Working with vulnerable males and HIV in Pakistan

1. Working with vulnerable males and HIV in Pakistan A one day seminar Shivananda Khan Naz Foundation International

2. Assumption • That participants have • knowledge on HIV and AIDS. • That we understand • dynamics and frameworks of male-male sex in Pakistan

3. Goals Process Level Institutionalise knowledge and understanding within NACP/PACP regarding male-to-male sexualities, masculinities, sexual behaviours, risk and vulnerabilities. Personnel/Capacity Level A deeper understanding of differing frameworks of male-to-male sex, risks and vulnerabilities in Pakistan, and towards developing knowledge-based interventions within a framework of agreed good practice principles in regard to HIV prevention, care and support programming amongst a range of highly vulnerable MSM sub-populations.

4. Learning Outcomes • Have a better understanding of male-male masculinities and sexualities in Pakistan. • Have a better understanding of male-to-male sexual behaviours, genders and identities, along with risks and vulnerabilities in Pakistan. • Be able to integrate this knowledge into progamme planning and design for MSM sexual health interventions • Have access to a range of knowledge resources

5. We will be exploring: • Current epidemiological knowledge • Why work with MSM and HIV • Who is MSM • Why males have sex with males • Risk and vulnerability • Issues, needs and concerns • Changing Behaviours • Building an enabling environment • Developing a response

6. Personal sensibilities • We will be discussing male-male sexualities and sexual practices. • There needs to be an open discussion. • How do you feel about talking about sex, particularly stigmatised sex.

7. HASP Presentation

8. Why work with ‘MSM’ • Why we should work with male-to-male sex and HIV prevention, care and support? • Because: • It is the right thing to do on humanitarian grounds. • It is the right thing to do epidemiologically. • It is the right thing to do from a public health perspective.

9. Males who have sex with males (MSM) whether their self-identity is • linked to their same sex behaviour or not, have: • The right to be from violence and harassment; • The right to be treated with dignity and respect; • The right to be treated as full citizens in their country; • The right to be free from HIV/AIDS; • MSM who are already infected with HIV have the right to access • appropriate care and treatment equally with everyone else, regardless • of how the virus was transmitted to them.

10. Who are MSM?

11. Who is involved in male-to-male sex? • Feminised males • Masculine males • Teachers • Students • Relatives • Street males • Prisoners • Males in a occupational groups: truck drivers, boatmen, fishermen, taxi drivers, etc. • Politicians • Bureaucrats • Labourers • Farmers • Male sex workers • Males in uniformed services • Male friends • Foreigners • Adolescent males What distinguishes these men from each other?

12. Who are hijras? • To often there is a major confusion between hijras and zenanas, with both sub-populations being grouped as one. But this is not so. • Hijras represent a specific community with its own rules, regulations and order. To become a hijra is not only about dress code, behaviour and language. They have adopt the hierarchy absolutely. • There are rituals to perform (Reet) which is a ritual where a young male (and sometimes not so young), primarily zenana identified, who enters a hijra household through ritual offerings made to the guru/nayak, who have absolute authority over the new chela. • Thus the hierarchy is chela - guru - nayak.

13. Chelas must get permission from their gurus, and gurus must get permission from their nayak - head of a particular hijra household (not a dehra) to be involved in any activity. • Hijras have specific beliefs relating to their spiritually given powers over fertility, which are granted following the castration ritual. • Not all hijras are castrated, but this is the end goal. • Not all zenanas are hijras unless they adopt the rituals and authority of the hijra community.

14. Who are zenanas? • Hijras and some zenanas are not the same, even though they make look alike in terms of dress and gender performance. • Zenana is a term that identifies a particular male who is feminised both in behaviour and sexual preference and practice, that is receptive anal and oral sex. • Not all zenana-identified males cross dress either full-time or part-time, and many are only situationally zenanas. • Some zenana’s imitate hijra households by having a guru and chela system, but they don’t conduct the Reet rituals nor belong to a specific hijra household. • It needs to be noted that it is not unknown for zenana identified males (as well as some hijra chelas who sell sex) to also penetrate other males.

15. Questions • What do we mean by the words: • Sex • Gender • Sexuality • Masculinity • Need to think in terms of genders, • sexualities, masculinities

16. Masculinities A term used to think about men/males and how it is expected that they should behave. • What does it mean to be a male? • What does it mean to be a man? • What does it mean to be masculine? • What does it mean to be an “effeminate” man?

17. Why males, and not men? The word MAN is a culturally loaded term, and carries significant beyond that of biological age and performance. It also is host to concepts of adulthood and personhood, social obligations and family duty. A zenana does not define himself as a man. An adolescent male is not defined as a man.

18. Why do males have sex with males?

19. Desire for other males – gender/orientation • Desire for specific acts – anal/oral • Pleasure and enjoyment from discharge – “body heat” – also play and curiousity • Wives do not do anal or oral sex – ashamed to ask

20. Males are easier to access –females are more socially policed and can be more difficult to access • Protecting a girls virginity – maintaining chastity • For money, employment, favours • Anus is tighter than vagina and gives more pleasure • No marriage involvement • Its not real sex

21. Feminine males who desire other males - receptive • Masculine males who desire other males - penetrative • Males who both penetrate and get penetrated • Males who just want anal or oral sex - discharge, ‘body heat’ • Situational male-male sex behaviours

22. Frameworks of male-to-male sex • Gendered framework • Male to male desire based on feminised gendered roles • an identification - sexual acts based on gender roles, i.e. • man/not-man • Discharge framework • Male to male sexual behaviours arising from immediate • access, opportunity, and “body heat”. They involve • males/boys/men from the general male population

23. Many males from the general male population will also access feminised-identifiedmales or boysfor anal/oral sex . These males do not see themselves as “homosexuals”, or even their behaviour as “homosexual”, since they take on the “manly” penetrating role in male to male sex. Nor do their partners see themselves as homosexuals because they either see themselves as “not men”, or they are involved in play - not sex.

24. Emergent gay framework • Male to male desire framed by sexual orientation. • Primarily used by middle and upper classes. Such • gay identified men usually seek other gay identified • men as sex partners.

25. And of course not to forget, males/men in all male • institutions, such as prisons, the uniformed forces, • colleges, university, schools, religious institutions, as well as a range of occupational groups and situations.

26. Most male-to-male sexual behaviours are invisible and not gay/homosexual/kathoey/apwint identified • Sexual/gender identities tend to be based on class, education, and sex roles • Many males involved in male-to-male sex will also often have sex with wives/other women • Male-to-male sex is not uncommon and involves males across the economic and social spectrum, rural and urban • MSM then is no an exclusive category or “target group” – it reflects a behaviour which may be relatively common • The issue is risk and vulnerability

27. Thus in Pakistan MSM can be categorised as: • Hijras • Zenanas • Chawas/murwasi • “college boys” • Gay/homosexual identified men • Male sex workers, including malaishes who sell sex • And there sexual partners

28. Who should we focus on? • Identity/groups or behaviour? • Why?

29. Identities and/or behaviour Various types of self-identified zenanas Real men who penetrate - called giryas by zenanas/hijras

30. Identities and/or behaviour Two male sex workers - chavas and one self-identified zenana who also sells sex A malaisha who also sells sex to males and females - will penetrate and be penetrated

31. Multiple partners Anal sex as primary sexual activity Low condom use Significant levels of STIs Sex with both male and female partners Marriage Stigma and discrimination Invisibility and denial Myths and misconceptions Risks and vulnerabilities

32. Gendered framework Sexual violence Illegality and conflict of state policies Poor access to treatment Low coverage of appropriate sexual health services Poverty Low levels of knowledge and understanding Risks and vulnerabilities

33. Issues, needs and concerns

34. Issues, needs and concerns • Significant levels of male-to-male sex • Anal sex the predominate behaviour • Multiple partners • Significant levels of commercial sex work • High rates of STIs • Low levels of health seeking behaviours

35. Issues, needs and concerns • Inadequate STI services: anal and oral STIs • No water-based lubricant • Stigma and discrimination • Violence and harassment • Low level of condom use

36. Issues. Needs and concerns • Female partners including wives • Psychosexual issues and myths • Legal, police, judiciary • Very low service coverage • Low technical skills and capacity

37. Issues Environment social exclusion Legal and policy advocacy sensitization Understanding and knowledge epidemiology ethnographic/anthro behavioral • Meaningful Involvement • of the affected • Populations • Group interface • Effectiveness • and impact assessment Services Appropriateness Delivery environment availability accessibility

38. There are only 2 main strategies for promoting sexual health • THE MORAL STRATEGY – DON’T DO IT • THE PRAGMATIC STRATEGY – DO IT SAFELY WHICH STRATEGY WOULD BE THE MOST EFFECTIVE?

39. Frameworks for prevention • Identity/behavioural based interventions through self-help organising and peer pressure • Including unprotected anal sex as high risk behaviour in any HIV prevention programme for occupational and situational populations, i.e. truck drivers, prisoners

40. Changing behaviours

41. What I feel DESIRE What I believe THINK What I do BEHAVIOUR CONSEQUENCE

42. Changing behaviour requires Knowledge Desire to change Will to change Skills to change practice Power Access to sexual health services and products An enabling environment

43. Sexual Health Sexual health is the integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love. WHO, 1975

44. This means: • Developing responses that address the needs that • arise from the: • Physical • Emotional • Intellectual • Social

45. Building an enabling environment

46. A disempowering environmentWhat does this mean? • Stigma, discrimination and social exclusion affects the ability of vulnerable populations to protect themselves from HIV/AIDS. • It disempowers them from support and care. • It disenfranchises them from accessing what services may be available. • It reduces opportunities to develop appropriate services.

47. An enabling environmentWhat does this mean? To enable: Authorise, empower, supply with means to take action. To provide with adequate power, means opportunity, or authority. Equity: A system of justice founded on principles of natural justice and fair conduct. Thus to develop an enabling environment means to create systems of empowerment, social justice, and equity for the most marginalised populations.

48. An enabling environmentWhat does this involve? • To empower affected and infected populations to develop and deliver their own self-help services. • To increase the technical skills of service providers and those that deliver services • To ensure appropriate resources are easily available.

49. Empowerment • Address low self-esteem and self-worth • Provide skills and knowledge • Provide resources, technical, financial, institutional • Advocate on their behalf • Create and enabling environment • Assist in self-help organising • What other steps can be taken?

50. Developing a response