Male sex workers: Are we ignoring a risk group in Mumbai, India?

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  Male sex workers: Are we ignoring a risk group in Mumbai, India?

Santosh Shinde1, Maninder Singh Setia2, Ashok Row-Kavi3, Vivek Anand3, Hemangi Jerajani4,  1 Department of Dermatology, LTM Medical College, Mumbai; The Humsafar Trust, Mumbai, India,

2 McGill University, Montreal, Canada, 3 The Humsafar Trust, Mumbai, India, 4 Department of Dermatology, LTM Medical College, Mumbai, India,

Correspondence Address:

Hemangi JerajaniDepartment of Dermatology, LTMM College and LTMG Hospital, Sion, Mumbai - 400 022, India

AbstractBackground:

Male sex workers (MSWs) have recently been recognized as an important

risk group for sexually transmitted infections (STIs) including human

immunodeficiency virus (HIV) infection. Although there are global

studies on MSWs, few such studies describe the behavioral patterns and

STIs among this population in India. Methods: MSWs were

evaluated at the Humsafar trust, a community based organization

situated in suburban Mumbai, India. We report on the demographics,

sexual behaviors, and STIs including HIV of these sex workers. Results:

Of the 75 MSWs, 24 were men and 51 were transgenders. The mean age of

the group was 23.3 (+ 4.9) years. About 15% were married or lived with

a permanent partner. Of these individuals, 85% reported sex work as a

main source of income and 15% as an additional source. All the

individuals reported anal sex (87% anal receptive sex and 13% anal

insertive sex). About 13% of MSWs had never used a condom. The HIV

prevalence was 33% (17% in men vs 41% in transgenders, P = 0.04). The STI prevalence was 60% (58% in men vs 61% in transgenders, P = 0.8). Syphilis was the most common STI (28%) in these MSWs. HIV was associated with being a transgender (41 vs 17%, P = 0.04), age > 26 years (57 vs 28%, P = 0.04), more than one year of sex work (38 vs 8%, P = 0.05), and income < Rs. 2000 per month (62 vs 27%, P

= 0.02). Conclusions: The MSWs have high-risk behaviors, low consistent

condom use, and high STI/HIV infections. These groups should be the

focus of intensive public health interventions aimed at reduction of

risky sexual practices, and STI/HIV prevention and care.

How to cite this article:

Shinde S, Setia MS, Row-Kavi A, Anand V, Jerajani H. Male sex workers:

Are we ignoring a risk group in Mumbai, India?.Indian J Dermatol

Venereol Leprol 2009;75:41-46

How to cite this URL:Shinde S,

Setia MS, Row-Kavi A, Anand V, Jerajani H. Male sex workers: Are we

ignoring a risk group in Mumbai, India?. Indian J Dermatol Venereol

Leprol [serial online] 2009 [cited 2009 Dec 10 ];75:41-46

Available from: http://www.ijdvl.com/text.asp?2009/75/1/41/45219

Full Text Introduction The

organized sex trade has been a focus of intense discussion within the

context of the human immunodeficieny virus (HIV) epidemic in

Maharashtra as well as in India. [1] The female sex workers and their

clients represent a high-risk group for acquisition of sexually

transmitted infections (STIs) including HIV. Maharashtra's, and

especially Mumbai's, organized brothels and various commercial sex

sites are frequently visited by men native to the city, and also by the

massive number of individuals migrating to the highly developed state

in search of employment. Also, the sex workers themselves come from

both within and outside the state. Since the first case of

HIV/AIDS was identified, prevention programs have recognized the

importance of understanding the sex work industry. This included

collecting systematic and reliable data on sex work, and contextual

issues around selling of sex. [2],[3],[4] While research on female sex

workers is extensive, comparatively less information exists on male sex

work. Yet we cannot simply assume that the pattern and characteristics

of the female sex industry will be the same as that of the male sex

work industry. Coupled with sex trade and industrialization, social

marginalization of groups such as male sex workers (MSWs) which include

men who have sex with men (MSM) make prevention efforts with these

extremely vulnerable groups all the more difficult. [5] MSM

are a diverse and often hard-to-reach group, spanning all age groups

and socioeconomic backgrounds. [6],[7],[8] MSM in India can be divided

into various subgroups: self-identified MSM (gay identified, kothis,

panthis ), behaviorally MSM with no identity, bisexual men, and

male-to-female transgenders ( hijras ).Other groups include

subpopulations who are vulnerable because of their

occupations/profession, and often engage into 'survival sex'; work is

often intermittent and irregular for these men and they may actually

have to offer sex in exchange for money. [9] This study aims

to understand the prevalence of sexual behaviors and STIs including HIV

in MSWs. We further aim to understand the association of

sociodemographics and HIV in this risk group. Methods The

present study is a cross-sectional analysis of unlinked anonymous

secondary data. We assessed the sociodemographic, behavioral, and

clinical characteristics of MSWs attending an STI clinic in an urban

setting in India, Mumbai.The study was approved by the Institutional Review Board at the Humsafar trust as a secondary data analysis project.Study site The

data were collected from men attending an STI clinic at the Humsafar

trust, a community based organization that provides services to various

groups of MSM. The clinical services include a voluntary HIV testing

centre and an STI clinic. About 100 new individuals access the services

of the clinic every month. These individuals are from all socioeconomic

strata of the society; a large number of them are self-identified gay

men reporting for STI/ HIV testing and counselling. Subjects All

individuals presenting at the STI clinic above the age of 18 years were

eligible for the present analysis. We defined MSWs as men or

transgenders who engaged in sexual activities with individuals in

return for benefits either in cash and/or in kind, and included them in

the analysis.Measurements Data were collected on a

structured interviewer-administered questionnaire. We used demographic

information: age, marital status, education, employment other than male

sex work if any, and income, for our analysis. We also used specific

information on sex work: age at first sexual exposure, number of

clients per day, meeting place for clients, preference of clients, type

of sexual practices (oral insertive, anal insertive, vaginal, anal

receptive, or oral receptive) in the past six months, in the present

analysis. In addition, we included information on other behaviors:

condom use, alcohol use, injection drug use, and any past history of

blood transfusion, in our analysis.Clinical evaluation Subjects

were clinically evaluated by trained physicians for the presence of any

STIs. Blood was collected for VDRL testing, Treponema pallidum

hemagglutination assay, hepatitis B surface antigen, HSV 2 IgG,

hepatitis C, and HIV. Urethral discharge, if present, was evaluated

with Gram stain to identify white blood cells and Gram negative

intracellular diplocooci. Patients with genital ulcers were treated

clinically for syphilis, chancroid, and/or herpes. Patients with

symptoms of proctitis underwent anoscopy. All the subjects were treated

according to the guidelines laid down by National AIDS Control

Organization, India. Subjects were evaluated for HIV after consent and

adequate pre-test counselling by trained counsellors. They received

their results at the clinic after one week; they were post-test

counselled during this visit. Clinicians evaluated the response to

medications in the subjects, and treatment was modified according to

the response to the previous medications.Data analysis Data

were entered in EpiInfo 2000 and converted to Stata (version 10) for

analysis. Distribution of responses was calculated using means and

standard deviations (SD), medians, and proportions. Continuous

variables were visualized using histograms. We used t -test to

calculate the difference between the means of the continuous variables.

Pearson's chi square tests and Fisher's exact test (low expected cell

counts) were used to evaluate the association of categorical estimates.

We calculated the odds ratio (OR) and the 95% confidence intervals

(CIs) as a measure of association. Results Data

from 75 consecutive MSWs, 24 men and 51 male-to-female transgenders,

were analyzed. The HIV prevalence in the whole group was 33%; it was

significantly higher in transgenders compared with men (41% vs 17%, P =

0.04).Characteristics of sex workers The mean age (SD)

of sex workers was 23.3 (+ 4.9) years. There was no significant

difference between the mean ages of men and transgenders, 22.2 (+ 4.0)

vs 23.7 (+ 5.2), P = 0.20. Majority of the sex workers were single

(85%) and were educated up to secondary or higher secondary school

(55%). In our population, we found that transgenders were more likely

to be illiterate compared with men (43 vs 25%), although the difference

was not statistically significant ( P = 0.15). About 13% of

the sex workers reported having anal insertive sex and about 87% of

them reported having anal receptive sex in the past six months. Men

were more likely to report anal insertive sex compared with

transgenders (38 vs 2%, P vs 98%, P vs 86%, P = 0.22). In addition,

three men reported having vaginal sex in the past six months. None of

the transgenders reported having vaginal sex.About 33% (25/75)

of the sex workers had always used a condom, about 53% (40/75) had

sometimes used it, and about 13% (10/75) had never used it; there was

no statistical difference in condom use by men and transgenders. The

most common reason for not using a condom was nonavailability (43%),

followed by refusal of condom use by the partner (20%). About 15%

(11/75) sex workers had tattoos, of these six were HIV infected. Only

one transgender reported injection drug use. About 32% (24/75)

of the sex workers were diagnosed with a clinical STI at the time of

presentation to the clinic. Among these STIs there were - seven cases

of perianal warts and genital scabies; four cases of perianal herpes

infection; and one case each of urethral gonorrhoea, rectal gonorrhoea,

penile wart, perianal molluscum contagiosum, primary syphilis, and

secondary syphilis. We have described certain demographic characteristics and STIs including HIV in these sex workers in [Table 1].Characteristics of sex work About

80% (60/75) of our population identified sex work as their primary

occupation. All the transgenders stated that sex work was their primary

occupation. About 77% (58/75) of the MSWs met their clients at public

places. However, 67% (50/75) of the sex workers reported having sex in

a private environment (clients home, their home, or a hotel). About 85%

(64/75) of them reported sex work to be their primary source of income

for survival. These MSWs were more likely to be HIV infected compared

with those that reported sex work to be an additional source of income

(39 vs 0%, P = 0.01). All the transgenders had reported sex work to be

their primary source of income. MSWs whose primary source of income was

sex work were more likely to report anal receptive intercourse with

their clients compared with others (92 vs 55%, P 26 years of age, in

those whose total income was less than 2000 rupees per month, in those

who reported sex work to be the primary source of income, and in those

who have been a sex worker for more than a year. About 15% of the sex

workers were married to a woman or lived with a male partner, and 45%

of these sex workers were HIV infected. Only 33% of these sex workers

had always used a condom. About 60% of the sex workers had an STI

(clinical and/or serological) at the time of presentation. Only 48% of

the sex workers perceived that they were at risk for HIV infection.

recommends using Maloney's definition of an MSW as 'any male who

engages repeatedly in sexual activities with persons with whom he would

not otherwise stand in any special relationship and for which he

receives currency and/or the provision of one or more of the

necessities of living (food, clothing, and protection)'. [10] The

groups commonly involved in male sex work in Mumbai are masseurs,

transgenders, young migrant men practicing male sex work for survival,

or men with other occupations practicing male sex work for extra money.

[11] Among the sex workers, kothis are effeminate MSM who may

have sex with men and/or women. Though they are MSM, they nevertheless

can turn their feminine behavior on or off as the situation demands.

This fluid behavior potentially helps them to 'play with gender' in the

context of sex work. However, in the case of transgenders or hijras ,

the issue is compounded by their cross-dressing and 'crossing over' to

the female gender. They may be seen as objects for penetration because

of their cross over into the female gender. The noncastrated

transgenders have the option of being the insertive partners for other

males; their sexual behavior may still be fluid. Castrated transgenders

can only offer receptive sex; this 'fixed' gender identity and sexual

behavior potentially makes them most vulnerable for HIV/AIDS within the

context of male sex work. [11],[12],[13] MSM are at a high risk

for acquiring STIs including HIV. [14] The HIV prevalence in our sample

of MSWs was higher compared with other global studies.

[15],[16],[17],[18] Although, we did not find any published studies on

HIV prevalence in MSWs in India, Dandona and coworkers have reported

that the probability estimates for acquiring HIV by men who sell sex

were 6.7 (95% CI: 4.9-9.2) times higher compared with women who sell

sex. [19] Thus, MSWs are an important risk group in the context of the

HIV epidemic, and adequate attention should be accorded to them. Though

sex work per se is not a risk factor for HIV; sharing drug-injecting

equipment, condom use that varies between types of partners, unsafe

sexual behaviors, and inconsistent condom use increase MSWs'

vulnerability to STIs including HIV. [20] Stigmatization of

same sex behavior often results in hurried sex in the dark. In our

population, we found that although the common venues to access clients

were public places, the most common venue for the sexual act was a

private venue. The private space may potentially help in increasing

condom use with clients. However, condom negotiation may depend on

various factors: economic considerations, physical and/or emotional

attraction toward the clients, types of sexual practices (oral vs anal

sex), and type of sexual partners. [12],[21] In our sample, we found

that individuals reporting sex work as the primary source of income

were more likely to be HIV infected. This observation was potentially

confounded by the type of sexual activity; majority of the sex workers

who reported sex work as main source of income were transgenders and

reported anal receptive sex. However, the role of economic factors in

sexual activity and condom negotiation by these sex workers should not

be ignored. Clients of MSWs form a heterogeneous group; broader

understanding of the interaction between the client and the sex worker

may help us design effective public health strategies.[22] One

of the limitations of the study was its sampling - it was a

clinic-based convenience sample, and hence may not be representative of

the sex work in the population. However, the Humsafar trust has a good

peer outreach program and provides information to various sections of

the sex worker community. Our study was conducted in an MSM STI/HIV

clinic. Although there is a category of MSWs who indulge purely in

heterosexual sex trade, our study population did not include these men.

Thus, these findings may not be applicable to that population. Since

our data were collected in clinical settings, sex workers are more

likely to report socially desirable behaviors of safe sex practices;

hence, we may have underestimated risky sexual behaviors. In

spite of the above limitations, this is an important study which

provides information on MSWs in Mumbai. Unlike female sex work, where

all other identities of a woman are superseded and the primary identity

becomes that of a sex worker or woman in prostitution, in male sex

work, they can hide under various labels like masseurs, bar boys, etc.

They can get away with these 'other' identities and still practice sex

work without the stigma attached to it. These groups should be the

focus of intensive behavioral intervention - safe sex and condom use,

and STI/HIV prevention and care programs. [23] Qualitative research

would be an important tool to identify social aspects of sex work and

negotiation skills. Issues related to STI care access by these groups

need to be explored for effective public health interventions. Acknowledgment We

would like to acknowledge the services of Specialty Ranbaxy Laboratory

for conducting the serological tests for STIs, Dr. Dethe for evaluating

the patients, and the outreach workers for assistance with data

collection. One of the co-authors (MSS) is funded by CIHR-IHSPR

Fellowship and CIHR-RRSPQ Public Health Training Programme for his

doctoral studies at McGill University. The Humsafar Trust would like to

acknowledge support from Mumbai Districts AIDS Control Society.

References1

Gisselquist

D, Correa M. How much does heterosexual commercial sex contribute to

India′s HIV epidemic? Int J STD AIDS 2006;17:736-42.

2Dandona R, Dandona L, Gutierrez JP, Kumar AG, McPherson S, s F, et al . High risk of HIV in non-brothel based female sex workers in India. BMC Public Health 2005;5:87.

3Dandona

R, Dandona L, Kumar GA, Gutierrez JP, McPherson S, s F, Bertozzi

SM. Demography and sex work characteristics of female sex workers in

India. BMC Int Health Hum Rights 2006;6:5.

4Sarkar

K, Bal B, Mukherjee R, Saha MK, Chakraborty S, Niyogi SK, Bhattacharya

SK. Young age is a risk factor for HIV among female sex workers: An

experience from India. J Infect 2006;53:255-9.

5Mahalingam

P, Watts R, J, Sundari E, Balasubramaniam S, Chakrapani V.

Stigma and discrimination affect access to medical care of HIV-infected

men who have sex with men (MSM) in Chennai, India. [abstract no.

TuPeD5068]. 15th International Conference on AIDS. Thailand: 2004.

6Asthana

S, Oostvogels R. The social construction of male ′homosexuality′ in

India: Implications for HIV transmission and prevention. Soc Sci Med

2001;52:707-21.

7Chan R, Kavi AR, Carl G, Khan S, Oetomo D, Tan ML, et al . HIV and men who have sex with men: Perspectives from selected Asian countries. AIDS 1998;12:S59-65, S67-58.

8Khan S. Culture, sexualities, and identities: Men who have sex with men in India. J Homosex 2001;40:99-115.

9The Humsafar Trust. MSM Circle. In. Mumbai; 2008. Available from: http://www.humsafar.org/resource_materials.htm. [last accessed on 2008 May 18].

10 E. The development of male prostitution activity among gay and bisexual adolescents. J Homosex 1989;17:131-49.

11Kavi AR. Reaching out. Beyond the monsoon. India: AIDS Action; 1991. p. 4.

12Venkatesan

C, Fernandes S, Ganapathy M, Mallika J. The hidden population of male

sex workers in Chennai, Tamilnadu - The need to develop specific

intervention programmes. In: II International Conference on AIDS.

Chennai: 2000.

13Venkatesan

C, , Fernandes S, M. High-risk sexual practices among

hijras in commercial sex work in Chennai, Tamil Nadu: Implications in

prevention and control of HIV. In: II International Conference on AIDS

Chennai: 2000.

14Setia MS, n C, Jerajani HR, Kumta S, Ekstrand M, Mathur M, et al

.. Men who have sex with men and transgenders in Mumbai, India: An

emerging risk group for STIs and HIV. Indian J Dermatol Venereol Leprol

2006;72:425-31.

15Coutinho

RA, van Andel RL, Rijsdijk TJ. Role of male prostitutes in spread of

sexually transmitted diseases and human immunodeficiency virus.

Genitourin Med 1988;64:207-8.

16Estcourt

CS, Marks C, Rohrsheim R, AM, Donovan B, Mindel A. HIV,

sexually transmitted infections, and risk behaviours in male commercial

sex workers in Sydney. Sex Transm Infect 2000;76:294-8.

17Minichiello V, Marino R, Browne J, son M, K, Reuter B, et al . Male sex workers in three Australian cities: Socio-demographic and sex work characteristics. J Homosex 2001;42:29-51.

18Tomlinson

DR, Hillman RJ, JR, - D. Screening for sexually

transmitted disease in London-based male prostitutes. Genitourin Med

1991;67:103-6.

19Dandona

L, Dandona R, Kumar GA, Gutierrez JP, McPherson S, Bertozzi SM. How

much attention is needed towards men who sell sex to men for HIV

prevention in India? BMC Public Health 2006;6:31.

20Pleak RR. Sexual behavior and AIDS knowledge of young male prostitutes in Manhattan. J Sex Res 1990;27:557-87.

21Venkatesan C. Male sex work in Chennai. In: First National male sex worker network. Thiruvanthanpuram: 2003.

22Minichiello V, Marino R, Browne J, son M, K, Reuter B, et al . A profile of the clients of male sex workers in three Australian cities. Aust N Z J Public Health 1999;23:511-8.

23Steen R, Mogasale V, Wi T, Singh AK, Das A, Daly C, et al

.. Pursuing scale and quality in STI interventions with sex workers:

Initial results from Avahan India AIDS Initiative. Sex Transm Infect

2006;82:381-5.