Male sex workers face social stigma and poor access to care

In Cameroon male sex workers have been left out of HIV and Aids prevention and control programmes and face discrimination in gaining access to healthcare

by Anne Mireille Nzouankeu, in Douala,
Aurélie is a transvestite sex worker in Cameroon’s largest city, Douala. Last month, after a condom he was using broke during sex, he went to a public hospital to ask for post-exposure prophylaxis (antiretroviral drugs that provide protection against the virus if taken within 72 hours). He was turned away. “The nurse told me that it is the risk of my job,” says the 28-year-old. “She told me to go to a private clinic in order to spend the money I earn through prostitution.”

Aurélie’s experience is not unusual. Prostitution is prohibited and punished in Cameroon. While formal prosecution is not common, male sex workers are frequently targeted by police. To compound this, as in most African countries, homosexuality is illegal and men who have sex with men (MSM) face endemic political, religious and social hostility.

The Cameroonian penal code punishes “sexual relations with a person of the same sex” with imprisonment of between six months and five years and a fine of up to 200,000 CAF francs ($410) – a huge sum in a country where the average monthly wage is around 50,000 CAF francs.

According to popular beliefs, homosexuality is either a spell put over people to bewitch them, a cult or a perversion. In public discourse, the French word homosexuel has come to mean all things evil, according to a 2010 Human Rights Watch report on rights abuses of the gay community in Cameroon.

Being a male sex worker is like a double curse. Stigma, violence and detention are widely reported. As a result, male sex workers operate in secrecy and their male clients are also forced underground. Some, like Aurélie, dress up as women and work on the streets. But many keep their masculine appearance. They seek their clients in snack bars and strip clubs.

“Fleur”, 32, a sex worker, says he’s bisexual with a preference for men. “Sometimes the police come to arrest us,” he says. “Girls are quickly freed but the treatment of men is different. The police beat us. They say it is to remove the demon of homosexuality in us. They make us sleep on the floor in the cells and only free us after tough negotiations.” As he tells his story, tears spill down his cheeks. “This hatred makes me sad. But I feel worse because discrimination is felt even in our families and in places such as schools and hospitals.”

“When we go to state hospitals, we have to lie to get treatment,” says Cyril, another sex worker. He says nowadays doctors are less likely to report them to the police but they ask their receptionists turn them away. “I’ve had this experience and many people I know have too,” he says.

In Cameroon, as in many African states, the government does not recognise men who have sex with men as a risk group. HIV in Africa was originally thought to be transmitted mainly through heterosexual intercourse but there is growing evidence that transmission through MSM is a significant problem.

Criminalisation of homosexuality means these men are not included in any HIV and Aids prevention and control programmes, which are mainly aimed at young people and women. The state keeps no statistics on HIV prevalence among gays, lesbians and bisexual men and women, and has conducted no survey of the knowledge or behaviour in these communities related to transmission of HIV.

A Lancet review, co-authored by Adrian Smith of the Department of Public Health at Oxford University in 2009, highlights studies that indicate widespread existence of MSM groups across Africa, and high rates of HIV infection, HIV risk behaviour and evidence of links between MSM and heterosexual networks.

“The research that has been done suggests that these men generally have much higher rates of HIV infection than heterosexual men,” says Smith, “but have little or no access to appropriate sexual healthcare, such as health education, preventive counselling and sexually transmitted disease testing, treatment and care.”

Adonis Tchoudja, president of Aids Acodev, a local sex workers’ association, is determined to change this. The association has partnered with two male nurses and one female nurse who visit sex workers at home and provide health checks and information.

“Just because we are sex workers does not mean we should be denied the same right to health as anyone else,” says Tchoudja. Since its creation in 2009, Aids Acodev has been distributing condoms to sex workers. Members of the association are also given advice on HIV prevention. They are encouraged to find out their HIV status, and those who are HIV-positive receive advice about treatment and how not to infect others.

Although male sex workers are seen by the police and society as gay, they do not all view themselves that way. Bruno Atangana, 30, says he’s heterosexual but he sometimes has sex with men. “It’s just a job, not a sexual orientation,” he explains. However, the job has caused his family to reject him. He hasn’t spoken to them for four years. “My parents told me they were ashamed of me and they consider that I am dead. I prostitute myself to live but my parents told me they would have preferred that I was, for instance, a gigolo instead of having sex with men,” he says.

In addition to social stigma and poor access to care, sex workers and their clients indulge in risky behaviour due to a lack of awareness about HIV and other sexually transmitted diseases. “Big Mami”, 27, has been a sex worker for about seven years. He confesses he does not use condoms consistently. “If I like someone, if he wants me to use condoms, we use them; if he doesn’t want to, we don’t use them. But when I don’t like someone, I always use condoms,” he says.

His clients are mostly married men and single women over 50. Asked whether he is afraid of infection, he says: “As soon as we end sex, I clean myself and I’m OK.” Such misconceptions among male sex workers may increase the spread of HIV.

Sex workers are rarely mentioned in the public debate on HIV, despite the fact that the National Aids Control Committee (CNLS) considers them to be “the main power units and bridges of the epidemic”. The committee’s plan of action for 2011-15 declares that sex workers are “people at high risk of HIV exposure [because they] may play a role in the spread of infection to the general population, because of the multiple sexual partnership that characterises them [and] the systematic non use of condoms”. The plan, published in December 2010, reveals that in 2008 there were 18,000 sex workers in Cameroon (men and women) out of a total population of around 20 million.

HIV prevalence among sex workers increased from 26.4% in 2004 to 36.8% in 2009, according to the CNLS. This compares with HIV prevalence of 5.3% among 15- to 49-year-olds, according to Unicef. To date, no study focuses specifically on male sex workers so it is difficult to gauge how many there are or estimate HIV-prevalence rates. Tchoudja says he works with around 120 male sex workers, which he estimates is around one-third of those in Douala, one of Cameroon’s 10 regions.

Male prostitution is in “constant evolution”, according Tchoudja. He says around half of sex workers protect themselves. “What they need most,” he says, “are the lubricating gels. Those who do not protect themselves are mostly homosexuals who are not sufficiently aware. Spot advertisements on TV show only heterosexual couples. Men who have sex with men feel that Aids does not concern them.”

Tchoudja is campaigning for the inclusion of lesbian, gay, bisexual and transgender people in awareness messages on HIV and Aids. In November Tchoudja organised a conference about sex workers in Francophone Africa, where groups came together to discuss the stigmatisation and marginalisation of male and female sex workers. “It’s a very large community. We must act to save it,” he says.

Tchoudja faces an uphill battle. A source at CLNS says: “Prostitution is illegal in Cameroon, and the country is highly homophobic. Including these two groups of people in awareness campaigns, such as advertising spots, would be a way to legitimise the practice. Nobody is ready to take this risk for now.”

Meanwhile, the continued denial of HIV prevention and care to men who have sex with men and sex workers harms the national HIV and Aids response, putting the wider population at risk.

Source – The Guardian