1. Introduction

An estimated 3.97 million people in India are infected with human immunodeficiency virus (HIV) which amounts to a prevalence rate of 0.7 percent of the total adult population and HIV prevalence in India is greater within high-risk groups such as men who have sex with men (MSM) at 5.69 percent; intravenous drug users (IDUs) at 8.71 percent; and female sex workers (FSWs) at 5.38 percent. ¹ India continues to be in the category of concentrated epidemic characterized by unprotected paid sex, anal sex, and injecting drug use with contaminated injecting equipments. ² Concentrated HIV epidemic in India has opened the avenues for the diverse studies related to at-risk populations and enhanced HIV prevention interventions across the country. In last two decades, Indian scholars have shown interest in the studies related to MSM and studies have moved from nature, extent, frequency of same sex contacts, the context in which same sex acts take place, type of sexual activity, knowledge on HIV/AIDS and STIs, usage of condoms, safe sex practices, social and sexual network of MSM ^{3,4,5,6,7,8,9,10,11,12,13} to the psychosocial stressors of MSM.^14,15,16,17 Earlier studies have explored and explained psychosocial stressors of MSM and also suggested HIV prevention interventions, but author could not find a single study that has documented psychological, social, and cultural structures and health risk in Indian or International journals. This study attempted to understand visible and invisible psychological, social, and cultural structures that regulate behaviors of MSM, which influence their health, sexual and mental health. This study also suggests implications for further studies and effective implementation of targeted interventions in India.

2. Methods

A qualitative research method was appropriate for the objectives of the current inquiry. With grounded theoretical framework, fifteen MSM were interviewed using semi-structured interviews and four focus groups interviews with seven to nine respondents in each focus group. With theoretical sampling, seven respondents self-identifying with the Koti identity, five bisexual, two identifying as MSM and one gay identified respondent were recruited in the study. Further, to add diversity, married as well as unmarried respondents were included.

2.1. Analytic Framework

After the data collection, data was translated and organized into categories.¹⁸ The text was then coded with open and axial coding. ¹⁹ In order to ensure reliability, one external expert (a professional counselor who worked with the MSM population) had reviewed the coding and analysis, and feedback was incorporated.

2.2. Procedures

Author, who was trained in qualitative interview techniques, conducted in-depth interviews with MSM, both one-to-one and focus groups. In order to make respondents comfortable and ensure privacy, they were interviewed at their preferred place and convenient time. Four respondents were interviewed at their respective homes, five interviews were conducted at Drop-In-Center (DIC) of the Lakshya Trust; and the rest of the interviews, including the focus group interviews, were conducted at office.

3. Results

3.1. Respondents’ Profile

Among the 15 MSM in the current study, six were 25 years old; two were 27 years old; three were 29 years old; one was 23 years old and the others were 30, 33 and 42 years old, respectively. Ten respondents had completed ten years of schooling; three had completed twelve years of schooling; and two had graduated college (12 years of schooling and 3 years of college education). Many of the MSM (8) were working as daily wage laborers; four were working with governmental or non-governmental organizations. Three of them were operating small independent businesses. Eleven respondents were married. Nine respondents had children; Six respondents had one male child; two had two children (a girl and a boy); and one had three children (two girls and a boy). One respondent wanted to have children but could not and another was planning to have a baby. Almost thirteen respondents lived in joint-family (multi-generations of a family living together). Two had migrated from a village nearby, and rented a house in Vadodara city.

Characteristics of risk context of MSM

All men knew the meaning of STIs, HIV/AIDS and strategies to protect themselves from STIs. They also availed sexual health services such as treatment of STIs, health check-ups, free condoms, and counseling from targeted interventions implemented by the Lakshya Trust. The analysis of all interview scripts found discordance between knowledge and practice. Despite their familiarity with condoms and knowledge that the use of it can significantly reduce chances of contracting STIs, including HIV, failure to use condoms with regular partner, lover, and spouse was common. Exclusive safe sex practices such as body sex, rubbing the body with the partner’s body, and inter-femoral sex known as thigh sex, moving the penis between the upper thighs of a partner, was perceived boring, unsatisfying and thus remained uncommon. MSM had around five-six partners other than spouses per week. Each Koti and gay had a lover or lovers with whom they are romantically committed and sexually active and atleast one regular partner that they are emotionally attached to and have regular sexual relations with them. Bisexually identified men and MSM both had female and male sexual partners.

3.2. Sexual Identity and Untold Societal Norms

Homosexuality in Indian society is considered inappropriate and shrouded in secrecy. Identity finds its roots in self-perceptions in relation to specific social setting²⁰ and the subjective adoption of a roles or roles by an individual. ²¹ Certainly negative notions about homosexuality create a dilemma for homosexually oriented men to choose gender and sexual roles and appropriate identities. Eleven respondents mentioned that they were confused with their own same-sex feelings, attraction and interest in same-sex sexual activities. One respondent with bisexual orientation said, “I feel bad for my feelings for other men, and sexual activities I do. I do not know why God has made me such.” Other respondent who identified him as Koti stated, “People laugh on my effeminate behavior. I try to become like other men but I just can’t. Sometimes I can’t control my feelings and desires to cross-dress. I want to stop cross-dressing, sex with other men but I can’t stop.” Such experiences often lead to the development of dual self-identities. Duality in turn creates an identity confusion and role conflict, which is usually expressed through non-acceptance of one’s sexuality, secret homosexual activities, risky sexual behaviors, multiple sexual relationships, self-destructive behavior, substance abuse, unstable relationships, and internalization of homophobia. ¹⁵

All unmarried men (7) in the study concurred that they want to marry, and desire to father a child. Fathering a child is demonstration of proven manhood and the fulfillment of one of the social requirements of married man.¹⁸ Married men shared reasons for their marriage. Primary reasons were parental pressure and their own conviction with the notion of heterosexual marriage. They had fear that if they had not married, it would defame their parents’ status; and siblings would not be able to marry. This itself show invisible layer of internalized stigma associated with own homosexual orientation and self-discrimination as the biggest personal barrier in development of health sexual identity and impair development of healthy sexual identity.

3.3. Gender Identity and Gender Expression

All Kotis, in this study, liked to perform feminine roles (nursing─taking care of others, cooking, dressing, and behaving like a woman), without being uncomfortable with their male body. Kotis are essentially men, with feminine traits. They internalize feminine gender identity, express feminine traits in their behaviors, and gender roles they adopt, which is against the societal norm to be masculine. Thus, there is disparity in their sexual and gender identity and gender expression. Four Koti experienced sexual abuse during childhood. Out of four, two Koti reported to be sexually abused by goons and police in the last six months; rest two were abused by close relatives (cousin and uncle). Kotis were also victims of verbal abuse by family members, relatives, neighbors and at workplace for their feminine behaviors. Ironically, Koti faced more verbal and physical abuse than any homosexually oriented men with masculine traits did. It is largely perceived feminity of Koti as a performance based identity that creates stigma, discrimination, social exclusion, and violence. Three Kotis had left their job due to verbal abuses by labeling them as “bayalo,” (feminine); “homo,” or “homosexual.” Respondents mentioned the meaning of the term “bayalo,” as weaker, soft, not able to do anything on own. These cultural meanings of feminine traits are usually ascribed to women. Feminine traits are often considered negative. Further, men are expected to show masculine traits and hide feminine traits. Out of three who left their jobs, two were involved in sex work as their livelihood. Sex work is safe until it is secret to the larger world but public in confined sexual space where all men seek sexual company of other men. Their perception of safe sex work is not protective sex (use of condom) but the sex work that can be safely hidden from larger world consisting their family members, relatives, and police, around them. Men are voiceless against their sexual abuse by local raudies, and police. They believe to submit to them to keep sex work as their survival strategy. Human rights abuse and biomedical risks are not perceived as important as social risk of being exposed to the world about their secrets. One respondent said, “I take care that my family members, relative do not know about my homosexuality and sex work.” Those who are not acting out the normative masculinity often face social exclusion, less employment opportunities, which increase economic vulnerabilities, and concomitantly increase the potential for sex work as survival strategy.

3.4. Performance Based Sexual Identities and Marginalization

Focus Groups interviews shed light on conception of sexual identity and how culture shapes sexual identity.

Gay

English speaking, modern, educated people often identify them as a gay. Their sexual role is flexible, active partner penetrates penis to his partner’s anus, and passive partner is penetrated by active partner. Gay often penetrates and as well as penetrated. They usually call their other male partner “Boy friend,” or “Gay,” and often one partner adopts feminine or passive role and other masculine or active role. They do not often mingle with Koti, MSM, Bisexual, and Double, as there is class difference.

Koti

Koti are usually effeminate men and passive partner who receives penetration. Though some Koti penetrate, however, largely their sexual role is passive. They express their feminity explicitly, especially among Koti or with partner privately and those who already come-out publicly. They call their partner or any masculine men, Ghadiya. They always refer their partner as Ghadiya.

Double Decker

Double Decker, usually refer as Double, who are versatile, they penetrates and as well as penetrated by their partners. Many Doubles also identify them with Koti. Doubles often maintain masculine outlook, though they do like cross-dressing. They participate in all cultural events, such as Garba¹, Vat-Savitri², Kutnu³, with Koti. The Lakshya Trust organizes such events as part of HIV prevention program.

Bisexual identity

Bisexuality theoretically means a person having erotic, romantic, and sexual attraction to both genders.²¹ Sexual behavior and sexual orientation are two both distinct matter. All who keep homosexual behaviors may not have homosexual orientation or identify them with homosexuality. Similarly, all men who keep bisexual relationship not necessarily bisexual men unless they feel equally erotic romantically attracted to both genders.

In this study, many married men identified them as bisexual men, though they had not any attraction to women or any female sexual partner other than the spouse. It was also confirmed during focus group interviews that MSM perceive married men as bisexual men. Marriage and sexual activity with spouse determined themselves as bisexual men. Cultural conception of bisexuality is different from theoretical framework. Many bisexually identified men also resembled themselves with Koti. This further confirms that sexual identities are fluid and are not watertight compartments. ¹⁴

MSM

Men’s identifying themselves as MSM is new phenomena. Earlier studies have noted that some men have started identifying themselves, as ‘MSM’ and thus the term ‘MSM’ is being adopted as another identity.^14,16 MSM identified men are dominantly masculine, active partners of Koti; however, feminized men, who do not identify them as either Koti, Doubles, or Bisexual men, identify them with MSM.

3.5. Popular Culture

Existing social environment, peer group, and exposure to local culture determines adoption of particular sexual identity and cultural practices. Personal interviews and Focus groups interview revealed that men from low socio-economic strata identify themselves with Koti, Double, or MSM identity whereas men from middle or upper middle class, educated, English speaking men adopt Gay identity. Gay are confined to group of similarly identified men, organize parties in hotels, go for a long trip, and meet online, search partners through internet, share pictures. They are more resourceful in terms of accessing gay magazines, gay rights movements, and elite gay networks. They have usually sexual activities in hotel, or friends’ home. Not only class factor determines adaptation of gay identity, but also exposure to resources is also important factor that shapes sexual identity as Gay. For example, a gay identified respondent was living in the street where Koti or Double identified men stayed. He often happened to interact with Koti or double identified men. However, his exposure to gay community through internet, interaction with more sophisticated men who self-identify as gay, conceived him to relate himself with gay community strongly than Koti community.

Condom use in gay community is slightly high compared to Koti as one respondent shared that he always use condom and all his partners keep condom with them. He once did not use once when both, he and his partner, were drunk too much and had sex. He had sexually transmitted infection that he treated. After this experience, he and his entire group uses condom regularly. Koti, double and MSM are organized. They search partners from cruising places such as garden, open ground, bus stand, and some cruising places in the city. Sexual activities usually take place, preferably in night, in public toilets, barren building, and corner of the open ground, and rarely at home. Condom use is irregular as their sexual activities take place largely in the public places where they have to quickly finish sexual activities for the fear of being caught or seen by police or someone.

4. Discussion

4.1. Socio-cultural Structures and Risk Behaviors of MSM

Indian society and culture prohibits homosexuality, homosexual and bisexual activities. Such prohibitions inhibit men’s expression of sexual and gender identity in public, which result into secretive expression of their sexuality and gender identity. It creates sexual space where prohibited behaviors are expressed safely and social space where prohibited sexual behaviors are inhibited and safely hidden. The same culture creates opportunity structure to perform inhibited sexual behaviors and lend cultural meaning to homosexuality, safe sexual activities. Homosexuality is a sin and abnormal that needs to hide so as homosexual and bisexual activities. Further, sexual activities with other men and women are part of manhood─something that they do not have control over it. Social and cultural structure, knowingly or unknowingly, make MSM victim of human rights abuses, put them and their partners at risk of STIs including HIV infection by engaging in behaviors that generally make good sense in a given social and cultural contexts, but such behaviors produce significant sexual and mental health risk. MSM navigate opportunities and constraints that are often economically, socially, and culturally more significant to them than their emotional wellbeing and biomedical risk of HIV transmission.

4.2. Gender, Sexual Space, and Opportunity Structures

All MSM were essentially forced to marry in order to achieve the status of a fully adult man. MSM maintain publicly acceptable, platonic relations with other men, while keeping their homosexual relationships confined to a clearly articulated spatial context within which they are socially safe. ¹⁷ The most salient criteria for men’s sexual identities is not whether they have sex in private with men or with women, but rather what their public gendered self-presentation i.e., whether they act and dress like conventional men. ^{23, 24} Those men who cannot perform normative gender role, especially Koti, becomes subject to various levels of abuses. Ideal sexual orientation ought to be heterosexual and gender role to be masculine, whereas the sexual relations that flourish in private can be multiple sexual partnerships, and risky sexual practices. Two distinct sexual spaces (public and private/secret) create socio-cultural structures that mobilizes respectable social image of their gender and sexuality that includes secret homosexual life. The social organization of gender and sexuality is characterized by such socio-cultural structures. Success in keeping homosexual life or extramarital sexual activities is often rewarded with respectful social image as a man. Therefore, social organization of sexuality of MSM is an intricate balance between the intense heteronormative public life and private homosexual life with relatively frequent and unsafe homo/bi-sexual relations.

4.3. The Psycho-Socio-Cultural Structures and Health Risks

In the present study, most MSM stayed in the joint family. Living in the joint family was seen as more out of social and economic compulsion. Such compulsions were perceived inevitable. MSM face unavoidable pressures to adhere to social and cultural norms, in which, heterosexual marriage pressure is one of them. There have been Indian studies showing that MSM are forced to marry heterosexually ^{15, 17, 25} or they choose to be married heterosexually for various cultural and ideological reasons, one of the most evident reasons is to protect their social prestige by conforming to the social norm. Institution of marriage provides opportunity structure to explore secretive homosexual or bisexual activities. Homosexual or bisexual activities are common in local culture thus acceptable within the local culture, which is a fraction of the larger culture in which such activities are prohibited. Such discrepancies between private/secret and public life of MSM creates various psychological and mental health concerns such as dual sexual identity, intra-psychic conflicts such as confusion related gender and sexual identity, anxiety related to same-sex attraction and guilt for their involvement in socially prohibited sexual practices etc.

During focus groups interviews, respondents expressed that safe sex practices are starting point of love making (with lover/s and some close regular partners) that result into penetrative sex. During this transition from safe sex to penetrative sex, condom has limited or no chance to be part of lovemaking process, which poses the risk of STI transmission. Often condom is considered an obstacle by MSM in their lovemaking. Such psychological processes that maintain behaviors that have potential health risk and resist behavior change have not been documented in published literature. Further, sociocultural structures too operate these behaviors in a subtle way. For example, maintaining respectable social image by secret sexual life is very important than the risk of being socially excluded by exposing socially and culturally prohibited sexual identity and sexual practices. These secret pursuances expose them to range of human rights abuses and host mental health and sexual health morbidities. Sexual health interventions specifically designed for MSM population must address these invisible psycho-socio-cultural structures and mental health needs to ensure their holistic well-being.

5. Conclusions

The risk of HIV infection and mental health morbidities of MSM is characterized by complex psycho-socio-cultural structures, gender inequalities, social organization sexual orientation–the way society regards and treats sexual orientation and sexual activities. Men’s risk behaviors are regulated primarily those invisible psycho-socio-cultural structures; therefore, unveiling those structures become a critical element in HIV prevention. There exist a high degree of knowledge and denial of human rights abuses of MSM. The process of self-stigmatization, which arises from the concept of masculinity in the given sociocultural context, leads to marginalization, social exclusion, and abuse of the most vulnerable of the homosexual men.

The extent and effectiveness of India’s efforts to bring behavior change through counseling intervention strategy, (that addresses invisible system that operates risk behaviors), will play a significant role in containing the HIV epidemic. An intervention strategy, focusing only on MSM and their risk behaviors ignores psycho-socio-cultural structures in which they operate. The psycho-socio-cultural structures, that regulate sexual behavior, require attention, not mere an individual who apparently does not have control over these invisible structures. Further, merely focusing on behavior by ignoring social and cultural constructs fail to bring sustainable behavior change and make the intervention ineffective. Without creating conscious awareness in individuals about their roles in creating and perpetuating inequality, empowering them about their rights, and healthy sexuality, existing prevention efforts cannot be instrumental in helping prevention of sexual and mental health morbidities in MSM population.

6. Implications

6.1. Implications for MSM-Targeted Interventions

HIV prevention-oriented research needs to explore further about how psycho-socio-cultural factors shape risk of sexual health and health practices in the MSM population. MSM need to be reoriented about the potential threats of HIV/STI transmission from risk behaviors to them and their partners including their wives and their unborn children. Communication strategy should be developed based on understanding of socio-cultural context and psycho-socio-cultural structures. Further, culturally tailored behavior change messages should be evolved through participatory approach actively involving MSM population in designing culturally tailored communication strategies. These communication strategies should be used during educational group sessions, individual, and group counseling sessions in the field or at Drop-in-Center to create awareness regarding healthy sexuality, sexual health, and mental health.

Large-scale mixed-method research need to be conducted to build primary data on the topic, and validate concepts evolved in the study. Similar study with Transgender population is also required.

6.2. Implications for the Counseling

Counseling is an important aspect in HIV prevention targeted intervention. However, programmatically counseling component is not viewed as strategic. Counseling, in targeted intervention merely reduced to activities of information sharing (about potential risks involved in risks activities, risk reduction alternatives, and available services). This study shed light on the important fact that risk behaviors are regulated by the invisible psycho-socio-cultural structures and individual has no control over it. These structures need to be addressed carefully within the framework of Targeted Interventions (TI). Counselors should gain deeper understanding of MSM population and know their risk practices. Further, identifying potential community members to become community counselors and train them in counseling will be helpful strategy to reach out un-reached MSM population.

ACKNOWLEDGEMENTS

The author thanks Prince Manvendrasingh Gohil, Chair and Sylvester Merchant, Executive Director of the Lakshya Trust for their support to this study. Staff members of Lakshya Trust deserve hearty thanks for their support in reaching out to the respondents. Special thanks to Mrs. Siddhi Pandya, my wife, for her review, valuable feedback on this research paper and unstinted support.

Notes

1. Garba-traditional group dance is played during the Navratri (Nine nights) festival. Garba originated in the Gujarat state of India.

2. Vat Savitri Vrat, where Hindu married women observe fast and worship the Vat (Bargad) tree with an intention of preserving their husband’s good fortune. On this day, early morning the women take bath, wear new clothes, bangles, apply vermilion on the fore-head and the hair-parting line; and worship the Vat (Bargad) tree.