When the going gets tough

Last week, I attended the quarterly meeting of the National MSM Technical Working Group (NMSMTWG) in one of the hotels here in Phnom Penh. This working group was convened by the Cambodian National AIDS Authority (NAA) to address MSM-related issues on the national response to the HIV/AIDS epidemic in Cambodia. Just over a year old, it is composed of representatives of government, civil society, donors, and (supposedly) the MSM community (to the uninitiated, MSM stands for males-who-have-sex-with-males, a behavioural term that arose during the AIDS epidemic to connote males who have sex with other males without identifying themselves as gay or bisexual).

As an independent consultant, I am the only member of the TWG who is not affiliated with any organizations I have mentioned. Except perhaps, the MSM community. This, however, is something I don’t like to claim because of a fundamental fact: I am not Cambodian. I will elaborate on this point later.

One of the highlights of the day’s meeting was the presentation of the results of the 2007 Behavioural Sentinel Surveillance (BSS). This was an important milestone because since the BSS was first conducted in 2007, it has never included MSM. A total of 729 MSM participated in the surveillance, from 5 provinces that have always been covered by the BSS. Significant findings on MSM included: the existence of male and female sexual partners, about half of the respondents hadn’t had an STI check-up, very low lubricant use, moderate reach of outreach work, a little over half had HIV Antibody Test at VCCT centres, and an alarmingly high rate of drug use, including injecting drug use.

In the discussion that followed, Tony Lisle, the UNAIDS Country Coordinator, expressed concern at the figures presented. He underscored a very important point when he asked, ‘Are we preventing new infections among MSM?’ I didn’t think so. He called for a re-thinking of HIV prevention interventions for MSM because, in his words, ’something is not working with the kind of outreach that is currently being done’. And health services for MSM are severely lacking as well.

The discussion soon (d)evolved into what interventions should be done to reach the varied MSM groups: the srey saat (long-haired MSM, or what we’d call transgender), the pros saat (short-haired MSM, or the average-looking fellows), the visible (always the srey saat, sometimes the pros saat), and the hidden (possibly, the pros saat who never go to the bars, who often have girlfriends or wives). This last group is, of late, the focus of interest of many NGOs working with MSM.

While there are no laws that discriminate against Khmer gays and (the more invisible) lesbians, there are also no laws that protect them. Like other countries in the region, same-sex behaviour is not frowned upon per se in Cambodia, as long as the man marries and creates a family. Buddhism views homosexuality as a result of a bad deed in one’s past life, hence a more compassionate stance towards it. Families, meanwhile, are of a different matter. One of the participants mentioned the effects of discrimination in the family on the health of MSM. Once a man is found out to be gay, he will almost always be driven out of his home and be disowned by his parents. To a Khmer, this is unacceptable. So many of them choose to marry, while continuing to have illicit sex with other men.

Previous studies on MSM have hinted at the significance of this group in the response to HIV/AIDS. Largely un-reached by programs, they seem to be very active sexually with both females and males and do not access the existing information and services for MSM. And because MSM have recently come under the spotlight of government, the donors, and civil society, at least in terms of HIV/AIDS programming, reaching these ‘hidden’ MSM suddenly became an imperative.

As the discussion became protracted, I got lost in the programmatic and epidemiological jargon and semantics. I realized that for all the talk of programs, projects, and interventions for MSM, a critical element was lacking in the MSM response to HIV/AIDS. A personal stake.

I mean, we were talking about doing outreach, establishing MSM-friendly clinics, and advocating for MSM. But on a personal level, what does advocacy really mean to, let’s say, a 13-year-old boy who lives in a remote province who’s just starting to realize he’s different from the other boys because he is growing to be sexually attracted to them?

In the TWG, for example, how many people can honestly say that s/he has not said or done anything discriminatory against an MSM? People from NGOs who work with MSM in HIV prevention still utter jokes about MSM that raises my hackles. I know that at least 5 men in the meeting that day are gay or MSM but I doubt if they will categorically admit that fact. In fact, one of them was my lover for almost 3 years, and while people in the NGO sector seem to be aware of his sexuality (and our relationship), his family doesn’t know a thing.

Discrimination against MSM in Khmer families is, by this time, a known reality. This has always been cited as one of the important reasons why Khmer MSM choose to hide their sexuality. But what is always left out in discussions on coming out is that ‘taking risks in coming out has tangible rewards’, to use Tony’s phrase. The most obvious reward being, because one has been ‘unburdened’ of the need to hide, he can now freely express himself, increasing his access to information and services that will benefit not just his health but his general well-being too. This is part of what I’m referring to as a personal stake.

I remember that one of the reasons I got into AIDS work (in 1994) was my own concern for my health and well-being. Along the way I also learned that one of the elements that could determine the success of behaviour change is the personal recognition of one’s risk. This helped cement my commitment to the issue. Unfortunately, this is not the case in Cambodia, where most people got into NGO work because it is seen as a lucrative career.

That MSM are not adequately represented in national bodies is also another known fact. MSM focal persons in government agencies and in many NGOs are not even remotely MSM at all. Bandanh Chaktomuk, the national network of MSM, was created a year ago with the financial and technical support of various NGOs. Unfortunately, it hasn’t stepped up to do its mandate when it was conceived, due to many other reasons. I am personally hopeful that the current Executive Committee of Bandanh Chaktomuk will perform better, in terms of representing the interests of Cambodian MSM.

In my opinion, no matter how competent one is in developing and implementing interventions for MSM (or any marginalized group, for that matter), this will not be enough without a personal stake. Because in my opinion, a personal stake allows people to be more creative and innovative in thinking of ways to reach out to MSM. A personal commitment strengthens and enhances interventions tremendously. On the side of the supposed beneficiaries of these interventions, the personal commitment of a service provider will nurture the client’s own commitment towards their health, in turn making them more receptive to behaviour change messages.

The challenge is going about this in Cambodia, where culture and gender are very strong threads in the fabric of its citizen’s psyche. Many things have been done, with varying degrees of success. The number of NGOs working with MSM on HIV/STI prevention, health, and rights advocacy has increased. Future programs and interventions appear to be promising. Government recognition has manifested in positive ways, e.g. the support to MSM programming on a national level, the formation of the national technical working group, and the inclusion of MSM in surveillance activities. However, judging from the way things are, a lot more still needs to be done, especially in terms of real and effective MSM involvement and participation in programs and interventions, and genuine and active MSM representation in national bodies.