(WAPCAS)
FIRST DRAFT
Revealing the Pandora Box or Playing the Ostrich?
A Situational Appraisal of Men Having Sex With Men
in The Accra Metropolitan Area and its Environs �
Ghana
Dr. Dela Attipoe
Greater Accra Regional HIV/AIDS Co-ordinator
National AIDS/HIV/STI Control Programme
PO Box AN7622
Accra-North
E-mail: [email protected]
Tel: (Office) 021 241452 Ext. 6
(Cellular) 020 813 4317
March 2004
Table of Contents
1 Background 7
1.1 Aim and Objectives of the Study 7
1.2 Methodology 7
1.3 Limitation of the Study 8
2 Literature Review 9
3 Findings 11
3.1 Background of Respondents 11
3.2 Areas of Operation / Known MSM Sites 14
3.3 Factors Influencing MSM in Ghana 15
3.3.1 Pleasure Versus Economic Reasons 15
3.3.2 How Respondents were introduced to MSM 16
3.3.3 Type of Sex Respondents Engage in 17
3.3.4 Multiple Male Sex Partnership among Respondents 18
3.3.5 Sharing of Body piercing Instruments and Use of Drugs 19
3.3.6 Social Problems and Coping Strategies 19
3.4 STI/HIV/AIDS AND MSM 21
3.4.1 Knowledge of STIs/HIV/AIDS 21
3.4.2 Modes of transmission of HIV 22
3.4.3 Protection Against STI 23
3.5 Health Problems Associated with MSM 25
3.5.1 Management of Associated Health Problems 25
3.5.2 Introduction of an Intervention Strategy 26
3.6 Bridging from Bisexual Men to Women 29
4 Conclusion and Recommendations 30
5 Annexes 33
Acknowledgements
This work was commissioned by the West Africa Project to Combat AIDS and STI (WAPCAS). It could not have been realised without the personal interest and contribution of the National Director, Dr. Khonde Nzambi, who provided most of the articles and ensured that the study went on even when it did look as if it was never going to get off the ground.
Special thanks to Mr. Mac-Darling Cobbinah, National Director of CEPEHRG, who welcomed the study, invited members to serve as Research Assistants and personally assisted in data gathering. I wish to recognise the contributions of Messrs. Moses Agbeko and Miguel Boakye for their patience and the frustration they went through in getting willing respondents to administer the questionnaires.
The inputs of Mr. Jojo Jackson of YPEP as an additional Research Assistant was very valuable in broadening the base of respondents and introducing other dimensions to the study.
To the many who agreed to be interviewed in spite of the odds and their expressed fear of being given too much exposure, I say a big thank you.
It is my express desire that this study will be an eye opener to many including decision-makers as it was to me and bring about a radical shift in our perceptions and bring about a better health status for all Ghanaians. This desire is not restricted to Ghana alone but to other developing countries with similar social characteristics.
Dr. Dela Attipoe
List of Abbreviations and Acronyms
AIDS Acquired Immune Deficiency Virus
ATR African Traditional Religion
CHRAJ Commission for Human Rights and Administrative Justice
CIDA Canadian International Development Agency
CPEHRG Centre for Popular Education and Human Rights of Ghana
CSW Commercial Sex Workers
FSW Female Sex Workers
GAFUND Ghana AIDS Fund
GHS Ghana Health Service
GLBT Gay, Lesbian, Bisexual and Transsexual
HIV Human Immunodeficiency Virus
IE&C Information Education and Communication
JSS Junior Secondary School
MOH Ministry of Health
MSM Men having sex with men
PLWHA People Living with HIV/AIDS
RA Research Assistants
SSS Senior Secondary School
STI Sexually Transmitted Infections
UNAIDS United Nations AIDS Programme
VCT Voluntary Counselling and Testing
WAPCAS west Africa Project to Combat AIDS & STI
YPEP Youngsters Peer Education Programme
Executive Summary
Introduction
Since the onset of the HIV/AIDS pandemic, tremendous shift has been recorded in the management of health as a social issue requiring sector wide approaches going beyond the remit of the health sector. It has also brought about a shift in some aspects of our social lives such as discussions of taboo topics such as sex and extension of health services to prostitutes long considered as outcasts. Another aspect of our social lives that has either not been recognised or is being denied but which could reverse any gain made in the fight against HIV/AIDS is �same-sex-sex� particularly �men having sex with men� (MSM) since sex is the commonest mode of transmission of HIV.
The study is to assess the MSM situation in and around Accra, Ghana so as to make recommendations for the introduction of an intervention to control sexually transmitted infections (STI) including HIV/AIDS among MSM in support of the national response to the HIV/AIDS menace.
Methodology
The study, which is exploratory in nature, was carried out using a semi-structured questionnaire. Members of NGOs, which have been working with the gay, lesbian, bisexual and trans-sexual community, were used as research assistants (RAs) to collect the data using a snowball referral system. Every willing practicing MSM either known or referred to the RAs was interviewed and regular meetings held with them to correct any deficiencies and fill in the gaps.
In all 156 questionnaires were returned as 6, which were considered inconsistent discarded from the analysis.
Key Findings
1. MSM is real in Ghana with Ghanaians fully involved. It is not a recent phenomenon being visited on Ghana and Ghanaians by �whites� or foreigners
2. The youth is actively being drawn into it and most of them at a very young age by their peers and older colleagues and relatives
3. MSM in Ghana cuts across all social classes, religions, ethnicity and married men are involved
4. It is practically happening everywhere, particularly where people gather for celebrations and merry making in urban areas and in places most people will least suspect
5. There are many prevailing factors that make MSM attractive particularly to the youth including adventure seeking, poverty, ignorance, lure of older gays looking for partners and the belief that anal sex is safer than vaginal sex
6. Public�s reaction to gays and homosexuality, has driven it underground creating a safe haven for people to practise and making it difficult for services to be rendered to them
The current state of affairs comes with a high price that could potentially setback the national response to HIV/AIDS. This is seen in the following:
1. Very poor knowledge of STIs other than gonorrhoea and HIV
2. Erroneous belief that these infections could not be transmitted through anal sex because they believe that anal sex is safer than vaginal sex
3. High level of promiscuity with multiple sex partners/customers yet with a high level of trust in sex partners
4. Low usage of condom for protection against infection during gay anal sex with the erroneous belief that antibiotics, herbal preparation and spiritualism could offer protection
5. Fairly high rate of MSM related health problems making them potential candidates for HIV infection
6. Active bridging between bisexual men and their women partners without protection creating more avenues for the spread of HIV
A large majority of respondents will welcome the introduction of curative and preventive interventions and have suggested ways of making this possible.
Conclusion and Recommendation
HIV/AIDS is taking its toll on the socio-economic lives of many in Sub-Saharan Africa and it is possible that MSM is contributing significantly to the statistics. Without any health intervention targeting MSM, the struggle against HIV/AIDS cannot succeed. The Ministry of Health/ Ghana Health Service (MoH/GHS) in accordance with its mission, vision and code of ethics and the Health Partners owe it a duty to the nation and to posterity to improve the overall health status and reduced inequalities in health outcomes of all people living in Ghana including men having sex with men. To this end both short term and long-term recommendations have been proposed as follows:
In the short-term a confidence-building programme should be initiated with the NGOs working with the gay community and the youth to start developing and implementing both curative and preventive services around the existing STI Clinics. Health workers in these clinics should be re-oriented in the management of MSM related health problems and members of the gay community invited and trained as peer educators.
In the long term, the health sector and its partners should work with other sectors including the Judiciary, the media, and public etc to remove all obstacles to resource mobilisation and the successful and smooth implementation of health interventions for MSM.
The challenges posed by the HIV/AIDS pandemic are real and require very pragmatic solutions. Ghana cannot afford to fail in this regard and should cease the opportunity to act now.
1 Background
The HIV/AIDS pandemic continues to be the one disease or social condition that has and continues to test all aspects of the political, economic and social development of nations and the international community. It has already proven that health is also a social condition, the management of which goes beyond the remit of the health sector to involve other sectors of the economy. It has made the various sectors of the economy recognise the need to have a vested interest in the health and social lives of their workforce to sustain productivity. Presidents have assumed full responsibility for spearheading the fight against the disease. HIV/AIDS has also led to many issues such as sex, long considered to be a taboo topic, to be brought into the open for discussion. It has also brought about the introduction of health services to female sex workers even in countries where prostitution is not legalised.
Another topical issue that has either not received much attention in many African countries or is being denied, but which can potentially reverse any gains so far made in the fight against HIV/AIDS or have dramatic negative consequences is �same sex-sex� particularly �men having sex with men� (MSM). This is even more important since sex is proven to be the commonest mode of transmission of HIV.
As a nation, we have not stopped to ask whether men are having sex with men in Ghana and if so what the potential contribution to the HIV/AIDS epidemic could be. Our national response to the epidemic failed to recognise MSM as a vulnerable group and does not include programmes to curtail any potential threat from MSM. Recent developments in the country as captured by the media rather bring to the fore the level of intolerability of the system to homosexuality and the obstacles that would have to be overcome in introducing an intervention for MSM.
1.1 Aim and Objectives of the Study
The main objective of the study is to assess the MSM situation in Accra, Ghana so as to make recommendations for the introduction of an intervention to control sexually transmitted infections (STI) including HIV/AIDS among MSM in support of the national response to the HIV/AIDS menace. The specific objectives are:
1. To describe the situation of MSM in Accra Metropolitan Area and its environs
2. To define the social dynamics among MSM
3. To assess the knowledge, attitudes, behaviour and practices of MSM toward HIV/AIDS and STI and
4. To identify intervention strategies to reduce risk and vulnerability among MSM
1.2 Methodology
The study was carried out during a period that most of the homosexual stories were making the headlines in the print and electronic media. This made it very difficult to get willing respondents to come forward as most were driven even more underground for security reasons. The search for willing respondents eventually led to the recruitment of three members of a Non-Governmental Organisation (NGO), which has been working with the homosexual community called Centre for Popular Education and Human Rights Ghana (CPEHRG) as research assistants. CPEHRG was established to provide care and support, peer education, advocacy, condom distribution, counselling and capacity building for People Living with HIV/AIDS (PLWHAs), Commercial Gay Sex Workers, Homosexual Men and Youth, and Lesbians Women and Youth.
A semi-structured questionnaire was developed (Annex 2) based on available literature on MSM from other countries. This was discussed with the NGO for acceptability since some of the questions might be considered too sensitive or the reason for asking them might be misinterpreted.
The study is an attempt to describe the MSM situation but combines qualitative and quantitative methods. The Research Assistants administered the questionnaires to as many willing respondents as they can get without going through any sampling procedure. Starting with members of the NGO, the Interviewers proceeded to interview other willing known non-members or other men that were recommended to them (snowball referral). Regular meetings were held with the Interviewers to review answers provided for consistency and to prepare them to ask probing questions and for more information other than what the tools was originally designed for. Notes were made of any additional information and included in the final report. Where possible the Assistants were asked to go back and collect additional information or seek a clarification on answers provided.
A fourth Research Assistant from another NGO called Youngsters Peer Education Project (YPEP) who had prior experience working on sexual health issues in some communities in Accra was later added and the same procedure followed.
In all 156 questionnaires were administered and each of the four Assistants had very varied responses, which could be explained by the different groups interviewed by each Assistant. Six (6) questionnaires were deleted from the final analysis because they were either too inconsistent or looked rather similar especially, where they have been filled by the same assistant and are near each.
1.3 Limitation of the Study
Caution must be exercised in interpreting the findings of the study in that it cannot be generalised to the universal set of MSM in Ghana. As could be observed from the analysis not many business executives were interviewed even though comments gathered from respondents indicate that there are top business executives and politicians who engage in MSM.
The validity of the study is also dependent on the frankness of those interviewed against the backdrop of the sensitive nature of the questions; a high level of insecurity among members; fear of a significant number of interviewees of undue exposure from the interview; and the desire to remain underground.
Even though the findings of this study cannot be said to be representative of MSM in the Greater Accra Metropolitan Area, it nevertheless presents us with more than enough information to start a health intervention programme for MSM in Ghana. The introduction of an intervention will undoubtedly lead to other intervention studies, which will hopefully lead to a better understanding of MSM in this part of the world.
2 Literature Review
As in many other African Countries, homosexuality is criminalized and considered a taboo in Ghana. A Ghanaian BBC Reporter is on record to have said that Ghana is in fact reported to be so inhospitable for gay men that it is near to �impossible to find anyone who will admit to being homosexual, unless you are one of them� . This report amply describes the bare reality in planning an intervention and reaching out to MSM in Ghana. This should however not hold back the health sector as the price we pay for inaction can be quite high.
Anal intercourse is a well-known mode of transmission of HIV worldwide and is in fact more efficient in this regard than vaginal intercourse. In a study that compared published estimates of the probability of HIV transmission per unprotected sexual act, anal sex among MSM groups was found to carry a higher risk than vaginal sex between heterosexual couples . In this study, while the probability of HIV transmission per unprotected vaginal sex in Europe ranged from 0.03% to 0.09% for female-to-male transmission and 0.05% to 0.15% for male-to-female transmission, the probability for anal sex in the USA ranged from 0.3% to 3.0% for receptive and 0.01% to 0.18% for insertive anal intercourse.
In Central and South Americas and parts of Asia between 40% and over 50% of the cumulative AIDS cases between 1983 and 1994 is believed to have resulted from homosexual transmission . Several studies in the Developed World since the onset of the HIV/AIDS pandemic have extensively explored and confirmed the contribution of MSM. There is however, very little comparable information from many Developing Countries including many parts of Africa to guide decision-making .
Even tough heterosexual intercourse is believed to represent the main mode of transmission of HIV in most Developing Countries, some Latin American and Asian countries report that MSM contribute a very significant number of reported AIDS cases . Studies in Latin America, the Caribbean, India, Senegal and many other places have revealed that a significant number of men who have unprotected sex with men also engage in unprotected vaginal sex and or anal sex with women. This sexual �bridging� from bisexual men to women is believed to account for a substantial proportion of heterosexual transmission of HIV in those countries. , , .
In spite of these facts, many African countries have legal provisions criminalizing homosexual behaviour and this has been shown elsewhere to be a major impediment to research and in carrying out HIV/AIDS work among MSM groups. In India, it has been reported that an NGO filed a petition with a New Delhi High Court to decriminalise homosexual behaviour because not only did these provisions make it difficult to reach the gay community, but also even NGOs working with the gay community have not escaped Police harassment . Such legal provisions also make it difficult to adopt policies that will facilitate the introduction of interventions for MSM as in the case of India where it has been found out that condoms officially imported into the country were unsuitable for oral or anal sex .
Even though the words homosexuality and sodomy do not appear in the Criminal Code of 1960 (Act 29) of Ghana, the Act makes �sexual intercourse with a person in an unnatural manner, a crime . The Act does not define what �sexual intercourse in an unnatural manner� means but any suspicion of homosexuality is swiftly punished and the culprits incarcerated for a number of years. Some recent developments, which have been given prominence by the vibrant Ghanaian media include:
? �CHRAJ won�t push for gay rights�: - In this story the Commissioner for Human Rights and Administrative Justice in Ghana is reported to have �ruled out any idea of advocating for gay rights�
? �Four homosexuals jailed 2 years each�: - A story of 4 boys who were jailed on their own plea for �indecent exposure� after they were found to be in possession of photographs showing them in �compromising homosexual acts�
? �Crowd attacks man in a woman�s dress� � A story of an 18 year-old boy dressed up like a woman, who was taken to bed by a man, and �was subjected to a severe beating by the crowd� when it was found out that he was not a woman.
These and many other stories that one could be stigmatised, ostracised even by family members have driven MSM in Ghana underground, where only the adherents know themselves. Operating underground in itself creates a safe haven where adherents have developed their own languages and systems of protecting themselves from exposure. It also makes it difficult to introduce an intervention for MSM as part of the national response to HIV/AIDS.
Though not officially acknowledged, homosexual behaviour is also believed to happen in non-MSM groups especially in situations where men are kept together for a long time with very limited access to women. These include prison inmates, uniformed personnel on assignments away from home, boarding houses etc. In Ghana, it has been reported that HIV/AIDS is the number two-killer of prisoners and accounts for 17.5% of prisoner deaths in the country after tuberculosis, which accounted for 20.6% of deaths in 2002 . For this reason, the Prisons Authorities are adopting measures to check sodomy in the prisons. The Police themselves have also come under scrutiny in studies in Senegal and India where a significant number of men reported being raped by policemen , .
Currently all working documents of the country on HIV/AIDS recognise only heterosexual transmission of HIV. The National HIV/AIDS Response Analysis and the Ghana HIV/AIDS Strategic Framework 2001-2005 list a number of vulnerable groups but failed to identify MSM as a potential mode of transmission of HIV. The contribution of MSM to HIV transmission in Ghana is also not highlighted in the AIDS Impact Modules (AIM) , which are designed as advocacy materials on the epidemic. Facts available at the international level also indicate zero transmission of HIV by homosexual and bisexual groups in Ghana.
At the beginning of the HIV/AIDS epidemic in Ghana, the female to male ratio was 6:1. (REF) The higher female prevalence was at the time attributed mainly to female sex workers returning from countries with high HIV prevalence. This high female to male ratio declined rapidly to almost 1:1 as the disease began being transmitted locally. This decline was largely explained by heterosexual transmission only and the contribution of MSM was never investigated.
3 Findings
3.1 Background of Respondents
The ages of those interviewed vary between 15 years and 40 years and above with the majority being in the younger age group. Over 75% of the respondents are aged between 15 years and 29 years with almost 50% being under 25 years. The educational background of respondents spans all the levels of education with 12 (8.0%) having had no education at all. While 56 or 37.3% have primary education up to Junior Secondary School (JSS) Level, 52 or 34.7% have secondary education and 28 or 18.7% had tertiary education including vocational/technical training. It must be emphasised that a number of respondents in the secondary and tertiary categories are currently in students (See Occupation).
Table 1: Age Group Distribution Table 2: Educational Status of Respondents
Age-groups No. of Respondents Percentage Educational Status No. of Respondents Percentage
15-19 yrs 16 10.7 None 12 8.0
20-24 yrs 57 38.0 Primary � JSS 56 37.3
25-29 yrs 40 26.7 Secondary (Incl. SSS) 52 34.7
30-34 yrs 21 14.0 Tertiary (Inc. Vocational etc.) 28 18.7
35-39 yrs 11 7.3 Not stated 2 1.3
40 and above 5 3.3 TOTAL 150 100.0
TOTAL 150 100.0
The duration of involvement in MSM correlates fairly well with the age of respondents with most of the older men being involved the longest � up to 30 years in one case. Over 90% of the �15 � 34 years� age-group have been into MSM for periods ranging from below 1 year to 15 years and most of the 35 years and above being in it for
between 16 and 30 years. This finding is contrary to the belief that MSM in the country is a new phenomenon being driven by homosexual tourists. When the age-group distribution is weighed against how long respondents have been involved in MSM, it was observed that most respondents were exposed to MSM very early in life. In most cases exposure took place before the age of 24 years and in some exceptional cases at the very early stages of the adolescence period.
Table 3: Comparison between the Age of Respondents and How Long they�ve been involved in MSM
Age-group How long Respondent has been involved in MSM (in years) TOTAL
<1 1-5 6-10 11-15 16-20 21-25 26-30
15-19 0 (0.0%) 11 (78.6%) 3 (21.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 14 (100%)
20-24 0 (0.0%) 31 (56.4%) 22 (40.0%) 2 (3.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 55 (100%)
25-29 1 (2.6%) 16 (41.0%) 16 (41.0%) 6 (15.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 39 (100%)
30-34 1 (4.8%) 1 (4.8%) 10 (47.6%) 2 (9.5%) 5 (23.8%) 2 (9.5%) 0 (0.0%) 21 (100%)
35-39 0 (0.0%) 1 (9.1%) 5 (45.5%) 3 (27.3%) 0 (0.0%) 1 (9.1%) 0 (0.0%) 11 (100%)
40+ 0 (0.0%) 0 (0.0%) 1 (20.0%) 2 (40.0%) 0 (0.0%) 2 (40.0%) 1 (20.0%) 5 (100%)
Not stated - - - - - - - 5 (100%)
TOTAL 2 (1.4%) 60 (41.1%) 57 (39.3%) 15 (10.3%) 5 (3.4%) 5 (3.4%) 1 (0.7%) 150 (100%)
Over 80% of the respondents are single, 12 (8.0%) are married, 5 (3.3%) divorced, and 8 (5.3%) separated. Some married men claim their wives know and approve their gay sex orientation.
Others who got to know of their husbands� sexual orientation later have either divorced or are separated as a result.
In one instance after the wife got to know of the man�s sex orientation, they agreed to stay together and take care of their children but have nothing sexual between them. The man now has the freedom to bring home his male friends and the wife does not complain.
The occupation of respondents also varies from unemployed through unskilled profession and white coloured jobs. While students make up the majority of the respondents a significant number are artisans or involved in jobs traditionally regarded as the occupation of women. Only 2 (1.4%) of respondents described themselves as Sex Workers.
It is also of importance that no man of high social class was interviewed even though respondents gave indication of the involvement of such men as in the comments below:
Table 4: Marital Status Table 5: Occupational Status
Marital Status No. of Respondents Percentage Occupation No. of Respondents Percentage
Single 125 83.3 Unemployed 25 16.7
Married 12 8.0 Students 39 26.0
Divorced 5 3.3 Trader, Businessman, salesman, video rentals 26 17.3
Separated 8 5.3 Baker, Caterer, Waiter, etc 14 9.3
Widowed 0 0.0 Carpenter, Mechanic, Steel Bender, Welder, Apprentice 9 6.0
Total 150 100.0 Hairdresser, Tailor/Fashion Designer, Modelling 9 6.0
Public Servants (Customs Officer, Accountant, Clerk, Nurse, Social Worker etc) 9 6.0
Table 6: Religion of Respondents
Religion No. of Respondents Percentage Self employed 4 2.7
Christian 101 67.3 Houseboy 4 2.7
Moslem 17 11.3 Teacher / Trainee 3 2.0
ATR 8 5.3 Footballer 2 1.3
None 21 14.0 Commercial Sex Worker 2 1.3
Others 2 1.3 Dancer 1 0.7
Not stated 1 0.7 Driver 1 0.7
Not stated 2 1.3
Total 150 100.0 Total 150 100.0
The religion and ethnicity of the respondents are quite representative of the country at large with 67% of respondents being Christian and 11% being Moslem. Other reported religions include African Traditional and Asian Religions.