Young gay and bisexual men in Kenya experienced high levels of stigma and discrimination in public healthcare facilities, while reporting more positive experiences in private and gay-friendly clinics. Online interventions were seen as a way of catering to priority needs and reducing stigmatising experiences, according to a recent qualitative study.
Background
Gay sex is illegal in Kenya, which can make finding non-stigmatising services challenging. The Kenyan Ministry of Health recognises that gay and bisexual men are a key population when it comes to HIV and other STI prevention. This enables community-based and non-governmental organisations to offer gay-friendly services. However, the social stigma related to being gay, and having gay sex, is widespread and displayed by many healthcare providers across the country.
Dr Samuel Waweru Mwaniki from the University of Nairobi and colleagues had previously interviewed healthcare providers on their perspectives on treating gay men. In this study, they speak to gay men themselves about experiences of stigma and discrimination in healthcare settings, and possible remedies for these systemic ills.
The study
Twenty-two young gay and bisexual men aged between 18 to 24 from a larger bio-behavioural study were interviewed for this qualitative study. These men were attending a university or college in Nairobi, had tested negative for HIV and had interacted with a healthcare provider during the previous year. Researchers were specifically interested in the perspectives of young gay and bisexual men not living with HIV. Results were published in BMC Public Health.
All participants identified as cisgender, with most stating that they were gay (73%) and a smaller number identifying as bisexual (27%). The majority were in either their first or second year of study (59%), attended a public institution (59%) and lived in college or rented housing (73%). Most had a smartphone at the time of the interview (96%).
Many men described not only what they had experienced first-hand, but also what their gay friends reported experiencing when seeking out sexual health services. The researchers state that this may also be due to participants’ deep need to conceal their own experiences and instead present them from the perspective of a ‘friend’. Thus, many experiences were shared in third person anecdotes. This is further indicative of the harsh societal stigma and possible criminal implications of admitting to gay sex.
The men emphasised differences in public and private healthcare provision, highlighted gay-friendly clinics as providing exemplary service, and shared their thoughts on reducing stigma.
More stigma and discrimination in public and university healthcare settings
Largely, participants reported experiencing greater stigma and discrimination related to their sexuality and sexual behaviour in public healthcare settings and those affiliated with universities.
“There’s a time I took my friend, because he had been raped… and then this person [healthcare provider] asks, ‘Are you sure you were raped, or it was your deal gone wrong?’ So, you are like, ‘this person is traumatized, why are you even asking such questions?’ That is why I hate public hospitals by the way. I would rather die.”
These experiences included ridicule, the use of derogatory terms and healthcare providers gossiping about participants’ sexual behaviour.
“He was asked what’s wrong with him and he said he has anal warts. Then he [the doctor] asked him, ‘Wewe ni shoga [are you gay]?’ That word [shoga] is what he told me hurt him the most…He told me he felt that he had been condemned so much… so he just left. He said he will never go back there.”
It is clear from this participant’s narrative that the word ‘shoga’ – when used by a member outside the gay community – is used in a hurtful and disparaging way, as is ‘faggot’ in English.
In both community and university settings, there was a fear of being outed in the neighbourhood or on campus because of seeking out sexual health services.
“It [campus clinic] doesn’t focus on people like me, LGBTs, you know… So, when you are going to tell the nurse some sensitive information it’s like you are exposing yourself, so I would rather stay like that [without seeking care]. I can’t, I can’t risk.”
In addition to the stigma from healthcare providers, participants were also sensitive to how other patients in healthcare settings viewed them, and if it was suspected that they were gay.
“In the public facilities, there is abuse, there is harassment, so even when you are on that queue the looks you get from other people you will just feel you are the odd one out. So, if they know you are MSM [having gay sex], you’ll just have to go away.”
Some men were denied care outright because the condition was linked to gay sex:
“He was having an MSM issue… anal warts. So, when the nurse found out how it happened, she told him that they don’t deal with STIs of such nature.”
These experiences mainly worked to discourage participants from attending these facilities in future, even when seeking non-sexual health services.
“He wasn’t taken through a very good experience… so, he will be afraid…the fear of going to that place, that those people know who I am. So, I won’t go there…even if you are going to get normal [non-sexual health-related] services, it will stop you…yeah.”
However, there were some instances where participants took a stand and demanded their right to care, even when it was clear that the STI was linked to gay sex. In this instance, the participant had initially been told that he could only receive treatment if he brought his sexual partner in to receive treatment too:
“He was like, ‘yeah this is a government facility; I should seek services here as you are supposed to give me the services.’ I mean, he made it clear and they just gave him the services without having to bring his partner.”
Positive experiences in private settings and those catering to gay men
In contrast to the experiences described above, participants who were able to access private care – either through health insurance, or by paying out of pocket – spoke of receiving a higher standard of care. This non-judgemental care was also found in community pharmacies that operated for profit.
“If it is a private clinic where you have to pay, no one will ever judge you… I mean your money talks. You pay and you are like if they start gossiping, you go find another clinic. So, if it is private clinics, it’s so good.”
“If you are good [have money], you can go to the chemist [community pharmacy], explain your problem and they will sort you out… as long as you are paying, they have no problem.”
Gay-friendly services run by community-based or non-governmental organisations in Nairobi provided a welcome alternative for some of the men interviewed, when they had access to such services. The care was non-stigmatising care and free of charge, with free condoms and lube also being provided.
“If I had an STI, I would go to the MSM [men who have sex with men] facilities since it is a non-judgmental place… and a friendlier place… also, you can be treated for free, there are no costs.”
What would make for better healthcare experiences?
Participants were also asked to describe what would make for better overall healthcare experiences.
The men said services should address their mental health, STI and substance use needs.
“The health facilities should reach out to educate us on PrEP, PEP, on use of condoms, lubricants and self-test kits [for HIV]. We also need regular screenings for STIs because as young adults we are very sexually active.”
“Yeah… because we are a small community, I would say the influence [to use drugs] is infectious… there is a lot of peer pressure… If we could have services that would help out with these issues, that would be really great.”
Participants suggested that digital (online) interventions might offer greater privacy and a way of avoiding stigma. The appeal of digital communications and services was linked to reduced chances of being outed.
“You cannot give them [gay men] a pamphlet on PrEP to go read. They will just trash it in the next dustbin because also they do not want to be seen with it. If the clinics can share short videos on Instagram or YouTube on how to like properly use condoms… the benefits of PrEP… one can watch these videos privately...”
“And then there are the online doctors. They can give you services if you don’t like going to a facility where you might be judged…”
Mostly, men wanted healthcare providers to simply provide the necessary services without judging them any differently because of their sexuality. Gossiping among healthcare providers was seen as particularly harmful.
“They [healthcare providers] should know that there are those diseases like anal warts that mostly affect MSMs and they should help them… even if they’re queer, do not discriminate, just give them the services they are looking for.”
“They should stop judging people, stop talking about people and respect people’s privacy. That way, the whole healthcare system will be good for everyone, not just gay people.”
Conclusion
Considering the high levels of stigma experienced in public health settings, the findings call into question how much additional stigma gay men living with HIV would face. However, the researchers do not address this.
“To address these health disparities experienced by young men who have sex with men, there is urgent need to train and sensitise healthcare providers in public and institution-based health facilities so as to equip them with knowledge and skills required to offer culturally competent services that meet the unique needs of young men who have sex with men,” the authors conclude.
“Digital health interventions should be considered for reaching young men who have sex with men with the services they need, including but not limited to sexual and mental health services… The discreet nature, appeal and potential of digital media to reach more people compared to traditional media, was considered a collective strength that could be leveraged on to improve access to and use of health services by young men who have sex with men.”
Mwaniki S W et al. “What if I get sick, where shall I go?”: a qualitative investigation of healthcare engagement among young gay and bisexual men in Nairobi, Kenya. BMC Public Health, 24:52, 2024 (open access).