1. Managing STIs among men who have sex with men (MSM) & Transgender (male-to-female) persons attending a community-based clinic: Lessons Learnt Dr. Venkatesan Chakrapani, MD FLD Fellowship grantee of the MacArthur Foundation

2. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Objective To share the experiences in managing STDs among MSM attending a community-based clinic. To speculate about how these lessons learnt can be of use in providing better clinical services to MSM attending government STD clinics.

3. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Men who have Sex with Men (MSM) Denotes all those men who have sex with other men regardless of their sexual identity.

4. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 MSM in India – Identities/labels/behaviors MSM who don’t have any specific identity Kothi-identified homosexual males ‘Panthi’ (masculine partners of kothis) “Double-decker” (DD) Gay-identified homosexual men Bisexual-identified men with same-sex/ bisexual behavior

5. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Transsexual/Transgender - Individual whose gender identity is that of the opposite gender Male-to-female transsexuals (transsexual women) Ali / Aravani / Hijra Ali – identify as ‘kothi’. Akwa and Nirvan Focus of this presentation – on MSM and not on Alis

6. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 MSM 1

7. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 SWAM A community organization started by and for MSM in 1996 in Chennai. Services offered to MSM in Chennai: - Outreach education (HIV/STD) - Condom promotion and distribution - Drop-in center - STD clinic - VCT - Day care center for HIV-positive MSM

8. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Why a STD clinic was started in SWAM? Main reason: Certain subpopulations of MSM did not go to govt. or private medical practitioners due to fear of discrimination (if they revealed their same-sex behavior or if physicians found out that they have anal STDs).

9. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 STDs – Clinical pattern Duration: Sep 2003 to May 2004 Total number of new patients: 136 Other anogenital conditions: Candidal intertrigo – 3 Scabies - 4 STDs: (Clinical Diagnosis) Genital warts – 5 Perianal and genital warts - 3 Primary chancre – 5 Acute Gonococcal urethritis – 3 Chancroid – 2 Genital Herpes – 3 Epididymo-orchitis (non-gonorrheal) - 5

10. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 HIV testing (VCT) HIV testing – in collaboration with ICMR From Jan 2004: - Total tested: 68 - Tested positive: 9 (13%) Follow-up

11. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: BISEXUAL BEHAVIOR Many MSM have bisexual behavior. Many are heterosexually married or eventually will be married. Relevance: - Need to educate MSM to consistently use condoms irrespective of the sex of the partner. - Need to ask them to refer their male and female steady partners for clinical examination and testing.

12. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: SEXUAL ROLE Many MSM (including “obviously feminine” MSM) may practice both insertive and receptive penetrative sex. ‘Kothi’-identified MSM may deny involving in insertive sex. Relevance: - no assumption about the sexual practices based on gender expression or self-reported identity (like ‘kothi’) - need to ask for insertive and receptive sexual intercourse even in “obviously feminine” MSM.

13. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: DENIAL OF CERTAIN SEXUAL PRACTICES Even among who denied penetrative sex, penile STDs were found. Even among who denied receptive sex, peri-anal STDs were found. Relevance: - All MSM should be asked about specific symptoms of peri-anal STDs since they may not tell (due to fear of rejection and discrimination). - clinicians to examine genital and anal areas irrespective of the self-reported sexual history.

14. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: NEGOTIATION SKILLS Many MSM may found it difficult to ask their casual masculine partners (‘Panthi’) to use condoms. Relevance: -Provision of condoms and condom demonstration alone may not be helpful. Patients need to be taught about condom-negotiation skills and sexual communication skills.

15. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: CONDOM USE & PARTNER TYPE Condom use differs according to partner type: steady partner – low, casual or commercial – relatively high Relevance: Educated to consistently use condoms irrespective of the type (regular or casual) of sexual partners.

16. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: MARRIED MSM Many married MSM do not want to go to government hospitals since treatment for them is not given unless the wife is brought for examination. Relevance: - Certain populations of MSM will not be using the government clinical services. -Appropriate mechanism need to be developed to solve this issue.

17. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 ‘Partner treatment’ or ‘Partner notification’ What is done at SWAM clinic regarding ‘partner treatment’ or ‘partner notification’? -casual male partners can not be traced by the patient. -Patient has to inform his steady male or female partner regarding STD or HIV status. -Asked to bring their steady male partners. -To refer their wife to some O&G specialists for examination. -“patient-directed partner treatment’ tried.

18. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: ORAL SEX & CONDOM USE Many MSM may not use condoms for oral sex. Relevance: - Need to educate MSM that oral sex is not absolutely risk free. -Availability of flavored condoms (strawberry, chocolate) can be told.

19. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: RIMMING & DENTAL DAM A significant proportion practice ‘rimming’ (oro-anal sex’). Relevance: -Risk of STDs from rimming need to be educated. -Asked to use dental dams (oral dams).

20. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Anilingus/Cunnilingus & Dental Dam

21. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: MSM WITH NO IDENTITY The masculine partners (‘Panthi’) of kothi-identified MSM go to government hospitals or private practitioners for sexual health care. Relevance: - same-sex/bisexual behavior need to be routinely asked in all males and should not be asked only in “obviously feminine” males. -Most MSM coming to the government hospitals may not be revealing their same-sex behavior hence we will loose opportunities to provide information about same- sex behavior and safer sex practices -Those MSM with out any specific identity could not be referred to community-based organizations

22. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: HIV-TESTING High prevalence of HIV among MSM Presence of HIV among MSM who denied unprotected penetrative intercourse Relevance: - routinely offer HIV testing irrespective of self-reported risk behavior.

23. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Observations & their relevance: JAUNDICE & VACCINATIONS A significant proportion of MSM reported having had jaundice after their sexual debut. Relevance: -Need to be educated about sexually transmissible hepatitis virus infections (HAV, HBV) -Need to be educated about preventive measures (HAV – dental dam, HAV vaccine; HBV – HBV vaccine)

24. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 Conclusions Clinicians need to be educated about the specific issues related to sexual health care of MSM and transgendered persons. Creating an nonjudgemental and nondiscriminatory environment in the government hospitals is crucial for MSM to utilize government STD clinics.

25. Kodaikanal Govt. STD Medical Officers Seminar, June 2004 THANKS cvenkatesan@hotmail.com Kindly visit www.indianGLBThealth.info