Academic journal article Gender & Behaviour

Risk from the Frontlines of a Hidden Epidemic Sexuality, Masculinities and Social Pressures among Men Who Have Sex with Men in South Africa: An Overview

Academic journal article Gender & Behaviour

Risk from the Frontlines of a Hidden Epidemic Sexuality, Masculinities and Social Pressures among Men Who Have Sex with Men in South Africa: An Overview

Article excerpt


The context of risk for young men who have sex with men (MSM) globally and in South Africa

There is little research that focuses on young men who have sex with men (MSM) in South Africa (McIntyre, Jobson, Struthers, De Swardt, & Rebe, 2013). Because young MSM exist and engage in sexual practice within wider social dynamics and structures, discussion of their risk must be situated within broader contexts, of young people generally but also of larger populations. Specifically, young people and adolescents in South Africa, as elsewhere, constitute a special population within HIV/AIDS epidemiology, even though within the group, females have HIV prevalence that is several times higher than men (Shisana et al., 2014). The South African National HIV Prevalence, Incidence and Behavior Survey (SABSSM) 2012 furthermore reports how, for men, HIV prevalence starts from a low of under 1% in the 15-19 age group, then reaches above 17% among the 25-29 age group, and 26% in the 30-34 group, to peak at 28.8% in the 35-39 age-group (Shisana et al., 2014). These trends are important given the widespread age mixing, but also bisexuality among MSM, and the fact that condom use is reported to decrease with age (Shisana et al., 2014).

Globally, MSM are up to 13 times more likely to acquire HIV infection than the general population ((UNAIDS), 2013). Different studies in South Africa, largely based on respondent-driven samples, report prevalence rates between 10-43% (DTHF, 2011) compared to adult prevalence which rose from 15.3% in 2001 to 17.9% in 2012 ((UNAIDS), 2013). Individual risk factors among MSM include unprotected receptive anal intercourse, which carries risk of infection 16 - 18 times its vaginal corollary (Beyrer et al., 2012; McIntyre et al., 2013); high frequency of male partners, high number of lifetime partners, and injecting drug use, among others. It is further estimated that combined, per act transmission probability and role versatility explain 98% of the difference in epidemics between MSM and heterosexual populations, and behavioral factors only 2% of the difference (Beyrer et al., 2012). In the United States, high rates of HIV infection among Black MSM have reportedly been attributed in part to high prevalence of sexually transmitted diseases that facilitated HIV transmission, and to undetected or late diagnosis of HIV infection as Black men were less likely to be aware of their HIV status or to be taking antiretroviral drugs (Beyrer et al., 2012). There was no evidence of higher frequency of risky sexual behavior or reported use of alcohol or illicit substances, among others (Maulsby et al., 2014; G. Millett, Malebranche, Mason, & Spikes, 2005), and this was held to suggest that lack of access to health services carried greater weight than risk behaviors per se (Beyrer et al., 2012).

What is critical is that MSM are a diverse group (McIntyre et al., 2013), and in diverse settings such as South Africa, they span a range of socio-economic backgrounds, sexualities, racial profiles, and ages, only sharing in common having sex with other men (Rebe, De Swardt, Struthers, & McIntyre, 2013). Moreover, MSM risk and practice are shaped by various factors in highly complex ways, from wider historical and socio-economic dynamics, through race and gender relations, and policies and the articulation of rights and health service delivery (McIntyre et al., 2013). These factors are discussed below, with stress put particularly on the hiddenness of the MSM HIV epidemic. For convenience, the factors are collapsed under two categories, which must be read as concentric and relational rather than exclusively juxtaposed.

Framing a hidden epidemic: a focus on structural factors

Structural factors that heighten MSM's vulnerability at the global level include the criminalization of homosexuality, stigma and discrimination, homophobia and insensitivity in health care systems, and poverty and inequality, violence and racism, as well as gender norms ((MSMGF), 2012; DTHF, 2011). …

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