at risk of HIV and STI and the cost of
testing (and cost of possible treatment) are likely to be some of the reasons. For men who have sex with
men, the fear of disclosing or being identified as a man who has sex with other men is also a
consideration. Thus, men who have sex with men have specific health needs that can only be met by
counselling and medical care providers who are fully aware of and sensitive to the issues involved.
Counselling and clinical staff should be made aware that some men have sex with other men and
recognise that they may also have sex with women.

However, counsellors often fail to ask about male-to-male sexual behaviour due to negative attitudes
toward same sex behaviour, preconceived notions about a client’s behaviour and identity, or out of fear of
asking sensitive questions. Counsellors must assess all male clients for possible same sex behaviour,
even if they do not identify themselves as men who have sex with men, as part of the risk assessment for
HIV and STI. To do this, counsellors need an ability to deal with the issues in a non-judgmental way,
using neutral or supportive language and appropriate non-verbal behaviour to elicit a client’s sexual
history. Moreover, the client must be assured that confidentiality will be maintained, respecting their right
not to divulge their sexual behaviour and gender/sexual identity, along with the results any testing, to
others

Although many of the issues surrounding HIV are similar for men who have sex with men to the rest of
the population there are other issues that may arise during health care visits. These can include:

Beliefs about masculinity: Healthy and strong men don’t get sick or cannot get infected. These beliefs
may be supported by previous experiences of non-condom use. It is important that you acknowledge the
difficulties the client experiences with these issues and challenge these beliefs. This indicates to the client
that no matter how strong and healthy they are, that they are susceptible to HIV and other infections if
they do not protect themselves.

Diagnosis and treatment of STI: Ideally, all health care providers need to recognise genital, oral and/or
anal symptoms of STI that may be disclosed by the client during the HIV risk assessment. When STI are
suspected, clients need to be referred to a properly equipped laboratory for diagnosis and treatment.
Doctors and other medical staff must be trained in identifying and treating infections in the mouth and
anus, as well as the sexual organs.

Internalised homophobia: This is when a client feels uncomfortable about their sexual identity and sexual
behaviour. When the client is unwilling to admit same sex behaviour and is therefore unwilling to take
protective measures it is important that you explore the reasons for the discomfort and unwillingness to
protect themselves. Clients who have significant difficulties with their sexuality may find it beneficial to
see a counsellor or to review some of the information for clients available on the websites or in the
references provided at the end of this handbook.

Poverty: The inability to practise safer sex because of the cost of condoms and appropriate lubricant and,
as in some cases, the need for financial reward takes precedence when a paying partner refuses to use
prevention or offers a higher payment for unprotected sex.

Safer sex strategies: Clients need to gain knowledge and skills in safer sex strategies specific to male-to-
male behaviour.

HB page 16

Sexual dysfunction: Issues of sexual identity fear of infection, and/or HIV status may prevent the client or
his partner from maintaining an erection, affecting the ability to use condoms. Similarly men may
experience difficulties with reaching sexual climax (known as retarded ejaculation) and a typical response
to this is to remove a condom or avoid the use of condoms in the first place in order to maximise
stimulation. It is important that you normalise the possibility of these difficulties by saying, “Many men I
see report that they have difficulties maintaining an erection or reaching sexual climax and this often
results in their not being to use a condom….I am wondering if you experience any of these difficulties?”.
If the client informs you of these difficulties you can offer suggestions on alternate sexual practices, or
ways to increase stimulation whilst the condom is in place; a referral to a doctor who may be able to
assist the client can also be made. Often sex worker peer counsellors or educators can assist in these
situations.

Sexual violence: More men than we would like to believe are victims of rape or coercive sex. This is
seldom discussed out of fear of being emasculated. If sexual violence is disclosed or suspected then
sexual assault protocols should be followed;

Suicide ideation: MSM are at higher risk of suicide due to double stigmatisation from same sex behaviour
and HIV positive status. If the client discloses thoughts about suicide, protocols in suicide risk
assessment should be followed. All MSM and especially those who indicate they are having difficulties
accepting their sexuality, difficulties with forming relationships, and those who experience rejection by
partner, families or who use significant quantities of drugs and alcohol may be at heightened risk of
suicide.

HB page 17

Section 7: Safer Sex Strategies

Strategies for prevention are the same for men who have sex with men as they are for other individuals,
namely abstinence, mutual fidelity, condom use and non-penetrative sex. However, the social and
psychological issues of men who have sex with men may prevent some men from succeeding in some of
these. Therefore, counsellors need to assist the client in assessing safer sex strategies, namely condom
use and non-penetrative sex. In particular, the counsellor will need to assess the client’s access to
condoms and the ability to use and negotiate for their use.

Moreover, counsellors need to assist the clients in developing a harm reduction strategy that will be both
pragmatic and effective. Counselling sessions will need to explore a range of options to fit the behaviours
that actually take place in the clients’ lives. Some strategies for safer behaviour include:

Condom use. When used properly, condoms can significantly reduce risk of HIV and STI. Thicker
condoms have been recommended for use in anal intercourse, but recent studies suggest that thickness
of the condom makes no difference as long as lubricant is used.

Female condom For some, the female condom may also be an alternative to the male condom in anal
intercourse. Usually the inner ring is removed and the condom is placed over the penis before insertion.
The advantages of the female condom include greater comfort for the penetrative partner and it does not
require a full erection before use. The disadvantages include availability and the comparatively high cost.

Appropriate lubrication.Because the anus does not produce lubrication, friction cause from the sex act
may cause the condom to tear. While the use of appropriate water-based lubricant is recommended the
cause is beyond the reach of most men who need it. Lubricants commonly found in the home – cooking
oil and hand-lotions among others – are used. These will actually weaken and begin to dissolve condoms.
Therefore a key activity in working with men who have sex with men is to ensure easy access to
appropriate lubricant.

Safer oral sex. Although the risk of transmission of HIV and most other STIs is significantly smaller in oral
sex, condoms should be used. However, many men find the taste and sensation unpleasant so they
prefer not to use them. If not used, ejaculating in the mouth is more likely to cause infection. Withdrawing
from the mouth before ejaculation will reduce risk.

Non-penetrative sex. A menu of non-penetrative sexual behaviours may also provide some additional
options for consideration. For example, intercrural intercourse (thigh sex) in which one partner places his
penis between his partner’s thighs, usually directly under the groin, creating friction and pressure that
provides pleasure to both partners. These behaviours may provide occasional alternatives to intercourse
rather than replacing it. Knowledge and skills in condom use and in the negotiation for their use are still a
necessity.

Negotiation / refusal skills. The client needs the ability to communicate with a partner or partners about
using condoms or non-penetrative sex, identify barriers they may face in discussing these issues, and
develop or strengthen the skills needed to negotiate for safer behaviour. The client may also need to have
refusal skills if the partner is unwilling to comply.

MSM behaviour specific information materials.
The counselling session is also an opportunity to distribute information materials related to safer sex
strategies for MSM and to refer clients to organisations which conduct workshops on issues of concern to

HB page 18

MSM, including HIV/AIDS; STI diagnosis and treatment; condoms and lubricant and negotiation for their
use; modifying risk behaviours; sexual identities and gender; marriage and families; wives and other
female sexual partners; legal and human rights issues; discriminations and stigmatisation; and, sex work.

Risk reduction among MSM with female partners

When men present for HIV testing they may not volunteer their sexual identity. When conducting a risk
assessment it is best to first of all remind the client that the interview is confidential. Then ask them
“When you have sex, do you have sex with men, women or both?” Asking a client if they are
heterosexual, homosexual or bisexual is asking about sexual identity rather than sexual practice. It is
also important to understand that men who identify as homosexual may not disclose that they also have
sexual relationships with women unless explicitly asked. If you only ask questions related to sexual
identity you may miss discussing specific exposure risks.

Men who are in relationships with female partners and who engage in sexual activities with male partners
and who cannot introduce the use of condoms into their heterosexual relationships should be advised to
have regular HIV tests and to use condoms with male partners.

It is also important that the risks associated with mother-to child transmission be discussed with men who
have female partners. It is important that during HIV counselling associated with HIV testing that men
who have indicated that they are either at risk of HIV infection or who test positive consider ways to
reduce infecting female partners. Furthermore you should ask if the partner is pregnant, if they indicate
that they are, and then men should be offered advice on preventing unplanned pregnancy and offered
referral for family planning. It should be reinforced that condoms can not only reduce HIV and STI
transmission but that they can also prevent unplanned pregnancies. Men who test positive should be
offered support in disclosing their HIV status to their partners, even if they do not wish to fully
acknowledge that they contracted HIV through same-sex behaviour.

All men irrespective of their status should be warned explicitly about the risks of transmitting HIV through
unprotected sex whilst their partner is breastfeeding.

To understand more about counselling MSM it is important that you follow-up the materials cited as
references at the end of this handbook.

Specific risk reduction strategies for transgender clients

Whilst all people are at risk of contracting the HIV/AIDS virus regardless of their age, gender or sexuality.
People with gender issue issues may face unique risks that general prevention literature fails to address.
It is important for counsellors to be aware of these and be able to offer specific risk reduction strategies.
Below are some precautions that may have particular relevance to transgender and intersex clients.

Rectal douching or neo-vagina douching. If clients have a neo-vagina (created through surgery), a natural
vagina or engage in receptive anal intercourse they may practice douching to keep these passages clean.
They should be informed that douching weakens the lining of the anal passage or vagina and removes
friendly bacteria and mucous, exposing the porous membranes (surface skin lining) and increasing the
risk of HIV transmission. The practice of douching is generally discouraged by health workers. Clients

HB page 19

should be reminded that douching and gels are not an alternative for safe sex, and that only condoms can
offer protection from the HIV virus and other sexually transmissible infections during intercourse. If clients
should douche because they are concerned about vaginal odours, they should see a doctor as these
odours may indicate an infection.

Advice on precautions following gender reassignment surgery. If clients are thinking of, or have recently
undergone, any gender reassignment surgery involving areas of their body that may be exposed to body
fluids during sex, then they should be sure to cover the area until they are completely healed.
Water based-lubrication and neo-vaginas. Although a neo-vagina may produce some lubrication during
intercourse it may not be enough for comfortable sexual activity. You should counsel clients regarding
the use of water based lubricants such as “Wet stuff” and “KY Jelly”. These will help avoid breaks or
tears in the vaginal lining which occur naturally during intercourse but which also increase the risk of the
virus being transmitted.

Hair Removal. Your clients should be advised that when they shave or wax the body or pubic hair they
must be careful of creating cuts and scraping the skin. They should be advised to cover any cuts and
abrasions before sex and never allow anyone’s body fluids (blood, semen or vaginal fluids) to touch
damaged skin. They should be especially careful if they shave their pubic hair, legs, chest or armpits and
then engage in “trick sex” (having intercourse between closed thighs or under armpits etc.).

Needles. Some people may use syringes/needles for hormone injections. HIV and other dangerous
viruses including Hepatitis can be found in a shared needle or syringe. If you clients inject their own
hormones or help friends with theirs, they should be advised to keep a clean supply and never share
needles or syringes.

Taping, Strapping and Tucking. Taping, strapping or tucking the genitals could create a warm, moist area
leading to skin disorders, chaffing and dermatitis. Removing tape roughly could result in damaged or
broken skin. Any of these increase the risk of the virus penetrating skin during sex. Clients should
generally be advised to remove tape carefully and remove any traces of adhesive with something gentle
and soothing oil.

Sex workers and HIV risk

Sex workers are especially vulnerable to HIV transmission due to their large number of sexual partners
and often high rates of other sexually transmitted infections. Sex workers often feel disempowered to
negotiate safer sex practices with clients on whom they rely for income. In some cases, sex workers may
accept a higher price with a client refuses to use a condom.

Research in some countries has shown that there is a difference in how sex workers negotiate safer sex
and this depends according to the extent of the emotional relationship. While with new clients sex
workers may use condoms, with their regular clients or ‘lovers’ to whom they have developed an
emotional relationship, they do not think about using a condom. In some situations, there is an
overlapping risk for sex workers between injecting drug use and commercial sex work. This requires the
simultaneous implementation of prevention strategies from two separate disciplines - harm reduction for
IDUs and sexual transmission reduction – in recognition of the two sources of risk among this population.
Sex workers have particular needs and HIV testing and counselling and psychosocial interventions
should be tailored specifically to ensure effectiveness. It is crucial that HIV testing and counselling

HB page 20

services reach this vulnerable population, both to protect the sex workers from HIV and other STI
infections and to prevent transmission to their clients and partners.

Some key prevention interventions with sex workers

Teaching sex workers to recognise visible symptoms of STIs is important. Photographs can be helpful.
They should depict conditions which sex workers are most likely to see rather than pictures of more
extreme symptoms. Of course, it must be stressed that there are many infections which have no visible
symptoms, including HIV and hepatitis.

Advising against the practice of douching and cleaning. Male, transgender sex workers use a number of
personal hygiene methods. Unfortunately these often include the use of harsh chemicals and detergents
which are not suitable for use in the anus or vagina because they break down the natural protection
against infection. The same is true of vaginal drying agents. Both sex workers and their clients need to
be made aware that these practices may actually cause tissue damage that places them at increased risk
of HIV and other STI.

Advising and referring for advice on microbicides and spermicides. Microbicides are chemicals which kill
germs or viral material, including those that may cause many sexually transmitted diseases. Spermicides
are chemicals designed to kill sperm. Nonoxynol 9 (N9) is the most commonly used spermicide.
Research has been carried out to see if it also has a microbicidal effect. So far, research has shown that
N9 does not reduce the risk of HIV transmission. Many people have reported that N9 irritates the skin in
the anus or vagina; it might therefore increase the risk of HIV transmission. Most services discourage
routine use of N9 because its harmful effects may outweigh any benefits.

HB page 21

Section 8: Challenges of Counselling Positive MSM

Everyone diagnosed with HIV faces a range of concerns, which may include ongoing health, whether to
disclose their status to partners, and HIV/AIDS-related stigma and its consequences, such as loss of
employment or home. Men who have sex with men who learn they are HIV positive face additional
difficulties, including potential disclosure of their sexual activity and in maintaining a relationship.
Counselling can help MSM identify and work through some of these issues.

Whatever the situation, confidentiality should always be maintained by VCT services. This applies both to
health, in particular whether the individual has tested positive to HIV or an STI, and to behaviour and
gender/sexual identity, i.e. respecting the individuals’ right not to divulge their sexual behaviour and
identity to others. Confidentiality around HIV should be respected whatever the result, particularly since
willingness to disclose a client’s negative status may suggest that those whose statuses are not disclosed
are HIV positive.

Men who have sex with men, like other clients who have tested positive for HIV, will need information on
health, rest, exercise, diet, safer sex and infection control. Follow-up counselling visits may be necessary
to answer further questions and to assess the impact of the diagnosis on the client’s relationships,
occupation, sexual behaviour and living situation. Special attention should be given to problem solving in
each of these areas, but in particular to the disclosure of HIV status to partners and others. Telling a
current partner or an ex-partner that they are HIV positive will be probably one of the hardest situations
the client must face. The difficulty may be compounded if same sex behaviour is revealed at the same
time – or, conversely, when relationships with the opposite sex are revealed to same sex partners.

After the client has learned their HIV positive status, a range of risk behaviour may continue. Counsellors
need to assist the client in developing a harm reduction strategy that will be both pragmatic and effective.
Counselling sessions will need to explore a range of options to fit the behaviours that actually take place
in the client’s life. A single counselling session will not be sufficient to explore all the issues. Ongoing
counselling is idea but, where it is not possible clients should be referred to groups and organizations that
can provide the needed support and assistance.

HB page 22

Section 9: Reorienting the Clinical Environment 10

This chapter provides guidelines for the development of a health care environment that is welcoming and
friendly for MSM and transgender people. It is a basic principle of health promotion to make health
services accessible and acceptable to the community they serve.1

Many MSM and transgender people experience ridicule, humiliation, violence and imprisonment as a
result of disclosing their sexual behavior to health care providers. Research has shown that fear of
discrimination and stigma cause many MSM and transgender people to postpone or decline seeking
medical care. Others, once in care, withhold personal information that may be critical to their care. It is
therefore no surprise that a clinical environment can be very threatening to MSM and transgender people
when presenting with anogenital symptoms or being asked questions related to sexual behavior.
Undisclosed behavior, especially anal sex and symptoms lead to poor clinical care by the clinician and
poor health outcomes for the patient.2

Some health care providers believe they have no MSM or transgender clients or staff in their facilities;
many are unsure about what their role should be in identifying and addressing MSM and transgender
issues and few have policies to guide staff or clients.

Using external cues, clients will have formed views about the friendliness of a service before they arrive
or speak to a member of staff. For example, the location of the service (is it easy to get to?), the opening
hours (are they convenient for the staff or the clients?), service signage (is it discreet, or confronting by
revealing the intentions of those who enter?), the availability of community newspapers (do they reflect
the values of the readers?) and clinic decoration (does it reflect community issues or tastes?) all provide
correct or incorrect impressions of the service. New clients may already have spoken to other clients of
the service about how friendly the staff are or what happens to you when you attend. The client will also
be sensitive to language and manners that suggest discrimination against them when they approach
reception staff or complete registration forms. While waiting, the client may hear staff speaking to new
clients at the reception area or on the telephone and note how much personal or identifying information is
discussed publicly. Are there client brochures available–about the service and how it operates-about
sexual health problems-and are they written in an easily understood manner? All of this happens before
the new client has even seen the doctor!

One basic approach to service development maximizes the success of any reorientation initiatives.
Actively seek the views of the MSM and transgender communities. An active engagement with the MSM
and transgender communities during service development will demonstrate that your service seeks and
values the views of the communities and that there is a commitment to their health care. By contributing
their knowledge to the clinic operations, MSM and transgender community members also develop a
sense of ownership of the success of the service and therefore share the rewards and help to seek
solutions to any failures.

MSM and transgender community input can help with decisions about the scope of services, location,
times and signage for the clinic, what decorations are in the clinic (and even creating the decorations),
pilot testing the client sexual health literature and registration forms and participating in the recruitment of
new staff.

During service delivery, many specific issues arise that are beyond the scope of these guidelines; these
issues will require local solutions. Most challenges to service delivery can be overcome by a process of
adequate consultation and negotiation between affected parties. Solutions in one service cannot always
be duplicated exactly in another clinic but can provide ideas and directions. An example of a specific
service challenge is when male-to-female transgender clients in a general STI clinic wish to use the
women’s toilet or sit in the women’s waiting room in a clinic where there are separate rooms for men and
women.

10
Excerpt from IUSTI Asia Pacific Branch [ ], Clinical Guidelines for Sexual Health Care of Men who have Sex with Men, IUSTI,
Bangkok.

HB page 23

It may be a female sex worker clinic session during which transgender sex workers also attend, or an
MSM clinic session for which there is only a male toilet. Some clinics and clients have no problem with
this arrangement; in others, both the female and male clients complain about it. Consultation with the
affected parties usually reveals the true problem (is it a specific individual or a larger issue?), a solution
and/or a compromise that will work for most clients most of the time. Solutions include having separate
men’s, women’s and other (or “unisex”, meaning any sex) toilets and having separate clinic times. Notices
should inform clients and the affected communities about the agreement reached during consultation and
staff should be prepared to revisit the decision at any time. Staff will also need to be prepared for the
times when the arrangement does not work, to prevent escalation of conflict and disruption of the service.

General guidelines for MSM and transgender health care services*

There are six key areas that require attention when orienting services to MSM and transgender clients:2
1. Clinic staff
2. Client rights
3. Client reception
4. Service planning and delivery
5. Confidentiality
6. Community relations

Within each key area there are two or more applicable standards. These offer minimum standards for
the conduct of a clinic. It would be unrealistic to expect that all of these policies could be adopted and
implemented immediately. Therefore, a step-by-step approach should be explored with the full inclusion
of staff and clients alike. Examples are provided of quality indicators within each area to assist with
fulfilling the standard.

Key area 1: Clinic staff

Standard 1: Employment of qualified MSM and transgender staff at the clinic where possible

The strongest indicator of a non-discriminatory, welcoming workplace for MSM and transgender clients is
the employment of MSM and transgender staff. Even when it is not obvious to clients that these staff
belong to these communities, the staff possess unique knowledge and skills that will not only benefit the
clients but also assist with training other staff in behavioral and cultural issues. MSM and transgender
staff should be visible to clients and not employed only on hidden tasks. Their visibility is one of the key
assets of the service.

Standard 2: A workplace free of discrimination and harassment for MSM and transgender staff

Once employed in the service, MSM and transgender staff must have the same workplace and
employment conditions as other staff. This may be viewed as “special treatment” by heterosexual and
non-transgender staff who are familiar with the usual discrimination, harassment and abuse of MSM and
transgender people in their community. However, equal terms and conditions of employment must be
vigorously enforced for MSM and transgender staff. Without the safety of this equality, the service will
simply reinforce the destructive aspects of MSM and transgender people’s lives rather than serve as an
environment in which staff can work effectively for their communities. If a service is unsafe for MSM and
transgender people to work in, it will be seen by their communities as a clinic that is also unsafe to attend
as a client and it will be counterproductive to the promotion of MSM and transgender health. When a
service is reorienting towards the MSM and transgender community, non-MSM and transgender staff
need to be included in workplace changes to ensure they can voice their views and acquire the necessary
skills and attitudes. Further, it should not be assumed that MSM understand transgender issues or vice
versa.

Key area 2: Client rights

Standard 3: Policies for non-discriminatory service delivery

High-quality sexual health care cannot be delivered to MSM and transgender people in a discriminatory
clinical environment. A high-quality service has comprehensive policies prohibiting discrimination in the

HB page 24

delivery of services to MSM and transgender clients. Staff need to learn and use culturally appropriate
language when dealing with MSM and transgender clients. Written forms and policies will also need to
use such language. Information brochures about the policies should be provided to clients when they
attend and posters clearly outlining the anti-discrimination policies of the service should be prominently
displayed. The policies will need to be discussed regularly during clinic promotion to the MSM and
transgender communities. Examples of unacceptable discriminatory practices by clinics and doctors
include requiring male-to-female transgender clients to wear male clothes in the waiting room, staff
leaving early from or arriving late to an MSM clinic; rushing examinations; and not asking MSM or
transgender people about sex with women.

Standard 4: Complaints procedures for anti-discrimination policies

Once anti-discrimination policies are written and implemented it is important to know whether they are
effective. The effectiveness of policy implementation can be assessed in several ways, such as observing
interactions between staff and clients in the clinic, seeking the views of clients or having a clear process
by which clients can complain about the service. Criticism or complaints are often viewed negatively
because they are often delivered with strong emotion and are about something that has gone wrong. But
it need not be this way. Criticism is an opportunity for the service to reflect on a staff–client interaction in
detail and to review the expectations of the service and community. Community members must feel that
they can provide feedback (or criticism) and staff must respect this right. On the other hand, managers
must ensure that staff members are not victimized in the process but are supported so that they can learn
from a complaint.
Services should have comprehensive and easily accessible procedures in place for clients to file and
resolve complaints alleging violations of anti-discrimination policies.

Key area 3: Client reception

Standard 5: MSM and transgender sensitive clinic reception procedures and staff

The first person to greet a client in most clinics is a receptionist or administration clerk who will need to
adopt an open, welcoming and non-judgmental manner. Commonly, the clerk’s main task during
reception is to gather identifying information to create a unique client record (usually with a unique record
number) to be used by staff at the clinic. This information usually includes personal and family names,
date of birth, sex and contact details and is gathered by asking the client to complete a form or brief
questionnaire. Clients should not be asked to show official identification papers. This reassures them that
there is no link between the clinic and official (usually government) agencies. Clients with low literacy
skills need assistance.

Clients must be reassured that their personal information is confidential (see below under Key area 5:
confidentiality) and given a brief explanation why this information is gathered and how it is protected.
Clients should be encouraged to provide true details because false details may jeopardize their care by
creating confusion between clinic records. However, when clients are hesitant, they should be offered the
option of providing a minimum of three pieces of identifying information such as a first name, a birth date
and sex, for example “Mohamed, 10/12/1970, male.” If the information appears to be false, the client
should be told to remember the information because it will be used to confirm the medical record and
number for any subsequent visits.

Providing an “other” option for sex in addition to male and female shows a sensitivity to transgender
clients who do not wish to identify as either male or female. Reception staff also need to be familiar with
culturally appropriate language, behavior and manners of MSM and transgender people. Registration
forms should allow optional self-identification of gender identity and marital or partnership status. Clients
should have an opportunity for further written or verbal explanation about the registration procedure

The role of the reception clerk is pivotal to the smooth operation of the clinic, so a strong investment in
cultural training and technical skill is essential. In summary, the key elements of good client reception are:
• Open and friendly manner
• Creating a unique client record and number
• Explaining why identifying information is needed
• Reassuring the client about confidentiality
• Gathering a minimum of three items of identifying information

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• Investing in skill development for reception staff

Key area 4: Service planning and delivery

Standard 6: Culturally competent in MSM and transgender issues services
An effective reorientation of a clinic to meet the needs of the MSM and transgender community can occur
only if all staff members have a basic familiarity with MSM and transgender cultures and manners. This
should include an understanding of the issues affecting their lives including discrimination, harassment,
poverty, victimization, rejection by families, and unemployment. External members of management
boards should also undertake such training. Some staff will have greater skill than others in managing
MSM and transgender issues and an early referral to these staff will ensure the best health care outcome
for the client.

Key area 5: Confidentiality

Standard 7: Confidentiality as a cornerstone of sexual health care

Confidentiality is a cornerstone of high-quality sexual health clinical care. Clinics need clear confidentiality
policies that are vigorously enforced and publicized. Staff orientation and regular training need to cover
confidentiality of client data, including information about sexual behavior and transgender issues. MSM
and transgender clients should be informed about data collection that includes references to sexual
behavior and/or gender identity, including the circumstances in which such information may be disclosed,
whether it may be disclosed as aggregate or individual information, whether personal identifiers may be
disclosed, and how and by whom such information may be used.

A simple approach that covers most of these issues is to have a clinic policy that prevents release of any
identifying information about a client without the written consent of the client. De-identified, aggregate
data is commonly used for service planning and evaluation and should not pose a serious threat to a
person’s confidentiality. However, if there are very few people with a specific condition or behavior from a
defined location, care will be needed as a community and individual members of the community may then
be identifiable within aggregate data.

There are many ways to maintain confidentiality within the clinic. For example, when discussing cases or
calling a patient from the waiting area, some clinics use only the client’s first name (although when the
patient’s name is common, their identity will need to be confirmed once in a private space, say by asking
them for their family name), while others use only the client’s registration number when referring to
patients. Care will also be needed when discussing a patient’s sexual health care with colleagues to
ensure that names, diagnoses, behaviors or gender issues are not linked, if the discussion can be
overheard by others.

Standard 8: Privacy

Another important aspect of patient confidentiality is privacy. Many clinics have space restrictions and
struggle to provide a quiet, private and comfortable space for sexual health consultations. A flimsy curtain
on a doorway is a poor sound barrier and is open for people to walk through without warning, even if this
is accidental. A consultation cannot be confidential if it is not private. Patients are asked to disclose
intimate personal details about their lives and then to undress, exposing the most personal part of their
body to a person they do not know. A screen between the interview desk and the examination couch
allows patients some privacy while they undress. For a comfortable and effective consultation, the basic
requirements are a room in which the consultation cannot be heard or seen by others (preferably with a
door and, when the door is closed, a sign alerting outsiders that a consultation is in progress), and where
there will not be any interruptions (except in emergencies). Knocking on doors should be standard clinic
practice to alert room occupants that someone wishes to enter. The occupants can then provide their
permission if it is convenient. Also, the patient must provide their consent to other people being in the
room, including chaperones.

Standard 9: MSM and transgender youth and children issues

In some countries and states, the sexual health care of MSM and transgender youth who are children or
minors (as defined by local laws) may be complicated by a clinic’s legal obligations to report child sexual

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abuse to government agencies. The clinic should be familiar with country and state laws on whether
minors can give consent for care and treatment. Staff should be trained and clients of the service who are
minors informed of various mandated reporting laws and their implications.

Key area 6: Community relations

Standard 10: MSM and transgender community input to protocols and procedures

Just as employing MSM and transgender staff helps to reorient a clinic, opportunities for representation
from MSM and transgender communities on the clinic board of directors and other institutional bodies
should be encouraged. This representation demonstrates transparency in the procedures required to
operate clinics and will, for example, allow for early input from community members to policy changes
affecting them and ensure support for the implementation of the policies.

References
1. Ottawa Charter for Health Promotion. Adopted at the First International Conference on Health Promotion. Ottawa. November 21,
1986. WHO HPR/HEP/95.1. At www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf. Accessed January 14, 2004.
2. Community Standards of Practice for Provision of Quality Health Care Services for Gay, Lesbian, Bisexual and Transgendered
Clients. Boston, MA: Gay, Lesbian, Bisexual, and Transgender Health Access Project, 2001. At www.glbthealth.org. Accessed
January 14, 2004.

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Section 10: Concluding Note for Health Care Providers

Men who have sex with men have specific health heeds that can only be met by health service providers
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-judgmental way (using neutral or supportive language an 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 when the individual has contracted HIV or a
STI.

Ideally, all health care providers should be aware that some men have sex with other men, but health
services 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 the service provider and client.

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

If a client tells you they have sex with the same sex.

• Don’t criticize the person for being different. Listen and learn. Find out about his/her
experiences. Understand issues that are important to him or her.
• Don’t
• Strive to develop trust and openness with you rather than conformity.
• Don’t discriminate against or oppress the person.
• Don’t demand that he/she try to change.
• Don’t tell the person it is a phase.
• Know that the person confiding in you feels vulnerable and frightened.
• Know that the person has probably spent countless hours preparing himself to come to your
service and share this information with you.
• Know that this person know that you have been raised in a society, like he/she has been, that
despises people like him. He/she fears how you may respond.
• Keep opportunities for communication open.

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References

Family Health International (2002), HIV/AIDS Interventions With Men Who Have Sex With Men (MSM)
http://www.fhi.org/en/aids/impact/briefs/msm.htm

Family Health International (2002), HIV/AIDS Interventions With Men Who Have Sex With Men (MSM)
http://www.fhi.org/en/aids/impact/briefs/msm.htm

Family Health International, et al. (2007) Peer and Outreach Education for Improving the Sexual Health of
Men who have Sex with Men: A Reference Manual for Peer and Outreach Workers. Bangkok: FHI.

Family Health International (2008). Facing the facts: Men who have sex with men and HIV/AIDS in
Vietnam. ENCOURAGES Project-CIHP-Collected working paper. Bangkok, FHI ARPO.

HIV and Men Who have Sex with Men: HIV/AIDS and Human Rights in Southeast Asia. Background
paper prepared for Expert Meeting on HIV/AIDS, Organized by Asia-Pacific Regional Office of the United
Nations of the High Commissioner for Human Rights (OHCHR), 23 – 24 March 2004

International HIV/AIDS Alliance (2003), Between Men: HIV/STI Prevention for Men Who Have Sex With
Men. Key Population Series. International HIV/AIDS Alliance.

IUSTI Asia Pacific Branch [ ], Clinical Guidelines for Sexual Health Care of Men who have Sex with
Men, IUSTI, Bangkok.

Malcolm McCamish, Graeme Storer, Greg Carl. 'Refocusing HIV/AIDS interventions in Thailand: the case
for male sex workers and other homosexually active men'. Culture, Health and Sexuality, Vol 2 No 2 April-
June 2000.

Naz Foundation (India) Trust (2001) Training Manual: An Introduction to Promoting Sexual Health for Men
Who Have Sex With Men and Gay Men, Samrat Offset Pvt, Ltd.

Shivanandra Khan (1996) “Bisexualities and AIDS in India”, Bisexualities and AIDS International
Perspectives, ed Peter Aggelton, Taylor and Francis: London, p 163

Shrivananda Khan (2004) MSM, HIV/AIDS and Human Rights in South Asia. Background paper prepared
for Expert Meeting on HIV/AIDS, Organized by Asia-Pacific Regional Office of the United Nations of the
High Commissioner for Human Rights (OHCHR), 23 – 24 March 2004

Treat Asia (2006). MSM and HIV/AIDS Risk in Asia: What is Fueling the Epidenic Among MSM and How
Can It be Stopped? The Foundation for AIDS Research [amfAR]

UNAIDS (2000) AIDS and men who have sex with men, Technical Update, Geneva: UNAIDS

UNAIDS (2006), HIV/AIDS and Men who have Sex with Men in Asia and the Pacific. Best Practice
Collection. Geneva: UNAIDS

HB page 29

MSM Awareness Handbook Thailand

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