Two recent qualitative
studies highlight Jamaican men who have sex with men (MSM) and transgender
(trans) women’s heightened vulnerability to HIV. These groups are at higher
risk of infection as a result of various socioeconomic inequalities –
homelessness, lack of employment, the criminalisation of same-sex practices and
high levels of stigma and violence.
As a result of
poverty, both groups frequently engage in transactional sex. Sexual
decision-making, pleasure and risk management strategies are based on immediate
needs for protection, food and shelter; this is navigated in the context of
heightened socioeconomic inequalities and daily survival challenges.
The studies were published
in Culture, Health & Sexuality by Dr
Orlando Harris at the University of California San Francisco and in Reproductive Health Matters by Dr Carmen
Logie and colleagues at the University of Toronto.
Jamaica has the
highest HIV prevalence among MSM in the Caribbean, estimated at 32%. It is
similarly high for trans women at 25%. This is compared to a 1.7% prevalence of
HIV in the general Jamaican population. Additionally, MSM account for 40% of
all new infections in the country. Jamaican law criminalises consensual anal
sex between men and offers no protection against anti-LGBT discrimination. This
has resulted in pervasive stigma and discrimination towards those who are
non-conforming in terms of either gender or sexuality. This stigma is
pronounced structurally and institutionally, often manifesting in healthcare and
employment settings. These factors leave MSM and trans women at a social and
economic disadvantage, increasing vulnerability to HIV infection.
Orlando Harris’ study
considered only MSM (30 participants, mean age 22); 20 in-depth interviews and a
focus group with ten men were conducted to explore their experiences, decisions
around sexual risk and barriers accessing HIV testing and prevention services.
Most men (30%) had some college education, with 36% indicating they were
self-employed (which could include sex work). A large percentage (40%) had been
forced into their first sexual experience.
Carmen Logie’s study
included both MSM (20 participants, mean age = 22) and trans women (20
participants, mean age = 23). Two focus groups (with ten MSM and eight
trans women respectively) were conducted as well as in-depth interviews with all
40 participants. Additionally, 13 in-depth interviews with key informants such
as HIV clinicians and outreach workers were conducted. Both studies had an age
range of 18-30 and used purposive sampling with most participants living in
Kingston, Jamaica.
There was a high
degree of thematic overlap emerging from the interviews and focus groups of both
studies. The combined results are presented below.
Socioeconomic factors
Several participants became
homeless during early adolescence as a result of family or members of the
community becoming aware of their sexual orientation or gender non-conformity.
Employment and housing opportunities were also affected as a result of sexual
orientation and accompanying stigma. This often led to transactional sex as a
means of survival. Homelessness, lack of employment and transactional sex were
linked to increased HIV risk by participants. The level and type of discrimination
experienced was closely linked to socioeconomic status and class.
“I was homeless at the time and bouncing from one place to the next. You
cannot do anything more than you have to say ‘yes’ [to sex] or else you will be
back on the street again.” (MSM, Harris
study)
“There is no employment whatsoever and the only way you can see your way
through is by self-employment. For the most part, people in the transgender
community are not educated enough to be self-employed. So, they do the one
thing that they don’t need training for and that’s sex work.” (Trans woman, Logie study)
“Class and money provide you with a whole lot of buffers. When you are
poor, you are a ‘batty man’ [negative term for gay men], but when you have
money, you are a homosexual. It is two different things.” (MSM, Logie study)
Management of HIV risk
was occasionally directly linked to economic factors as some participants were
willing to engage in condomless receptive anal intercourse if it came with
financial benefits.
“He refused to wear a condom. I was ok with it because I trust[ed] him.
I trusted him because he would do things for me financially… he was 38 or 39
and I was only 19.” (MSM, Harris
study)
“I am a top… I won’t allow anyone else to [penetrate] me… But if I am in
a situation and need money or a roof over my head and an offer is made, I will
do whatever to fulfil that need.” (MSM, Harris
study)
Stigma in healthcare settings
Most participants
reported experiencing stigma in public clinics in the form of verbal abuse,
discrimination and physical violence. This occasionally led to a delay or
avoidance of seeking out HIV testing or prevention services. Stigma also led to
difficulties accessing lubricant and condoms from pharmacies or grocery stores.
In addition to being
discriminated against by healthcare providers, there was also the risk of abuse
by other patients is waiting areas. Confidentiality was also a concern as
healthcare providers would ask for family contact details before providing
care. Participants who could afford private healthcare would seek out
gay-friendly doctors or instead go to community-based organisations for
assistance.
“I don’t like going to those public clinics… because I can’t bother with
the discrimination sometimes.” (MSM, Harris
study)
“They shun you away now so you don’t want to go there for any
information to get tested, you know for any condom or lube.” (Gay man, Logie study)
“I mostly felt discrimination from the people in the waiting room. They
look at you and call you battyman [faggot].” (MSM, Harris study)
“I have gone to the pharmacy before to buy lube. I don’t like it because
it feels uncomfortable… They look at you funny like why you need lubricant.” (MSM, Harris study)
Inadequate sexual health education
Some participants said
that they did not know much about HIV and its prevention at the time of
diagnosis. They explained that there was a lack of comprehensive sexual health
education in Jamaica, linked to the criminalisation of anal sex between men.
“When the doctor said the test came out positive, I was so happy. The
doctor asked if I knew what that meant. I told him it means I don’t have it.
Then he told me I did.” (MSM, Harris
study)
“Education and the lifting of the buggery law [would decrease HIV
prevalence]. If there was more tolerance for it, I don’t think it would be so
widespread.” (Gay man, Logie
study)
Nonetheless, many
participants showed an awareness of risk factors such as having multiple
partners and condomless sex.
“I love it raw… But using the condom is the safer way.” (Trans woman, Logie
study)
Agency: managing sexual risk and pleasure
Despite the challenges
described, many participants in Logie’s study also spoke about a sense of
agency and ways in which they navigate sexual and survival risks while still
deriving pleasure from sex. They used a range of risk-reduction strategies,
such as always using condoms, limiting the number of sexual partners or getting
tested prior to sex.
I don’t sleep with any and everybody. I have to trust you enough to do
these nice little things that we are to do as a couple. And believe me, we are
going to get tested before anything will happen.” (Bisexual man, Logie study)
“I fuck and I don’t use a condom. I know it sounds bad, but when I fuck,
I fuck one person alone. It mitigates risk to an extent.” (Bisexual man, Logie study)
Participants also
emphasised the importance of accessing social support and of having
self-confidence despite daily challenges.
“Try to find a more warm welcome space and go and stay and try to find
some new friends.” (Trans woman, Logie
study)
Participants expressed
that it was challenging to establish monogamous long-term relationships as a
result of the need to hide their identities. Thus, short-term casual
relationships were used as a survival strategy.
“If I meet a guy and fall in love with this guy, the next step will be
living together, but where will we live? We can’t live in my community because
they will kill us.” (Key
informant, Logie study)
Conclusion
Both these studies
illustrate the important role of socioeconomic risk factors associated with HIV
infection among MSM and trans women in Jamaica. Being gay or transgender often
results in homelessness, difficulty finding employment and subsequent
transactional sex as a means of survival. Widespread stigma is particularly
pronounced in healthcare settings and is a significant barrier to accessing
prevention and treatment services. Sexual decisions are often related to
immediate survival as opposed to long-term risk of contracting HIV.
However, many
participants also displayed agency and knowledge and enacted different risk
management strategies based on both immediate and long-term needs and desires.
Strategies to reduce high HIV infection rates in these populations need to
consider the broader social inequalities, including stigma, criminalisation, a
lack of protections, economic vulnerability and a lack of LGBTQ tolerance.
