Key Populations Health Service Provision Training

Session 2: Providing KP-Friendly Services for MSM

Welcome to Session 2! In this session we will be learning about some of the unique aspects of providing quality services to men who have sex with men (MSM).

Getting Ready For This Session

  • Remember to have your workbook and a pen or pencil handy.
  • On average, you will need about 85-100 minutes to complete the session.

Learning Objectives

By the end of this session, you will be able to:

  1. Define the terminology used to discuss MSM
  2. Describe the challenges and issues faced by MSM
  3. Talk about appropriate, quality healthcare for MSM

Learning Activities

  • Introduction (1 min)

    MSM are not always able to easily access healthcare services. In this session we will explore what it means to provide compassionate, effective health services to MSM.

  • Pre-Session Assessment (5 min)

    Let’s start off with a quick check of your knowledge and comfort about KP-friendly services for MSM. Each question will have a score for you to track in your workbook. Please track your scores as you go through this assessment and make note of any content areas that you answered incorrectly. This exercise will help to identify gaps and areas that need more attention as you go through the session content.

    1True or False. Men who have sex with men are all homosexuals.

    2Which of the following are considered psychological issues that impact MSM? Select all that apply.

    3What are some components of providing effective care for MSM? Select all that apply.

    4List at least three reasons why MSM are at greater risk of contracting STIs. Write your response in your workbook.

    5Which of the following are key health issues that should be considered when working with MSM clients? Select all that apply.

  • Munya (3 min)

    Let’s take a moment to listen to Munya describe his experiences accessing health services as an MSM, and where he feels like work needs to be done.

    Transcript
    Transcript

    Hello, good morning. Well, my name is Munya, and I'm a KP, I'm an MSM. So, I'm the man who have sex with other men. And I usually get services at Marlborough clinic. That is where I get services at Marlborough clinic, Wilkins, Parirenyatwa, and GALZ Clinic as well. That’s where I get my services. But my main concern going to the facility for care—I do feel like there's a lot that needs to be done in sensitizing healthcare practitioners in order for us to access the services. Because at some facilities it's a bit hard for us to go and access services because of stigma and discrimination. There's some people very accommodative, that have been sensitized, but there's some that are not sensitized, especially the stigma is literally coming from the gate—from the gateman, up until you reach to the receptionist, also known as Mabharani (in Shona), so I feel like there's a need to to on that. But basically, I am comfortable in approaching facilities and accessing services at facilities. And I'm very comfortable. It's only that there's a little bit of stigma when it comes to the security guards and nurse aides and as well as the receptionist who assist us. And also, healthcare providers, healthcare workers, they should know different types of people: who are we and where we come from. And we should access all services that we inquire from them and they should be able to assist us. Yes, that's all. Thank you.

    Munya

    Reflection: Think about what services for MSM look like in your facility. In your workbook, write down two or three areas that can be improved for better service. We will be reviewing strategies to improve MSM services throughout this session.

  • Who Are MSM? (5 min)

    a gay coupleWhen we talk about men who have sex with men, we are referring to all men who engage in sexual and/or romantic relations with other men. This includes the different settings where male-to-male sex takes place, the motivations for engaging in sex, and self-determined sexual and gender identities.

    It is important to pay attention to terms used by men across cultures and societies (e.g., gay, bisexual) to identify and affiliate in relation to their gender identity, sexuality and sexual practices. Experiences of social exclusion, sexual otherness, marginalisation, stigma, discrimination, and/or violence can be common among MSM.

    The term MSM includes not only gay (homosexual) and bisexual men, but also men who:

    • Do not identify as gay or bisexual
    • Are male sex workers
    • Are male-identified transgender individuals and have sex with other men
    • Are men who identify as heterosexual but may engage in situational sex with other men (e.g., in prisons, boarding schools, military barracks)
    • Identify across a range of culturally unique identities

    Not all MSM engage in sex exclusively with other men. Many MSM are married to women, have children, and continue to have sex with both men and women. As we learned in Session 1, sexual orientation and gender identity are not necessarily what they seem; it is important to not make any assumptions based only on what is visible.

  • Myths about MSM (10 min)

    Comments made about MSM are often negative and belittling, as well as potentially undermining their rights. Many of these comments are based on myths.

    Think about some of the things you have heard about gay men and MSM. Take a moment to write down a few statements that you have heard being said about gay men or MSM, whether you believe them to be true or not.

    For each statement drag the slider to indicate whether it is myth or fact.[1]

    Source: UNDP Advancing the Human Rights and Inclusion of LGBTI People: A Handbook for Parliamentarians, 2017
    Being gay is a ‘western phenomenon’.
    Being gay is incompatible with religion; it goes against God.
    Repealing laws that criminalise same-sex activities does not promotes homosexuality.
    Being gay is a mental disorder that can be cured.
    Not all gay men are HIV-positive.
    Children should not be around gay men; it endangers their well-being.
    You can't always recognise a gay man by how he looks or acts.

    There are many more misconceptions and stereotypes that hamper the ability to provide non-judgemental care.

    Reflection: Did you write down any of the same myths that were listed? Have you heard some of these myths and misconceptions before? Take a few minutes to think about your experience with how you have handled the situation when you have heard others say things that you know are not based in reality. If you have not experienced it directly with statements about MSM or gay people, how have you handled hearing myths about people living with HIV or other highly stigmatised health issues?

    • Did you stay quiet?
    • Did you speak up?
    • Did you try to educate?
    • How might you handle it differently now that you have more information?
  • Providing Healthcare Services for MSM (15 min)

    Let’s watch this presentation given by Vusisizwe Khumalo, KP Officer at Zim-TTECH, to learn about some of the basics of providing health services for MSM.

    This presentation was adapted from I-TECH Trinidad Key Populations Preceptorship training.

    Transcript
    Transcript

    In this lecture I am going to discuss some overarching issues that should always be considered when working with key populations. I will share some definitions and give a short overview about the key populations, or KPs, we will be covering in this training. And finally, I will provide some practical tips that should help you get more comfortable working with KPs.

    Let’s begin by discussing sexual orientation.

    Sexual orientation refers to how a person identifies their physical and emotional attraction to others. It refers to romantic and/or sexual attraction to people of a specific gender, though this often occurs on a continuum. Sexual orientation encompasses attraction or desire, behaviour, and identity. Orientations can include heterosexual, gay, lesbian, bisexual, etc. Sometimes, especially in social services or health fields, categories are based on behaviour rather than identity such as:

    • Men who have sex with men (or MSM)
    • Women who have sex with women (or WSW)

    In fields such as healthcare, or social work, there has been this tendency to group people based on their behaviours rather than identity. This is because in some cultures or situations, people may not personally identify as gay but may still be engaging in sexual activities with a same-sex partner. Some examples of this include: people on the 'down low' who may be in a heterosexual marriage but have sex with a same-sex partner, people who are incarcerated in prison, or people who are in the military and engage in sexual activity with same-sex partners though they do not personally identify as “gay” or “lesbian.”

    Now, let’s look at some of the components of sexual orientation.

    The diagram on this slide illustrates three dimensions of sexual orientation. The first is identity. This refers to how a person self-defines or labels their sexuality. Traditional sexual identity labels include gay, lesbian, bisexual, straight, heterosexual, homosexual. Some people also use terms like queer, same-gender loving (and others).

    The next dimension is behaviour. This refers to the gender of a person’s sexual and romantic partners (that is, what gender(s) are your sexual partners?)—that is, who is a person having sex with?

    The third dimension is attraction. This refers to the gender(s) a person is attracted to.

    It is important to note that attraction does not always align with behaviour or identity, and identity does not always align with behaviour. For example, you may have a person who is attracted to people of the same sex but doesn’t have sex with them. Or, you could have a person who has sexual relations with people of the same sex, but that person would not use the label “gay” or “bisexual.”

    So, how does a person’s sexual orientation develop?

    Researchers have proposed a variety of theories about different components that might influence sexual orientation, but there is not one clear scientific answer. Current research states that one’s sexual orientation is not a choice. Individuals do not choose to be homosexual or heterosexual. Sexual orientation is usually established during early childhood. Sexual orientation is not determined by any one factor. Research suggests sexual orientation develops by a combination of genetic, hormonal, and environmental influences.

    Self-understanding and self-acceptance of a gay, lesbian, bisexual, or transgender identity often evolves gradually over a period of many years.

    Although there continues to be controversy and uncertainty as to the science of variations in human sexual orientations, there is no scientific evidence that abnormal parenting, sexual abuse, or other adverse life events influence sexual orientation.

    Now, let’s talk about terminology. This is very important when working with people who are gay or MSM.

    It is important to accept and respect the self-identification and preference of each individual person in regard to the terms you use as the client’s health worker. Some clients may not identify with terms such as “gay” or “MSM” even though they may engage in same-sex sexual activities. They may be dealing with their own complex identities, or may have internalized stigma/homophobia, and do not want to be called these terms. Using respectful language that reflects your client’s identity can help to build rapport with the client. Ask for and use your client’s preferred name and pronouns, such as he, she, or they. When applicable, ask for and use your client’s preferred terms to describe body parts. Use layman’s terms and simple language to explain medical information. Understand sexual positions and practices and how clients self-identify. Note that it can be helpful to have some basic understanding of sexual positions.

    One term you may not be familiar with is “verse”. This stands for versatile, and is a slang term used to describe a gay or bi man who can be either a top or bottom during sex. Some other terms that you may hear when working with MSM are “power bottom”, which refers to an insatiably hypersexual bottom eager to please more than one top at a time. Another term is “uber-top,” who is an extremely masculine and rugged-in-appearance.

    Not all gay men want penetration. Bi-sexuality is not uncommon.

    These may or may not come up in your work with a client—always follow the client’s lead.

    Psychosocial issues impact many gay men and other MSM. Clients may have a history of negative experiences at healthcare facilities, including homophobia and stigmatizing interactions with staff and with other patients. Some patients may also fear unwanted or involuntary disclosure of sexuality or HIV status by staff or other patients. Some may have limited or no family support. Some people face workplace and housing discrimination, unemployment, and/or homelessness.

    Let’s also consider mental health issues that can affect gay men and other MSM. Homosexuality, same-sex attraction, transgender identity, and gender non-conformity are NOT mental disorders.

    MSM and other key populations have a higher incidence of depression, anxiety, and suicidality. This can be due to:

    • Living in secrecy, isolation and/or hostile, unsupportive environments, which can cause or worsen anxiety and depression
    • Concerns about acceptance and alienation from family can lead to distress and suffering
    • Coping with religious issues may also be a source of great concern

    MSM may also struggle with substance use and misuse as a means to cope with trauma, stress, stigma and guilt.

    Note that these mental health issues can impact other people in the LGBTQ community as well, including transgender people, lesbians, and the like. Some members of the LGBTQ community also experience challenges related to gender dysphoria, which is distress caused by the incongruity between gender identity and physical characteristics. (This will be discussed more in the presentation about transgender health, but it can also affect people who do not identify as transgender.)

    As with all clients, effective communication skills are critical when working with MSM clients. Learn the appropriate questions to ask and how to ask them. For example, ask about a partner, rather than wife or husband. Preface questions by saying it may be uncomfortable. You can structure and layer the questions. Give reasons or rationale for the questions.

    Let’s also take a moment to think about what NOT to say. Avoid talking about religion; avoid preaching or being “judgy”. Do not say things like:

    • You don’t look gay.
    • You are so handsome; you could easily get a woman.
    • What a waste!
    • Would God want you to be this way?

    Next, we’re going to talk about the different components of providing effective care to clients who are gay or MSM.

    • Provide a safe and respectful environment. Be sure that sensitivity training is something that all staff in the health facility participate in.
    • Provide care and services in a non-judgmental manner.
    • Always demonstrate professionalism.
    • Support the client’s autonomy as much as you can. Allow the client to lead—they are in charge of their own life.

    Another part of effective care is helping the client to build a support system. Client can be counselled on the benefits and risks of disclosure. You can connect a client with peer-led education and support groups. You can help to identify family support, including considering both biological family and the client’s chosen family. Remember that it is very important to approach all discussions of family with sensitivity, being aware that family relationships can often be complicated for people who are gay or MSM.

    Health workers can help to assess the client’s friend and community support and the client’s sense of belonging. They can also help to empower the client to practice self care.

    Referrals are another component of effective care. Acknowledge the need for referral to the services that can best help the client. Carefully screen referrals to ensure no discrimination. Walk with the client for the introduction. Effective referrals can help to build rapport. Consider referrals for:

    • Educational support: Can they read? How can you assist them to move forward?
    • Homeless services
    • If MSM engages in sex work, consider support services geared to that issue

    You may also have noticed that the points on this slide actually apply to working with all key populations—not just MSM.

    Vusisizwe Khumalo, KP Officer, Zim-TTECH
  • Contextual Factors Around MSM Health-Seeking Behaviour (5 min)

    young manMSM are one of the key populations at high risk of contracting HIV and other sexually transmitted infections (STI). The fact that many MSM also have sexual relations with women or are married also contributes to the spread of disease. Some of the reasons why MSM may be at increased risk for HIV and other STIs are:

    • Unprotected anal sex carries a much higher risk of STI transmission than vaginal sex due to biological factors. For example, STIs can more easily pass through delicate rectal mucosal membranes.
    • Incorrect use of condoms and lubricant during anal sex. They may not have been educated on how to use them correctly.
    • Difficulty accessing condoms and water-based lubricants.
    • Unprotected sexual relationships with multiple partners.
    • Lack of access to information and treatment.
    • High levels of undiagnosed or untreated STIs.
    • Poor adherence to ART.
    • Some may avoid or delay seeking health services for fear of being embarrassed, stigmatised or shamed.
    • When at the facility, MSM may be hesitant to volunteer their sexual history to a healthcare worker who is thought to be judgemental. This may result in missed opportunities for sexual health services, including HIV prevention, treatment, and care.
  • Communicating with MSM (5 min)

    young man standing outsideAs healthcare workers, we must often discuss topics that are uncomfortable by nature. It can therefore be challenging to get all the details needed for a sexual history. Beyond asking about the sexual partners of MSM, we should also be helping to assess risk factors through questions about the type of sex (oral, anal, vaginal) they have engaged in; if anal sex, whether it was insertive or receptive; and if condoms and lubricants are being used.

    It is essential to be non-judgemental and ensure confidentiality. This will help your client to feel safe and cared for.

    Here are some things to remember when you are communicating with MSM clients at your facility:[2]

    Source: MSMGF: Promoting the Health of Men Who Have Sex With Men Worldwide-A Training Curriculum for Providers, July 2014
    • Do not assume all MSM clients are homosexual.
    • Do not assume sexual orientation, identity, or behaviour and gender identity based on appearance.
    • Listen to clients and the way they describe themselves and their partners.
    • Ask clients what sexual identity terms (pronouns) they prefer, as asking usually does not offend.
    • If you make a mistake, apologize and ask the client what they prefer. Most will appreciate the good intention.

    Here are a few general tips for conducting successful sexual history interviews with clients:

    • Use professional, comfortable body language, gestures, tone of voice, and proximity to create a non-threatening environment to put your client at ease.
    • Explain matters of confidentiality to the client.
    • Reassure the client that it is acceptable to ask why questions are relevant.
    • As appropriate, use open-ended questions to encourage the client to give in-depth descriptions, rather than questions that result in ‘yes’ or ‘no’ answers.
    • Speak with language that is appropriate to the client’s level of education but not biased to age, gender, race, religion, sexual orientation, or culture.
    • Ask the client to clarify any confusing answers.
  • Walter (5 min)

    Walter, a 23-year-old male, comes to your facility to be treated for syphilis. The client states that he is ‘straight’, but that he sometimes has sex with other straight men. He does not use condoms for anal sex because he states that his older partners prefer ‘raw’ sex. The client denies being a receptive anal sex partner. When asked for permission to do an exam of his rectum, he declines. A review of his medical record lists a previous diagnosis of rectal chlamydia. The doctor approaches him about pre-exposure prophylaxis (PrEP), but the client states that he does not think he needs it. He says that it is good for ‘gay guys’, but not for him. He has heard that all guys who use PrEP are ‘bottoms’, and that taking PrEP means that they are ‘whores’.

    After reading the scenario, answer the questions below.

    1How do you deal with stigma related to same-sex behaviors in this client? Write your response in your workbook and then tap for feedback.

    2What is the strategy for providing this client with good clinical care given the limits he has set? Write your response in your workbook and then tap for feedback.

  • Appropriate Clinical Services for MSM (5 min)

    As stated earlier, MSM are at increased risk for certain diseases and health issues. STIs are difficult to diagnose and treat, so they are a concern for MSM. Also, an STI increases susceptibility to HIV.

    Below are some of the key health issues that should be considered when working with MSM clients:

    • HIV
    • Chlamydia
    • Gonorrhoea
    • Syphilis
    • Hepatitis
    • Herpes
    • Anal papilloma
    • Prostate, testicular, and colon cancer
    • Substance use
    • Depression and anxiety
    • Physical and sexual violence

    Remember that when you are talking about sex with your clients, you are asking questions and discussing issues pertaining to their healthcare. Be careful to not come across as judgemental or use stigmatising language; ask only what is relevant for the clinical assessment. Do NOT ask personal questions for your own curiosity.

    Combination HIV Prevention

    The combination HIV prevention recognises that:

    • Different people have different HIV prevention needs.
    • For a given individual, prevention needs can change over time.
    • No single intervention can fully address all prevention needs.

    To achieve a sustained reduction in new infections, a combination of structural, behavioural, and biomedical interventions is used.

    • Combinined approaches are generally more effective than single interventions.
    • Antiretroviral drugs (ARVs) are now used as additional tools in combination prevention.

    PrEP, the use of ARV drugs by HIV-negative persons to prevent acquiring HIV prior to potential exposure, is recommended as a prevention option for MSM at substantial risk of acquiring HIV infection. It is safe to use. PrEP is NOT meant to replace existing interventions; rather, it complements them. PrEP should be offered in combination with condoms, STI screening and treatment, HIV testing, and voluntary medical male circumcision (VMMC).

    Refer to the Section 2.3.2, pages 42-44 of the Operational and Service Delivery Manual for the Prevention, Care and Treatment of HIV in Zimbabwe (OSDM) for more details on screening and implementation of PrEP.

  • George (10 min)

    George is a 21-year-old, HIV-positive MSM receiving health services at Mobata Clinic (both George and the clinic are fictitious, based on real experiences). The way the clinic is set up, he needs to separate out his HIV care from any focused care for KPs. George lives with his grandmother and comes from a very religious family, so he is not able to discuss sexual health issues in the home. In addition, as he states, he grapples with pill burden:

    Sometimes I feel as if I’m just wasting my time, and sometimes it feels [like] it’s time for me to go because I can’t take it anymore. This is too much for me, taking tablets constantly. Imagine if I am to go to a gathering, then my time is going to be there. I’m going to have to move away from people. I’m going to have to do my separate thing [and] then come back [to] people [asking] me what I was doing. It’s hard for me to explain to them because they don’t understand me. So, it’s just a thing that disturbs me constantly. And it’s hard.

    George further states:

    The facility does not have queer persons. It’s a government facility. So, when I am receiving counselling, I don’t open a lot. I choose what to say. I don’t talk about my sexual orientation or most issues that I am dealing with and focus only on my HIV care.

    1True or False. Young MSM often suffer with more than one type of discrimination.

    2How best can the healthcare worker assist George?

    3What strategy can the healthcare worker use to probe for other issues affecting George? Select all that apply.

    4What would be appropriate for the nurse to discuss with George as they start to talk about adherence? Select all that apply.

    It has become clear that George is experiencing treatment fatigue. He understands that disclosing one’s status to trusted family members or close friends is recommended for support, but he is not quite ready for disclosure. His counsellor helps him understand that disclosure is a process and encourages him to take his time. He is also encouraged to join friendship or buddy groups of other KPs where he can get emotional support and information.

    5Since George is not ready to disclose his status, what might be some strategies that he can use to stay adherent while keeping it confidential? Select the best response.

  • MSM Service Improvement (5 min)

    Look back at the reflection activity from earlier in this session where you identified some areas that need improvement to deliver more effective health services to MSM.

    In your workbook, list actions that you will take to help make improvements. Additionally, list any resources you will need and who will help and set a goal date for the change to be implemented.

  • Post-Session Assessment (5 min)

    Now that you have completed this session, let’s take time to check your knowledge and comfort about providing KP-friendly services for MSM. Please track your scores as you go through this assessment, compare them with your pre-test scores, and make note of any content areas where you answered incorrectly.

    1True or False. Men who have sex with men are all homosexuals.

    2Which of the following are considered psychological issues that impact MSM? Select all that apply.

    3What are some components of providing effective care for MSM? Select all that apply.

    4List at least three reasons why MSM are at greater risk of contracting STIs. Write your response in your workbook.

    5Which of the following are key health issues that should be considered when working with MSM clients? Select all that apply.

  • Summary (2 min)

    In this session we covered some terminology related to MSM, discussed who MSM are, and dispelled some of the myths we have heard about MSM. We identified some communication tips and learned about contextual factors associated with MSM. We also reviewed key health issues that we need to be aware of when working with MSM.

  • Resources

    Below are links to resources relevant to this session.

    Title/Source File
    Operational and Service Delivery Manual for the Prevention, Care and Treatment of HIV in Zimbabwe (2022 Edition) Click to open file.