Understanding health needs of men who have sex with men in Agra district of India: a community based mixed method study

INTRODUCTION

Men who have sex with men (MSM) refer to all males (of any age) who engage in sexual relations with other males. The gross stigmatization of homosexuality and discrimination of homosexuals have always affected the life and health of MSM (especially young MSM). Sexually transmitted infections, including HIV, are major concerns in MSM.¹ besides HIV, MSM account for 75% of reported primary and secondary syphilis infections and more than one-third of gonorrhoeal infections.^2,3 Outbreaks of hepatitis C infection transmitted by sexual contact have also been reported in HIV-infected MSM in urban areas.⁴ Also, rates of human papilloma virus-associated anal cancers among MSM are seventeen times those of heterosexual men, with even higher rates among individuals concurrently infected with HIV.⁵ In addition, MSM individuals experience more depression and anxiety than their heterosexual counterparts and are more likely to attempt suicide.⁶ In short, Premature death rates are higher among MSM as compared to their heterosexual counterpart.⁷

In India, after Supreme court verdict about section 377 on September 2018, MSM emerged as a legal community but still it’s one of the excluded groups of society, incidences of stigma and discrimination are often seen.⁸ this has adverse impact on their social, physical, sexual and mental health. To achieve ‘Universal health coverage’ and ‘health for all’, healthcare needs of this group must be addressed as they had been living in shackles of exclusion. Now as homosexuality is no more considered as disorder under Indian classification of disease and it is no more a punishable offence, their distinct health needs must be understood.

With this background, study was conducted to understand health needs of MSM using community based mixed method technique in Agra district of India.

METHODS

Qualitative research

This qualitative study was conducted in MSM population in Agra district of Uttar Pradesh state in India between December 2017 and November 2018. The participants were recruited through snowball sampling. The first participant was recruited through a non-profit peer group. Further participants were subsequently referred by the participants from their peer circles. The inclusion criteria for the participants of the study are: Self-reported same sex behaviour in last 1 year and 18 years or older at the time of interview. The exclusion criteria are: Self-reported HIV positive status, critically ill or suffering from end stage disease and lack of willingness to participate or provide written consent.

The participants were informed about the study and a written consent was taken for their participation and for audio-recording their interviews. The questionnaire was semi-structured and was constructed using guidelines of In-depth interviews (IDIs).⁹ In-depth interviews were conducted with the eligible participants at the place of their choice, in the language as per their fluency (Hindi and/or English) and were audio recorded. Each interview lasted for 30-45 minutes. The audio was converted in to transcript. The transcripts in Hindi language were converted in to English and were analysed after each interview. The interim data analysis was done using thematic analysis. Potential issues and concepts were identified from relevant words, phrases, sentences and paragraphs of the text and were marked (labelled) and coded. Potential themes were extracted as a part of analysis as per relevant experiences, behaviours, attitudes and acts of the participants. Data saturation was achieved after 13 In depth interviews. The audio recordings were simultaneously deleted after each analysis. No identifier was mentioned in the transcripts.

Quantitative research

The Snowball technique for sampling was used. Firstly, participants were recruited through a non-profit peer group. Further participants were subsequently referred by the participants from their peer circles. Data collection was done from October 2018 to September 2019. A total of 52 MSM participated in the study.Inclusion and exclusion criteria were same as the qualitative study. The proforma schedule used for quantitative assessment were pretested, predesigned and semistructured. A mixed questionnaire was used in the study where closed ended questions were asked to assess their socio-demographic charecterstics, and open ended question was kept to explore the reasons for prefering a health care facility. Before start of the interview, the participants were explained about the purpose of the study and sensitive nature of the questionnaire. Informed consent was taken and confidentiality was assured. Information collected on the study schedule was transferred on pre-designed classified tables and analyzed according to the aims and objectives and represented by tables analysed through MS excel.

The ethical clearance for whole study was taken from Institutional Ethical Clearance Committee, SN Medical College and Hospital, Agra.

RESULTS

Socio-demographic characteristics

This descriptive study was conducted among fifty-two MSM residing in Agra city of Uttar Pradesh, India. The study found that 65.39% of MSM were in the age group of 20 to 29 years. Mean age of respondents was 27.75 (±6.48) years ranging from 19 to 45 years. Majority of them were Hindus (55.77%) and Muslims (38.47%). Educational status varied from primary school pass outs (1.92%) to graduate/postgraduate degree holder (50%) but none of them was illiterate and 7.69% were professionally qualified. Majority of them were residing in an urban area (71.16%), were unmarried (86.54%) and belonged to a nuclear family (73.10%). Highest (32.69%) of them were working as clerk/shop-keeper/farmer and 19.24% were unemployed. Majority of them belonged to lower middle (61.5%) and upper lower socio-economic class (30.76%) as per modified Kuppuswamy’s classification (Table 1).

Healthcare needs of MSM

Multiple overlapping responses were received regarding the health needs of the MSM community; most common responses were related to the increase availability of testing for various STDs and HIV and MSM friendly atmosphere at the health care facility. Easy availability/ free availability/low cost availability of HIV and STD testing (32.69%) was foremost cited health need. 26.92% of respondents said they can’t say anything about health needs of MSM. 25% of respondents told to increase the number of MSM friendly STD clinics as their health need. 15.38% of respondents think that doctor should be taught not to discriminate with MSM and there should be increased awareness about MSM people in the medical curriculum. 11.53% think that doctors should be more compassionate and non-judgemental. 9.61% of respondents sought for testing facilities of HIV and STD’s in rural areas and 5.76% asked for psychiatric and medical counselling for MSM. 3.84% of respondents said that right to surrogacy to MSM community was their prime need and another 3.84% think that inclusion of Ayurveda in government health care for STD’s was much needed. 1.92% of respondents said that HPV vaccination and pre-exposure prophylaxis of HIV (PREP) was their health need. 1.92% of respondents asked for more research on HIV while 1.92% of respondents told cheap medicines at affordable price as their health need (Table2).

*as per Kuppuswamy’s classification.

*Multiple responses.

Qualitative findings

A total of 13 individuals who identified themselves as active MSM and were living in Agra city participated in this study. They were aged between 22 to 45 years, 2 of them were married and 9 were full-time students.

At the start of the interview, the respondents reacted with a sense of scepticism and disbelief that someone is really interested to talk to them on this issue. Got varied responses. Important qualitative findings are cited as follows

On asking about his health care needs, one of the respondents complained of poor understanding and attitude of health care workers towards MSM whenever approached for any health problem and he wanted empathetic doctors towards MSM: “People if suffer from medical ailment due to this behavior, he is not clearly able to talk to the doctor. I need doctors who are employed in government hospital should be compassionate enough to understand this issue and tackle it without mocking or without any stigma. Government should have created more awareness even to doctors, health workers as well as people involved in health industry” (IDI-7, 45 years, employee, married).

Another respondent stated straight forwardly: “Psychiatric health services and counselling available hona chahiye, sexual health clinics stigma and discrimination free hona chahiye, aisi cost me jo sab afford kar paye”. (IDI-9, 23 years, graduate, unmarried).

“There should be availability of Psychiatric health services and counselling. Sexual health clinics should be free from stigma and discrimination, and it should be at cost which everyone can afford.” (IDI-9, 23 years, graduate, unmarried).

One of the respondents told that his dermatologist didn’t even ask about his sexual behavior when he consulted him for an HPV treatment: “No they just asked me how active I am. They did not ask about my sexual behavior. I guess they thought…… heterosexuality is so common that (the dermatologist) didn’t bothered to ask that” (IDI-2, 25 years, graduate, unmarried).

One of the respondent was aware about Pre exposure prophylaxis of HIV and on being asked about his health need he narrated (taking deep breath) “Agar government ye kehti hai ki LGBT community ke logo ki vajha se hi STDs jaise ki HIV hota hai ya MSM community ke log hi HIV ko la rahe hain to prophylaxis roop me jo medicine aa rahi hai une vo sasti kimato pe de taaki harek insane unhe use kar sake, aur aage koi health issue na ho.”( IDI-4, 29 years, postgraduate, unmarried).

“If government says that LGBT community people are responsible for STDs like HIV or MSM community individuals are spreading HIV than Prophylactic medicine must be provided at lower cost so that everyone can afford it and can prevent health issues in future” (IDI-4, 29 years, postgraduate, unmarried).

Another respondent said “I want psychiatric counselling center or camp for LGBT people. I would also want govt to make more awareness about MSM health issues and STD’s and their mode of prevention” (IDI-11,25 years, graduate, unmarried). On asking about health needs one of the participants expressed his concern that “STD clinics should be MSM friendly and doctor should be empathetic and non-judgemental” (IDI-3, 24years, graduate, unmarried).

DISCUSSION

This study represents the first formative mixed method research of the healthcare needs of MSM in India. In the present study, through quantitative analysis we found multiple overlapping responses regarding the health needs of the MSM community, most of respondents want that testing facilities should be readily available for various STDs including HIV for MSM especially in rural areas. Many said that STD clinics must be MSM friendly and doctors should not discriminate and hear them compassionately. More than one-fourth of the respondents said that they can’t say anything about their health needs and this shows large proportion of MSM people are ignorant toward their overall health. Even though this study is conducted in smaller city Agra, but we got vivid responses like right to surrogacy to MSM community and availability of pre-exposure prophylaxis of HIV, this depicts changing socio-cultural norms, findings have a number of implications for future social service and health promotion practices, interventions and research. Clearly these findings point to the value of addressing the health needs of MSM in long run. Qualitative findings revealed that that they were mostly treated as heterosexual as nobody cared to ask them about their sexuality and sexual behavior on routine examination and history taking. Similar findings were seen in a qualitative study done by Wirtz et al in Malawi which highlights that though individual disclosure of same-sex practices to health care provider is not always necessary but it is a critical component for risk reduction counselling and ensures HIV and STD prevention messages which are inclusive and informative for them.¹⁰ Narratives of MSMs also highlighted that there is unmet need of cost-effective and discrimination free psychiatric counselling and sexual health services which they can easily afford. Other studies conducted by Lampalzer et al (2019) in Germany and by Alpert et al in United states also pointed to the need for the elimination of discrimination so that health professionals should treat MSM people non-judgementally.^11,12

CONCLUSION

MSM wanted a non-judgemental and discrimination free environment at health facilities and also suggested MSM inclusive STD centres and psychiatric counselling which should be cost-effective for better health and well-being of MSM. Training of medical and para-medical professionals about psychosexual health issues of MSM is needed to improve the health care of MSM by keeping a non-judgmental and compassionate attitude towards the MSMs. The main implication of the study was the need to recognize the existence and their diverse health needs and link them to appropriate health care.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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