Pukaar

Issue 78

the journal of Naz Foundation International July 2012

Transgender persons are Lost in Transition on human rights and HIV responses says new Asia-Pacific report
A lack of targeted research on transgender persons in Asia and the Pacific is significantly hindering their access to health services and blocking effective responses to HIV, says a groundbreaking study released by UNDP to mark the International Day Against Homophobia and Transphobia (17 May 2012) In the Asia Pacific region, where long marginalized sexual minorities are already bearing the brunt of the HIV epidemic, transgender persons are among the most socially ostracized, lacking fundamental rights including basic access to health care and social protection schemes. Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region is a comprehensive review of material gathered from across the region over the past 12 years. This unprecedented research in Asia, jointly released by the United Nations Development Programme (UNDP) and the Asia Pacific Transgender Network (APTN), calls for concerted action by governments, civil society, development partners and the transgender community itself to design and conduct further research to fill the lack of information about transgender people and their environments. Transgender individuals across Asia-Pacific are often highly stigmatized, targets of prejudice, harassment, violence and abuse, noted Clifton Cortez, Regional Practice Leader on HIV, Health and Development at the UNDP Asia-Pacific Regional Centre in Bangkok. We urgently need to shed light on their situation to better tailor social and public health responses to protect and empower these communities. The report emphasizes that inclusive research, designed and implemented in partnership with the transgender community, is critical to enable governments, community based organisations and supporting organizations to enhance HIV and sexual healthcare services specific to the needs of transgender people, and foster action by governments to adopt more socially equitable policies and practices to protect their rights. For too long, trans people have been lost in transition, said slope, a downward spiral that is difficult to reverse. Dr. Sam Winter from the University of Hong Kong, the author Another challenge is that transgender people are usually treated of the report and a noted expert on transgender people and their similarly as men who have sex with men when it comes to national challenges. We hope that this report will demonstrate the burning HIV programming and funding. We are most definitely not MSM, need to address a very human crisis, viewed through the prism of stressed Prempreeda Pramoj Na Ayutthaya, a noted Thai transgender HIV, which has taken a devastating toll on millions of our fellow researcher and activist. Many of us are physically very different, citizens in our region and beyond. either as a result of hormone replacement therapy or other medical Although national reported data remains limited, there is growing procedures. Some of us have had a complete sex change. There is anecdotal evidence that HIV prevalence rates among transgender much we still dont know about our particular vulnerability to HIV, people in the region have reached critical levels. These reported and that needs to change. numbers commonly exceed the prevalence rates among men who There are encouraging developments, however, as the report points have sex with men, and young transgender women are thought to out. Among these, across much of the region, is a developing transgender be at particular risk. Alarming figures from one Southeast Asian identity, a growing pride and an increasing willingness on the part of city have suggested that over the four-year period from 2003-2007, transgender communities to advocate for increased participation in HIV prevalence among transgender people rose from 25 percent policy processes and organize peer support services at a national and to 34 percent. regional level. The creation of advocacy networks, community-based Pushed to the social, economic and legal margins in a majority organisations and non-government organisations devoted to empowering of countries in this region, trans people often suffer from poor and strengthening our communities is a source of joy, said Prempreeda. emotional health and well-being, explained Dr. Winter. Many The Asia Pacific Transgender Network, for example, has been find themselves involved in risky behaviours and situations, such as recently established to advocate for the right to access health services, unsafe sex and involvement in sex work. Social exclusion, poverty to demand that laws which criminalize transgender people be repealed and HIV infection contribute to what we call a stigma-sickness and to reiterate that vulnerability to HIV is couched within the larger slope, a downward spiral that is difficult to reverse. context of human rights. Prempreeda continued, You cant separate Pushed to the social, economic and legal margins in a majority our social well-being and human rights from our efforts to address of countries in this region, trans people often suffer from poor HIV within our communities. Were pleased that the UNDP report emotional health and well-being, explained Dr. Winter. Many recognizes this. find themselves involved in risky behaviours and situations, such as To download the report, please visit: unsafe sex and involvement in sex work. Social exclusion, poverty http://www.snap-undp.org/elibrary/Publications/HIV-TG-peopleand HIV infection contribute to what we call a stigma-sickness rights.pdf

an international HIV and sexual health journal focusing on south asian masculinities and sexualities

Pukaar July 2012 Issue 78

Naz Foundation International (NFI) is a development agency specialising in providing technical, institutional and financial support for the promotion of sexual health, welfare and human rights of males who have sex with males and transgenders in South Asia. Strategic objectives 1. To strengthen and scale up the response to the sexual health and HIV needs of MSM and transgender populations through their direct engagement in planning, development, and service delivery and advocate for increased access to rights based, comprehensive HIV prevention, care, treatment and support services for these persons. 2. To improve the policy and social inclusion environment for MSM and transgender populations towards providing social protection and enabling environments for them. 3. Increase production and utilisation of strategic information to strengthen HIV and sexual health intervention programming as well as regional and national level advocacy efforts on MSM and transgender sexual health in Asia and the Pacific

Naz Foundation Internationals Ethical Policy Naz Foundation International is a development agency focusing on male to male sexualities and sexual health concerns in South Asia. In its work, Naz Foundation International will fully consider the implications of males who have sex with males, for themselves, for any male or female sexual partners such males may have, and for any clients of those males who do sex work. In this work Naz Foundation International will be guided by the following principles: 1. Promoting the reproductive, sexual health, and well-being of males who have sex with males by encouraging sexual responsibility and safer sexual practices. 2. Encouraging males who have sex with males to access sexually transmitted infections treatment whenever necessary. 3. Respecting confidentiality in the relationship between males and their sexual partners and/or clients. 4. Promoting the protection of children and non-consenting adults from abusive sexual relationships. 5. Promoting the reproductive and sexual health of any female partners of males who have sex with males, by encouraging sexual responsibility of their male partners. 6. Encouraging communication of sexual health information between sexual partners and promoting partner notification of sexually transmitted infections and HIV infection, irrespective of the gender of the partner. 7. Working with female reproductive and sexual health services, in order to facilitate appropriate access to services for infected female partners of males who have sex with males.

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Pukaar online www.nfi.net/pukaar.htm

Pukaar is produced and published for private circulation and not for sale by: Naz Foundation International 1.3 Quay House, 2 Admirals Way London E14 9XG, UK Distributed by: NFI Regional Programme Office 9 Gulzar Colony, New Berry Lane, Lucknow, 226001, India Naz Foundation International is a registered charity and company limited by guarantee in England and Wales Registration No. 3236205 Registered Charity No. 1057778 Registered office: 1.3 Quay House, 2 Admirals Way London E14 9XG UK NFI Secretariat 2nd Floor 5 Harbour Exchange London E14 9GE Tel: +44 (0)20 7517 6092 Fax: +44 (0)20 7671 7062 Email: info@nfi.net NFI Regional Programme Office 9 Gulzar Colony, New Berry Lane, Lucknow, 226 001, India Tel: +91 (0)522 2205781/2205782 Fax: +91 (0)522 2205783 Email:regional@nfi.net

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Pukaar

Pukaar is the quarterly journal published by Naz Foundation International. It provides a forum for discussion, information, and advice, as well as general interest, regarding HIV and sexual health, focusing on South Asian masculinities and sexualities. The opinions expressed in Pukaar reflect the writers views only and do not necessarily reflect the views of Naz Foundation International unless specifically mentioned. We will always try to ensure that what we report is relevant to our readers, and we ask you, the reader, to keep us informed as to what is happening in your corner of the world. Send us your questions, letters, articles, stories (fact or fiction), poetry, drawings, photographs. Tell us about what you think and feel, whether it concerns HIV, your sexuality, or whatever. Names will be changed and addresses will be withheld if required. Send all material to Pukaar, Naz Foundation International, 9 Gulzar Colony, New Berry Lane, Lucknow 226001, India
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Contents
p1 p3 p5 p6 p8 p11 p12 p13 p14 p17 p18 p19 p20 p21 p22 p26 p28 Lost in Transition End poverty in South Asia: LGBT and the World Bank President Obama: LGBT Pride Month Beyond marriage Between aid conditionality and identity politics Untreatable gonorrhea HIV prevention for men who have sex with men and transgenders in Nepal Homosexual teens encounter dilemma of discrimination It's time to talk top Gay and bisexual men who inject drugs Getting practical abut PrEP Increased risk of anal cancer A widespread pattern of abuse HPV and oral sex Defining 'men who have sex with men' Decolonialising sexual citizenship Is some homophobia self-phobia?

Pukaar July 2012 Issue 78

End poverty in South Asia: The World Bank and a lesbian, gay, bisexual and transgender perspective
Fabrice Houdart and Elizabeth Howton of the World Bank, are members of GLOBE (Gay and Lesbian Organisation of Bank Employees) who visited India and Nepal in May 2012 to obtain a better understanding of LGBT and development issues in the region. They also visited, NFIs Regional Office in Lucknow, India as a part of this mission. Fabrice and Elizbeth have posted blogs on these issues, which we reprint below, as they address significant issues around sexual orientation, gender identity, development and the World Bank.

Estimating the global cost of homophobia and transphobia

Submitted by Fabrice Houdart on Thu, 05/17/2012 Since 2004, May 17 has been the International Day against Homophobia and Transphobia a day of remembrance about how discrimination affects sexual minorities worldwide. Some of homophobias consequences are well-known: lack of access to education and health care, violence, unemployment, illiteracy, displacement to urban areas, lack of legal rights, loss of communitybased safety nets, brain drain, lack of economic opportunities, lack of access to land, exclusion from informal networks, mental health problems and substance abuse, suicide, imprisonment, lack of cultural representation, and, of course, HIV/AIDS. However, the amplitude of LGBT economic marginalization and the costs of homophobia are unknown. Those who suffer homophobia in the West are not always economically disadvantaged (think Elton John or most gay middle-class American men). Nevertheless, LGBT people worldwide, as I have experienced on my current trip to Nepal and India, are also very often poor, sometimes profoundly. Our lack of knowledge in this area constitutes a major impediment to triggering any interest from Bank economists: The modus operandi of our institution remains very clearly committed to the generation of economic growth, and undocumented questions of equity are often seen as distractions. Consequently, the Bank does not advocate the policies needed to address LGBT economic marginalization. Yet development institutions have been able to calculate the cost of discrimination against women and ethnic, racial and caste groups. Discrimination against a Twa pygmy in the Great Lakes region of Africa, a Dalit woman in India, a Roma in Eastern Europe or an African-American in the United States presents very similar traits to discrimination against LGBT people. As an example, transgender people are stigmatized as illiterate, criminal, and sexually reckless, while their experience of exclusion and discrimination encourages the very behavior that is stigmatized. However, these models relied on collection of sound statistics -- a prerequisite for any successful strategy to advance the rights of victimized groups. Although this can be very difficult in the case of individuals whose privacy must be protected at all cost to avoid state-sponsored violence, a window of opportunity is opening with the registration of third sex populations in Pakistan, Nepal, and India. There is a bit of a Catch-22 here because the World Bank economists and gender specialists will remain skeptical until they see numbers showing the economic cost of homophobia -- but until they allocate resources to research on LGBT population, nothing will happen. This is why it is crucial for LGBT communities in the South to make their voices heard in our institution. Poor communities that suffer discrimination on the basis of gender identity and expression or sexual orientation are often politically invisible and not represented by the small number of affluent LGBT decision-makers. It is essential to make sure that such groups are politically represented within public institutions, and that representatives of such groups are accountable to their communities, empowered to represent them and competent to communicate their interests effectively.

From India: Sexual minorities and the gender agenda

Submitted by Fabrice Houdart on Thu,05/17/2012 Indias estimated 700,000 hijras, or transgender women, generally get little or no schooling, their families often reject them, and they join marginalized and feudal communities where their employment options are sex work or ritualized begging. They are likely to die young, of violence like Anil Sadanandan, a transgender activist murdered in Kerala state during my recent visit to India or AIDS. They are among Indias most destitute women, yet they are ignored by the World Bank, despite its strong focus on the gender agenda. Lesbians in India who live openly in a same-sex relationship or display so-called masculine traits will be excluded from social networks, if they are not beaten to death by their families something occurring regularly in rural India or forced into marriage. They face discrimination in employment and lack access to already limited services. I spent the past two weeks traveling across India and Nepal to explore these issues. As I learned more about the courageous struggles of Indias hijras, khotis (or feminized men), gay men, and lesbians from local World Bank staff members and representatives of non-profit groups serving those communities, I was reminded every day that the lack of voice, sexual rights, cultural representation, and economic opportunities, as well as displacement and daily violence, they encounter stem from the same roots as gender discrimination. Hijras, khotis, gay men, and lesbians are rejected by society often at a very early age and in a violent manner because of their femininity (in the case of men) and the threat they represent to the patriarchal society imposed by British law and social norms. Homophobia is no more a cultural or religious issue than any other part of the gender agenda (and in fact, Hinduism and Indias history and literature are surprisingly homosocial and homoaffectionate). Although this reality was completely absent from the Banks continued on page 4, col. 1

Sexual Health

Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. WHO Definition Sexual rights embrace human rights that are already recognized in national laws, international human rights documents and other consensus documents. These include the right of all persons, free of coercion, discrimination and violence.
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Pukaar July 2012 Issue 78

The LGBT perspective on ending poverty in South Asia

continued from page 3, col. 2 2012 World Development Report on gender (in 458 pages the word transgender did not appear once), it was present throughout the preparation process. In their companion piece, Masculinities, Social Change, and Development (2011) Margaret Greene, Omar Robles, and Piotr Pawlak used the Gender Equitable Men (GEM) Scale to prove that homophobia and therefore discrimination against LGBT people is an unfortunate corollary of dominant masculinity. Their study found that 73% of Indian men surveyed said they would hit their sons if they found out they were gay. Some economists believe that gender let alone social justice for populations transgressing gender norms is a distraction from our very serious business of growth and poverty reduction. In addition, some fear that mentioning this aspect of the gender agenda would put the Bank squarely on one side of a global cultural and religion divide and undermine the Banks standing as a serious technical institution. Yet if the Bank is to fulfill its mission to end poverty, it must reach everyone women and men, gay and straight, transgender and hijras. Eventually, the Bank will have to confront these issues. Why not start now?

Development and change for LGBT Indians, Nepalese

Submitted by Elizabeth Howton on Tue, 05/29/2012 Arif Jafar had no choice about coming out as gay. In 2001, he was arrested in the northern Indian city of Lucknow at the AIDS prevention agency where he worked, charged with running a sex club, jailed for 47 days, and named in the newspapers, in a case that helped spark a legal challenge to Indias sodomy law, known as Section 377. (Needless to say, he denies that the AIDS agency was a sex club.) Before jail, I was open, but not that open, says Jafar, 42, a mosquegoing Shiite Muslim who now runs the Maan AIDS Foundation, an AIDS prevention group (maan means respect or pride). Now everybody in the city knows. Despite the arrest, Jafar (right) says he loves Lucknow and will never leave. If I ran away, people would start having the perception that I did something wrong, he says. Jafars case has dragged on for 11 years without coming to trial, but in the meantime, the law criminalizing homosexuality has been overturned in Delhi High Court. Retired Justice Ajit Shah, who wrote the decision, is an unassuming man, greeting us in sandals in his modest apartment. Yet his landmark opinion broke through several centuries of bias and freed up Indias nascent movement of lesbian, gay, bisexual, and transgender (LGBT) people to come into its own. The 2009 decision is being appealed to Indias Supreme Court, and theres no telling how itll turn out. But theres also no going back for the hundreds of activists, community leaders and ordinary Indians who have joined the movement and taken a stand. As I traveled across India and Nepal for two weeks in May, I met some amazing people, from Jafar to Shah to transgender sex workers in Chennai, from a high-powered openly lesbian executive in Bangalore to a Nepali transgender man kicked out of the army and jailed for 60 days for lesbian activity. As a lesbian myself, I was personally inspired and awed by these people, but I also was intent on learning how they fit in to my work at the World Bank and our mission to end poverty. For those on the lower end of the socioeconomic scale in South Asia, being part of a sexual or gender minority can be the straw that breaks the camels back, moving them from simple poverty into misery, deprivation, and often premature death. Sexual orientation does make you poor, says Manohar Elavarthi, a community organizer with Sangama in Bangalore. Poverty is not
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just economic you miss access to so many things: ration cards, inheritance rights, voter ID cards. In several South Asian countries, there are reports that LGBT people have even been denied access to disaster relief. And homophobia is intricately connected with other divisions in South Asian societies, particularly around gender but also religion and caste. Yet I saw many signs of hope and change in both India and Nepal. Those transgender sex workers in Chennai have organized a coalition, called V-CAN, of every single community-based organization in the state of Tamil Nadu that serves homosexual or transgender people. (At left, the coalitions secretary, Sonali, and president, Jeeva, make a presentation.) Working with the NGO Praxis, they have been able to gain access to some public benefits, such as pensions and registering as third gender on government ID cards. Activists in Nepals Blue Diamond Society have achieved similar results and more. Indias growing middle class is turning away from traditional patterns of same-sex behavior and adopting gay and lesbian identities similar to those in the West. Yet crushing family pressure to marry and produce children, along with employment and housing discrimination, remain issues even for those who are relatively well off, most likely intensifying the brain drain as some emigrate to countries where they can live more freely. The real battle has to come with family acceptance, says longtime Chennai activist Dr. L. Ramakrishnan, country director with Solidarity and Action Against the HIV Infection in India (SAATHII). Because people are afraid to come out to their families, they stay in the closet, helping maintain the number of Indians who have never met an openly gay person. Justice Shah (right) drew on Indian traditions of inclusiveness and respect for human dignity, enshrined in the countrys constitution, in his opinion. He was amazed by how the decision was received. I thought it would not be acceptable to the Indian community, he says. I was surprised at the positive reaction. It may surprise some Westerners to learn that Indias and Nepals LGBT movements are so vibrant and varied, but their organizing efforts provide a way for development organizations, including the World Bank, to access these communities, learn about the poverty they experience, and find ways to help. You can access these blogs directly Estimating the Global Cost of Homophobia and Transphobia <http://blogs.worldbank.org/voices/estimating-the-global-cost-ofhomophobia-and-transphobia> , May 17, by Fabrice Houdart http://blogs.worldbank.org/voices/estimating-the-global-cost-ofhomophobia-and-transphobia From India: Sexual Minorities and the Gender Agenda <http:// blogs.worldbank.org/endpovertyinsouthasia/india-sexualminorities-and-gender-agenda> , May 17, by Fabrice Houdart http://blogs.worldbank.org/endpovertyinsouthasia/india-sexualminorities-and-gender-agenda Development and Change for LGBT Indians, Nepalese <http:// blogs.worldbank.org/endpovertyinsouthasia/development-andchange-lgbt-indians-nepalese> , May 29, by Elizabeth Howton http://blogs.worldbank.org/endpovertyinsouthasia/developmentand-change-lgbt-indians-nepalese

You can access this and previous editions of Pukaar online at: www.nfi.net/pukaar.htm Other documents on related issues are available on the NFI website: www.nfi.net/publications.htm

Pukaar July 2012 Issue 78

Presidential Proclamation

Lesbian, Gay, Bisexual, and Transgender Pride Month, 2012 By The President Of The United States Of America A Proclamation, June 01, 2012 From generation to generation, ordinary Americans have led a proud and inexorable march toward freedom, fairness, and full equality under the law not just for some, but for all. Ours is a heritage forged by those who organized, agitated, and advocated for change; who wielded love stronger than hate and hope more powerful than insult or injury; who fought to build for themselves and their families a Nation where no one is a second-class citizen, no one is denied basic rights, and all of us are free to live and love as we see fit. The lesbian, gay, bisexual, and transgender (LGBT) community has written a proud chapter in this fundamentally American story. From brave men and women who came out and spoke out, to union and faith leaders who rallied for equality, to activists and advocates who challenged unjust laws and marched on Washington, LGBT Americans and allies have achieved what once seemed inconceivable. This month, we reflect on their enduring legacy, celebrate the movement that has made progress possible, and recommit to securing the fullest blessings of freedom for all Americans. Since I took office, my Administration has worked to broaden opportunity, advance equality, and level the playing field for LGBT people and communities. We have fought to secure justice for all under the Matthew Shepard and James Byrd, Jr., Hate Crimes Prevention Act, and we have taken action to end housing discrimination based on sexual orientation and gender identity. We expanded hospital visitation rights for LGBT patients and their loved ones, and under the Affordable Care Act, we ensured that insurance companies will no longer be able to deny coverage to someone just because they are lesbian, gay, bisexual, or transgender. Because we understand that LGBT rights are human rights, we continue to engage with the international community in promoting and protecting the rights of LGBT persons around the world. Because we repealed Dont Ask, Dont Tell, gay, lesbian, and bisexual Americans can serve their country openly, honestly, and without fear of losing their jobs because of whom they love. And because we must treat others the way we want to be treated, I personally believe in marriage equality

for same-sex couples. More remains to be done to ensure every single American is treated equally, regardless of sexual orientation or gender identity. Moving forward, my Administration will continue its work to advance the rights of LGBT Americans. This month, as we reflect on how far we have come and how far we have yet to go, let us recall that the progress we have made is built on the words and deeds of ordinary Americans. Let us pay tribute to those who came before us, and those who continue their work today; and let us rededicate ourselves to a task that is unending the pursuit of a Nation where all are equal, and all have the full and unfettered opportunity to pursue happiness and live openly and freely. NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim June 2012 as Lesbian, Gay, Bisexual, and Transgender Pride Month. I call upon the people of the United States to eliminate prejudice everywhere it exists, and to celebrate the great diversity of the American people. IN WITNESS WHEREOF, I have hereunto set my hand this first day of June, in the year of our Lord two thousand twelve, and of the Independence of the United States of America the two hundred and thirty-sixth. BARACK OBAMA

Meeting with the US Ambassador for India, Nancy Powell

Pukaar July 2012 Issue 78

Beyond marriage: democracy, equality, and kinship for a new century

By Lisa Duggan A few weeks after September 11, 2001, I went with my ex-lover to register as domestic partners with the city of New York. We had never registered our relationship with any state agency during the 17 years that we had actually been partners. But we changed our minds nearly a year after we broke up, on September 11, as we searched for each other in the chaos of that day. I had spoken to her on the phone that morning, but then lost phone service and all contact with her. She was teaching at Brooklyn Law School then, and I at New York University; we lived near each other only minutes from the twin towers. I did not know where she was, or how she would get home. I started to panic that she might have walked across the bridge right when the second tower fell. I imagined her hurt and me unable to find her, or unable to convince a city worker or hospital employee that she was my next of kin still, though no longer my lover. I worried that her Helms-voting mother in North Carolina might be able to take her away. When she finally came through my door late that evening, covered in grey dust and totally exhausted, we both grasped the significance of that term next of kin as we never had before. If anything happened to her, the importance of me being recognized as the one most responsible, the one most concerned, arose in my mind then as an absolute emotional and practical imperative. As soon as the relevant city offices reopened, we made the trip to city hall to registerthough given the requirements and assumptions of the domestic partner provisions, we had to lie and claim we lived together as a conjugal couple. We were not surprised that there was a long line of people waiting to register along with us. We were very surprised to find that nearly all were heterosexual couples. We asked the people around us why they were there, and their reasons were very much like ours. They did not want to be married, or they were not romantic couples, but their experiences since September 11 had convinced them that they wanted the basic legal recognitions that domestic partnership registration would provide. This experience of mine resonates with many othersof caretakers and friends or ex-lovers with HIV/AIDS, of long time roommates with intertwined lives and joint property, of lesbian and gay parents bound to each other and to children in complex non-nuclear ways, of lovers who do not want the state contract with all its assumptions that is civil marriage. There are legions of peoplestraight and gay, bisexual or transgendered, and otherswhose lives are intertwined in ways that do not fit with one-size-fits-all marriage. Yet the needs and desires we all haveemotional and materialare as real and compelling, as fundamental and as significant, as the needs that lead many romantic couples to want to marry. I have therefore been shocked at the way lesbian and gay leaders and organizations have prioritized same-sex marriage. It is not just one issue on a broad list, encompassing the many needs of a diverse constituency. Marriage equality has become the singularly representative issue for the mainstream LGBT rights movement, often standing in for all the political aspirations of queer people. Over the past decade, the campaign for marriage has consistently garnered the lions share of movement energy and ideological push. Of course, on the one hand, the pursuit of marriage equality makes some sense. It has been fueled by a wide range of overlapping priorities: a demand for equal rights under law, a need for access to the private health care system, a desire for inclusion in the elementary structures of kinship recognition. But, on the other hand, if we consider such priorities with a broad vision of economic and social justice in mind, the right to marry is a very narrow and utterly inadequate solution for the problems that most queer people face. Access to the state-regulated institution of marriage does not provide full equality, universal health care, or expansively reimagined forms of kinship that reflect our actual lives.
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As the army of lovers and ex-lovers we often imagine ourselves to be, queer people, perhaps more than others, might be expected to see marriage as a much too narrow and confining status to accommodate our elaborate, innovative forms of intimacy, interconnection and dependency. But rather than continue to expand the forms of partnership and household recognition begun by the LGBT movement in the 1970s, the marriage equality campaign has resulted in a contraction of options. Whether through the substitution of marriage for other statuses where marriage equality has been won, or through the impact of defense of marriage legislation in states where that fight was lost, other statuses (including domestic partnership and reciprocal beneficiary) have been disappearing. Too often, such alternatives are represented as second-class marriage rather than as alternatives crucial to the lives of so many of us. Why not diversify and democratize the ways we recognize interdependencies, rather than enshrine the right to marry as a singular priority goal? Its puzzling, really. How did marriage equality come to represent the ultimate progressive goal of queer politics? Since the Reagan 1980s, the emphasis on the importance of marriage as a national political issue has been anything but progressive. Various efforts to promote marriage have been attached to welfare reform legislation since 1996. Government-supported marriage education projects run by conservative Christians have doubled as moral or values pedagogy, and as tax-saving initiatives designed to push marriage as an alternative to public assistance. Efforts are ideologically directed to poor women and women of color, assumed to be immoral and inappropriately dependent on the upright taxpaying citizenry. In the broadest sense, marriage promotion in welfare policy aims to privatize social services by shifting the costs of support for the ill, young, elderly and dependent away from the social safety net and onto private households. Women are encouraged to marry to gain access to higher mens wages and benefits, while taking up the slack for lost social services with unpaid labor at home. For poor households, this requires more labor and responsibility with fewer resources, as employment based benefits shrink and disappear. In addition, poor single women with children are encouraged to rely on child support payments mediated by the state. They are encouraged, and sometimes coerced, into naming fathers on birth certificates, or on applications for public assistance, so that deadbeat dads can be located for legal action against them to collect funds. Surveillance, coercion, and pressure on people surviving on low wages and no benefits are the everyday realities of the personal responsibility advocated by welfare reformers. All the cost shifting is wrapped in the idealization of marriage, the private ideal deployed to replace public, collective social responsibility. In addition, a vigorous conservative marriage movement has arisen with a long list of goals for shoring up traditional marriage: restricting the grounds for divorce, punishing adultery, teaching abstinence, and bringing children and teenagers more tightly under the authoritarian control of parents. Marriage has been glorified not merely as the best way to privatize social welfare costs, but as the best way to exert social control generally, and to stem the decline in social discipline since the 1960s. Though the conservative marriage movement has generally opposed same-sex marriage in favor of so-called traditional marriage, some conservatives have endorsed gay unions for their contributions to good social order and discipline (e.g., the New York Times columnist David Brooks). Despite such conservative uses of idealizing rhetoric to support coercive policies on everything from marriage promotion in welfare reform to forced birth control for Black and Latina women, the marriage equality campaign has often echoed rather than attacked it. Same-sex marriage

Pukaar July 2012 Issue 78

proponents commonly represent legal monogamy as an unalloyed social good, and as the basis for a stable, happy, mature adulthood. For instance, one marriage campaign document, the Roadmap to Equality: A Freedom to Marry Educational Guide published by Lambda Legal Defense and Education Fund and Marriage Equality California, opined: Gay people are very much like everyone else. They grow up, fall in love, form families and have children. They mow their lawns, shop for groceries and worry about making ends meet. They want good schools for their children, and security for their families as a whole. [...] Denying marriage rights to lesbian and gay couples keeps them in a state of permanent adolescence [...] Both legally and socially, married couples are held in greater esteem than unmarried couples because of the commitment they have made in a serious, public, legally enforceable manner. For lesbian and gay couples who wish to make that very same commitment, the very same option must be available. There is no other way for gay people to be fully equal to non gay people. Well, might the abolition of marriage be one other path to full equality of gay and non-gay people? Nonetheless and in the meantime, it is obviously discriminatory to exclude same-sex couples from marriage. But given the demographic realitythe diversity of our actual relationships and householdsmight de-centering marriage and multiplying options be not just another, but a better path to meaningful equality?[3] Might opposition to the conservative marriage movements entire agenda be more effective than trying to mirror their idealizations in order to gain inclusion? Might real separation of church and state require that marriage per se become a private or religious matter, while the state offers civil union, domestic partnership, reciprocal beneficiary, and other recognitions to all equally? These are the questions that led to the formation of the group that produced Beyond Marriage, a statement with 250 original signatures from LGBT, queer and allied organizers, scholars, artists, writers, and educators (many more have signed on since the document was released on July 25, 2006). The publication of this document is just the beginning of an effort to widen the agenda of the marriage equality campaign to include a broader set of relationships and the goals of social and economic justice for more of us than marriage, as it exists in current law, can provide. Given the current political impassewith a few states providing the right to marriage or civil union, with a larger number prohibiting not just same-sex marriage but a range of forms of recognition for nontraditional partnerships and householdsorganizing for democracy and diversity in relationship and household recognition, as well as for an expanded social safety net for us all, might not only be right, but also a practical way to improve the lives of people in a wide range of situations: elder companionate relationships, multigenerational immigrant households, nonconjugal caretaking arrangements, and more. We do not have to settle for marriage. We deserve more. From A new Queer Agenda: http://sfonline.barnard.edu/a-newqueer-agenda/ Issue 10.1-102/Fall 2011/Spring 2012

Saudi Arabia and sex reassignment

The following story by Saudi newspaper Okaz offers a rare insight into the ongoing debate in Saudi society over the issue of sex reassignment. From advocacy perspective, the following facts from the article is worth considering: 1- In Saudi Arabia, only intersex individuals are allowed to undergo sex-reassignment process. According to a decree by the Saudi Ministry of Health -issued in May 2011-, all hospitals and medical centers can only perform sex-correction precedes only after the cases are confirmed by the Medical Treatment Office of the Health Ministry. 2- In Suadi Arabia, the religious principle for the sex-reassignment surgery can be condensed into one sentence: Correcting sexuality (which is caused by a birth defect) is allowed, changing sexuality is illegal. This is the view expressed by the head of the vice-president of the International Union of Islamic Scholars, Dr. Abdullah Bin Beah. The article argues that both the Saudi High Council of Religious Experts (the highest religious authority in Saudi Arabia) and AlAzhar University in Egypt hold same view on sex-reassignment. Under this doctrine, if the experts decide that the real sexuality of an intersex person is male, that persons sexuality will be corrected accordingly, regardless of the persons preference. 3- The only medical center in Saudi Arabia that performs sexcorrection procedures is the Sex Correction Center at King Abdul Aziz University Hospital. The center has performed 425 such operations in the past 27 years, on patients ranging from newborn babies to 40-year old individuals. According to the head of the Center, Dr. Yaser Jamal, 93% of intersex cases are diagnosed at birth and the corrective surgery is performed within the first-two-years after birth. 4- Despite the high number of sex-reassignment cases, the Kingdom of Saudi Arabia does not have adequate post-surgical psychological care. As a result, 60% of those who go through the sex-correction process cannot adapt to their new gender role and suffer from psychological problems, which may, in some cases, lead to suicide. In many instances, intersex individuals are harassed by family members, society, and the religious police, and sometimes end up in jail. Even though their sex-reassignment is legally approved, the police often consider them to be gay, which is a crime in Saudi Arabia. In order to remedy the situation, there have been advocacy efforts by members of the Saudi Consultative Council (Shura) to provide better legal protection for intersex individuals.Such a move is met with resistance from the Saudi religious police as well as some Saudi judges. 5- The Saudi religious police continues to crackdown on homosexuals. According to Sheik Ahmed Ali Al Ghamidi, a ranking member of the Religious Police in Riyadh, during a one-year period, 260 people were arrested and punished for homosexuality, including cases of cross-dressing, men wearing make-up, or men trying to pick-up other men. Mr Ghamidi complains that there are not enough treatment centers in the Kingdom to cure homosexuality. SOGI, 25/5/2012

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Between aid conditionality and identity politics the MSMtransgender divide and normative cartographies of gender vs. sexuality
Aniruddha Dutta Late last year, the UK and US governments made announcements supporting the global propagation of LGBT (lesbian-gay-bisexualtransgender) rights as human rights, suggesting that the future disbursal of aid might be made conditional on how LGBT-friendly recipient countries are perceived to be. The potential imposition of gay conditionality on aid has been rightly critiqued for imposing a US/European model of sexual progress on developing countries, which may justify covert geopolitical agendas and fail to actually benefit marginalized groups. But whatever form such conditionalities may take in the future, a more implicit and routine form of aid conditionality has been already at work, relatively unnoticed, for several years now the presumption of distinct and enumerable minorities corresponding to categories like homosexual or transgender as target groups for aid in socio-cultural contexts where gender/sexual variance may not be reducible to such clear-cut categories or identities. Increasingly, community-based organizations (CBOs) working to gain gender/sexual rights or freedoms need to define themselves in accordance with dominant frameworks of gender-sexual identity to get funding both from foreign donors and the Indian state, creating identity-based divisions among CBOs and presenting existential challenges to communities that do not exactly fit these categories. Through the past decade, India has seen a booming growth of NGOs working for sexual minorities, especially in the sector of HIV-prevention, funded both through the Indian state and foreign donors such as the UKs DFID (Department for International Development). While this has facilitated the coming out of queerness in the media, civil society, and state policy, it has also created a normative script for identity and recognition through implicit and explicit aid conditionalities through which sexual minorities get funded. Even as the Indian government has hesitated to support the decriminalization of same-sex relations, the Indian health ministry is actively involved in funding health-based interventions for gendersexually variant people especially for those born male (though not necessarily identifying as such), seen as being at high risk for HIV-AIDS. (Queer women and female-born transpersons are left out of HIV-AIDS funding, supposedly not at high risk a problem that needs separate exposition elsewhere). This article will focus on a spectrum of male-born gender/sexually variant persons and communities for whom the health ministry and the National AIDS Control Organization (NACO) mediate foreign aid for HIV-AIDS prevention, influencing not only whether their sexual/gender variance is to be decriminalized and politically recognized, but also how it is to be recognized. A binary framework What forms of identification are being legitimized through this process, and what forms of identity/behavior are not? While previously all funding for sexual minorities, including for third gender hijras, was disbursed through interventions for MSM (men-who-have-sex-withmen or males-who-have-sex-with-males), now the health ministry and NACO have started separating sexual health interventions into MSM and TG (male-to-female transgender) categories, as announced in the NGO world and mentioned in at least one media report. Herein lies a story, for both MSM and TG categories, in the way they are currently conceptualized, carry normative ideas of gender/sexual identity, ultimately based on a binary man-woman divide. The MSM-TG division may not only exclude people who do not fit these labels, but also splinter existing marginalized communities of gender/sexually variant people into narrow identitarian groups. This particularly affects communities and community-based organizations
8

in non-metropolitan and rural areas, which are more dependent on such funding than metropolitan middle class LGBT groups. In the new funding regime that is increasingly getting standardized, the two broad legitimized categories for male-born people are MSM/ gay/homosexual (men desiring men) on one side and male-to-female transgender on the other, where TG is commonly glossed as those identifying as or desiring to be women. Hijras are either seen as a subset of TG or a closely linked group (see this 2008 UNDP report for emerging MSM-TG divisions and this 2009 report for emerging definitions of TG). These reports mark a shift from common perceptions where homosexuality and gender variance have often been seen as closely related, if not the same thing witness the widespread stereotyped equation between gayness and effeminacy in the media. This association was implicit in state policy as well; one of the primary sub-categories of MSM in India under the third phase of the National AIDS Control Program (NACP-III, 2007-12) was the kothi, a complex and ambiguously-bordered category used in lower class community networks and hijra groups, which NACO defines as males who show varying degrees of femininity (see document on high-risk groups available here). However, increasingly, the government, its funders and larger NGOs have become very interested in distinguishing exactly who among gender-sexually variant people are really transgender (commonly defined as female/ women in a male body), and who are really men having sex with men (increasingly narrowing MSM from its former inclusion of all biological maleness into a gendered category for men). While the MSM category focused mainly on sexual behavior, transgender allows for gender identity and gender-based discrimination to be factored into funding policy: which is certainly a positive development. However, if MSM and TG are understood in simplistic terms as mutually exclusive and separable identities/communities (rather than flexibly overlapping terms), it creates a restrictive binary cartography or framework for identification in the same old societal mould that is being contested, involving the question of who is really a man (albeit a same-sex desiring one), and who is really a (trans) woman. Such an MSM-TG division can have wide-ranging and divisive effects on organizations and communities that in practice have been flexibly overlapping. It threatens to split marginalized communities and networks into separately funded, competing groups communities where, as a PhD student/researcher, I have observed a complex spectrum of masculine to feminine identified people. This could include people who identify as (trans)women or hijra, people who identify as feminine males (using terms like kothi, dhurani, gay), people who switch between identities and gender presentations, people who dont identify as anything at all but still participate in such networks/ communities, people who identify only during specific occupations such as dancing at festivals or sex work, and so on. However, to fall into the ambit of government-funded AIDS interventions now, one has to be classified as either MSM or TG. Moreover, it is sometimes stipulated that a single community-based organization (CBO) cannot have both MSM and TG people, as seen in an empanelment call for CBOs by the State AIDS Control Society in Bengal in 2011, which asked for TG-exclusive CBOs. Like the above call for CBO empanelment, several national coalitions of NGOs too increasingly ask member organizations to identify as working with either MSM or TG communities, or at least to sub-divide their population into precisely enumerated MSM and TG sub-groups. To many small non-metropolitan CBOs, this has posed problems. Working with a complex community spectrum

Pukaar July 2012 Issue 78

ranging from feminine males to transwomen, they have to now classify themselves as either MSM or TG to the state, and/or have to sub-divide their population into this binary framework for other foreign-funded projects such as the Global Fund-aided Project Pehchan. This causes confusion regarding the correct term to identify with, and anxiety about the potential to miss out on funding if the representation is not consistent. In some cases, the process of arriving at a correct and acceptable representation for the state has caused delays in achieving funding, even as people died for lack of HIV-AIDS related services in the area. For instance, Sangram, a CBO in mid-North Bengal, was not able to get HIV funding for several years between 2006 and 2011, despite an estimated nine AIDS-related deaths in their district during the period. First told that they did not have enough sexual minority population in the area, there was further delay over whether they were to be empanelled as a TG organization or as an MSM one. CBO representatives even wondered whether they were expected to put on particular attire or present themselves in a particular way (either more or less feminine) in order to be perceived as authentically TG or MSM by representatives of the West Bengal State AIDS Prevention and Control Society. Finally, after being empanelled during the TG empanelment process, they were given an MSM project. Meanwhile, at least two people with AIDS died in the area. These hurdles of representation further worsen the bureaucratic hassles with funding that routinely hamper state-funded MSM/ TG intervention projects including long gaps between funding cycles, months-long delays in getting staff salaries, and corruption or misappropriation of funds at higher administrative levels of state AIDS control bodies (as exposed by this report from West Bengal). Just as importantly, the imposition of identity stipulations also adds to a hierarchical, exploitative system where community-level workers (especially peer educators, the foot soldiers of HIV-AIDS prevention) are paid less than minimum wage salaries (usually honoraria of less than Rs. 2000 per month), as this report from Karnataka attests. Meanwhile, their partners in metropolitan NGOs and funding organizations enjoy far more generous salaries and commensurate social recognition, further exacerbating class and experiential divides. The arrival of transgender This is not to deny the importance of the entry of transgender into policy, which was a necessary development. There is not enough space here to offer a detailed history of how TG became a funded category. But briefly, one way in which TG entered state and funders policy was due to activists demands to revise the funding regime to address gender issues more effectively as shown during national and regional consultations among NGO leaders conducted by UNDP (the United Nations Development Programme) in 2008 and 2009. The third phase of the National AIDS Control Programme (NACP-III) designed targeted interventions for MSM, and marked MSM/TG as a singular entity. The subsumption of all groups under the epidemiological and behavioral label MSM neglected gender-based discrimination and violence, and marked sexual health as the overarching issue. Thus all male-born sexual minorities were reductively seen as biological males (though not necessarily men), and interventions primarily addressed the risks of unprotected male-male sexual behavior. Quite justifiably, activists demanded that interventions should recognize those not identifying as males, and criticized MSM interventions for failing to address gender issues and discrimination. TG emerged as the umbrella term to accommodate gender variance, and newer NGO networks such as the Association of Transgender/Hijra in Bengal sought to explicitly deal with gender discrimination: again, a laudable development. This was parallel to the political demand to add other as an option in the census and other government documentation, opening up the parameters of official identity beyond male and female also an urgent and necessary demand. However, rather than the reform and expansion of existing MSM interventions to better accommodate the gender variance of their target communities and address gender discrimination, TG soon

became conceptualized as a separate identity and a competing funded group. This separation creates a new problem where the recognition of gender variance is effectively reduced to the sex-gender binary of male/female (homosexual males vs. transwomen). Indeed, gender (transgender) and sexuality (homosexuality) themselves become conceptualized separately, with gender variance becoming primarily the province of TG identity/activism (as David Valentine has argued about the gay-transgender divide in the US context). This does not address gender variance within existing MSM interventions making MSM itself into a narrowly gendered term and confines gender-based anti-discrimination work to TG projects/interventions. Moreover, once TG is opposed to MSM as a separate identity, rather than seen as an overlapping category that can be strategically used to address gender-related issues affecting a variety of persons, its scope is reduced to cover only a very narrow script of transgender identity. As I describe below, for male-born people, TG often gets circumscribed as per conformity with cultural femininity and may establish what Ricki Wilchins has called a hierarchy of legitimacy where some are more authentically TG than others. And of course, there is no mention of caste/class issues in both the older and newer funding regimes, even though MSM-TG communities who rely on such funding are often lower-middle to lower class, which is crucial to understanding and mobilizing from their social situation. The dangers of unitary identification Although the MSM/TG divide now exists on paper and within funding mechanisms, in practice attempts to produce a separate, clearly demarcated or unified transgender identity have run into problems and not resulted in any consensus. A news article in Bangalore claims that most TGs want to be identified as female (and not other or transgender) on official forms. But another Hyderabad-based report states that some TG-identified people complain about being forced to identify as female, and indeed want to identify as other. While in the first case an NGO activist claims that the majority of TGs want to be women-identified, in the second case the local NGO is disappointed with those identifying as female, and politically favors that TGs should identify as other. Both the articles want to seek out a majority and a singular definition of TG which risks marginalizing any minority section that does not fit whatever the right definition of transgender is supposed to be in that particular NGO or community. The absurdity of the attempt is compounded by the fact that transgender is a relatively new term even in English, and is obviously unfamiliar to a lot of lower or lower/middle class gender-sexually variant communities. The dangers of basing official recognition or service provision on unitary identities is well demonstrated by the case of gender variant people who have encountered life-threatening problems due to having a combination of male and female listed on different forms like the case of Bini, a hijra community member who couldnt get easily admitted to hospitals in Kolkata because of having her sex listed differently in different forms (see this report in the Bengali media). Proposing female or other as a unitary identity for all transgenders might not solve but actually compound this problem, given that many community members already have female or male on different forms, and unless they change all forms of identification to achieve one consistent identity, they might still be denied services on account of not being properly transgender, unambiguously other. The demand for unitary and consistent identity, associated with middle class civil society and citizenship, might therefore be detrimental to communities lower down societal and organizational rungs. A better strategy seems to be to dissociate essential governmental and health services from sex-gender unless it is medically relevant, and/ or to promote and permit flexible identification on a personal and case-by-case basis which is challenging on a logistical level, yet perhaps crucial for long-term change. continued on page 10, col. 1
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Between aid conditionality and identity politics

continued from page 9, col. 2 Separation and overlap On the level of organized HIV prevention and human rights work, an MSM-TG separation would make some sense where communities have formed along a masculinized gay identity (men-desiring-men), encouraged by the ubermasculine culture of gay porn which has little space for gender variance, or by the online culture of popular gay dating sites in India like www.planetromeo.com where injunctions like no feminine guys please are common on many personal profiles. Such communities, organized around a normatively masculine gay identity (partially in response or reaction to the effeminate gay stereotype), would indeed not have much space for gender variance and for femme, genderqueer, transgender, kothi, male-to-female transsexual (etc.) people. (For instance, certain well-known urban gay groups have been known to explicitly forbid cross-dressing in their events.) In such contexts, it is not my aim to advocate some anodyne homosexual-transgender unity (such as that signified by increasingly commoditized and banal images like the rainbow LGBT flag), which would only serve to disguise the privilege and all-too-common transphobia of many masculine men-who-havesex-with-men, whether gay-identified or not. Such a plastic queer or LGBT unity might prevent rather than create the proverbial safe space for those who really need it. However, in most small towns and villages in Eastern India where I have worked over the last five years, networks and communities have not grown around such a rigid gay vs. transgender identity split, perhaps partly because it is not conventionally masculine-identified people who have been at the core of such spaces. Rather, there is a spectrum of gender variant persons spread between formal hijra gharanas (clans/groups) on one end, and loose cruising (sexual) networks on the other. In response to social stigma or abuse, such persons come together at cruising spots, parks, roadside haunts, and slowly with institutionalization, CBO offices. There are also occupational networks among people who do sex work (khajra), beg in trains (chhalla), or perform as launda dancers (cross-dressed dancing during festivals or marriages, primarily in UP/Bihar). There is a range of terms used to describe gender/sexually variant persons in these networks kothi, dhurani, moga, launda, and of course, hijra which describe a gender spectrum that cannot be neatly divided into the two sides of gay/homosexual men vs. male-to-female transgender. During NACP-III, NACO tried to designate these complex community networks under the MSM sub-group kothi, reductively defining kothi as feminine males who take the penetrated position in sex, even while noting there are varying degrees of femininity among them. But even while the NACO and HIV interventions tried to stabilize this definition of the kothi, subcultural usages have remained more internally varied and flexible. Kothi is often locally translated and allied to terms like dhurani, meyeli purush (feminine male), and launda (in Bihar and UP). People might switch between labels or have ambivalent//plural identities across seasons or life stages like many male-attired dhurani/kothis who cross-dress as laundas or transition to hijras and moreover, there is no strict segregation between different kinds of people. There are some who cross-dress only occupationally, and talk of themselves as effeminate males, while others might see themselves as women all through, using metaphors like women-in-male-body all within the same community without a strict spatial demarcation separating the (feminine) males from the (trans) women. Metaphors like being a woman inside which designate fixed identities co-exist with behavior-based classifications like pon tonnapon (masculine-behaved), niharinipon (femininebehaved) which permit transitions. This is not queer utopia much of the fluidity is prompted by survival and occupational needs, and there might be tensions between those who are more fluid (e.g.
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laundas, sex workers) and those who have a more fixed identity (e.g. senior hijra gurus). However, there are also many friendships and kinships (e.g. sisterhood) among different people, facilitating identity switches and overlaps. (To an extent, this is true even in metropolitan communities where the aforementioned gay-TG divide is clearer). But instead of encouraging friendships and already existent kinship structures, the MSM-TG separation tends to divide community networks and build upon tensions. Ghettoization and transphobia Just as the emerging gay/TG divide in urban communities, stricter than their previous loose overlap, discourages boundary-crossings and perpetuates femme-phobia and transphobia, the identity politics around MSM-TG separation, linked to aid conditionality, might have similar effects in non-metropolitan communities. For instance, in West Bengal there have been intra-community allegations about crossdressers not being encouraged in some MSM CBOs. Conversely, as I observed in emerging TG interventions/projects, there may be pressures to fit into a normative idea of being TG in order to access organizational spaces and services. At a new TG intervention near Kolkata, I saw that too MSM behavior was not encouraged, since it must look like a TG CBO (i.e. participants should look as much like women as possible). Derided by a peer for being actually MSM, a kothi who was not really TG, one young community member said s/he would go in for laser facial hair removal, which is probably not something that s/he could easily afford. Thus, evolving ideas of proper TG-ness based on ideals of femininity has potentially adverse mental health impacts on those who do not fit, just as gayness increasingly valorizes a normative masculinity with exclusive effects. Can chhallawali kothis (cross-dressed train beggars outside hijra gharanas) or laundas who often switch between public gender roles pass as properly TG or properly MSM? TG loses its radical potential for addressing gender variance among male-born persons once it is opposed to MSM and aligned with some normative idea of being feminine, which simply cannot be afforded by many poorer community members. Moreover, instead of TG empowerment, such separation might result in a ghettoization of TG issues, such that MSM interventions could refuse to deal with the needs of gender variant people in their local community, which more often than not would have a gender spectrum including TG-identified people and hijras. This defeats the purpose of transgender activism by actually further preventing services for gender variant people, and by making CBOs accountable only to narrowly defined identities rather than the complex communities from which they have arisen. This is also dangerous as not all areas have both MSM and TG interventions. For example, a recent case concerns Sujata (name changed), an hijra living with HIV who is being looked after by a TG organization after being disowned by her hijra gharana, and thus can no longer move out of the TG organizations area for occupational needs or demand services of MSM organizations elsewhere. Such divisions along gender lines also cancel potential class/caste solidarity among the spectrum of differently-gendered people. Since many non-metropolitan communities did not form according to a gendered either/or binary between gay men/MSM and TGs, many CBOs are unsure about how to fit into this new identity politics. Often the MSM/TG division is locally understood as one between different kinds of kothis or dhuranis, rather than separate identities per se. Attempts to categorize these terms into the MSM-TG cartography have resulted in inevitable ironies kothi is mapped as TG by a 2009 UNDP-funded report, but as MSM in interventions by NACO and Project Pehchan. While policy documents do not acknowledge this overlap explicitly, it exposes the absurdity of the assumption that one has to be either MSM or TG, or that MSM and TG can be neatly separated and demarcated. As one kothi-identified person remarked to me, kothis not only get fucked but fuck too, so it is a controversial term, gesturing at the crossover of feminized receptive roles and continued on page 11, col. 1

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Untreatable gonorrhea spreading around world: WHO

Drug-resistant strains of gonorrhea have spread to countries across the world, the United Nations health agency said on Wednesday, and millions of patients may run out of treatment options unless doctors catch and treat cases earlier. Scientists reported last year finding a strain of gonorrhea in Japan in 2008 that was resistant to all recommended antibiotics and warned then that it could transform a once easily treatable infection into a global health threat. The World Health Organization (WHO) said those fears are now reality with many more countries, including Australia, France, Norway, Sweden and Britain, reporting cases of the sexually transmitted disease resistant to cephalosporin antibiotics -- normally the last option for drugs against gonorrhea. Gonorrhea is becoming a major public health challenge, said Manjula Lusti-Narasimhan, from the WHOs department of reproductive health and research. She said more than 106 million people are newly infected with the disease every year. The organism...has developed resistance to virtually every class of antibiotics that exists, she told a briefing in Geneva. If gonococcal infections become untreatable, the health implications are significant. If left untreated, gonorrhea can lead to pelvic inflammatory disease, ectopic pregnancy, stillbirths, severe eye infections in babies, and infertility in both men and women. It is one of the most common sexually transmitted diseases in the world and is most prevalent in south and southeast Asia and subSaharan Africa. In the United States alone, according to the Centers for Disease Control and Prevention (CDC), the number of cases is estimated at around 700,000 a year. The WHO called for greater vigilance on the correct use of antibiotics and more research into alternative treatments for gonococcal infections. The emergence of drug-resistant strains of gonorrhoea is caused by unregulated access to and overuse of antibiotics. Experts say an added problem with gonorrhea is that its strains tend to retain their genetic resistance to previous antibiotics even after their use has been discontinued. Major producers of antibiotics for gonorrhea include global drugmaking giants GlaxoSmithKline, Pfizer and Abbott, as well as Indian firms like Cipla. The WHO said it is not yet clear how far or wide drug resistance in gonorrhoea has spread, as many countries lack reliable data. The available data only shows the tip of the iceberg, said LustiNarasimhan. Without adequate surveillance we wont know the extent of resistance...and without research into new antimicrobial agents there could soon be no effective treatment for patients. Like passing razor blades Francis Ndowa, formerly the WHOs lead specialist for sexually transmitted infections, said gonorrhea has not only adapted to elude antibiotics but developed less painful symptoms, increasing its survival chances. They used to say that if you have urethral gonorrhea you go to the toilet to pass urine, it would be like passing razor blades. It was that painful, he explained. Now people with gonorrhea sometimes... only notice the discharge if they look when they pass urine, its not that painful anymore. So the organism has readjusted itself to provide fewer symptoms so that it can survive longer. Its an amazing interaction between man and pathogen, Ndowa said. Experts say the best way to reduce the risk of even greater resistance developing -- beyond the urgent need to develop effective new drugs -- is to treat gonorrhea with combinations of two or more types of antibiotic at the same time. This technique is used in the treatment of some other infections like tuberculosis in an attempt to make it more difficult for the bacteria to learn how to conquer the drugs. Gonorrhea can be prevented through safer sexual intercourse. The WHO said early detection and prompt treatment, including of sexual partners, is essential to control sexually transmitted infections. 6/6/2012

Between aid conditionality and idenity politics

continued from page 10, col. 2 more masculine penetrative ones within these communities. A narrow sense of TG thus might perform a restrictive representation of gender variant people that fails to address the complexity and internal variety of such communities. To conclude, transgender is a strategically important category that directs HIV-AIDS funding for male-born gender variant people to political organizing, and corrects the narrowly epidemiological focus of MSM on sexual behavior but only if it is kept open as a strategic umbrella term and not reduced to a bounded identity mutually exclusive with MSM. Overcoming such aid conditionality would necessitate solidarities across gay-kothi-launda-dhurani-moga-TGhijra-etc. categories, including and beyond identifications such as woman-in-male-body or man-desiring-man: flexible friendships and/or sisterhood against patriarchy open to both more masculine folks who are part of gender variant networks on one hand, and hijras and transsexuals on the other. Aniruddha Dutta is a PhD candidate in Feminist Studies and Development Studies at the University of Minnesota.

Why we must 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 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 free from violence and harassment The right to be treated with dignity and respect The right to be treated as full citizens in their countries 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.

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HIV prevention for men who have sex with men and transgenders in Nepal
Dr Ma Elena Filio-Borromeo, UNAIDS Country Coordinator, Nepal The Blue Diamond Society (BDS) recently organized a national consultation meeting of over 200 members of the MSM (men having sex with men), TG (transgender) and LGBTI (Lesbian, gay, bisexual, transgender, intersex) community from all over the country to deliberate on issues that affect the community, specifically the HIV prevention program. The national consultation came at a time when Nepal is about to draft its National Action Plan on AIDS for the next couple of years. It is expected that the results of this consultation will highlight and design the strategic priorities of the countrys response on HIV and AIDS, and resources will accordingly be allocated. There are an increasing number of studies and reviews that have been carried out in South Asia, including Nepal, about the risks and vulnerabilities of MSM, TG and LGBTI to HIV infection. While there is a call to design and conduct further studies to fill in the information gap about TG and LGBTI and their environment, there has been encouraging development, according to the recently published review titled Lost in Transition: Transgender people, Rights and HIV Vulnerability in the Asia Pacific Region, released by UNDP last month. This development includes: a developing transgender identity, growing pride and an increasing willingness on the part of transgender communities to advocate for increased participation in policy processes and organize peer support services at the national and local level. In Nepal, the establishment of BDS, an advocacy network of community-based organization working dedicatedly to empower and strengthen the MSM, TG and LGBTI community has been a laudable initiative. And we have seen much progress under the firm leadership of BDS. Amidst all these efforts however, in Nepal, there is little effort to reach out to the MSM, TG and LGBTI communities for HIV prevention and education, treatment, care and support services. Let me highlight some key reasons behind this, while also laying down some progress that is finally being made now. First, Nepals socio-cultural environment is just starting to get friendly with the cause of MSM, TG and LGBTI. Significant progress in the area of HIV related human rights had been achieved. For example, in 2007 the Supreme Court of Nepal had issued a ruling on recognizing the third gender and the equality rights of LGBTI population in Nepal. In the recent discussions on the new constitution, anti-discrimination provisions had been included. Progress is also evident in discussions between UN partners, government agencies and civil society organizations. For example, the National Human Rights Commission of Nepal has agreed to include sexual orientation and gender identity in its portfolio for the minorities. This initiative is being supported by the prime ministers office, Blue Diamond Society, UNDP, UNAIDS and the International Development Law Organization (IDLO). Despite this, however, the situation on the ground remains disturbing. For example, I met members of the MSM, TG, and LGBTI community in Pokhara and Morang and some of their feedback was highly perturbing. Most community members still experience verbal and even physical abuse, discrimination and rejection primarily because of their sexual orientation. Full access to comprehensive HIV and AIDS services is still a daunting challenge. Hence, we need to continue to support and push for the translation of those policy pronouncements into action on the ground. We need to walk the talk in order to make these policies meaningful. Second, targeted research on TG and LGBTI remains inadequate. This significantly impedes access to health services and blocks effective and timely response to HIV. An inclusive research, designed and implemented in partnership with the community, is imperative.
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Moreover, there is still a lack of understanding of the universe of MSM, TG and LGBTI, not only in Nepal but in Asia as a whole. To help address this, the regional DIVA project (Diversity in Action) supported by Global Fund through its Round 9 regional HIV grant, is embarking on generating more quantitative and qualitative evidences about MSM, TG and LGBTI. This will help us re-design our programs and be more responsive to the genuine needs of the community. Third, there is still no separate and specific approach to MSM, TG and LGBTI. These communities are lumped into one salad, instead of designing targeted intervention customized to the growing needs and realities of the community. In the new national strategy on HIV and AIDS 2012-2016, one of the priority strategies is related to MSM/ TG. Note that TG continues to be part of MSM, even when studies have shown that the needs and vulnerabilities of TG and LGBTI in the context of HIV are different. So in the development of the National Action Plan on AIDS, or the operational plan to translate the NSP into activities and actions, we need to ensure that a more specific approach and set of activities for TG and LGBTI are incorporated. The fourth is a challenge specific to Nepal and relates to the area of advocacy for action. There are a gamut of competing priorities for leaders in Nepal, leaving them with little space to take genuine action on issues related to MSM, TG and LGBTI in the context of HIV prevention and human rights programs. When we talk to leaders, either individually or in groups, they all agree that the issue has to be put forward, debated and acted upon. But with the long list of national priorities -- from constitution drafting, to issues related to rule of law, food insecurity, economic progress and good governance - all core and fundamental to Nepals development- the issue of MSM, TG and LGBTI will perhaps be dwarfed or sidelined. Clearly the issues, barriers and challenges that the UN faces in advancing the MSM, TG and LGBTI HIV prevention and human rights program are the same as what Nepals national stakeholders face. AIDS is a behavior-driven disease and we are often confronted with strong cultural beliefs and biases that hamper effective HIV prevention programs. Our response is shaped by the political and legal environment. To a certain extent, from the UN, the degree of challenges could be different as we do not experience, first-hand, ground-level discrimination and stigma as community members do. And we continue to pursue what we believe in - the right of every individual irrespective of color, creed, religious affiliation and gender, to universal access to HIV prevention, treatment, care and support services, at relevant district, national, regional or international forum. This is in line with the 2011 AIDS political declaration that Nepal had committed to. The UNAIDS family in Nepal continues to be prepared to help the country realize its national vision, goal and targets as enshrined in the 2012-2016 National Strategy on HIV/AIDS. The UN has a clear mandate and comparative advantage to assist the country in effectively responding to HIV and AIDS. Under our agreed division of labor, the empowerment of men who have sex with men and transgender people to protect themselves from HIV and to fully access antiretroviral therapy is being convened by the UNDP. We welcome the strategic support of UNDP, Nepal in this area, with the rest of the members of the UN joint team on AIDS. We continue to work with the hope and aim of making Nepal a truly equal and inclusive society. http://www.myrepublica.com/portal/index.php?action=news_ details&news_id=36606 19/6/2012

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Citizenship in Nepal
Anjali Subedi Due to lack of a clear identity matching their sexual orientation and outlook, individuals in the others category always had to face scornful queries whether to treat them as men or women. They would get harassed at police stations, offices, schools, colleges, hospitals and, not surprisingly, most often at public toilets. But this kind of treatment is now a thing of the past. In order to protect the rights and dignity of the third gender, the Home Ministry on Wednesday decided to provide citizenship under the others category to members of the LGBTI (lesbian, gay, bisexual, transgender, intersex) community. The Ministry has already written a letter to the Ministry of Law and Justice in this regard. Yes, the LGBTI community will from now onwards be categorized under others as per their wish. Only the technical process remains to be completed in this connection, said Shankar Koirala, spokesperson at the Home Ministry. We have already sent a letter to the Law Ministry to add the others head in all necessary forms, documents and indexes, he added. Euphoric over the government decision, transgender Dev Gurung remarked that the entire LGBTI community is now feeling empowered. The state has given us our right. This means we will no longer face harassment for having a different sexual orientation. Society might

take time to recognize and accept us for what we are, but what the state has given us now means half the battle is won, he said. Talking to Republica, another transgender, Badri Pun, stated that the legal recognition of others has direct implications for employment opportunities and greater acceptance in all quarters. We used to be discriminated against at schools, colleges, hospitals, workplaces and in other public spaces. With the state now duly respecting our different sexual orientation, people cannot challenge us any longer, at least not on legal grounds, he commented. Pun, a transgender from Myagdi district, had moved the Supreme Court to get a citizenship certificate under third gender category in 2007. Earlier the same year, the apex court had granted such a citizenship to Bishu Adhikari after fighting a legal battle. However, the court order to treat such individuals as equal citizens had not been adhered to by the state so far. LGBTI community leader and founder of the Blue Diomond Society Sunil Babu Pant, who is also a lawmaker, has termed the development a great victory for all LGBTIs in Nepal. It was a constant battle for us. And now we are extremely happy. It has been possible thanks to Sushil Jung Rana, secretary at the Home Ministry, he exclaimed. We had been lobbying for it for so long, and this time he took the initiative to make it finally happen, Pant added. According to Pant, 8 to 10 percent of the population of the country is estimated to be LGBTI. 24/5/2012

Homosexual teens encounter dilemma of discrimination

A majority of homosexual students have suffered from communal discrimination and violence, including from their friends and teachers, according to experts addressing a workshop in the capital on Wednesday. The event took place on the occasion of the International Day Against Homophobia and Transphobia (IDAHO) on May 17. A recent survey conducted by the Centre for Creative Initiatives in Health and Population on 520 homosexual, bisexual and transsexual people with an average age of 21 revealed that nearly 41 per cent had suffered from discrimination and violence at school or university. Seventy per cent of them said they had been given offensive names, 38 per cent said they were treated unfairly, 19 per cent claimed to have been beaten and 18 per cent sexually harassed. The reasons cited for ill treatment included the students dressing or behaving in a different way while seemingly having feelings for people of the same sex. According to the survey, half of the students suffered from constant fear and nervousness and came to hate themselves for their different sexual tendencies, while 20 per cent lost the motivation to go to school and 36 per cent isolated themselves. More seriously, 35 per cent of those claiming they had been illtreated said they had considered committing suicides, half of them saying they had actually tried to take their own lives. It saddens me to see so many people losing hope for the future at such a young, innocent age, said Hoang Tu Anh, director of the Centre for Creative Initiatives in Health and Population (CCIHP), pointing out that nearly 40 per cent of those surveyed suffered from identity confusion. Tu Anh also pointed out that homosexual youngsters were often treated unfairly by their teachers who thought homosexuality was some kind of disease. She recounted the story of a student called abnormal by his teacher in front of the whole class, an embarrassing experience that haunted him for the rest of his life. Motivated by the situation, a society called the Sexual Rights

Alliance on May 14 sent a letter to Minister of Education and Training Pham Vu Luan demanding action to prevent violence against homosexual students at educational institutions. The alliance consists of six non-governmental organisations including the CCIHP, the Institute for Studies of Society, Economy and Environment (ISEE), the Centre for Family Health and Community Research (CEFACOM) and the Rutgers World Population Foundation in Viet Nam. The letter additionally proposed integrating education about sexual tendencies in school curricula to raise peoples awareness about homosexuality. While awaiting the Ministers response to their letter, the alliance has organised different activities to raise social awareness, including play and training courses about gender, sexuality and health. What we hope for is an environment where everyone respects peoples differences, said Dr. Vu Pham Nguyen Thanh, a researcher from CEFACOM, who added that discrimination against homosexuals was a problem facing the whole of society. IDAHO was begun by the Joint United Nations Programmme on HIV/AIDS. This years theme is Combating Homophobia In Education and Through Education. UNAIDS said the day was launched to celebrate diversity and to speak out against discrimination and violence. The growing number of events in Viet Nam every year held on the occasion is an indication of the growing confidence of the LGBT community and the openness and tolerance emerging in the country, according to Eamonn Murphy, UNAIDS Viet Nam Country Director. UNAIDS is full of hope as the LGBT communities in Viet Nam are speaking out more strongly about their rights and contributions to society, said Murphy. Homophobic bullying is a global problem and adversely affects young peoples mental and psychological health. Murphy quoted UN Secretary-General Ban Ki-moon as saying that it was a moral outrage, a grave violation of human rights and a public health crisis. VietNamNet/Viet Nam News

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Pukaar July 2012 Issue 78

Its time to talk top: the risk of insertive, unprotected anal sex
HIV Australia | Vol. 9 No. 3 | November 2011 http://www.afao.org.au/library/hiv-australia/volume-9/number-3/hiv-prevention-and-anal-sex This article describes the biological role of anal mucus and its association with the gastrointestinal immune system, which harbours a persistent reservoir of HIV that potentially leads to infectious anal mucus. Eric Glare argues that all HIV prevention discussions should highlight the role anal mucus plays in HIV transmission. Strategic positioning, where an HIV-negative man takes the insertive role in unprotected anal intercourse with an HIV-positive partner in order to reduce his risk of infection, has been associated with an intermediate incidence of HIV in cohorts of Sydney men who have sex with men (MSM).1 Circumcision of the insertive partner and an undetectable blood plasma viral load in the receptive partner are two factors often cited as contributing to risk reduction in strategic positioning practices, despite there being a paucity of data on HIV transmission by anal intercourse in men who take the insertive role in male-to-male sex.2 Men who practise strategic positioning are attempting to take perceived risks into account to form personalised boundaries around anal intercourse but, until recently, a comprehensive understanding of HIV transmission through insertive unprotected anal intercourse has not been widely canvassed in research literature. A 2008 study of risk factors associated with HIV seroconversion in gay men in England identified that some men taking the insertive role in anal intercourse contracted HIV because they did not perceive that they were at risk of infection.3 GMFA, a gay mens health charity based in the UK, responded with a campaign called Arse Facts that identified anal mucus as a body fluid containing HIV at potentially infectious levels.4 Anal mucus is increasingly being mentioned in Australian campaigns as the infectious body fluid potentially infecting the insertive partner during unprotected anal intercourse.5,6,7 At times, the explanation of the role that anal mucus plays in transmitting HIV to the insertive partner has been relegated to in-depth discussions of topics such as risk reduction, but is frequently left out of more introductory information about HIV transmission (e.g. Whereversexhappens.com 8),and some campaigns discuss the risk of insertive anal intercourse without mentioning any body fluids involved.9 Some campaigns warn that even if an HIV-positive person has an undetectable blood plasma viral load they might have higher viral load in anal mucus, particularly if they also have another STI.10,11 However, it should also be noted that a recent study, looking at men who have sex with men, found that plasma and rectal viral load were correlated, and that STI in the rectum did not increase the likelihood of detecting HIV in anal mucus, including those that had low or undetectable levels of HIV in their blood.12 This study suggests that a lower HIV viral load in blood plasma would also mean a lower viral load in anal mucus. The role of anal and gastrointestinal mucus Anal mucus13 and, more generally, gastrointestinal mucus found throughout the length of the gut are the body fluids that protect the delicate inner lining of our gastrointestinal tract. Mucus lubricates, prevents drying and protects the mucous membranes that line our nose, mouth, lungs, eyes, inner ears, our urinary-genital organs and our gut. Mucus in the gastrointestinal tract forms a defensive divide between the fragile epithelial cells that absorb nutrients and the digesting slurry of acids, enzymes, food and commensal bacteria that transit our gut. Studies in rats have shown that the mucus in the gastrointestinal tract consists of two constantly renewed layers that in the colon total 0.15mm thick.14 The outer layer that is most exposed is loose and moves with faecal material lubricating its passage down the gut. The
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inner mucus layer is firmly pinned to the gut wall rather like pieces of paper on a noticeboard. The adherence of the inner mucus layer allows the outer mucus layer to slide over the inner layer as material moves down the gut. This ensures that the gastrointestinal wall from oesophagus to anus is always covered and protected by a layer of mucus. Whilst the outer layer functions in lubricating, the firmly adhered mucus layer functions 15,16 more as a protective barrier from corrosive stomach acids and bacteria creating a stable microenvironment at the mucosal surface.The gastrointestinal tract is home to ten times more bacteria than human gut cells; these bacteria are essential for healthy nutrition but are detrimental to our health if they get into other areas of the body. Bacteria are found in the outer mucus layer but not in the inner layer of mucus, which forms a tight net-like structure lining the gut epithelium. The sub-microscopic molecular pores of the mucus net allow nutrients to cross to the epithelium, and viruses to varying extents, but not bacteria.17 Schematic diagram of the mucus layers in the anus and rectum. Rivet-like mucus molecules pin the adhered mucus layer to the epithelium18 so that the wall of the rectum is always protected. The loose mucus layer moves with faecal material (indicated by arrows) lubricating the passage of faeces by sliding over the adhered layer of mucus. Anal mucus and HIV From the early days of the epidemic, receptive anal sex with ejaculation has been known to carry the highest risk of sexual transmission of HIV, and this is dependent on HIV penetrating the mucus layers of the rectum. What has not been widely appreciated is that mucus in the rectum of infected people also contains infectious HIV19 virus that has moved in the opposite direction from the gut wall into the mucus.20 HIV viral load in anal mucus is difficult to measure, but it is typically higher than in blood plasma or semen taken from the same person, even for those on highly active antiretroviral therapy (HAART).21 HIV replication in the gastrointestinal tract is responsive to HAART and blood plasma viral load reflects the overall amount of active viral replication in the body. In men who had undetectable viral load in blood plasma, HIV viral particles were rarely detected (2%) in rectal samples but plenty of HIV infected cells were still found in the mucosa.22 In a study measuring HIV shedding into the rectum, the presence of HIV-infected cells and local inflammation were the principle determinants of rectal HIV levels amongst individuals with a low plasma HIV viral load of less than 10,000 copies/mL, suggesting that the HIV was locally produced.23 When HIV-infected cells were present in the rectal wall, increased blood plasma HIV viral load did not increase the risk of shedding of HIV into the anal-rectal canal but inflammation from other STI such as human papilloma virus (HPV) did increase the amount of virus released. Although the act of taking samples could have stimulated release of HIV particles from the rectal wall or from the circulation by micro-bleeding, the trauma was likely to have been considerably less than that associated with anal intercourse.24 The gastrointestinal tract is the largest immune organ in the body.25 Approximately 70% of the immune system is found in the gastrointestinal tract in what is called gut-associated lymphoid tissue (GALT). The tonsils and adenoids at the back of the throat as well as a diffuse network of immune cells throughout the length of the gut are all part of the GALT.26,27 The major sites of HIV replication in the body are the lymph nodes and the GALT of the gastrointestinal tract; relatively little HIV is produced in the blood.28

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While mucus provides a physical barrier of protection, GALT harbours immune cells that can specifically target any microorganisms that penetrate the gut mucus. In healthy people,CD4 lymphocytes are found in their largest numbers in the gut and, due to their active surveillance role, they are often mature and activated bearing coreceptors such as CCR5,preferred for HIV infection.29 These CD4 cells are important both as the primary target of HIV infection following unprotected receptive anal sex and as the main source of HIV in rectal mucus that might infect subsequent insertive partners.30 The role of the mucus bilayer as the bi-directional frontier of the immune defence of the gut emphasises the importance of anal and rectal mucus in HIV transmission, whether through receptive or insertive anal intercourse. CD4 counts in blood plasma drop over the months and years following infection, but CD4 cells in the gastrointestinal tract are depleted rapidly in the acute phase of HIV infection. In a group of 32 newly infected men (mean = 37 days from infection), CD4 cells in the gastrointestinal wall were greatly reduced within the first few weeks of infection.31 Impressively, the study included six men first sampled within 19 days of infection. The study found that gastrointestinal CD4 cells remained depleted at more than 50% of normal levels, even in people who had a relatively normal blood CD4 count due to long-term HAART.32 The enduring depletion of gastrointestinal CD4 cells indicates a failure of immune reconstitution of GALT in the gut despite active recruitment of effector and naive CD4 cells.33 This is currently an active area of research; it has been found that some of the CD4 cells are as expected killed by cycles of HIV infection, but other uninfected CD4 cells are killed by inflammation as bystanders to the primary fight against HIV.34 From the earliest stages of infection of the many CD4 cells in the gastrointestinal mucosa, HIV causes a breakdown in the delicate balance protecting the gut wall from bacteria and their toxins. Epithelial cells struggle to maintain and repair junctions between cells, leading to impaired barrier function and increased permeability of the epithelium.35 This damage allows toxins and microbes to invade the gut wall and the circulation close-by. Bacterial products can be found in the bloodstream of people with HIV. Known as microbial translocation, this process triggers systemic immune activation.36 The immune response increases HIV replication increases activation of CD4 cells and their susceptibility to HIV infection, and induces immune cell death in the gastrointestinal tract. Essentially, the immune response against microbial translocation amplifies the damage caused by HIV in the gut, preventing effective immune reconstitution in many people. It is not known what happens to the mucus bilayer during microbial translocation but it is likely that it is disorganised and not efficient at protecting the gut wall. The implication of the failed immune reconstitution in the gastrointestinal tract is that the gut is a major reservoir of HIV persistence even in people receiving HAART.37 This, in turn, suggests that anal mucus might be the body fluid most capable of returning to infectious levels of HIV, albeit momentarily, in people on well-maintained HAART. Interestingly, a Sydney study of men who have sex with men conducted from 2001 to 2007 found that the per-contact probability of HIV transmission due to unprotected anal intercourse, both insertive and receptive, was similar to estimates from developed countries in the pre-HAART era.38 This was despite the more recent cohort having a high proportion of HIV-infected men who were on HAART and had an undetectable blood plasma viral load. The immunobiology of the anus and rectum strongly implicates anal mucus in HIV transmission; it is not known to what extent blood contributes to transmission, although micro-bleeding is thought to occur during anal intercourse. In the absence of a major bleed from conditions such as haemorrhoids, fissures, tears and trauma, the predominant body fluid by volume is likely to be mucus, although

this has not yet been confirmed by specific data. Implications for HIV education From an educational point of view, talking about anal mucus makes sense. Anal mucus is macroscopic, it is visible particularly with diarrhoea or after douching, and people can feel its moistness; microscopic invisible blood has none of these associations. Anal mucus is well known to people who practise fisting, where keeping individualised aliquots of lubricant from cross-contamination with body fluids is central to play-etiquette.39 Anal mucus can vary in appearance from clear to white, or brown. Because people can see and feel mucus, they can understand the role it plays in HIV transmission through their own personal association with the body fluid. Mucus provides a more powerful, less mysterious mechanism for transmission than microscopic blood. Vaginal mucus is directly analogous to anal mucus in HIV transmission and whilst blood is likely to be a factor and a plausible mechanism of vaginal-penile transmission, in prevention education vaginal mucus is said to be the infectious body fluid. The rectum is much more susceptible to trauma than the vagina, as the rectal wall is very thin compared to the vagina and more easily damaged, and there is a much bigger stigma against anal intercourse that jointly might account for the comparative lack of anal mucus in many explanations of transmission. In both vaginal and anal intercourse, blood resulting from rough sex, binge sex, large toys and fisting is seen as an amplifier of the risk of transmission (e.g. see Wherever sex happens 40). Talking about anal mucus counters stigma that says anal sex is not natural and causes tissue damage which facilitates transmission. This conversation makes HIV transmission seem a more normal biological process because it does not rely solely on the explanation of damage to the rectum to facilitate transmission; HIV is present in mucus in the rectum, not just further away in the circulation. During anal sex, HIV can be transmitted to the insertive partner when a bodily fluid containing HIV from the receptive partner, such as anal mucus, enters the body of the insertive partner. This can occur through the foreskin and surrounding areas, the eye of the penis to the urethra (also a mucous membrane), or through tiny (often invisible) breaks in the skin of the penis. HIV prevention discussions that neglect to explain how the insertive partner in anal sex is infected leave a hole in the discourse as well as a gap in the understanding of how HIV is transmitted during anal sex. Explaining the potential roles of both anal mucus and blood is a direct rebuttal to the taboo of talking about the specifics of anal sex. This must be good for prevention. References 1 Jin, F., Crawford, J., Prestage, G., et al. (2009). HIV risk reduction behaviours in gay men: unprotected anal intercourse, risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men. AIDS, 23(2), 243252. doi:10.1097/ QAD.0b013e32831fb51a 2 Jin, F., Jansson, J., Law, M., Prestage, G., et al. (2010). Percontact probability of HIV transmission in homosexual men in Sydney in the era of HAARt. AIDS, 24(6), 907913. doi:10.1097/ QAD.0b013e3283372d90 Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852627/ 3 INSIGHT case-control study findings: Elam G., Macdonald, N., Hickson, F., et al. (2008). Risky sexual behaviour in context: qualitative results from an investigation into risk factors for seroconversion among gay men who test for HIV. Sex Transm Infect, 84(6), 4737. doi:10.1136/ sti.2008.031468 See also: Macdonald, N., et al. (2008). Factors associated with HIV seroconversion in gay men in England at the start of the 21st century. Sex Transm Infect, 84(1), 813. 4 GMFA the gay mens health charity. (2008). Arse Facts. continued on page 16, col. 1
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The risk of insertive, unprotected anal sex

continued from page 15, col. 2 Available at: http://www.gmfa.org.uk/londonservices/ adcampaigns/gmfa#arse-facts (accessed 5 October 2011). 5 ACON. (2007). HIV & AIDS The Basics: A safe sex guide for gay men. Available at: http://www.acon.org.au/sites/default/files/ Safe-Sex-Basics_0.pdf (accessed 29 September 2011). 6 Australian Federation of AIDS Orgnaisations (AFAO). (2002). HIV+ Gay Sex: A booklet about being gay, having HIV and sex. AFAO, Sydney. Available at: http://www.afao.org.au/__data/ assets/pdf_file/0005/6953/HIV_Positive_Gay_Sex.pdf (accessed 29 September 2011). 7 Australian Federation of AIDS Orgnaisations (AFAO). 2008. the Drama Downunder. [Online] (See specifically: Introduction/ STIs and HIV transmission HIV/How do you get it?) Available at: http://thedramadownunder.info. (accessed 29 September 2011). 8 Victorian AIDS Council/Gay Mens Health Centre (VAC/ GMHC). Wherever sex happens. (see specifically: risk reduction: tops and bottoms) [Online] Available at: http:// whereversexhappens.com/ (accessed 5 October 2011). 9 Victorian AIDS Council/Gay Mens Health Centre (VAC/ GMHC). (2010). Staying Negative. [Online]. (See specifically: HIV/AIDS and safe sex: bottom or passive partner). Available at: www.stayingnegative.net.au (accessed 5 October 2011). 10 AFAO 2008, op. cit. (See specifically: Introduction/STIs and HIV transmission/HIV-positive men and STIs). 11 VAC/GMHC Wherever sex happens, op. cit. (See specifically: risk reduction:sections undetectable viral load and tops and bottoms). 12 Kelley C. F., Haaland R. E., Patel P., Evans-Strickfaden T., Farshy C., Hanson D., et al. (2011) HIV-1 RNA rectal shedding is reduced in men with low plasma HIV-1 RNA viral loads and is not enhanced by sexually transmitted infections in the rectum. J Infect Dis., 205(5), 76167. doi:10.1093/infdis/jir400 13 Mucus (noun) is the secretion produced by mucous (adjective) membranes. Anal mucus is used elsewhere and here for simplicity, particularly for people who do not have English as their first language. Much of the research refers to rectal mucus because that is where the fluid was sampled; also referred to as mucosal secretions or rectal secretions. Anorectal mucus is probably the most accurate name for the body fluids involved in HIV transmission but this has not been confirmed by specific data to date. 14 Atuma, C., Strugala, V., Allen, A., and Holm, L. (2001). the adherent gastrointestinal mucus gel layer: thickness and physical state in vivo. Am J Physiol Gastrointest Liver Physiol, 280(5), G9229. Available at: http://ajpgi.physiology.org/content/280/5/ G922.full.pdf 15 ibid. 16 Phillipson, M., Johansson, M., Henriksns, J., et al. (2008). the gastric mucus layers: constituents and regulation of accumulation. Am J Physiol Gastrointest Liver Physiol, 295(4), G80612. doi: 10.1152/ajpgi.90252.2008 Link: http://ajpgi.physiology.org/ content/295/4/G806.full.pdf 17 Johansson, M., Phillipson, M., Petersson, J., et al. (2008). the inner of the two Muc2 mucin-dependent mucus layers in colon is devoid of bacteria. Proc Natl Acad Sci USA, 105(39), 150649. doi:10.1073/ pnas.0803124105 18 ibid. 19 Zuckerman, R., Whittington, W., Celum, C, et al. (2004). Higher Concentration of HIV RNA in Rectal Mucosa Secretions than in Blood and Seminal Plasma, among Men Who Have Sex with Men, Independent of Antiretroviral therapy. The Journal of Infectious Diseases, 190(1), 15661. doi: 10.1086/421246
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20 Kiviat N., Critchlow C., Hawes S., et al. (1998). Determinants of Human Immunodeficiency Virus DNA and RNA Shedding in the Anal-Rectal Canal of Homosexual Men. The Journal of Infectious Diseases, 177(3), 5718. doi:10.1086/514239 Link: http://jid.oxfordjournals.org/content/177/3/571.long 21 Zuckerman, R. et al., op. cit. 22 The mucosa is the mucous membrane layers forming the inner surface of organs such as the gastrointestinal tract; includes the epithelium and aggregates of immune cells in GALT follicles. In: Lampinen, T. M., Critchlow, C. W., Kuypers, J., et al. (2000). Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in the anorectal mucosa of homosexual men. AIDS, 14(5), F6975. Available at: http://journals.lww.com/aidsonline/ Fulltext/2000/03310/Association_of_antiretroviral_therapy_ with.1.aspx (accessed 4 October 2011). 23 Kiviat, N. B., et al., op. cit. 24 ibid. 25 Janeway, C., Travers, P., Walport, M., and Shlomchik, M. (2001). Mucosal Immunity. In: Janeway, C., Travers, P., Walport, M., and Shlomchik, M. J. (eds.), Immunobiolgy, 5th Edition: The immune system in health and disease. Garland Science, New York, 10.1310.20. Available at www.ncbi.nlm.nih.gov/books/ NBK27169/ (accessed 4 October 2011). 26 ibid. 27 Spahn, T. and Kucharzik, T. (2004). Modulating the intestinal immune system: the role of lymphotoxin and GALT organs. Gut, 53(3), 45665. doi:10.1136/gut.2003.023671 28 Mehandru, S., Poles, M., Tenner-Racz, K., et al. (2007). Mechanisms of gastrointestinal CD4+ T-cell depletion during acute and early human immunodeficiency virus type 1 infection. J Virol, 81(2), 599612. doi:10.1128/JVI.01739-06 29 Brenchley, J., Schacker, T., Ruff, L.,et al. (2004). CD4+ T cell depletion during all stages of HIV disease occurs predominantly in the gastrointestinal tract. J Exp Med, 200(6), 74959. doi:10.1084/ jem.20040874 30 Kiviat, N. et al. op. cit. 31 Mehandru, S. et al. (2007)., op. cit. 32 Mehandru, S., Poles, M., Tenner-Racz,K., et al. (2006). Lack of mucosal immune reconstitution during prolonged treatment of acute and early HIV-1 infection. PLoS Med, 3(12), e484. doi:10.1371/journal. pmed.0030484 33 Hofer, U., and Speck, R. (2009). Disturbance of the gutassociated lymphoid tissue is associated with disease progression in chronic HIV infection. Semin Immunopathol, 3 (2), 25766. doi:10.1007/s00281-009-0158-3 34 ibid. 35 Shacklett, B. and Anton, P. (2010). HIV infection and gut mucosal immune function: Updates on pathogenesis with implications for management and intervention. Curr Infect Dis Rep., 12(1), 19-27. doi:10.1007/s11908-009-0072-9 36 Hofer, U. and Speck, R., op. cit. 37 Shacklett, B. and Anton, P. op. cit. 38 Jin, F. et al. (2010), op. cit. 39 Herrman, B. (1991). Trust the hand book: A guide to the sensual and spiritual art of handballing. Alamo Square Press, San Francisco. 40 VAC/GMHC Wherever sex happens, op. cit. (see specifically: Drug use/decreased physical awareness and Risk reduction/tops and bottoms/there are other risk factors/point 5) Eric Glare (PhD) is a PLHIV speaker and educator with the Positive Speakers Bureau, People Living With HIV/AIDS Victoria. He did his PhD studies on PCR technology and the gene expression of CD4 cells in asthma and allergy and is now retired as a biomedical researcher. MSM-Asia, 14/4/2012

Pukaar July 2012 Issue 78

Gay and bisexual men who inject drugs more likely to have HIV than other men who inject drugs
Michael Carter HIV prevalence is four times higher in gay and bisexual men who inject drugs, compared to heterosexual, male, injecting drug users, UK investigators report in Sexually Transmitted Infections. The study also showed that prevalence of infection with the hepatitis C virus was significantly higher among gay and bisexual male injecting drug users (IDUs). The investigators believe that the higher HIV prevalence seen in gay and bisexual IDUs was due to sexual transmission of the virus. However, the higher rate of hepatitis C is largely attributed to sharing injecting equipment. The study showed that gay and bisexual men were significantly more likely to report unsafe injecting practices than heterosexual men. Studies conducted in the US and Brazil have previously shown higher prevalence of HIV and hepatitis C in gay and bisexual men who inject drugs compared to heterosexual male IDUs. Investigators wished to see if this was also the case in the UK. They therefore analysed data from national surveys of injecting drug users conducted between 1998 and 2007 in England, Wales and Northern Ireland. To be included in the current analysis, people had to be aged between 15 and 60 years and to have both had sex and injected drugs in the previous twelve months. Prevalence of HIV and hepatitis C in the participants was determined using anonymous oral antibody tests. Participants also completed a brief questionnaire covering demographic information and sexual and drug use risk behaviours. A total of 8671 male injecting drug users were included in the study. Overall, prevalence of HIV was 1%; 33% of participants were infected with hepatitis C. Just over half the participants (53%) reported ever having had an HIV test. A large proportion of people with HIV (39%) were unaware they were infected with the virus. The prevalence of both infections was significantly higher in London compared to other regions. Sex with another man in the preceding twelve months was reported by 4% of men. This proportion was unchanged over the ten years of the study. Most of the men who reported sex with men also reported sex with women (79%). . Prevalence of HIV infection was significantly higher in gay and bisexual men than heterosexual men (3.2 vs 0.79%; p < 0.001). Gay and bisexual men also had a higher prevalence of hepatitis C virus infection (43 vs 32%; p < 0.001). The prevalence of co-infection was slightly higher in gay and bisexual men, but not significantly so (0.63 vs 0.48%). Higher-risk sex was reported by three-quarters of gay and bisexual injecting drug users compared to 40% of heterosexual IDUs. Sharing found on Facebook of injecting equipment was also more common among gay and bisexual men than heterosexual men (38 vs 27%; p < 0.001). Gay and bisexual men and heterosexual men were of a comparable age (approximately 29 years) and had been injecting drugs for a similar length of time (seven years). Prevalence of HIV (p = 0.046) and hepatitis C (p < 0.001) were higher in those who reported injecting both opiates and stimulants. Prevalence of the infections also increased with age and number of years of injecting. The investigators calculated that gay and bisexual IDUs were four times more likely to be infected with HIV than heterosexual IDUs (adjusted OR = 4.08; 95% CI, 1.9-8.5). Gay and bisexual men were approximately one-third more likely to have hepatitis C infection than heterosexual men (adjusted OR = 1.34; 95% CI, 1.1-1.8). The low level of hepatitis co-infection among HIV-infected gay and bisexual injecting drug users suggested to the investigators that HIV was largely sexually transmitted in this group. In contrast, they believe that the main mode of hepatitis C transmission in these men was injecting drug use. They found that gay and bisexual men were significantly more likely to report sharing injecting equipment in the previous four weeks than heterosexual men (adjusted OR = 1.72; 95% CI, 1.3-2.2). However, they do not rule out the possibility of sexual transmission of this virus. MSM [men who have sex with men]-IDUs in the UK are at a greater risk of blood-borne viral infections than MSW [men who have sex with women]-IDUs, comment the authors. They conclude that their findings show a need to explore the impact of the overlap of injecting drug use and sex between men on the HIV epidemic in the UK. They also emphasise the need for more public health research on the health needs and risk behaviours of MSM-IDUs. Reference Marongiu A et al. Male IDUs who have sex with men in England, Wales and Northern Ireland: are they at greater risk of bloodborne virus infection and harm than those who only have sex with women? Sex Transm Infect, doi: 10.1136/sextrans-2011-0504450, 2012. http://www.aidsmap.com/Gay-and-bisexual-men-who-inject-drugshave-very-high-risk-of-HIV/page/237-731/ 30/5/2012

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Pukaar July 2012 Issue 78

Getting practical about PrEP

By David Evans Time to bring in the referees: a U.S. Food and Drug Administration (FDA) panel has voted to approve the first HIV prevention medication for adults in the history of the epidemic--and some people are not at all happy about it. On May 10, 2012, an FDA advisory panel recommended with near unanimity that the antiretroviral (ARV) drug Truvada (tenofovir plus emtricitabine) may be used not only by HIV-positive people to treat their HIV, but also by some HIV-negative people to prevent them from acquiring the virus. The panels recommendation, which the FDA will likely follow, should have been an occasion for great joy--the triumph of the first new prevention tool in the 30-year history of the epidemic--but the hearing, just like the public discussions that led up it, was marred by apprehension, misinformation and controversy. In my capacity as Director of Research Advocacy for Project Inform I attended the marathon twelve-and-a-half hour FDA advisory meeting, one that highlighted a schism among the audience members and some of the panelists, and suggests contentious public discussions about resource allocation and on PrEPs efficacy and safety are still to come. Since the vote, several prominent activists and researchers have expressed their displeasure, citing concerns about side effects and drug resistance and worries that people will throw out their condoms. While its understandable that tempers are running hot as we dissect the science, pragmatism, from all sides, is whats truly needed. AIDSmeds very own Tim Horn gives an excellent overview (http:// www.aidsmeds.com/articles/hiv_truvada_prep_1667_22382.shtml) of the full hearing and its outcome here (so I wont go into a blowby-blow account), but I do want to draw attention to a presentation given at the beginning of the hearing by Susan Buchbinder of the San Francisco Department of Public Health, who made one of the most compelling cases for PrEP that Ive heard yet. Buchbinder described how condoms and behavior change alone have failed to put even a small dent in the epidemic for some time. There are myriad reasons for this, but at the heart of it is that lots of people struggle to use condoms consistently for vaginal or anal sex and our efforts to fix that have been only modestly successful. We are going on 16 years of flat HIV numbers overall--more than 50,000 new cases per year in the United States--and HIV rates are rising in young men who have sex with men (MSM), particularly young MSM of color. In fact, in some cities nearly 80 percent of young black men could become infected by the age of 60 if something doesnt change-not because of greater risk-taking behavior, but simply because HIV is so prevalent among their sex partners that even one or two slip-ups can have devastating consequences. On top of that, Buchbinder explained, our best interventions to help reduce HIV risk through behavior change have rarely demonstrated long-lasting effects in most people, nor have those studies ever documented an actual reduction in new HIV infections. Lastly, for many people condom use means risking the loss of a relationship or safe housing, or in some cases physical violence. Such people desperately need prevention tools that take such risks into account and that dont require the consent and cooperation of their sex partners. PrEP fully meets those conditions. Given the stigma and emotional hardship of an HIV diagnosis, the risk of discrimination and prosecution, the reduced life expectancy and astronomical cost of health care, allowing 50,000 more people to become infected each year is an unfolding moral and financial catastrophe. Like condoms, PrEP can be a highly effective technology--more than 90 percent effective when used correctly. And just like condoms, PrEP only works if it is used. Unlike condoms, however, which are cheap, abundant and safe, Truvada for PrEP is expensive, and carries
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the risk of side effects and of causing those who become infected while taking Truvada to develop drug resistance. This is a substantial point of controversy. But as Buchbinder and others have pointed out so eloquently, for tens of thousands of people each year the choice wont be one of PrEP versus condoms, but PrEP versus nothing at all. Its fair to assume that most people share the same goal at heart: to end the AIDS epidemic in a way that respects the rights and wellbeing of those living with HIV and those at risk for becoming infected. PrEP, I believe, is a critical step toward that aim, if we apply it properly. Heres how: Give people the facts--the whole picture--and let them decide whether PrEP is right for them Lets tell people how effective the drug is when they actually take it as prescribed--over 90 percent effective--and stop quoting statistics from the clinical trials where they averaged all of the people together whether or not they were actually taking the drugs. People are going to need motivation to adhere well to PrEP and telling them that it will only cut their chance of becoming infected by 42 percent (the iPrEx study) or 75 percent (Partners PrEP) is not only dishonest, it could significantly undercut their willingness to take a pill every day. How would people feel if we said that condoms were only 30 or 40 percent effective and never revealed that this figure is true only because we counted all of the people who never used condoms in the first place? Lets also stress that in the clinical studies, PrEP was used with condoms, at least some of the time by some of the participants, and that it shouldnt be seen as a complete substitute. That said, the fear that people will forgo condoms for PrEP is a reasonable one. Therefore, I believe strongly that we should be targeting PrEP to those who are struggling most with condom use, for whatever reason. Lets also emphasize that while side effects were rare, and not immediately serious in the vast majority of PrEP-takers in trials, we honestly dont know what long-term side effects will look like. People who ultimately end up taking PrEP for more than two years are entering new territory, as are people who might have greater underlying risks for kidney or bone disease. PrEP is not benign, but neither is HIV; lets strive for balance and accuracy in describing both. We all have a responsibility to correct inaccurate information where we find it, whether in our community publications or blogs, local planning meetings or in our groups of friends. We can never know whos in most desperate need of PrEP and who might be swayed inappropriately one way or the other by misleading or cherry-picked information. Speaking of correct information, lets also spread the message far and wide that disco dosing, whereby people only take Truvada during sex, is completely untested and that there are reasons to fear it wont work. Misuse of PrEP is a realistic concern, and we should do what we can to discourage it, but prohibiting PrEP for everyone out of fear that some will misuse it is the worst kind of paternalism. At the beginning of the AIDS epidemic a group of HIV-positive men and women assembled in Denver and produced whats called the Denver Principles: a manifesto that demands the rights of people with HIV to make their own healthcare decisions based on the best possible scientific knowledge available; that health care providers stop treating people with HIV like ignorant children who arent capable of being full partners in their own health care. We should afford the same rights and respect to HIV-negative men and women seeking to protect themselves from becoming infected. Advocate fiercely for demonstration projects, where we test how best to use PrEP in real-world settings We know how PrEP works in the artificial confines of a clinical trial (efficacy), but we dont yet know how it works in the real

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world (effectiveness). Understanding the difference is crucial and the only way well learn this will be in the multiple demonstration projects that will be slowly rolling out over the coming months and years. Yet, paradoxically, one prominent HIV organization tried to shut down two large demonstration projects in California this spring for reasons that were never entirely clear, but were apparently due to out-and-out opposition to PrEP altogether. Right-wingers spew enough anti-science rhetoric around HIV as it is (e.g. opposition to needle exchange and promotion of abstinence only education). We certainly dont need that coming from within our community. Here are the things that each of us can do to support these demonstration projects: Insist that our local, state and federal AIDS organizations are advocating for demonstration projects in our communities. Well never learn how to use PrEP safely and effectively if we dont. The AIDS Vaccine Advocacy Coalition (AVAC) will be helping us keep tabs on demonstration projects and the target communities of those projects on their website (www.avac.org). Lets do what we can to reduce the stigma associated with participating in these kinds of trials. If we hear our peers or our community leaders denigrating HIV-negative people who struggle with safer sex or who might be considering PrEP, or claim that people cant be trusted with this technology lets call them on the carpet. Turn down the emotion on conversations regarding resources for PrEP At a time when we still have thousands of people with HIV who dont have health care, and when we still have waiting lists for the AIDS Drug Assistance Programs (ADAPs), its completely understandable that people would fear anything that might further stretch resources. Still, we dont have to let that fear shut down reasonable and necessary discussions, or cause us to neglect the facts. Some have expressed fears that if public or private health insurers choose to cover PrEP it will lead to a reduction in resources for people with HIV. Health insurance plans arent generally set up that way, however, and extending services to one group rarely results in reduced services to another. So if PrEP wont take resources away from HIV-positive people on Medicaid, Medicare or private health insurance, what about

Ryan White or the AIDS Drug Assistance Programs, which provide healthcare and HIV drugs to low-income HIV-positive people who dont have insurance? By law, no money from these programs can ever be spent on HIV-negative individuals health care. Whats more, we have never had federal budget discussions where an increase in prevention funds at the CDC had to be offset by cuts to Ryan White, and that has been true throughout the last five years of extreme shortages in ADAP funding. At the state and local level, the reverse has actually been true. Moreover, Truvadas maker, Gilead Sciences, has promised to offer PrEP for free to lower-income individuals who dont have health insurance, as well as to provide vouchers to cover HIV testing and condoms. Thats a massive reduction in the likely costs for PrEP to cash-strapped state and local HIV prevention programs. Well still need to find money from our HIV and STD prevention funds for doctor visits, adherence support and tests to monitor a persons bone and kidney health, but thats a more manageable task given that awareness of PrEP among those at high risk for HIV is quite low and so we arent expecting a huge and immediate upswing in demand for it. If PrEP uptake is as low and slow as many expect it to be, we will have plenty of time for the hoped-for demonstration projects to reveal how effective it is in real-world settings. Armed with that information a couple of years down the road, we can then have reasonable conversations about the resources required to reach those who need PrEP most. We can also figure out where PrEP will be most cost effective. Given that PrEP itself will be free to some of those who need it most, experts have already estimated that this will be incredibly cost saving when compared to a lifetime spent on ARVS if they become infected. HIV-positive and HIV-negative activists have partnered hand-inhand for nearly thirty years to advocate for both care and treatment for people with HIV and prevention services for those not living with the virus. Its been a winning, effective combination. I hope when it comes to PrEP we can overcome fear, suspicion and rancor and ensure that this partnership stays strong. 23/5/2012

Increased risk of anal cancer for all groups with HIV

Michael Carter Gay men are not the only group of HIV-positive patients who have an increased risk of anal cancer, according to North American research published in the online edition of Clinical Infectious Diseases. The researchers found that incidence of the cancer was also significantly higher in non-gay HIV-positive men as well as HIV-positive women when compared to individuals in the general population. We confirmed that HIV-infected MSM [men who have sex with men] experienced the greatest risk of anal cancer, write the authors. We also found that both HIV-infected other men and women had substantially higher rates than HIV-uninfected men and women, and that HIV-infected other men and women had similar rates. They believe that their findings may have implications for anal cancer screening strategies. Thanks to improvements in HIV treatment and care the prognosis of many HIV-positive patients is now near normal. However, HIVpositive patients appear more likely to develop certain malignancies, including anal cancer, compared to their HIV-negative peers. Understanding the incidence of anal cancer in the different populations affected by HIV can help develop strategies to prevent the cancer. Therefore investigators from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) analysed findings from 13 US and Canadian studies. Their aims was to determine incidence of anal cancer in HIV-positive patients, who were divided into three categories MSM, other men and women. Rates of anal cancer in these HIV-positive patients were compared to those observed in HIV-negative men and women. Analyses were also conducted to see if there were temporal trends in anal cancer incidence, and if any specific risk factors for the malignancy in HIV-positive patients could be identified. A total of 34,000 HIV-positive patients (55% MSM, 19% other men, 26% women) and 110,000 HIV-negative controls (90% men) were included in the study. Data gathered between 1996 (the year effective HIV therapy first became available) and 2007 were examined by the investigators. Incidence of anal cancer in MSM was 131 per 100,000 patient years. Among HIV-positive other men incidence of the malignancy was 46 per 100,000 years, and incidence in HIV-positive women was 30 per 100,000 person years. Incidence was therefore significantly higher in HIV-positive MSM compared to other men (p < 0.01). However, incidence rates for HIV-positive other men and women did not differ significantly. Over the same period, the incidence of anal cancer in HIV-negative men was just 2 per 100,000 person years. There were no cases of the malignancy in HIV-negative women. continued on page 20, co. 1
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Pukaar July 2012 Issue 78

Increased risk of anal cancer

continued from page 19, col. 2 The investigators calculated that the risk of anal cancer was 80-times higher for HIV-positive gay men compared to HIV-negative men (RR = 80.3; 95% CI, 42.7-151.1). HIV-positive other men were almost 27 times more likely to develop anal cancer compared to HIV-negative men (RR = 26.7; 95% CI, 11.5-61.7). Our finding of high anal cancer incidence rates in HIV-infected MSM, other men, and women suggests the need for enhanced primary and secondary prevention efforts among all HIV-infected persons, as opposed to a targeted approach, write the authors. Incidence of anal cancer increased significantly in HIV-positive gay men between 1996-99 and 2000-2003 (p < 0.03). However, new cases of the malignancy then stabilised. A similar trend was observed in HIV-positive other men and women. The investigators suggest that the initial increase was a function of the improved prognosis of HIVpositive patients, which allowed long-term cell changes caused by high-risk strains of human papilloma virus to become cancerous. In contrast, the levelling of cancer rate was attributed to the beneficial effects of antiretroviral treatment on the immune system.

HIV-positive MSM were significantly more likely to develop anal cancer than other HIV-positive men (RR = 3.3; 95% CI, 1.8-6.0). The risk of the cancer was near identical for HIV-positive other men and women. Other risk factors for the malignancy included older age (RR per additional ten years = 1.3; 95% CI, 1.1-1.5). A higher baseline CD4 cell count was protective against the development of the cancer (RR CD4 cell count above 500 cells/mm3 vs. 200 cells/mm3 = 0.2; 95% CI, 0.1-0.3). There is currently disagreement about the value of anal cancer screening for HIV-positive patients. However, the investigators suggest that this is likely to be cost effective. They note the New York State AIDS Institute guidelinesrecommend anal digital rectal examination for all patients, anal targeted anal cytology for MSM, for individuals with a history of anogenital warts, and for women with a history of abnormal cervical or vulvar histology. Reference Silverberg MJ et al. Risk of anal cancer in HIV-infected and HIVuninfected individuals in North America. Clin Infect Dis, online edition. DOI: 10.1093/cid/cir1012 MSM Asia, 16/2/2012

A widespread pattern of abuses against LGBT people worldwide

The U.S. Department of States 2011 Human Rights Report, released yesterday, catalogues an ongoing range of abuses and discriminatory treatment directed at lesbian, gay, bisexual, and transgender (LGBT) people worldwide starkly underscoring what Secretary Hillary Clinton has called one of the remaining human rights challenges of our time. Speaking in Geneva last December, Secretary Clinton noted that, too often, LGBT people remain an invisible minority, members of which are arrested, beaten, terrorized, even executed while authorities empowered to protect them look the other way or, too often, even join in the abuse. The newly released report bears witness to such abuse. Most disturbingly, it documents that police, other government security forces, and prison personnel have been implicated directly in the harassment or abuse of LGBT citizens in a range of countries, including (but not limited to) Afghanistan, Cameroon, Cote dIvoire, El Salvador, Guatemala, India, Indonesia, Kuwait, Kyrgyz Republic, and Panama. Harassment and abuse often were directed in particular at transgender individuals. In Turkey, a range of LGBT organizations complained of harassment by police and government authorities. In Cote dIvoire, the report notes that gay men were reportedly subjected to beatings, imprisonment, verbal abuse, humiliation, and extortion by police, gendarmes, and members of the armed forces. The report also describes broader patterns of discrimination against LGBT individuals in many areas of the world. In Sierra Leone and India, LGBT people have been denied basic social services, from health services to housing. In Botswana and many other countries, governments failed to register LGBT advocacy groups or recognize their status as legitimate civil society organizations. In Russia, Bosnia-Herzegovina, and elsewhere, LGBT employees have been driven from their jobs, or faced discrimination in hiring, because of their sexual orientation or gender identity. In Nigeria, local authorities again failed to take any legal action against persons who stoned and beat members of the House of Rainbow Metropolitan Community Church, an LGBT-affirming church in Lagos in 2008. During the past year, church parishioners and clergy continued to receive threatening e-mail messages, phone calls and letters. The report notes that in South Africa, the countrys largest LGBT organization received in Cape Town alone an average of 10 new cases every week of lesbians being targeted for corrective rape.
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This disturbing trend also was noted in other countries, where men raped lesbians to punish them for being lesbian and to attempt to change their sexual orientation. Finally, various reports include instances in which the internet has been a source of discrimination against LGBT people. These include Oman, where authorities took measures to block LGBT related content from the internet, and Iran, which monitored internet websites for information on LGBT individuals. The Council is grateful to our Foreign Service personnel who understand that, as Secretary Clinton has said, LGBT rights are, in fact, human rights. We urge that the State Department and Congress work together to carry out a serious, sustained and purposeful dialogue with governing officials in all countries, as identified in the Departments report, that have failed to recognize this essential reality, with a goal of ensuring that LGBT people are treated with the dignity, fairness, and equality to which all people should be entitled. We further urge ongoing scrutiny of the degree to which foreign governments respect and honor the rights of their LGBT citizens, in keeping with the democratic and human rights principles on which U.S. foreign policy should be based. Excerpts of the reports findings on LGBT issues in every country can be found on the Councils website at http://globalequality.org/ publications/state-department-reports. Celebrating International Day Against Homophobia and Transphobia in Tehran: Iran. Invisible people speaking out

Pukaar July 2012 Issue 78

HPV and oral sex: a risky mix

Whats the cause for the alarming 225 percent increase in oral cancer? Could it be heavy smoking or drinking? Well a new study in Clinical Oncology shows human papilloma virus (HPV) and oral sex are the culprit. Certain oral cancers have declined by more than 50 percent thanks to decreases in tobacco use. Meanwhile, HPV related head, neck and throat cancers have exploded along with the popularity of oral sex (and deep kissing). One long-term effect of the HIV epidemic has been an oral sex free-for-all. Also, many young people dont think being orally receptive is committing a sexual act. So as the the popularity of oral sex zoomed, one unintended consequence appears to be an increase in HPV related oral cancers. A 2007 New England Journal of Medicine study showed that having oral sex with more than 6 different partners increased the risk of developing throat cancer by 3.4%. Performing oral sex with 26 or more partners tripled that risk. Thats because having more sexual partners increases the chance of being exposed to HPV cancer causing types 16 and 18. The Journal of Clinical Oncology study also revealed that oral sex may increase oral cancer risk more than smoking! And if trends continue, by 2020, HPV related throat cancer may be more common than HPV related cervical cancer. HPV related cancers: A mens problem also Another report published in JAMA shows that cancer causing oral HPV infections are now more common in men than women, as are HPV oral cancers themselves. According to the study about 7 percent of the population, ages 14 and 69, are infected with oral HPV with the rate of infection three times higher in men than women. Even more alarming is that 1 percent of the population may be infected with cancer causing HPV type 16, the study shows. Among men, the rate of oral HPV-16 infection is five times more common than in women. HIV at-risk and HIV-positive adults are infected with oral HPV-16 at even higher levels. That high rate of oral HPV-16 explains the explosion of HPV-related oral cancers among men. Patients infected with oral HPV-16 have a 14 times greater risk of developing these cancers which can form on the tonsils or the back of the tongue. HPV vaccines working According to recent studies (in the NEJM and The Lancet) the HPV vaccines are decreasing the development of cervical and anal/rectal pre-cancers in those vaccinated. Only some types of HPV are known to cause cancers. Cervarix, the bivalent vaccine (effective against 2) protects against the two types of HPV most associated with HPV cancers, HPV-16 and HPV-18. Gardasil, the quadrivalent vaccine (effective against 4), protects against those two HPV types as well as HPV-6 and HPV-11, which cause genital warts. Shots for the boys Women may still bear the brunt of HPV related cancers. Thats because, in addition to developing HPV related cervical cancer, more women develop HPV related anal cancer than men (even more so than gay men). But HPV is an equal opportunity virus. Its a mens health issue too. In addition to HPV related anal cancer, men can get HPV related penile cancer, not to mention HPV related oral cancers. With this in mind, the federal the Advisory Committee on Immunization Practices recommended routine use of the HPV quadrivalent vaccine Gardasil in males aged 11 or 12 years and for males aged 13 through 21 years. Some men aged 22 through 26 years may still benefit from vaccination as well. One reason for doing so is herd immunity. The theory that, overtime, as more become vaccinated there will be an increase in the protected population, or herd. That also means fewer people to spread HPV-16 and HPV-18. HPV vaccination for gay, bisexual males and those with HIV Gay and bisexual men (MSM) are at higher risk for conditions associated with HPV types 6,11,16, and 18 than heterosexual men. These include a higher incidence of HPV genital warts, anal intraepithelial neoplasia ( a cance precursor) and anal cancers. Recent data on the HV vaccines have demonstrated efficacy in preventing genital warts (Gardasil only) and precursors of anal cancer. For people with HIV, HPV genital warts are more common and difficult to treat. Anal intraepithelial neoplasia and anal cancer are also common in HIV-infected MSM with data suggesting that effective HIV therapy has not reduced development of HPV-related anal cancer. One small trial in HIV-infected boys and girls and another with HIV-infected men found the HPV vaccine Gardasil to be safe and effective in establishing an HPV immune response. Ongoing studies will evaluate the efficacy and duration of that HPV immune response. Few health problems caused by vaccines, report finds Despite what some presidential candidates have said there are few health problems connected with vaccinations. Thats at least according to new study done by a committee of experts convened by the Institute of Medicine. Those experts scoured the scientific literature - up to 1,000 research articles - on the adverse effects of vaccines. They found evidence of 14 vaccine health outcomes -including seizures, inflammation, fainting -- yet these occurred very rarely. The study also refutes any real connection between the MMR vaccine and autism, the flu vaccine and bells palsy and asthma, or the Dtap vaccine and diabetes. These vaccinations do cause, though not often, allergic reactions and temporary joint pain. Statements of unsubstantiated vaccine side-effects have angered physicians and public health officials for undermining serious, lifesaving, public health initiatives. For a glimpse of why, check out the website of The Consul on Foreign Relations. It has a map that plots global outbreaks of diseases preventable through vaccination. The map is at www.cfr.org. If you build it, will they come? So, vaccines work and are pretty safe. But that doesnt mean people will take them, even those who really need to. One recent study demonstrates that reluctance. Published in the American Journal of Public Health the study centered on a major vaccine trial. Vaccine misconceptions by those in the study mirrored concerns of much of the public. The study sought to find out what high-risk communities understood about HIV vaccines and how that impacted their willingness to enter a study. Participants expressed fear that vaccines involve being injected with dangerous amounts of the pathogen from which they sought protection. It was a falsehood that affected their willingness to be vaccinated. When some in the study became infected with HIV (through behavior, not the vaccine) they felt it wasnt an unforeseen consequence and that the researchers running the study should have been able to predict it. There was also confusion surrounding why research targets people at high-risk. Some study participants thought this unfair but it is a very important strategy for studying and controlling infectious disease. The study shows that better communication is needed so both people at-risk and the general public better understand vaccine risks and research. Kyle Washburn is the National Health and Fitness Editor at Edge Publications, Inc. He earned a BS in Physiology, M.Ed in Sport Psychology and Counseling and an MBA. He is a certified personal trainer through NASM and ACE and has been training for over ten years. He is an avid triathlete, softball and tennis player, runner, hiker and enjoys the outdoors. MSM Asia, 10/3/2012
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Defining men who have sex with men (MSM) in South Asia for the purpose of population size estimation
A guidance note for National HIV Programme Managers
Based on the discussions in the Project DIVA workshop: South Asia Regional MSM and Transgender Size Estimation Workshop: Strengthening National Reporting on HIV among MSM and Transgender persons (April 3 - 5, 2012, Colombo, Sri Lanka), UNDP Asia Pacific Regional Centre UNAIDS Asia Pacific Regional Support Team A. Purpose of this guidance note International definitions of men who have sex with men (MSM) exist.1 2However, confusion persists when it comes to defining MSM for size estimation of this population. A single universal definition of MSM may not be sufficient for different purposes, and hence it is important to specify how the term MSM is defined for a particular purpose. Based on the deliberations held in the Sri Lanka workshop, April 3-5, 2012, we summarize two possible ways of defining MSM for the purpose of MSM population size estimation: 1. When estimating the population size of MSM through desk review of available data from population-based surveys. 2. When estimating the population size of MSM through primary data collection either by using mapping-based (geographical mapping of cruising sites or hot spots where MSM meet other MSM) or survey-based size estimation methods (e.g., multiplier and/or capture/ re-capture methods). B. Elements to consider when defining MSM for a particular purpose When defining MSM for any purpose, it is important to consider the following elements in the definition. 1. Age: Whether age needs to be mentioned? If so, above what age and up to which age? 2. Timeframe: Whether timeframe within which MSM had sex with other men needs to be specified? (e.g., ever had sex with men or had sex with men in past month?) 3. Type of sex: Whether the types of sex MSM have with other male partners need to be specified? (oral, anal, oral and anal, or any type of sex) 4. Gender of partners: Whether those men who have sex with only men are defined as MSM or whether any men who have sex with other men irrespective of whether or not they have sex with women are included? 5. Number of male partners over a time-period: Whether the number of male partners over a particular time period needs to be specified? 6. Inclusion or exclusion of male-to-female transgender people: Whether male-to-female transgender people are included under MSM? 7. Inclusion or exclusion of MSM in sex work: Whether MSM in sex work are included under MSM or as a separate category male sex workers3? C. Proposed definitions of MSM for population size estimation of MSM There are basically two situations when a definition for MSM is needed for size estimation of MSM population: Situation 1: For arriving at a national level estimation of MSM population size by conducting desk review of available data from population-based surveys Situation 2: For estimating the population size of MSM based on actual data collection either using mapping-based or survey-based size estimation methods. Below, we elaborate on these two situations and explain how the proposed definitions of MSM will help in each of these two situations.
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Situation 1: Definition of MSM for national level estimation of MSM population by conducting desk review of available survey data We need to define MSM in one particular way to estimate the size of the entire population of MSM defined in that manner. Please note that the size estimation arrived using this definition is not for setting target for program coverage but to know what is the universe of MSM defined in a particular manner. Also, if high risk MSM4 can be defined in a particular way (e.g., men who received money for having sex with other men in the past month, MSM who engaged in unprotected anal sex - receptive and/or insertive - in the past month, number of male sexual partners in the past month)5, then through desk review of survey data it is possible to estimate the size of high risk MSM who need to be reached through targeted HIV prevention programmes. Below, we provide a way of estimating the total number of MSM at the national level and then discuss about how having an explicit definition of MSM for this purpose will be helpful. In the best case, the percentage of men who have sex with men is derived from national population-based studies (if available) of all sexually active adult men/males6 (A in Figure 1), or they can be derived from any agreed upon national average based on information from behavioural surveys among specific male populations (migrants, STI clinic attendees, truck drivers, etc.). However, the estimate will depend on the timeframe criterion one chooses to use for defining MSM. Again, some of the options include: using a timeframe of ever had sex with other men (B in Figure 1); sex with other men in the past one year (C in Figure 1); or sex with other men in the past one month (D in Figure 1)7. One can assume that if the latter (sex with other men in the past one month) criterion is chosen then that estimate is more likely to include high risk MSM (E in Figure 1). Figure 1. Options for defining MSM for national level estimation of population size through desk review of available data8

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Thus, for this type of estimation by desk review based on survey information, the age and timeframe are the two important components that are part of the definition of MSM. Implicit assumptions made are: MSM includes men who have sex with men irrespective of whether or not they have sex with women, irrespective of whether or not they engage in sex work and irrespective of their gender identity (that is, male-to-female transgender people are included under the term MSM here. However, where needed, one can differentiate between MSM and male-to-female transgender people).9 Even though options are available for defining MSM (as shown in Figure 1 and explained above) for estimating the population of MSM through desk review, one definition that can be considered for wider use is given in Box 1. Such a common definition will then be useful for comparisons with other countries in South Asia region. Box 1. Proposed definition of MSM for national level estimation of population size through desk review of available survey data Men/males who had any type of sex with men/males in the past one year, - regardless of their gender expression/identity, sexual orientation or sexual identity, and - regardless of whether or not they have sex with women, and - regardless of whether they pay or receive money for sex with other men/males Situation 2. Definition of MSM for population size estimation through actual data collection using mapping-based or surveybased methods MSM can be defined in one particular way to estimate the population size of all MSM (irrespective of their risk behaviours) who congregate at or use particular venues (cruising sites or hot spots10). This type of estimate, which involves geographical mapping of venues combined with various types of size estimation methods for assessing the number of men at the sites, is useful to both locate the sites for potential interventions and to identify the number of MSM who needs to be reached through these physical venues. Thus, it also provides the number for setting program targets to reach MSM. Whether one is going to use mapping-based or survey-based (multiplier or capture/re-capture) size estimation methods, a common definition that can be used is given in Box 2.

a particular venue. Also, it is important to reach all MSM who access cruising sites or hot spots (to socialize with other MSM or to find male sexual partners), because this population often overlaps with that of high risk MSM11 to be reached. Acknowledgements: Based on the discussions of the workshop, this guidance note was developed by a team that included Venkatesan Chakrapani, Ashok Row Kavi, Shivananda Khan, Edmund Settle and Amala Reddy. Endnotes 1 WHO, 2010. HIV/AIDS among men who have sex with men and transgender populations in South-East Asia. http://www.searo. who.int/LinkFiles/Publications_MSM-combined.pdf 2. WHO, 2010. Priority HIV and sexual health interventions in the health sector for men who have sex with men and transgender people in the Asia-Pacific Region. http://www.searo.who.int/ LinkFiles/Publications_Priority_HIVandSH_interventions_May10. pdf 3 Some countries use the term male sex workers to refer to both MSM in sex work and male-to-female transgender people in sex work 4 High risk MSM can be defined as a subset of men in general, or as a subset of MSM 5 In an article on population size estimation of MSM using available survey data, the authors define high risk MSM as men who had sex with other men during the last 12 months and who either report unprotected anal sex or commercial sex during that period. (Cceres C, Konda K, Pecheny M, Chatterjee A & Lyerla R. Estimating the number of men who have sex with men in low and middle income countries. Sex. Transm. Inf. 2006;82;3-9) 6 Data on total number of men belonging to different age groups can be obtained from national census 7 For example, in an article by Cceres et al., 2006, that examined the period 1990 to 2004, fairly high proportions of men reported having ever had sex with a man in Southeast Asia (7 to 12%), and South Asia (6 to 8%). When limited to only those men who have had sex with another man in the last year, the proportions reported from the best available data decreased to half in Southeast Asia (4%), but remained around the same in South Asia (7-8%). (Cceres C, Konda K, Pecheny M, Chatterjee A & Lyerla R. Estimating the number of men who have sex with men in low and middle income countries. Sex. Transm. Inf. 2006;82;3-9) 8 The relative sizes of the subsets (B to E) in this figure are not purported to be or based on actual proportions 9 For this differentiation, however, the surveys need to have questions that capture the gender identity of the respondents. The survey questions related to sex with men will be the same irrespective of whether a person identify as a man or a male-tofemale transgender person (e.g., Have you had anal sex with a man in the last year/month?). 10 An explicit definition of hot spots then need to be provided, based on the country context 11 Depending on the way the term high risk MSM is defined. For example All MSM in sex work who visit hot spots. Also see earlier discussions on high risk MSM in relation to the first definition and refer to E in Figure 1.

Box 2. Proposed definition for estimating MSM through actual data collection* using mapping-based or survey-based methods (that is, to provide the denominator of MSM to be reached through targeted HIV interventions) Men who have sex with men are those men/males who had any type of sex with men/males who access cruising sites or hot spots, - regardless of their gender expression/identity, sexual orientation or sexual identity, and - regardless of whether or not they have sex with women, and - regardless of whether they pay or receive money for sex with other men/males *Note: A timeframe for having had sex with men (e.g., past one month) is NOT provided in this definition, because it would not be possible to only estimate the MSM who had sex with men in the past one month when nomination technique (best guesstimate) is used to ask the community key informants about how many MSM access

www.apcom.org
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World Health Organisation releases groundbreaking report condemning 'conversion therapies'

From Pan American Health Organisation Services that purport to "cure" people with non-heterosexual sexual orientation lack medical justification and represent a serious threat to the health and well-being of affected people, the Pan American Health Organization (PAHO) said in a position statement launched on 17 May, the International Day against Homophobia. The statement calls on governments, academic institutions, professional associations and the media to expose these practices and to promote respect for diversity. Twenty two years ago, on May 17, the World Health Assembly removed homosexuality from the list of mental disorders when it approved a new version of the World Health Organizations International Classification of Diseases (ICD-10). "Since homosexuality is not a disorder or a disease, it does not require a cure. There is no medical indication for changing sexual orientation," said PAHO Director Dr. Mirta Roses Periago. Practices known as "reparative therapy" or "conversion therapy" represent "a serious threat to the health and well-beingeven the livesof affected people." The PAHO statement notes that there is a professional consensus that homosexuality is a natural variation of human sexuality and cannot be regarded as a pathological condition. However, several United Nations bodies have confirmed the existence of "therapists" and "clinics" that promote treatment intended to change the sexual orientation of non-heterosexual people. The document notes that no rigorous scientific studies demonstrate any efficacy of efforts to change sexual orientation. However, there are many testimonies about the severe harm to mental and physical health that such "services" can cause. Repression of sexual orientation has been associated with feelings of guilt and shame, depression, anxiety, and even suicide. As an aggravating factor, there have been a growing number of reports about degrading treatments, and physical and sexual harassment under the guise of such "therapies," which are often provided illicitly. In some cases, adolescents have been subjected to such interventions involuntarily and even deprived of their liberty, sometimes kept in isolation for several months. "These practices are unjustifiable and should be denounced and subject to sanctions and penalties under national legislation," said Dr. Roses. "These supposed conversion therapies constitute a violation of the ethical principles of health care and violate human rights that are protected by international and regional agreements." To address the problem, PAHO makes a series of recommendations for governments, academic institutions, professional associations, the media, and civil society, including: Conversion or reparative therapies and the clinics offering them should be denounced and subject to adequate sanctions. Public institutions responsible for training health professionals should include courses on human sexuality and sexual health in their curricula, with a focus on respect for diversity and the elimination of attitudes of pathologization, rejection, and hate toward non-heterosexual persons. Professional associations should disseminate documents and resolutions by national and international institutions and agencies that call for the de-psychopathologization of sexual diversity and the prevention of interventions aimed at changing sexual orientation. In the media, homophobia in any of its manifestations and expressed by any person should be exposed as a public health problem and a threat to human dignity and human rights. Civil society organizations can develop mechanisms of civil vigilance to detect violations of the human rights of non-heterosexual persons and report them to the relevant authorities. They can also help to identify and report people and institutions involved in the administration of reparative or conversion therapies. PAHO, which celebrates its 110th anniversary this year, is the oldest public health organization in the world. It works with its member countries to improve the health and the quality of life of the people of the Americas. It also serves as the Regional Office for the Americas of WHO.

The US Embassy, Pakistan, and LGBT issues

From Qasim Iqbal, Executive Director, Naz Male Health Alliance, Pakistan, 25, June 2012 Some of the readers may well remember the response from certain sections of the Pakistan civil society when the US Embassy in Pakistan hosted an LGBT function at the Embassy, which was publicised and brought about a verbal wrath on all things LGBT. One of the unanticipated consequences was that it also impact on the HIV work of Naz Male Health Alliance. I think the LGBT community in Pakistan is largely closeted. You have your Begum Nawazish Ali and rumoured famous lesbians and gays and all that, but nothing that is sufficiently impacting for there to be rights violations on a massive scale. For lesbians particularly, a lot of the rights violations that have happened happen anyway as a result of being a woman and/or happen because of the way the family is structured to control womens lives. Groups of queer people have been getting together quietly time and again for at least a decade, possibly longer, to organize themselves or provide support. No one has yet suggested any kind of large coming out act, any legal changes. This is because a) the anti-sodomy law does not impact very largely and b) what society is unwilling to accept is not going to be affected by a change in the law because the state is weak and uninterested in challenging the family. And the family is the main unit of oppression for anyone. In all of this climate, the embassy debacle did two things: 1) It brought the publics attention on queers and 2) it soldered queers to the US agenda. This is detrimental because, as I mentioned above, the community as whole has not expressed interest in coming out at this point in time and because along with a hatred for all things sexual and all things queer, the society at large also has a hatred for all things US. So, quite contrary to any kind of happy light being shined on an issue getting no attention, it brought scrutiny into the communal closet, and attention that most queer did not want. In the week after the embassy event, there were protests in Lahore and Islamabad by Muslim groups. In Islamabad, they tried to storm the Diplomatic Enclave with a view to marching on the US Embassy itself. In Lahore, the banners they held called for the US to stop bringing its perversions to Pakistan and promoting homosexuality. There was column upon column in the Urdu papers that were dead against homosexuality, homosexuals gathering, the US supporting homosexuals. The Urdu papers have the widest circulation. In contrast, the supportive blog posts on the English language Tribune newspaper, while heartening, were largely anonymous and had only an online English language audience. continued on page 25, col.1

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Indias shunned transgenders struggle to survive

Seema, a husband and father of two, gets ready for another night of work on the streets of New Delhi, placing two halves of a yellow sponge ball into empty bra cups. The 33-year-old then plucks out the stubble on his chin, applies foundation from a pink heart-shaped make-up box and combs his chin-length black hair in front of a large mirror. Seema is transgender, one of hundreds of thousands in conservative India who are ostracised, often abused and forced into prostitution due to no legal recognition, even as the world marks International Day against Homophobia and Transphobia on May 17. "It's necessary for me to do sex work because I have to look after my family," Seema said, adjusting a deep red scarf. "Nobody does it of their own wish. We have sex because we have no other choice." Male-to-female transgenders, also known as "hijras", have a long history in South Asia, experts say. The Sanskrit texts of the Kama Sutra, written between 300 and 400 B.C., refers to a "third sex". The Kama Sutra is an ancient Indian Hindu text on human sexual behavior in Sanskrit literature. During the Mughal empire in the 16th and 17th centuries, castrated hijras - or eunuchs - were respected and considered close confidants of emperors, often being employed as royal servants and bodyguards. These jobs were so coveted that historians say some parents actually castrated their sons in order to attain favour with the Mughal kings and secure employment for their children. But despite acceptance centuries ago, hijras today live on the fringes of Indian society and face discrimination in jobs and services such as health and education. "I think things are different today because of the kind of laws that were introduced to India when the British came. The whole

US Embassy, Pakistan
continued from page 25, col. 2 The climate of fear that all of this activity has created is almost indescribable. Where we had space to organize and talk, where we had the freedom to set our own pace and plan our own strategies and initiatives, the US Embassy blundered in and forced the issue. Now we are all much more cautious, and have much less room the maneuver. We were being ignored. Now were being watched. Case in point: some group called the Muslim Youth Front has been putting up banners all over Lahore telling the humjins parastis (gays) of Pakistan to stop organizing, to remember what happened to the People of Lot, and telling them to leave Pakistan immediately. What all this means is that: a) the US embassy has no idea what it is doing; b) but it does imagine itself to be bringing some sort of liberating force to Pakistan which is c) a gross misunderstanding because d) Pakistani queers have already been atttempting to organize themselves and e) not one of them asked the Embassy to bring the queer agenda to the public table. The US State department MUST ADOPT A POLICY OF NONINTERFERENCE. There is absolutely nothing positive that the US Embassy can do at this point. They need to commit to sitting quiet and letting the queers of Pakistan decide whats best for us. We do not want their help. Comment: At the very least, US Embassies (as with all other Embassies engaged in similar activities) should engage with local LGBT and MSM HIV activists in the country before they host LGBT events that could lead to even more difficulties for those that the US wants to support.

concept of unnatural and natural was defined in our law," said gay rights activist Anjali Gopalan. Many hijras are now sex workers or move around in organised groups begging or demanding money from families who are celebrating the birth of a child or a marriage. They threaten to curse the happy new couple or the newborn if they do not pay up. Many Indians fear a hijra's curse, which is said to bring infertility or bad luck. But transgenders are the biggest victims, say activists. Hate crimes against the community are common yet few are reported, partly due to a lack of sensitivity by authorities such as the police. Last week, an activist fighting for transgender rights had his throat slashed in Kerala. The previous month, in Tamil Nadu, a 42-year-old transgender was strangled to death with a rope. Her real self By day, in a cramped one-room home in west Delhi, Seema is known by her male birth name Hardeep and is a loving father of a one and six-year-old who call her "daddy". As night falls, she goes to a local charity to paint her face and transform into Seema, who sells herself on the street under a busy city flyover. She earns about 200 rupees, offering oral sex or "thigh sex," in which the client will place his penis into her clamped thighs. Other hijras generally offer anal sex too. Within 15 minutes, a black car pulls up and she is whisked away before returning to serve another client - this time a man on a motorbike in a dark shirt and light blue jeans. The job comes with many risks. In 2009, Seema was raped by a policeman inside a roadside booth, and she is now HIV positive. "First and foremost, they are vulnerable to HIV/AIDS. Due to their job, they get beaten up left, right and centre almost everyday," said Abhina Aher from the India HIV/AIDS Alliance. According to the India's National AIDS Control Organisation (NACO), HIV prevalence amongst transgenders is 20 times higher than the general population. Activists say some progress is being made in lifting discrimination. Three years ago, the British-era law banning gay sex was overturned. In Tamil Nadu, pensions, free sex "re-assignment" surgery and university scholarships are now offered. But hijras like Seema believe more needs to be done. "If the government wants to help, they should do some sensitisation with people so that they don't discriminate," said Seema. "We are also human beings. It's not my choice God made me this way. I can't help it." Reuters, 17/5/2011

Celebrating diversity in Bandhu Social Welfare Society, B angladesh

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Decolonising sexual citizenship: who will effect change in the south of the Commonwealth?
Colin Robinson April 2012, Opinions, Commonwealth Advisory Bureau Colin Robinson argues that it is ill-judged to place too much emphasis on law and litigation as a means of advancing sexual autonomy in the Global South of the Commonwealth. The rhetorical handwringing and neo-colonial undertones of western NGOs and campaign groups do nothing to foster southern-based local and subregional solutions to the achievement of sexual citizenship and sexual emancipation. If Global North advocates wish to be part of the movement to end sexual apartheid, they must resist the temptation to take the reins. They must engage in genuine North-South dialogue and international solidarity. They need to get behind Global South initiatives and push in the directions carved out by southern activists. It is important to reimagine how the cause of sexual citizenship in the south of the Commonwealth should be advanced. By the South, I refer mainly to the former Empire the vast majority of Commonwealth nations (outside Australia, Canada, Cyprus, Malta, New Zealand and the UK) that are still developing economies, however large. By sexual citizenship, I mean how autonomy over ones sexuality becomes part of the core promise of dignity guaranteed by states to every human being; how consensual erotic pleasure and relationships and their expression in privacy and in public are protected from violence and the interference of the state and others; and how society and nation recognise that sexuality is a precious part of personhood. And by reimagine, I mean that a lot of noise has been made about sodomy laws, but not a lot of thought and careful deliberation given to these issues. Our best chance ever for LGBTI [lesbian, gay, bisexual, transgender, intersexual] rights, one campaigner termed the last Commonwealth Heads Meeting (CHOGM) in Perth. Comments like these serve only to underscore the divergence between the analysis and strategies of the people I work with and those of the controversial activist Peter Tatchell, who uttered them, and whose campaigns, in my opinion, do not work. Nor do public scoldings of peers by certain Commonwealth politicians, such as foreign minister Kevin Rudd, in the run-up to the CHOGM in Australia. These peers included: Kamla Persad Bissessar, the Prime Minister of my native country Trinidad and Tobago and former Chair-inOffice of the Commonwealth, whose party (when last in power in 2000) increased the sentence for buggery to 25 years; her predecessor Yoweri Museveni, President of Uganda, during whose tenure as Commonwealth chair a bill was introduced in the national parliament applying a death sentence for homosexuality in some instances, and where a polarising witchhunt by media and clerics against homosexuals has dragged on; and president Goodluck Jonathan of Nigeria, the Commonwealths fourth most populous state, whose Senate, during the most recent CHOGM, was busy considering a bill (which they eventually passed) imposing criminal penalties for participating in same-sex marriage ceremonies and public displays of same-sex affection and outlawing gay organisations and advocacy. Tatchell and the retired gay Australian judge Michael Kirby have been two of the loudest non-governmental campaigners on this issue: It will not happen just because proponents of change feel angry, heap abuse on opponents and jump up and down. Nor will it happen because other countries of the Commonwealth have changed their laws, reasoned Kirby, somewhat to my surprise, in a pre-CHOGM opinion piece about what he indelicately coined ending sexual apartheid.
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I lost faith in the effectiveness of Kirbys voice at a UNDP forum in Trinidad and Tobago we both attended months earlier. On that occasion I cautioned him along similar lines that such lecturing was ineffective because it was perceived as imperial. His reaction was markedly different from what he says above: he retorted that countries like mine had had 30 years to get rid of our sodomy laws. What he failed to mention was how it compares not too unfavourably with the UKs 25-year journey from the Wolfenden Report to the Dudgeon European Court case. As we hadnt abolished them, he said, others were stepping in to do the job. And the new idea in the North is that the enduring laws in nowindependent Commonwealth states, which continue to criminalise sexuality our colonists deemed unnatural, are, as Kirby has written, just a dear little legacy of the British Empire ... a very special British problem that requires, well, British intervention. This is new in the sense of neocolonial. The arsenal of silken lawsuits, which represents the Human Dignity Trusts (HDT) solution to the sexual citizenship issue, seems similarly unproductive as a primary approach. We will fundraise, and there is something rather charming that you can say to somebody: If you give us 50,000, I can more or less guarantee that you will have decriminalized homosexuality in Tonga. And actually, you know, thats great, CEO Jonathan Cooper enthused to The Guardian on 14 September 2011. Advocates, including the Commonwealths Eminent Persons Group (EPG), have trodden the HIV track for decades now in an effort to cut a path through resistance to sexual liberty. Calculating that HIV has achieved mainstream ownership, EPG argued (in their embargoed report to CHOGM on how to save the Commonwealth from irrelevance) that the Heads should take steps to encourage the repeal of discriminatory laws because they impede the effective response of Commonwealth countries to the HIV/AIDS epidemic. But linking sexual citizenship to disease control is risky, and only goes so far: it is not about building the values needed to sustain our embrace of sexual rights and the dignity of same-sex sexuality. Threatening to cut off aid, which the UKs Conservative Prime Minister David Cameron appeared to do immediately after CHOGM (but then seemed to want us to think he didnt), might be useful to end a crisis, but it certainly isnt going to foster local ownership of sexual rights either. In fact, it has done exactly the opposite, with leaders in high-income Commonwealth Caribbean states that receive no General Budget Aid rushing to show off their sovereignty in response to Camerons remarks. The HDT believes outlawyering our governments to court victories is the silver bullet, one that can be peddled to a donor for any given country. But even this leaves losers and division in its wake. It has muscled into a carefully planned constitutional suit by local and regional actors in Belize, daringly spun in the media as the Trusts global campaign kick-off. The heavy focus on litigating sodomy laws is in itself questionable, when there are several much more fruitful fronts for policy change and opportunities for including sexuality in frameworks of gender justice, kinship and humanity. In short, old Empire solutions wont work in a new Commonwealth. Furthermore, nothing, not even the strongest Charter, will end at a stroke the criminalisation and stigmatisation of same-sex intimacy across so much of the Commonwealth. So, what can work? In my opinion, local and sub-regional solutions, supported by international solidarity, South-South dialogue,

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and North-South listening. The Commonwealth boasts about its role in ending apartheid in South Africa. But it didnt do that without respecting the leadership and agency of South African strategists. The first step can only be to support the initiatives of those who are criminalised and are actually doing the hard and long-term work of developing organisations, nurturing communities of resilience, forging alliances, building nations of inclusion and growing cultures of sexual rights. Those of us who live in, understand and engage daily with the states and the localities we wish to change must form the pivot around which any international advocacy strategy or emancipatory movement is built. Scores of local and national organisations working on sexual citizenship exist across the Commonwealth. Some are feminist groups like the Development Action for Women (DAWN), some focus specifically on gay, lesbian, bisexual and transgender concerns. Most understand the necessary intersections between sexual citizenship and other justice and gender preoccupations. Some are affiliated into regional networks like African Men for Sexual Health and Rights, the Coalition of African Lesbians, the Pacific Sexuality Diversity Network and the newly revitalised Caribbean Forum for Liberation and Acceptance of Genders and Sexualities, which I co-chair. Some, like Indias Alternative Law Forum, the main strategists behind the Section 377 sodomy lawsuit, work broadly on justice and equality. Some like the Caribbean Vulnerable Communities Coalition, founded by Robert Carr, focus on marginalised and vulnerable groups. Others like Fahamu (a movement for social justice in Africa), pioneer the building and organisation of social justice networks. Yet more diverse coalitions engage broadly with sexuality. These are the people I talk to, admire and learn from across the south of the Commonwealth. Gay rights can be advanced in the South through domestic political advocacy and organisation, just as they were in the North. And the most productive pathways to change may include some in which institutional nonprofits in the North are prohibited or deemed ill-suited to work. In some places there will be participation across sexual orientation in freedom struggles and revolutionary or emancipatory struggles more generally, a core reason South Africas post apartheid formal legal systems fundamentally respect sexual diversity. Contrary to common belief, the Commonwealth meetings have not provided safe or friendly spaces for us. Those working dayto-day to bring about change in the South braved humiliation and physical assault at the 2007 Commonwealth Peoples Forum (CPF) in Kampala and discriminatory laws at the CPF in Port of Spain two years later. In using our bodies and voices to open up space at these meetings for dialogue about sexual citizenship, we were given little protection from the Commonwealths machinery. In 2009, some of our allies from the North helped ensure there was representation from LGBTI people from a quarter of Commonwealth nations across three global regions. The civil society dialogues and statements in those meetings made LGBTI issues visible in unprecedented ways. In contrast, at last years best chance ever opportunity in Perth, we did not fare well in the competition for spaces at the Peoples Forum, where two out of every five places reportedly went to Australians, and our appeals for special efforts to be made to include us in what was to be an urgent discussion of our liberty were not successful. But earlier in 2011, Commonwealth Secretary General Kamalesh Sharma, addressing the Law Ministers July meeting, subtly but powerfully transformed the Commonwealth dialogue on sexual rights. He shifted its frame simply by asking not whether the remaining 43 member nations of the Commonwealth should follow the example of such states as the Bahamas, India, South Africa and Vanuatu in moving to eliminate punitive laws, but how. And he suggested it was a matter of finding practical ways forward that are local and imaginative. Though he was applauded, I am not sure many in the North really listened to his message. He challenged

both legislators and jurists to use law in ways that make sense in each member state in order to expand gender justice and sexual citizenship, and to embrace apolitical and measured pathways to such justice, recognising the ways in which contemporary understandings of old laws must change with time. He also framed this goal using Amartya Sens vision as that of nations using law to expand the life choices and human capacity of their people. He described the process of forward movement as exchanges reinforced with practical action and collaboration. It is lovely rhetoric, but it is also how and why change on this issue will happen. The Secretary Generals intervention illuminates the possibility of a different and more creative Commonwealth dialogue about sexuality, justice and the law, and a means of moving away from the axis on which much of the debate on sexual orientation leading into the last CHOGM has hinged. I welcome the opening he created and the new direction with its vital focus on national solutions. It is important to remember that the origin of legal frameworks in Global South Commonwealth nations targeting same-sex intimacy was patently part of a colonially imposed agenda of injustice and regulation. But that says nothing about the dismantling of those laws which will not instantly create equality or make stigma disappear. As Grenadian writer Audre Lorde has warned: The masters tools will not dismantle the masters house. The work in each state will of necessity be unique, with particular challenges, national and local barriers as well as urgencies and openings furnished by the peculiarities arising in each domestic situation. In Trinidad and Tobago, for example, as in many other places, we face the incursion of Global North religious zealots in our case because we are perceived as being very ready to embrace sexual citizenship. The comfort and foreign appeal of fundamentalism, whose goal is to narrow gender and restrict sexuality, are a balm against powerlessness and alienation in a small, stratified society grappling with uncertainty in a world of violence, climate change and globalisation. My organisation is trying to build an LGBTI movement here that is strategic and imaginative. Although sodomy laws, even when unenforced, continue to fuel stigma and sanction discrimination, repealing them doesnt repeal the Bible or Quran. Polarising national debates over the formal legal status of still-misunderstood and misrepresented sexualities can easily foreclose other gains and opportunities to deepen shared values on non-discrimination, vulnerability and fairness, and expand their application in policy and practice. So we question the value of an automatic focus on sodomy law changes, and have eschewed movement on this, instead encouraging our Government to declare a moratorium on prosecutions, which is already in effect. Contrary to what weve been told, that discrimination protections for sexual orientation are not something we can achieve before decriminalisation happens, we see the fight for such protections as a political first step, one on which there is wide public consensus and little political risk. We have also focused on the idea of building government capacity on sexual orientation and gender identity issues, working to get other states and donors to offer technical assistance and funding to government to build its competence and conduct research. How we handled the HIV/Aids epidemic holds lessons here. Incentives and capacity are as important as judgments and mandates. We also advocate for state programming that again building on lessons from dealing with HIV addresses particular vulnerabilities of sexual minority status, like homelessness and school bullying; and we target the impact of stigma in daily policing on access to justice. Michael Kirby has asked how we move the logjam so that the river of reform will begin to flow. But who are the we to whom he refers? Continued on page 28, col.1
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Is some homophobia self-phobia?

Homophobia is more pronounced in individuals with an unacknowledged attraction to the same sex and who grew up with authoritarian parents who forbade such desires, a series of psychology studies demonstrates. The study is the first to document the role that both parenting and sexual orientation play in the formation of intense and visceral fear of homosexuals, including self-reported homophobic attitudes, discriminatory bias, implicit hostility towards gays, and endorsement of anti-gay policies. Conducted by a team from the University of Rochester, the University of Essex, England, and the University of California in Santa Barbara, the research will be published the April issue of the Journal of Personality and Social Psychology. Individuals who identify as straight but in psychological tests show a strong attraction to the same sex may be threatened by gays and lesbians because homosexuals remind them of similar tendencies within themselves, explains Netta Weinstein, a lecturer at the University of Essex and the studys lead author. In many cases these are people who are at war with themselves and they are turning this internal conflict outward, adds co-author Richard Ryan, professor of psychology at the University of Rochester who helped direct the research. The paper includes four separate experiments, conducted in the United States and Germany, with each study involving an average of 160 college students. The findings provide new empirical evidence to support the psychoanalytic theory that the fear, anxiety, and aversion that some seemingly heterosexual people hold toward gays and lesbians can grow out of their own repressed same-sex desires, Ryan says. The results also support the more modern self-determination theory, developed by Ryan and Edward Deci at the University of Rochester, which links controlling parenting to poorer self-acceptance and difficulty valuing oneself unconditionally. The findings may help to explain the personal dynamics behind some bullying and hate crimes directed at gays and lesbians, the authors argue. Media coverage of gay-related hate crimes suggests that attackers often perceive some level of threat from homosexuals. People in denial about their sexual orientation may lash out because gay targets threaten and bring this internal conflict to the forefront, the authors write. The research also sheds light on high profile cases in which antigay public figures are caught engaging in same-sex sexual acts. The authors cite such examples as Ted Haggard, the evangelical preacher who opposed gay marriage but was exposed in a gay sex scandal in 2006, and Glenn Murphy, Jr., former chairman of the Young Republican National Federation and vocal opponent of gay marriage, who was accused of sexually assaulting a 22-year-old man in 2007, as potentially reflecting this dynamic. We laugh at or make fun of such blatant hypocrisy, but in a real way, these people may often themselves be victims of repression and experience exaggerated feelings of threat, says Ryan. Homophobia is not a laughing matter. It can sometimes have tragic consequences, Ryan says, pointing to cases such as the 1998 murder of Matthew Shepard or the 2011 shooting of Larry King. To explore participants explicit and implicit sexual attraction, the researchers measured the discrepancies between what people say about their sexual orientation and how they react during a split-second timed task. Students were shown words and pictures on a computer screen and asked to put these in gay or straight categories. Before each of the 50 trials, participants were subliminally primed with either the word me or others flashed on the screen for 35 milliseconds. They were then shown the words gay, straight, homosexual, and heterosexual as well as pictures of straight and gay couples, and the computer tracked precisely their response times. A faster association of me with gay and a slower association of me with straight indicated an implicit gay orientation. A second experiment, in which subjects were free to browse same-sex or opposite-sex photos, provided an additional measure of implicit sexual attraction. Through a series of questionnaires, participants also reported on the type of parenting they experienced growing up, from authoritarian to democratic. Students were asked to agree or disagree with statements like: I felt controlled and pressured in certain ways, and I felt free to be who I am. For gauging the level of homophobia in a household, subjects responded to items like: It would be upsetting for my mom to find out she was alone with a lesbian or My dad avoids gay men whenever possible. Finally, the researcher measured participants level of homophobia -- both overt, as expressed in questionnaires on social policy and beliefs, and implicit, as revealed in word-completion tasks. In the latter, students wrote down the first three words that came to mind, for example for the prompt k i _ _. The study tracked the increase in the amount of aggressive words elicited after subliminally priming subjects with the word gay for 35 milliseconds. Across all the studies, participants with supportive and accepting parents were more in touch with their implicit sexual orientation, while participants from authoritarian homes revealed the most discrepancy between explicit and implicit attraction. In a predominately heterosexual society, know thyself can be a challenge for many gay individuals. But in controlling and homophobic homes, embracing a minority sexual orientation can be terrifying, explains Weinstein. These individuals risk losing the love and approval of their parents if they admit to same sex attractions, so many people deny or repress that part of themselves, she said. In addition, participants who reported themselves to be more heterosexual than their performance on the reaction time task indicated were most likely to react with hostility to gay others, the studies showed. That incongruence between implicit and explicit measures of sexual orientation predicted a variety of homophobic behaviors, including self-reported anti-gay attitudes, implicit hostility towards gays, endorsement of anti-gay policies, and discriminatory bias such as the assignment of harsher punishments for homosexuals, the authors conclude. This study shows that if you are feeling that kind of visceral reaction to an out-group, ask yourself, Why? says Ryan. Those intense emotions should serve as a call to self-reflection. The study had several limitations, the authors write. All participants were college students, so it may be helpful in future research to test these effects in younger adolescents still living at home and in older adults who have had more time to establish lives independent of their parents and to look at attitudes as they change over time. Science Daily, 6/4/2012

Decolonialising sexual citizenship

continued from page 27, col. 2 Even when well intentioned, the shrillest voices advocating for Global South nations (whether in the Commonwealth or not) to expand justice and equality for their LGBTI citizens have too often been tone deaf. The chorus coming from the powers who gave us the sodomy laws in the first place has shifted to singing morality in a different key, often appealing more to righteousness than to shared values. And they have outshouted those of us working within our own nations to build ownership for a vision of postcolonial justice, national pride and liberty that includes sexual autonomy. But that does not mean we fight alone. Our voice needs to be enlarged, our capacity resourced and our leadership respected. Global North advocates wanting the same changes often believe they have the answers but get in the way by taking the reins too often rather than following our lead. It is essential that those who genuinely support our equality listen to us, get behind where we are going, and push in the same directions.
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