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“I don’t tell anybody that I am married”:

“I don’t tell anybody that I am married”: Understanding the vulnerabilities and associated HIV risks of Indian men having sex with men who are married to women. Sandeep Mane, Matthew J. Mimiaga, Steven A. Safren, Murugesan Sivasubramanian, Patricia Case,

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“I don’t tell anybody that I am married”:

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  1. “I don’t tell anybody that I am married”: Understanding the vulnerabilities and associated HIV risks of Indian men having sex with men who are married to women Sandeep Mane, Matthew J. Mimiaga,Steven A. Safren, Murugesan Sivasubramanian, Patricia Case, Carey V. Johnson, Vivek Raj Anand, Ashok Row Kavi, Arun Risbud, Raman Gangakhedkar, Kenneth H. Mayer

  2. Overview Formative, qualitative study Examining experiences and HIV sexual risk behavior 20 MSM who are married to women 20 MSM who are not married to women

  3. MSM in India Constitute a Core HIV Risk Group National AIDS Control Organization (NACO) 2007 HIV prevalence estimates: 7.4% for MSM 0.34% for general population Other HIV prevalence estimates among MSM in India range from 9 to 18%: 12% at The Humsafar Trust VCT clinic Mumbai 13% Tamil Nadu state; 9% Chennai 18% in Andhra Pradesh NACO, 2008; Kumta et al., JAIDS 2010; Solomon et al., AIDS Behav 2010; Sravankumar et al., IAS 2006

  4. MSM in India: Gay sexual identity and sexual behavior not necessarily linked Kothi – Feminine acting/appearing, predominantly receptive sex partner Panthi – Masculine appearing, predominantly insertive sex partner Double Decker – Both insertive and receptive sex partner Gay – Similar to the identity of “out” gay men in the U.S. Bisexual – Sexual behavior with men and women Hijra (Arivani) – Male-to-female transgenders, not MSM identified Asthana and Oostvogels, Social Science and Medicine 2001

  5. Pressure to marry is high in India Social recognition: a person is not recognized in society unless they are married MSM are a stigmatized group MSM are hidden, including married MSM If not married, loss of family property rights Potential HIV risk to self, to wife, to children Psychosocial stressors Victimization Harassment / assault Fear of rejection from friends and family Discrimination Depression/suicidality Additional stressors for MSM in India

  6. Many MSM Get Married 2009 Mental Health Study of MSM at Humsafar Trust (N=150) 21% of sample reported that they were married to women 2003-04 Humsafar VCT study (N=831) 23% married to a woman Being married to a woman was a risk factor for being HIV infected (AOR = 1.59; 95% CI = 1.27-2.78) This is likely an underestimate of the percent of MSM who are married These are MSM presenting at Humsafar Sivasubramanian et al., IAS 2010, paper in progress; Kumta et al., JAIDS 2010

  7. Study Design Qualitative interviews & brief survey 20 married MSM and 20 non-married MSM Voluntary counseling & testing for HIV Analysis: content analysis using NVivo qualitative software

  8. Descriptive Data Percentage sexual identities % % 25 kothi 20 bisexual 20 gay/other Married participants were older than unmarried (mean 28 vs. 24 years, p<0.03) 3 married, 2 unmarried were HIV+ Sex with women in past 12 months: 100% of married MSM 70% unmarried MSM Married and unmarried MSM were similar with respect to: Education Income Sexual risk behavior • 23 panthi • 10 double decker • 2 unspecified

  9. Theme: Stigma and Pressure to Marry 65% of MSM described experiences of stigma and harassment from family members and other social influences, particularly the pressure to marry: “No, nobody knows this [sex with men] so far, I have hidden all these things from them…No one will respect me, they will condemn me, this kind of things will happen.” 21 year old unmarried MSM, unspecified sexual identity “Four to five days before marriage my mother had locked me in a room with one pair of clothes as I had said her that I would flee as I do not want to get married…I don’t like it. I feel that I should become a wife of other [men].” 23 year old married double decker

  10. Theme: Childhood Sexual Abuse 22% respondents described childhood sexual abuse (CSA) experiences that were traumatic and/or unwanted This abuse was generally by older men in the community, family members or teachers: “I was going to school for studying, and teacher only did sex with me. He used to make me sit next to him and he was asking me to hold is organ. Hence I left studies…That time my age was 9.” 26 year old married kothi Although CSA does not cause homosexuality, a few respondents described these experiences as formative to their being MSM “Had he not done sex with me, I wouldn’t be in this state today. I wouldn’t be kothi or panthi today. I became kothi because he did sex with me.” 41 year old married kothi

  11. Theme: Concealment of Marital Status to other MSM 55% respondents reported that an individual’s marital status is not discussed or disclosed among other MSM Married MSM conceal their marital status from their sexual partners to maintain their identity as single and to remain sexually desirable: “I don’t tell anybody that I am married. I ask my partner whether he is married or not! Some of them say yes, some deny.” 28 year old married gay While respondents knew several terms to describe MSM and same-sex behavior, there was only one term to describe married MSM: “Paav Bhattewala”

  12. Theme: Concealment of MSM Behavior to Family, Friends, and Social Circle 75% of respondents reported conscious concealment of their MSM behavior from their wives and/or other family members “I am always having tension whether somebody is watching me, and by chance if they see me I have to tell my wife [a] lie.” 41 year old married kothi “My family is broadminded, but…I can’t expose my things to them because they won’t accept it. I never hurt them for any reason so I can’t hurt them by revealing this truth to them about me. My bhabhi [sister in law] is God for me. I don’t want to tell her all these things about me and make her sad.” 28 year old unmarried bisexual

  13. Conclusions MSM in India face unique, complex, and culturally specific stressors – HIV risk behaviors occur in this context Important psychosocial factors to consider in future interventions may include: Stigma and pressure Childhood sexual abuse Concealment of marital status to other MSM Concealment of MSM behavior to family, friends, and social circle HIV interventions may benefit from an increased awareness of this population and their specific prevention and treatment needs Future quantitative studies understanding the networks of married MSM are warranted Findings have been used to develop a larger, quantitative study (N=300) examining the social and sexual network characteristics of married MSM in Mumbai, currently in progress

  14. Thank you NARI/ICMR Kamini Walia NIMH/NIH Willo Pequegnat Indo-US JWG Brown CFAR and Fogarty AITRP Program Harvard CFAR Kalpita Langekar Patil Jesse Ripton Rodney VanDerwarker Girish Kumar P Study participants and Humsafar Research Team

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