1.1.1 Introduction of an Intervention Strategy
Questions regarding the introduction of a health intervention for MSM received the most confusing and interesting answers. This level of confusion was traced to the level of insecurity among the MSM community and the level of uncertainty of many respondents as to the genuineness of the introduction of an intervention. It is interesting to note that 7.3% of respondents do not want the introduction of any intervention at all. While 87.3% of respondents will welcome the introduction of preventive and curative services only 67.3% expressed the willingness to patronise such services. Peer education and outreach services will not be welcome by a further 10.7% and 14.7% respectively. Some of the fears expressed by the respondents are as follows:
Table 26: - Responses given to the introduction of an intervention for MSM
Intervention Strategy Yes No No answer Total
No service needed 11 (7.3%) - - 150 (100.0%)
Preventive services 131 (87.3%) 10 (6.7%) 9 (6.0%) 150 (100.0%)
Curative services 131 (87.3%) 9 (6.0%) 10 (6.7%) 150 (100.0%)
Patronise Services 101 (67.3%) 37 (24.7%) 12 (8.0%) 150 (100.0%)
Welcome the introduction of peer education 132 (88.0%) 16 (10.7%) 2 (1.3%) 150 (100.0%)
Welcome the introduction of outreach services 125 (83.3%) 22 (14.7%) 3 (2.0%) 150 (100.0%)
Other comments made by those who fear exposure include:
For those who will welcome the introduction of outreach services, the gender of the outreach worker also matters. Almost three-quarters of the respondents prefer males only as outreach workers and only 4% will welcome female only outreach workers and where females must be involved then men must accompany them. Another preference expressed by respondents is that peer educators and outreach workers must be of the Gay, Bisexual, Lesbian and Trans-sexual (GBLT) community: - �I will only accept outreach workers if they are gays.�
Table 27: - Preferred gender of Outreach Workers
Preferred gender of outreach worker Number of Respondents (n=150) Percentage
Males only 89 71.2%
Females only 5 4.0%
Both 46 36.8%
For most respondents, there is a feeling of desperation and a silent cry for help. This cry is summarised by this comment made by a young man in his early 20s who describe himself as exclusively gay.
As part of the intervention strategies some respondents are calling for a massive education of both the gay community and the Ghanaian public. Calls for the education of gays include:
Some have suggested the introduction of public fora, discussions, songs, drama and popular education as a way of creating public awareness on MSM.
A number of respondents have called for the review or removal of laws that drive them underground and replace these with those that recognise gay rights to facilitate the introduction and patronage of services for gay men.
1.2 Bridging from Bisexual Men to Women
Another important finding is that while 81 or 54% of the respondents described themselves as exclusively gay, 69 or 46% described themselves as bi-sexual. Female sexual partners of the bi-sexual men include wives 16 (10.7%), girlfriends 47 (31.3%), casual sex partners 24 (16.1%) and commercial sex workers 2 (1.3%). It should be noted that some of these men also have multiple female sex partners and some who are separated from their wives still have sex with them.
Some of the men also keep female partners as a way of removing any suspicion from their gay way of life.
While 62 (89.9%) of the bisexuals know that they could infect their female partners and vice versa, only 21 or 30.4% claim to use the condoms always for vaginal sex.
Table 28: - Use of condom for vaginal sex and gay anal sex
Use of condom for vaginal sex (n=69) Use of condom for gay anal sex (n= 147)
Number Percentage Number Percentage
Never 9 13.0% 31 21.1%
Sometimes 15 21.7% 77 52.4%
Most of the time 18 26.1% 22 15.0%
Always 21 30.4% 17 11.6%
Not stated 6 8.7% 0 0.0%
Total 69 100.0% 147 100.0%
When use of condom is compared, respondents in general were more likely to use condoms always for vaginal sex (30.4%) than for gay anal sex (11.6%). By the same token, they were less likely never to use it for vaginal sex (13%) than for gay anal sex (21.1%). These are indications that respondents believe that anal sex is by far safer than vaginal sex. Nevertheless a very significant number of bi-sexual men have very significant number of unprotected sex with women.
2 Conclusion and Recommendations
From the study, the following general conclusions can be made to guide decision-making on MSM in the country:
MSM is real in Ghana with Ghanaians fully involved. It is not a recent phenomenon and from all indication it is part and parcel of the way of life of some Ghanaians primarily and foreigners secondarily. The country abounds in factors that drive MSM and denial or wishing it away is not the solution. These factors include:
1. People�s belief that MSM is their sex orientation,
2. Poverty and the desire of many youth to make quick money
3. Peer pressure and adults playing on the ignorance of the youth
4. Thrill of adventure by the youth including the desire to travel abroad in search of greener pastures
5. Lure of older gays looking for partners
6. Belief that anal sex is safer than vaginal sex
7. Public�s reaction to gays and homosexuality, which is driving MSM underground and creating a safe haven for it while at the same time making it almost impossible to reach out to them
8. Slow but growing pool of boys, who after being introduced to it themselves become active members and maintain the cycle by introducing others
The price we end up paying as a country is that a good number of Ghanaians are left to their fate with untold repercussion on themselves, the rest of the population and the nation as a whole.
1. The majority of adherents ignorantly engage in a lot of unsafe sex including:
? Anal sex with inadequate lubrication
? Multiple sex partners/customers
2. Inadequate knowledge of most STI including HIV so as to take the necessary protections
3. Inadequate of protection against infection during gay anal sex and erroneous belief in antibiotics, herbal preparation and spiritual protection against infection
4. A fair share of MSM related health problems making them potential candidates to HIV infection and
5. Active bridging between bisexual men and their women partners creating more innocent avenues for the spread of HIV as has been reported elsewhere.
As a country we need to acknowledge homosexuality in all its ramifications and develop strategies and interventions to make it safer and thus remove any untoward complications is associated.
Globally Sub-Saharan Africa is home to 2/3 of all HIV/AIDS cases in the world. It is possible that MSM contributes 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) has a vision to bring about �improved overall health status and reduced inequalities in health outcomes for all people living in Ghana� (italics mine). By the same token, the mission of the MoH/GHS is to �work in collaboration with all partners in the health sector to ensure that every individual, household and community is adequately informed about health; and has equitable access to high quality health and related health interventions� . The code of ethics of the GHS mandates all service personnel to respect the rights of patients and safeguard the clients� confidence. Service personnel are also mandated not to discriminate against clients on the grounds of the nature of illness . The MoH/GHS therefore owes it a duty to ensure that men in Ghana having sex with other men are not left out of their stated vision and mission, as is currently the case.
A health intervention should be introduced for the homosexual community and in doing this it must not be assumed that the introduction of intervention programmes will bring about automatic patronage. A number of issues of interest to the gay community must be addressed to ensure that there will be the desired patronage. The following recommendations are therefore made in support of the national response to HIV/AIDS.
In the short-term, the Ghana Health Services and her partners should implement strategies similar to those used by the West Africa Project to Combat AIDS and STI (WAPCAS) for female Commercial Sex Workers even in the face of legal obstacles and a hostile public. These strategies include:
1. Dissemination of the findings and recommendations of this study widely to the relevant sections of the public and decision-makers
2. Starting a confidence building process by involving CEPEHRG and other NGOs working with the youth e.g. YPEP and Salvation Army to develop a programme of intervention for MSM. As a first step, the following could be done:
? Supplying the NGOs with lubricants and condoms to be sold or distributed to members and other gays
? Supporting the educational programmes of CEPEHRG as a way of building trust and addressing health problems facing gays
? Recruiting and training GBLTs as peer educators and outreach workers
3. Giving recognition to the clandestine gay associations and encouraging the formation of many such associations
4. Training and re-orienting health workers and services in the STI clinics in the management of homosexual related health conditions particularly in issues of privacy, confidentiality and the rights of the patient
5. Including MSM as part of IE&C messages on safe sex to the youth and developing health promotion/education materials on the dangers and precautions in anal sex
6. Ensuring that the HIV/AIDS programme of the Police and other uniformed personnel includes IE&C messages on MSM not only to protect the gays and the public but also the police themselves from infection
7. As part of the intervention to be introduced, a nation wide study should be mounted to better understand MSM in the country.
Long-term Recommendations
The long-term recommendations are those that aim at removing all obstacles to the successful implementation of health interventions for MSM including the removal of legal and social barriers. These will be more difficult and will require a lot of advocacy to persuade decision-makers and the public to achieve them. They include:
1. Decriminalising homosexuality by removing laws on our statute books that criminalize it. This will not only make it possible to fully implement interventions for MSM but will also make it possible for mobilising resources for such programmes
2. Public education to remove social barriers that drive MSM underground such as stigmatisation, discrimination and denials of male homosexuals
3. Educating all sectors of the public especially the youth and giving them the right information to take informed decision on their lives
4. Reviewing national documents on HIV/AIDS to give recognition to gays a a vulnerable group and MSM as a potential mode of HIV transmission
5. Mobilising resources to support programmes the management of MSM related health conditions and NGOs working with gays and the youth