Providing sexual health services to gay men in Kenya – where gay sex is illegal

Kenyan healthcare providers and staff at university clinics expressed a duty of care for young gay and bisexual men – even when this conflicted with their personal beliefs and when they felt ill-equipped to do so – according to a recent qualitative study.

Young gay and bisexual Kenyan men, aged 18 to 25, are more likely to contract HIV and other STIs than their straight peers. However, the prevention and management of HIV is hampered by societal stigma and homophobia – often emanating from healthcare providers who may be poorly equipped to deal with the needs of this group.

Gay sex is criminalised in Kenya, which results in multiple forms of societal discrimination towards gay and bisexual men.

While the Kenyan Ministry of Health recognises that gay and bisexual men are a key population in their national HIV response, the few gay-friendly clinics that exist in larger cities are usually run by community-based or non-governmental organisations. Gay men have reported experiences of stigma and discrimination from healthcare providers at public health facilities.

In addition to the current threat of arrest for engaging in gay sex, a bill similar to Uganda’s Anti-Homosexuality Act is currently being discussed in Kenya. This bill would go to greater lengths to criminalise the ‘promotion of homosexuality’. It includes a provision for the death penalty in instances of ‘aggravated homosexuality’, such as ‘transmitting a terminal illness through a sexual act’, presumably referring to HIV.

The study

Researchers, led by Dr Samuel Waweru Mwaniki from the University of Nairobi, focused on healthcare centres attached to colleges and universities, where many young gay and bisexual students receive care.

Thirty-six healthcare professionals from six universities in Nairobi participated in six focus group discussions in 2021. The discussions were separated based on profession, including front office staff, laboratory and pharmaceutical technologists, counsellors, nurses, and clinicians. Most of the participants were women (64%) and Christian (94%). Just over half were aged between 21 and 40 and had been working for between 11 and 20 years.

Participants were asked to share feelings, perspectives and challenges related to offering services to young gay and bisexual men.

Duty of care

Most participants expressed that they were trained to offer care and services to those in need, regardless of sexual orientation. In this sense, the sexuality of their clients mattered less than the care required. One doctor expressed it in this way:

“As health workers, we have to accept these people as our clients and treat them the way we treat other clients and give them help as we ought to, because when we were trained, we were not told that we should only treat those who we think are straight. So, I think our attitude is positive because these are people who have come for help and we must help them despite who they are.”

However, some participants, such as this pharmaceutical technologist, shared that her duties often came into conflict with her beliefs:

“My Christianity background does not allow me to accept that [homosexuality] as a way of life… I believe even Muslims don’t accept it. But I have agreed that I’ll bend over backwards to accommodate the other person because of my profession… to do the best that I can to help where I can.”

In some instances, religious beliefs provided an unexpected effect: providers framed their duty of care as a form of religious service, as expressed by this nurse:

“I am guided by Christian principles because the person who I follow, the Christ, was a person who basically came here for those people who were considered the scum of the earth. So, I act in a very professional manner without prejudice, and give the service that is due to them [gay men].”

Interestingly, the law criminalising gay sex did not seem to deter providers from offering services. This was likened to any other illegal behaviour their clients may engage in – it was viewed as unrelated to their services. However, this also meant that providers did not see themselves as playing any role in addressing criminalisation, as expressed by this front office worker:

“If a student came to you after getting beaten for allegedly stealing, are you going to apply the same principle and say stealing is illegal and so I am not going to treat you? Or does it just apply to men who have sex with men? No. You have to treat everyone equally… The criminalisation of homosexuality is really none of our business.”

Challenges providing care

Participants discussed challenges that arose when providing services to young gay and bisexual men. These included: lacking the appropriate knowledge and skills, focusing on deterring sexual behaviour and ‘converting’ gay men to being straight, and experiencing secondary stigma from other providers as a result of providing services to gay men.

A nurse had this to say about a lack of knowledge regarding STI symptoms more commonly seen among gay men:

“I have always felt I am incapable in terms of knowl­edge and skills… I don’t feel I have the capacity to integrate men who have sex with men services into my daily work. I find I am incapable because the knowledge that is given to us in college is very minimal and so sketchy. For instance, I never heard about anal STIs in college.”

Counsellors spoke about some of the inappropriate and overreaching strategies used with this group:

“But what I have realised, in the counselling centre, mostly, the first thing we do with MSM is trying to convert them [to heterosexual]. We try to make them feel that this behaviour [same-sex practices] is not right, even if they have come to seek help for unrelated issues…”

“The first time I met these guys [young men who have sex with men], I was left wondering, ‘what if this is my son? Will I encourage him to continue with whatever he is doing [having sex with other men], or ask him to stop?’ It was a challenge to me and I felt bad. But later on, I realised I am a counsellor and from there on I learned how to walk with [support] them without judging.”

A nurse spoke about the fear created by secondary stigma:

“You fear. How will the other staff see me if I am interacting with these people so much? Will they misjudge me and say I am also gay? So that hinders us sometimes from caring for these students and sometimes we might give them an appoint­ment somewhere else outside the university clinic.”

Overall, the lack of social acceptance and widespread homophobia created substantial barriers to seeking care, as outlined by this doctor:

“Because gay men are not accepted in the society, they find it very hard to seek medical attention and even if they do, they are not willing to come out clean [disclose and discuss same-sex practices] so that you can help them appropriately.”

Improving care

Researchers also asked participants about suggestions for improving care. Creating greater awareness, training, exposure, and offering approachable services specifically tailored to gay and bisexual were highlighted.

“By being friendly to them and serving them well, they realize they are not rejected. They feel, ‘yes, I can come if I need help.’ In turn, they normally tell their friends and partners that, ‘if you go, ask for so and so’ because they know that they will get friendly services from this person.”

“We need to be trained on men who have sex with men, how to treat them based on their health needs so that when they come to the clinic, even the health worker who is going to attend to them knows what to do.”

“I think time can make us change our opinions and attitudes. Because, as time goes by, you encounter more men who have sex with men than the ones you have encountered before, and also get to understand that it is their human right to have whatever sexual orientation they have and still get services.” 

Conclusion

Considering the widespread social stigma directed towards gay and bisexual men in Kenya, participants might have responded differently if they were interviewed one-on-one, with some peer pressure naturally arising from the use of focus group discussions.

Nonetheless, while disapproval of gay sex was certainly evident in their responses, they also made suggestions to improve services.

“All healthcare providers were generally cognisant of their professional duty to provide care to young men who have sex with men, but largely showed dis­approval of same-sex practices, and encountered chal­lenges in providing services,” the authors conclude.

“As such, there is an urgent need to implement interventions suggested by the healthcare providers such as training to equip them with the knowledge and skills required to address the unique health needs of young men who have sex with men.”