Orlando O. Harris, PhD, RN, FNP University of Rochester, School of Nursing July 24 th , 2014

1. "Survival Now vs. Survival Later”: Young Jamaican MSM’s Immediate and Delayed Assessment of HIV Risk Orlando O. Harris, PhD, RN, FNP University of Rochester, School of Nursing July 24th, 2014

2. Funding Sources & Support • United States Department of State, Institute for International Education (IIE) • Fulbright Fellows Program • US Embassy- Kingston, Jamaica • University of Rochester • School of Nursing • Center for AIDS Research (CFAR) • Faculty Support • Drs. Jane Tuttle, Craig Sellers, & Ann Dozier • University of the West Indies, Mona Campus • Dr. Leith Dunn

3. Overview of Jamaica

4. Homophobic Violence In Jamaica • Homophobic violence is widespread in Jamaica • Violent mob attacks are common • Societal and Cultural condemnation of homosexuality has created a hostile living environment for many JMSM • Discrimination towards JMSM is sanctioned by law • The “buggery” (sodomy) law punishes homosexual sexual behavior with imprisonment (maximum of 10 years) • Condoms and lubricants are difficult for JMSM to obtain • Often placed behind the counter • Need to be requested • JMSM are at increased risk for HIV transmission

5. Research Purpose • The purpose of this inquiry was to understand the circumstances that place JMSM at risk for HIV • Explore how they navigate their environment to enhance their personal safety

6. Methods: Design & Recruitment • Qualitative Description • Individual semi-structured interviews • Focus group discussion • Participants were recruited from • A local university • One community-based organization • Interviews and focus group discussions were recorded, transcribed, and analyzed using thematic content analysis

7. Sample (n=30) • Age of first sexual experience ranged from 7-24 years • Participants self-identified as • Gay (60%) • Bisexual (40%)

8. Sample

9. Violent Anti-Homosexual Environment “They treat gay people worse than how they treat dogs. They treat gay people bad. If it comes to it, they will come and tell you that they would light you and burn you in the middle of the road- I know they would do it.”Zack (age 21)

10. Rejection of Feminine Men “ When I was young, I left the country and came to Kingston to live with my mother. During that time, there was an issue with the community. I couldn't tolerate it so I decide to run away… I came back and was attacked when I was coming home from school. I guess I was too feminine to live there… so then my mother and siblings told me to cut down on my femininity and man up. I love my make-up you know. So that was hard for me to give up. So someone sent word to my mother that our safety was in jeopardy… Because I didn't want anything to happen to them or have our house destroyed... I wanted them to live there peacefully, so I left… I was only 15 years old.”Arron (age 24)

11. Society: Keep It To Yourself • JMSM learn from an early age that their sexual orientation must be kept private. • “I never knew what was happening to me... I thought it was an experience. I was young and almost a teen … but when I realized how the Jamaican society was at the age of fourteen… I couldn’t express it. I mean it does not work like that here and though I had a good relationship with my mother, she would say that ‘I can’t be this way and that it is not of God. It’s ungodly and you will go to hell.’ So I made the decision to keep it to myself.” Barry (age 22)

12. No Same-Sex Sex Education • JMSM received their information regarding homosexual sex through • Their peers (personal experience) • Cable television • Internet (pornography) • Community workshops (sponsored by the MOH) “The stuff I know about gay sex… I learn about it hands on…I didn‘t use the internet or anything. Mine was through experience. I just fit the puzzle together. When I was seven years old, me and my cousins would kiss, then we wondered if our penis could go in other places so, then we experimented and that was how we knew it could work.” Steve (age 25)

13. Mental Health Impact & Suicidal Thoughts “I tried to kill myself once because I didn’t want to deal with this lifestyle anymore… Well not to kill myself really but just to take the pain away…I don’t know if I should be telling you this. I tried it once. I use to cut myself. I was dealing with a bad depression when I was 16…I cut myself when I get stressed or have anxiety… When I don’t know what to do, I just cut.”Nick (age 23)

14. Survival Trumped HIV Concerns • Potential HIV infection was measured through an immedidate and delayed risk assessment. • Immedidate risk involved the possibility of being caught in a “compromising situation” with their partners, or any other circumstances that might affect their personal safety. • Delayed risk involved not being immediately concerned with HIV infection during intimate contact with their partners • “I guess I have been very lucky… I remember doing it [unprotected sex] with a person I know... He was a businessman where I was living… I didn’t know that he had HIV… I found out after we had sex…. I trusted him because he was someone who would do things for me because he is financially stable. I didn’t question it.” Frank (age 26)

15. Trading Sexual Favors for Safety • Engaged in undesired sexual activity with men who were able to provide them with life necessities. • “He said I had to sleep with him if I wanted to stay in his house, at that point I had no choice but to sleep with him… It was a time in my life where I had nowhere to stay and that was what I had to do in order to have a roof over my head… It made me feel small in myself [crying]. I guess that’s just a part of being gay.”Frank (age 26)

16. Navigation of Health Care • For some JMSM, their experiences with HIV have been directly linked to their present social and economic situation. • Access to and navigation of the relevant health care systems within the island presented many challenges.

17. Protection In Public Spaces • Changing your appearance or dressing more masculine • Avoiding being in the presence of more feminine JMSM in public “In most cases I would just try to act masculine in public. I create a edgy version of myself in public and around others who I know are strictly safe or who are against homosexuals… so basically just act rough or toughen up myself more than the real me… I’m never real unless I’m around good friends…I dress more clean, nothing that draws too much attention to anyone, just average.”Kevin (age 21)

18. Implications • Advocate for the removal of structural barriers, including legal barriers, that inhibit access to prevention services • Sensitization to and education of more culturally competent health care providers around issues related to • Gender, gender identity, gender expression, sexuality, and sexual orientation • Improve public healthcare facilities so that they are accessible and welcoming