Managing sexual and survival risks: the impact of inequity and stigma on Jamaican MSM and trans women

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.