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 Personnel/Capacity 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-identified males or boys for 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. Risks and vulnerabilities
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

32. Risks and vulnerabilities
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

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 Understanding and knowledge Services
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. Developing responses that address the needs that arise from the:
This means:
Developing responses that address the needs that
arise from the:
Physical
Emotional
Intellectual
Social

45. Building an enabling environment

46. A disempowering environment What 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 environment What 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 environment What 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

51. Education, clinics and products alone will
not build sustainable risk reduction.

52. Addressing the HIV prevention, care and support needs of Hijras & self-identified MSM and male sex workers
Need separate outreach strategies and implementation for hijras/zenanas and other sub-populations
Community development and mobilising
Clinical services providing VTC, STI (also addressing anal and oral STIs), rectal issues, castration and hormonal intake concerns as well as general health

53. Advocacy
Empowerment and self-esteem activities
Access to sexual health products such as condoms and lubricant
IEC and IPC resources for literate and non-literate populations
self-help organising and skills and capacity building

54. These services will need to be appropriate
Access to safe spaces for socialising and community building
Outreach specific to the needs of various sub-populations
Clinical Services
Access to condoms, lubricant and education materials
These services will need to be appropriate

55. advocacy & technical support
Field services
Outreach and friendship building
Community development and mobilisation
Education and awareness
BCC resource/condom distribution
Referrals
advocacy & technical support
Clinical services
STI management
HIV testing and counseling
Access to ARVs
Psychosexual counseling
General healthcare
Center based activities
Socialising and support groups
Vocational training and skills building
Drop in services
Community building activities

56. Principles of good practice
Most key stakeholders (international, national and local), including UNAIDS, based on their global experience, now recognise that for an effective, appropriate, and sustainable, HIV and AIDS prevention programme that focuses on any marginalised and socially excluded population, certain key indicators are required. These are:

57. Focused participatory interventions
Strategic focusing of participatory prevention programmes for MSM populations most at risk. Need 80% coverage of these sub-populations
Ownership of the issue
Those most at risk will also need to acknowledge their own risk and own the issues involved.

58. Self-help community-based organising
To ensure involvement of, and management by, beneficiaries, key individuals within marginalised populations should be recruited, provided training and skills building, and empowered to develop their own service organisation.
Access to appropriate and affordable STI treatment services
It is essential that clinicians providing STI treatment services are sensitised to the specific sexual health needs of vulnerable MSM, which includes providing STI management in regard to anal STIs and symptoms. Such services should be confidential, not only around STI status, but also with regard to sexuality and behavioural choices.

59. Access to appropriate HIV voluntary testing and counselling
Ensuring that confidential testing along with pre-test and post-test counselling appropriate and sympathetic to the needs of MSM is essential.
Access to appropriate HIV treatment and care services
Many MSM living with HIV/AIDS are not only stigmatised by their positive status, but also by the route of infection and their feminised sensibilities. Treatment, care and support programmes need to be sensitised to these different frameworks of stigmatisation and address them appropriately.

60. Access to affordable condoms and water-based lubricants
Reducing the risks of STI/HIV infection is central to any effective HIV/AIDS prevention programme. The most significant risk is through anal sex, both for the penetrated as well as for the penetrator. Regular use of condoms for anal sex is an essential component for any risk reduction strategy. However, in addition to this, ready access to appropriately packaged water-based lubricant is also an essential component of this, since anal sex by its nature increases the stress on condoms itself as well as reduces rectal damage.

61. Access to appropriate BCC materials
These materials need to be appropriate to the issues and concerns of MSM in languages, terminologies and imagery that are meaningful and understandable to them.

62. Long-term technical and financial support
It is most likely that the level of technical knowledge to develop, implement and manage an HIV/AIDS prevention and care programme for peer beneficiaries will be low if existent at all. Developing these skills and knowledge will require a sustained effort to share such information with those developing the service. At the same time, these self-help initiatives must also en ensured of appropriate levels of funding over a sustained period of time in order to develop these skills and continuity of service provision.

63. Advocacy on legal, judicial and social impediments to promoting HIV/AIDS prevention and sexual health for MSM
Along with advocacy on the above signifiers, advocacy on addressing the legal, judicial and social impediments to HIV/AIDS prevention and care programmes focusing on MSM is an essential requirement towards developing an empowering environment so that affected populations can reduce their risks to HIV/STI infections and modify their sexual practices in order to achieve this.

64. Thank you