Meeting the Sexual Health Needs of Men Who Have Sex With Men in Senegal

Full text

Meeting the Sexual Health Needs of
Men Who Have Sex With Men in Senegal
Institute of Enironmental Sciences,
Cheikh Anta Diop University
Senegal National AIDS Control Council (CNLS)
Horizons Program

Meeting the Sexual Health Needs of
Men Who Have Sex With Men in Senegal
Cheikh Ibrahima Niang, Moustapha Diagne,
Youssoupha Niang, Amadou Mody Moreau,
Dominique Gomis, and Mayé Diouf
Institute of Environmental Sciences, Cheikh Anta Diop University
Karim Seck and Abdoulaye Sidibé Wade
Senegal National AIDS Control Council (CNLS)
Placide Tapsoba
Horizons/Population Council
Chris Castle
Horizons/International HIV/AIDS Alliance

Acknowledgments
The researchers would like to acknowledge the following organizations that helped with the study:
Conseil National de Lutte contre le Sida (National AIDS Control Council), Institut des Sciences de
l’Environnement (Environmental Science Institute), African Consultant International, Organisation
Panafricaine de Lutte contre le Sida/Centre de Traitement Ambulatoire (PanAfrican Organization for
AIDS Control/ Center for Outpatient Treatment), Family Health International/Impact, and
USAID/Dakar.
Thanks to those who provided technical and editorial comments on this report, including Margaret
Dadian and Ellen Weiss of the Horizons Program, and to Sherry Hutchinson for layout.
In addition, we would like to thank all of the individuals who participated in this research.
This study was supported by the Horizons Program, which is implemented by the Population
Council in collaboration with the International Center for Research on Women, International
HIV/AIDS Alliance, Program for Appropriate Technology in Health, Tulane University, Family
Health International, and Johns Hopkins University. Horizons is funded by the U.S. Agency for
International Development, under the terms of HRN-A-00-97-00012-00. The opinions expressed
herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International
Development.
Published in September 2002.
The Population Council is an international, nonprofit, nongovernmental
institution that seeks to improve the wellbeing and reproductive health of
current and future generations around the world and to help achieve a
humane, equitable, and sustainable balance between people and
resources. The Council conducts biomedical, social science, and public health research and helps build
research capacities in developing countries. Established in 1952, the Council is governed by an international
board of trustees. Its New York headquarters supports a global network of regional and country offices.
Copyright © 2002 The Population Council Inc.

Table of Contents
Executive Summary 1
Introduction 4
Methodology 6
Orientation and initial contact 6
Ethnography 6
Survey 7
Group discussions 7
Ethical issues 8
Limitations of the study 8
Findings 9
Identities and social roles 9
First sexual experience and subsequent relationships 11
Stigma, violence, and rejection 12
HIV/STI vulnerability 13
Health-seeking behavior 15
Conclusions and Next Steps 17
References 18

Meeting the Sexual Health Needs of MSM
Executive Summary
Research conducted in many countries has highlighted the vulnerability of men who have sex with
men (MSM) to HIV and other sexually transmitted infections (STIs). Yet in Africa, they receive little
attention in HIV/AIDS programming and service delivery because of widespread denial and
stigmatization of homosexual behavior. In Dakar, Senegal, a study conducted by researchers from the
National AIDS Control Council (CNLS), Cheikh Anta Diop University, and the Horizons Program
used ethnographic and survey methods to elicit information about the needs, behaviors, knowledge,
and attitudes of MSM. In the ethnographic phase, the researchers conducted group discussions and
interviews with MSM and people who interact with them, such as bartenders, female sex workers, and
taxi drivers. In the second phase, the researchers surveyed a convenience sample of 250 MSM, ranging
in age from 18 to 53 years.
The research team recruited informants by visiting areas frequented by MSM and by making contact
and building trust with MSM and MSM leaders. As part of the research process, the research team
spent a lot of time examining their own preconceived notions about sexuality, working through
prejudices and taboos, and stressing the importance of maintaining the confidentiality of informants.
All interviews were anonymous and informants were asked to provide oral informed consent. Upon
consent, informants received a small stipend (2,500 F CFA) to cover travel costs, information on STIs
and HIV/AIDS, and a referral for a free medical consultation and treatment.
Key Findings
MSM have distinct identities and social roles that go beyond sexual practices. Broadly defined,
Ibbis are more likely to adopt feminine mannerisms and be less dominant in sexual interactions. While
society may formally reject homosexuality, this does not prevent Ibbis from occupying positions of
high regard in certain circles. For example, Ibbis often have close relationships with women who have
political or economic power, for whom they carry out important social ceremonies and functions. In
several neighborhoods, Ibbis enjoy the protection of the entire community. Yoos are generally the
insertive partner during sex and do not consider themselves to be homosexuals. Beyond these broad
categories, there are additional subcategories based on age, status, and type of relationship. However,
identification with a particular group is not a good predictor of an individual’s sexual practices.
The first sexual experience often occurs with an adult during adolescence. Survey respondents’
first sexual encounter with a man occurred on average at 15 years. This experience was often with
an adult, someone they knew or had recently met. A third of the sample reported that the adult was
part of the respondent’s extended family.
Sex with men is driven by many reasons, including love, pleasure, and economic exchange.
Many of the men’s histories highlight that their initial and subsequent sexual experiences occurred
in the context of emotional and physical attraction. Economic exchange also plays a significant
role. Two-thirds of the survey sample reported that they received money as part of their most recent
1

sexual encounter, and 9 percent had given money in exchange for sex. MSM reported a wide range
of sexual relationships, including a regular stable relationship with a single partner, a regular
relationship with one partner plus occasional partners, and irregular relationships with many
partners. The vast majority of MSM have had sex with women. Eighty-eight percent of the survey
sample reported ever having vaginal sex, and nearly a fifth had had anal sex with a woman.
The lives of many MSM are characterized by violence and rejection. Forty-three percent of
MSM had been raped at least once outside the family home and 37 percent said they had been
forced to have sex in the last 12 months. Thirteen percent reported being raped by a policeman.
Nearly half of the 250 men interviewed had experienced verbal abuse (including insults and
threats) from their family. Many also reported physical abuse (e.g., blows, stone throwing) by
family and community members and the police. The study found a good deal of mobility among
the men, both voluntary and involuntary; nearly a fourth reported being forced to move in the last
12 months. Numerous MSM emphasized the importance of keeping one’s sexual inclinations and
relationships a secret because exposure leads to ostracism, stigmatization, and physical or verbal
abuse.
Many MSM are at high risk of HIV because of unprotected sex, a history of STI symptoms,
and poor knowledge of STIs. When asked about condom use at last sex, only 23 percent of those
reporting insertive anal sex said they used a condom. The figure for receptive anal sex was much
lower: 14 percent. Condom use with women was also low: 37 percent said they used a condom the
last time they had sex with a woman.
Informants identified a number of obstacles to condom use, including reduced pleasure,
interference with establishing trust, and a lack of power on the part of some MSM to request
condoms. According to one informant, “If a Yoos doesn’t want to use a condom, there’s not much
an Ibbi can say.” Informants also mentioned the high cost of preferred condom brands and poor
access to water-based lubricants. Almost all of the MSM surveyed knew that HIV/AIDS could be
contracted through sexual intercourse and 80 percent cited condoms as a way to prevent the
disease, although actual use does not reflect knowledge.
Many respondents reported having experienced STI-related symptoms. For example, 42 percent
had had burning or penile discharge and 22 percent reported having had lesions or pustules on their
anus. When asked about the causes of penile discharge or burning, most respondents mentioned
such non-viral or bacterial causes as poor hygiene, irritation from intercourse without sufficient
lubrication, spicy foods, long periods of abstinence, masturbation, too much sex, or other illnesses.
More than a third said they had no idea of the cause.
Health-seeking behavior for STI symptoms frequently involves delay and concealment. MSM
noted that they are particularly resistant to the idea of revealing anal symptoms at clinics and
hospitals because they risk exposing their homosexuality. Some men noted that health center staff
had treated them with scorn or ignored them completely, and did not respect their confidentiality.
Hence some informants spoke of doing nothing to treat their symptoms or self-medicating with
medicine purchased without a prescription. However, because there is less stigma associated with
penile symptoms, such as discharge, burning, itching, and sores, MSM are more likely to visit a
2

Meeting the Sexual Health Needs of MSM
public hospital or clinic for treatment of these conditions. When asked where they would prefer to
go for treatment of anal and penile symptoms, the majority mentioned public hospitals and
dispensaries, provided that they remain affordable and treat clients with confidentiality and respect.
Conclusions and Next Steps
This study provides important insights about the sexuality of MSM, their risk of HIV/STIs, and the
role of violence and stigma in their lives. The findings also highlight the lack of sexual health
services and information available to meet their particular needs.
The findings from this study were disseminated at a meeting held in April 2001 in Dakar and have
catalyzed awareness of the public health importance of developing non-stigmatizing interventions
for MSM. As a result, a task force of NGOs and the USAID Mission, under the auspices of the
CNLS, has been formed to develop and coordinate services for MSM in Dakar. Potential
intervention components include behavior change communication, capacity building of MSM
leaders, training of peer educators, sensitizing service providers to the health needs of MSM,
creation of spaces that are safe and comfortable where MSM can gather to exchange information,
and liaising with police to reduce violence against MSM.
3

Introduction
Although sex between men occurs in most societies (Herdt 1997), its existence and importance for
HIV/AIDS prevention are frequently overlooked in the developing world (UNAIDS 1998). Denial
of sexual behavior between men, stigmatization or criminalization of MSM, difficulty in reaching
MSM, inadequate epidemiological information on HIV transmission through male-to-male sex,
inappropriate or inadequate health services, and the lack of donor funding are critical barriers to
research and service delivery (UNAIDS 2000a).
Despite widespread ostracism, denial, and rejection, MSM in the West have played key roles in
successful social mobilization efforts to prevent the spread of HIV/AIDS (Foreman 1998). Within
the African context, however, the question of the existence of MSM generally meets with severe
hostility (McKenna 1996). Compared to other regions of the world, Africa has the lowest level of
public awareness and discussion of MSM, and 55 percent of African countries have laws against
men having sex with men (McKenna 1996). The phenomenon of MSM is considered extremely
marginal, closely associated with European or Western contamination, and there is a deep belief
that it has no roots in traditional African society (McKenna 1996; Panos Institute 1991).
In Africa, very few social and behavioral studies exist on MSM. In the anthropological literature,
there are several references to the existence of male homosexuality in different parts of Africa
(Tauxier 1912; Evans-Pritchard 1929; Werner 1987). In Senegal, Crowder (1959) described its
existence in Wolof society and concluded that the phenomenon is well entrenched within this
society. There has been some documentation of men having sex with men in prisons in Africa with
the aim of developing strategies to prevent HIV/AIDS in that context. For example in a study
conducted by Simooya et al. (2001) in Zambia, 8.4 percent of prisoners reported homosexual
intercourse, although indirect questioning imply a much higher figure. Interviews with prisoners in
Nigeria suggest the existence of widespread male-to-male intercourse (Orubuloye, Omoniyi, and
Shokunbi 1995). But beyond research conducted with prison populations, there has been little work
by African researchers on the identity and behavior of MSM with the goal of developing HIV
prevention and care programs that meet the needs of MSM.
In Senegal there has been some investigation of MSM in the community context. Teunis (1996)
conducted an ethnographic study of MSM in Dakar, which describes how cultural and economic
forces shape their sexual and social relationships. Many of Teunis’ findings on the nature of
relationships among MSM were corroborated by researchers from the University Cheikh Anta
Diop as part of a study they conducted on migration and HIV/AIDS in Senegal (UNAIDS 2000b).
The research team conducted focus groups, in-depth interviews, and obtained life histories from
men recruited at bars, restaurants, and dance halls frequented by migrant and mobile populations.
Although the researchers did not set out to specifically investigate MSM, the study provided
important data about the sexual sub-cultures of MSM, their language and types of relationships,
and the social and economic environment of MSM in Senegalese society.
4

Meeting the Sexual Health Needs of MSM
This study builds on these earlier findings in order to better understand the lives of MSM in
Senegal so that appropriate STI/HIV interventions can be developed to meet their needs. Because
previous research indicates that many MSM also have sex with women, protecting MSM from
HIV/AIDS has wider implications for the health of families and communities (Foreman 1998).
5

Methodology
The study was a collaboration between researchers from the PNLA, Cheikh Anta Diop University, and
the Horizons Program. The aims of the study were to increase understanding about the sexuality of
MSM; identify the social, cultural, behavioral, and service delivery factors that place MSM at risk for
contracting STIs, including HIV/AIDS; and use this information to sensitize policymakers and
program managers to the need for non-stigmatizing interventions for this population.
The researchers used ethnographic and survey methods to elicit information from MSM, 18 years of
age or older, from several neighborhoods in Dakar. The study consisted of four phases: (1) orientation
to the study sites and initial contact, (2) ethnographic data collection through observation, informal and
semi-structured interviews, and case histories, (3) survey administration, and (4) group discussions.
Orientation and Initial Contact
During the first phase, the researchers visited bars, cafeterias, restaurants, and public places believed to
be frequented by MSM. Researchers first made contact with people who interact socially with MSM
(“gatekeepers”). It took several meetings between the researchers and these individuals for the latter to
understand the objectives of the research and its confidentiality safeguards. This phase was crucial for
putting informants at ease in order to elicit information on where MSM meet and to facilitate
introductions to MSM and others who interact with them. Sometimes the researchers faced reticence
and resistance when introduced to a potential informant, and only proceeded if the subject was willing
to do so and provided informed consent. Thus, the MSM who agreed to participate in the research
represent only a portion of the individuals who were initially contacted.
Ethnography
In the second phase, the researchers conducted observation at 19 sites where MSM meet and interact.
The researchers also carried out 23 unstructured individual interviews with individuals who are in
close proximity to MSM (e.g., bartenders, female sex workers, waiters, taxi drivers, female models);
with those who occupy positions of elder mentor, leader, or celebrity within the MSM community; and
with directors of programs or NGOs involved in combating AIDS.
Also as part of the ethnographic phase, the researchers conducted semi-structured interviews with 18
MSM and detailed case histories of eight other MSM in order to learn more about their sexual
initiation; family, social and sexual relationships; drug and alcohol use; and sexual health problems.
6

Meeting the Sexual Health Needs of MSM
Survey
In the third phase, the researchers administered a survey to a convenience sample of 250 MSM. The
survey elicited the following types of information from respondents:
• Sociodemographic characteristics.
• Problems encountered in the immediate and extended family, and in the community.
• STI knowledge, symptoms, treatment experiences, and preferred sources of information and treatment.
• HIV/AIDS knowledge, attitudes, and preventive behaviors.
• Attitudes toward people living with HIV/AIDS.
• Sexual behavior with men and women.
• Condom use.
The researchers interviewed a sample of 250 MSM using a structured survey instrument. To be
included in the survey, the respondent had to be 18 years or older and acknowledge ever having had
intimate sexual relations with a man. The researchers recruited subjects using snowball sampling,
which consisted of working with recognized leaders to recruit other MSM, who then helped to recruit
others until 250 men had been interviewed. Given that the questionnaires were anonymous, the
researchers attempted to put control measures into place to avoid cases of duplication. For example,
the MSM leaders were asked to stress to potential respondents the importance of being interviewed
only once.
Survey respondents ranged in age from 18 to 53 years, with a mean age of 25 years. Eighty-two
percent were single and 15 percent reported being married; some were in polygamous marriages.
About a fourth of the men had children. More than a third of the sample were Wolof, with many
other ethnic groups represented, including Toucouleur, Lébou, and Peul. The level of education is
relatively low: 15 percent had never been to school and 55 percent had not completed elementary
school. Respondents reported a range of income levels (low, middle, and high) and occupations,
including professional athletes, mechanics, artists, laborers, merchants, Muslim marabous, and
students. Twenty-four percent were unemployed.
Group Discussions
In the last phase the researchers conducted discussions with six groups of MSM to gather information
about sexual behavior and community attitudes toward MSM. Each group consisted of six to ten
participants. Older MSM who did not want to respond to the questionnaire made up one of the groups.
Other aims of the discussion groups were to obtain feedback on the data previously collected and
discuss the feasibility of intervention strategies that were emerging from the research.
7

Ethical Issues
As part of the research process, the research team spent a lot of time examining their own
preconceived notions about sexuality, working through prejudices and taboos, and stressing the
importance of maintaining the confidentiality of informants. All interviews were anonymous, and
informants were asked to provide oral informed consent. Upon consent, informants received a small
stipend (2,500 F CFA) to cover travel costs, information on STIs and HIV/AIDS, and a referral for a
free medical consultation and treatment. The interviewers always asked about preferred sites for data
collection. In some cases the researchers conducted interviews in cars or where MSM live or spend
time. Other times the interviews were conducted in an office at the university.
Limitations of the Study
Our study contains a number of limitations related to the respondents and the topics addressed. First,
snowball sampling was used to recruit informants. Although the technique was successful in recruiting
250 MSM, it nevertheless resulted in a selection bias. For example, 83 percent of survey respondents
were under 30 years of age. This may be due to the fact that all of the interviewers were young people
and that older MSM were reluctant to talk with someone their junior, especially about such a
stigmatized topic. Therefore we acknowledge that the sample is not representative of MSM in Dakar.
Second, the study focused on the experiences and perspectives of MSM in order to develop
interventions that respond to their needs. However, we did not interview some groups who would
be critical for intervention design and implementation, such as health care workers and policemen.
Finally, we note that a number of key HIV-related topics were not addressed in the interviews, such
as experiences with condom breakage, non-penetrative sex, HIV testing, and lubricants.
8

Meeting the Sexual Health Needs of MSM
Findings
Identities and Social Roles
In Wolof society, the most frequently used term for MSM is gor jigeen, which is translated literally in
English as “man-woman.” It implies a man who is very close to the world of women, to the point of
identifying with them. Gor jigeen is currently considered discriminatory and demeaning by MSM. As
one MSM stated, “The term Gor jigeen frightens us. When someone says it in our presence, it makes
us shiver. The term is like a siren sound that we expect to be followed by insults, blows, or stones
thrown at us by out-of-control mobs.”
Among MSM, they prefer the terms Ibbi and Yoos. Broadly defined, Ibbis are more likely to adopt
feminine mannerisms and be less dominant in sexual interactions. While society may formally
reject homosexuality, this does not prevent Ibbis from occupying positions of high regard in certain
circles. For example, Ibbis often have close relationships with women who have political or
economic power for whom they carry out important social ceremonies and functions. In several
neighborhoods, Ibbis enjoy the protection of the entire community. Yoos are generally the insertive
partner during sex and do not consider themselves to be homosexuals.
Beyond these broad categories, there are additional subcategories based on age, status, and type of
relationship. According to an informant from Médina, “Boys' men are young Ibbi; they are effeminate
[outwardly] and feminine in spirit, whereas the Gentlemen are young Yoos.” Gentlemen are described
as “tough” or “macho” and are heavily involved in alcohol and drug networks. The social construct of
the Yoos-Ibbi relationship is generally unequal in nature, revolving around the dominator/dominated,
masculine/feminine dichotomy. In ceremonies, the Yoos are served food by the Ibbi. Moreover, the
Yoos eat with spoons, while the Ibbi (like women) eat with their hands.
The categories Ibbi and Yoos have more to do with identity and status than with sexual practices. For
example, an MSM may call himself an Ibbi or be considered as such in the community, but he may
also have a sexual relationship with another Ibbi and they both may practice insertive and receptive
anal intercourse. Therefore, identification with a particular group is not a good predictor of an
individual’s sexual practices, as illustrated by one MSM, a fisherman by profession:
There are a lot of homosexual relationships among fishermen when they are at sea. In my
case, I was exclusively Yoos at the beginning, until one day, out of curiosity, I wanted to know
what it felt like to be an Ibbi, so I had a passive sexual encounter, and ever since, I can't do
without it. But I do it on the sly, and my regular partners still think of me as a Yoos.
9

Ibbi are often bound together by networks of intense relationships. Within their community, they
develop a system of communication by code to protect the secret of their sexual orientation. One of
them declared,
When two Ibbi meet in a car or a bus, they easily recognize each other right from the start. The
clothes they wear can be an external sign of belonging to the Ibbi family. Some Ibbi may wear
women's clothes, but that is not the case for most Ibbi. Their way of dressing is not enough to
identify the Ibbi. You know many individuals who wear a large boubou on Friday to go to
Muslim prayer; well, the Ibbi, if he wants, can wear the same boubou, have the same
masculine mannerisms, and identify completely with the faithful on the way to prayer. But
from the moment he wants to communicate with another Ibbi with him in the mosque, he has
a way of moving the sleeve of his boubou, of undulating his hips, of rolling his eyes, that
identifies him exclusively to the one who belongs to his community of sexual preference.
A young MSM said along the same lines, “You recognize a boys' man by his gaze, sometimes it's the
way he cinches his belt, or the buttons on his shirt that he doesn't close, or again, certain marks on his
clothing that give him away.”
Informants highlighted the importance of secrecy: hiding your inclinations, your relationships, and
your sexual practices. According to one MSM, “When you meet some of the older Ibbi, they will give
you the surname that you are to call them by. You never call them by their real name. They will do
whatever it takes to keep you from learning their real name.”
While the society at large may adopt attitudes of formal rejection toward homosexuality that may even
find expression in violence, this does not prevent the Ibbi from occupying positions of high regard in
certain segments of society. For example, some Ibbis have close relationships of trust and confidence
with women who are thought to have a great deal of political, economic, or social power. The Ibbi
perform specific tasks and functions for these ladies: They give them advice on clothes and make-up,
cook for certain special occasions, and help organize marriage and baptism ceremonies or social
gatherings. One MSM explained to us that during the years from 1950 to 1960, each “great lady”
affiliated with one of the competing political parties had around her a group of MSM who acted as her
publicists (advertising her virtues), hurling vitriolic verbal attacks at the great lady's women rivals. In
return, the ladies provided the MSM with material and financial support.
In addition to these ladies, traditionally called “Gor jigeen mothers,” an Ibbi might establish a special
relationship with a young woman, whom he then calls his “sister” (jigeen). He would see to her
appearance, preparing henna or make-up for her and doing her hair. He would be this young woman's
confidant, in a relationship of friendship and mutual respect without any possibility of having sexual
relations. The young woman, in return, would call him “Camen.”
In several traditional Lébou neighborhoods, we observed that the Ibbi enjoy the protection of the entire
community. One informant stated concerning this, “No one dares insult an Ibbi who is a member of
our community; he is protected the way you would protect the insane. If you hear that someone has
thrown stones at one of them, you can be sure that person was not from this neighborhood.”
10

Meeting the Sexual Health Needs of MSM
First Sexual Experience and Subsequent Relationships
The first sexual experience with a man often occurs during adolescence with an adult they know or
have recently met. Survey respondents’ first sexual encounter occurred on average at 15 years
(range: 7 to 31 years). A third of the survey sample reported that the adult was part of the
respondent’s extended family. According to one study informant :
We were seven boys in Kolda. Our mother waited a long time to have a daughter. And I was
the youngest. My mother made me wear girl's clothes. Also, I slept in the same room with my
uncle due to the lack of space in the house. I was 12 years old and he was much older. One
night, he took off my shorts, touched me on the behind and penetrated me. In the morning, he
left and didn't come back for a month.
Another informant told about the influence of a man known to the family:
One day, an adult man, an important gentleman who frequented the house, invited me to his
house. When I arrived, he asked me to give him a massage. I bowed to his wishes, and he
began to relax. I was afraid, because I didn't understand where he was going. Then he took my
hand and placed it on his sex. I let him do it. He also caressed my sex. Afterwards, he gave me
400 F CFA to cover my transportation. That shocked me. Nevertheless, he invited me back
again and I accepted the invitation. That time, everything went too fast; he penetrated me and
we had sexual relations.
In some cases, the relationship with an adult was preceded by sexual play with other boys. As one
MSM recounted:
At home, I took baths with my friends and my cousins, and we amused ourselves trying to
penetrate each other with soap. At the age of ten, I went to the beach with some friends, and I
met a gentleman who approached me under the pretext that I looked a lot like his nephew. He
promised to show me his nephew so that I could see our resemblance for myself. One day, as I
was leaving school, I saw him. We spoke. He suggested that I come to his house. He gave me
1,000 F CFA for the taxi. The day came and I went to his house. I expected to see his nephew.
After long discussions over soft drinks and cake, he admitted to me that he had no nephew and
that he lived alone. He told me he wanted to make love to me; I was afraid and I told him so.
He told me I just had to try it. One thing led to another, and as he caressed me, I remembered
that I had done that with my cousins and my friends. But with him, I went much further.
Some of the men’s histories highlight that their initial and subsequent sexual experiences occurred
in the context of emotional and physical attraction.
In 1993, I got my diploma and moved along with my family. I met a man who asked me to
accompany him to a party of other men. I was curious about his milieu, and I went. Another
day, I came home at 11 p.m. with him. He introduced me to his friends. He came on to me and
11

caressed me a lot. I felt a tremendous amount of pleasure. We went to his house and he
penetrated me. I felt happy and proceeded to have a very strong love relationship with him.
In other cases, financial need was a main motivation for first engaging in sex with a man. As a young
Wolof man recalled:
He invited me to his house the following day. He gave me money. I kept my date with him.
We were alone. The atmosphere was hushed. Around 2 a.m., he asked me to lie down on the
couch. He went to take a shower, and came back in a bathrobe, and we began to caress each
other. When it came time for me to leave, he again offered me a lot of money, really a lot. And
he asked me to come back as often as I liked, which I accepted. In the end, we had sexual
relations with penetration. And I acquired a taste for the pleasure and for the money. He took
care of all my debts. For my part, I made myself available to him every Saturday.
Economic exchange plays an important part in the current sexual experiences of the men in our
study as well. Two-thirds of the survey sample reported that they received money as part of their
most recent sexual encounter with another male, and 9 percent had given money in exchange for
sex.
Given that sex among men is driven by many reasons—love, pleasure, and economic gain—it is
not surprising that MSM reported a wide range of relationships, including a regular stable
relationship with a single partner, a regular relationship with one partner plus occasional partners,
and irregular relationships with many partners. The vast majority of MSM have also had sexual
relationships with women. Eighty-eight percent of the survey sample reported ever having vaginal
sex, and nearly a fifth had had anal sex with a woman. Some of these sexual encounters involved
an exchange of money: 21 percent of MSM reported giving money at the time of their last sexual
encounter with a woman and 13 percent said they received money.
Stigma, Violence, and Rejection
The lives of many MSM are characterized by violence and rejection. Forty-three percent of the
MSM surveyed had been raped at least once outside the family home, and 37 percent said they had
been forced to have sex in the last 12 months. Thirteen percent reported being raped by a
policeman. Nearly half of the 250 men interviewed had experienced verbal abuse (including insults
and threats) from their family and 19 percent at a police station (Table 1). As one informant noted,
“The most humiliating thing was when the police officer told my mother, who had come to see me
while I was being detained: ‘You didn’t bring a male child into the world; your son is a
homosexual.’”
12

Meeting the Sexual Health Needs of MSM
Table 1 Percent of MSM experiencing abuse (n = 250)
Source or Setting of Abuse
Family Community Police Station
Verbal abuse 49 40 19
Physical abuse 28 12 13
Many also reported physical abuse (e.g., blows, stone throwing) by family and community
members and the police. The study found a good deal of mobility among the men, both voluntary
and involuntary; nearly a fourth reported being forced to move in the last 12 months. Numerous
MSM emphasized the importance of keeping one’s sexual inclinations and relationships a secret
because exposure leads to ostracism, stigmatization, and physical or verbal abuse. According to
one informant:
In certain neighborhoods, when they find out you are an Ibbi, you may be just passing
through, but the young people will get together and start throwing stones at you….You
have the impression then that it’s raining stones.
Religious reasons are the ones most frequently invoked to justify rejection of the MSM. A Muslim
dignitary explained, “Since the Muslim religion forbids homosexuality, we cannot accept homosexuals
either in our homes or in our mosques.” Another cleric explained that when a Muslim shakes hands
with a homosexual, a certain number of prayers are required for his purification. MSM often invoke
religious reasons to affirm that their homosexual life is only for a limited period of time; they say that
they expect to renounce it some day when they have grown old in order to bring themselves in line
with the Muslim religion.
HIV/STI Vulnerability
Many survey respondents reported having experienced symptoms of STIs. For example, 42 percent
had had burning or penile discharge, and 22 percent reported having had lesions or pustules on the
anus (Table 2). When asked about the causes of penile discharge or burning, most respondents
mentioned such non-viral or bacterial causes as poor hygiene, irritation from intercourse without
sufficient lubrication, spicy foods, long periods of abstinence, masturbation, too much sex, or other
illnesses. More than a third said they had no idea of the cause.
13

Table 2 History of STI symptoms (n = 250)
Symptom Percent who experienced
symptom
Discharge and burning in the penis 42
Bleeding and discharge from the anus 42
Swollen ganglia in the groin area 36
Itching and sores around the penis 24
Sores and pimples around the anus 22
Painful and swollen testicles 12
In contrast to limited knowledge about STI symptoms, almost all of the 250 MSM knew that
HIV/AIDS could be contracted through sexual intercourse and 80 percent cited condoms as a way
to prevent the disease (Table 3), although actual use does not reflect knowledge.
Table 3 Knowledge of ways to prevent HIV/AIDS (n = 250)
Means of prevention Percent
Condoms 80
Avoiding dirty objects 24
Choosing your partners well 15
Having a single partner 13
Other 10
Prayer or God's protection 4
Not having sex 4
Avoiding giving blood 4
Don't know 3
Avoiding blood transfusions 2
Note: Respondents could give more than one response.
14

Meeting the Sexual Health Needs of MSM
When asked about condom use at last sex, only 23 percent of the survey sample that reported
insertive anal sex said they used a condom. The figure for receptive anal sex was much lower: 14
percent. Condom use with women was also low: 37 percent said they used a condom the last time
they had sex with a woman. Informants identified a number of obstacles to condom use, including
reduced pleasure, interference with establishing trust, and a lack of power by some MSM to request
condoms. According to one informant, “If a Yoos doesn’t want to use a condom, there’s not much
an Ibbi can say.” Informants also mentioned the high cost of preferred condom brands and poor
access to water-based lubricants. Availability of condoms does not seem to be a barrier: 86 percent
of MSM thought condoms were easy to find.
Health-seeking Behavior
Health-seeking behavior for STI symptoms frequently involves delay and concealment. MSM
noted that they are particularly resistant to the idea of revealing anal symptoms at clinics and
hospitals because they risk exposing their homosexuality, whereas symptoms on the penis, even if
they revealed certain “shameful diseases,” do not in themselves reveal their homosexuality.
Homosexuality is considered to be less well tolerated than such “shameful diseases.” Some men noted
that health center staff had treated them with scorn or ignored them completely, and did not respect
their confidentiality.
Hence some informants spoke of doing nothing to treat their symptoms or self-medicating with
medicine purchased without a prescription. However, because there is less stigma associated with
penile symptoms, such as discharge, burning, itching, and sores, MSM are more likely to visit a
public hospital or clinic for treatment of these conditions.
When asked where they would prefer to go for treatment of anal and penile symptoms, the majority
mentioned public hospitals and dispensaries, provided that they remain affordable and treat clients
with confidentiality and respect. Most MSM believe that doctors are the most reliable source of
information on STIs, which is why they would prefer to seek information and care from the formal
health system. Healers and marabous were rarely cited as preferred sources of treatment. There also
was little support for a special facility because they said it would risk reinforcing their ostracism.
Similarly, the most preferred source of information on HIV/AIDS is the health center, even though
radio and television have been the most common sources of information on the topic (Table 4).
15

Table 4 Current and preferred sources of information about HIV/AIDS (n = 250)
Current source of
information (%)
Preferred source of
information (%)
Radio 54 25
Television 50 20
Friends 22 19
Lectures/small group talks 17 19
Other 16 11
Newspapers 13 6
Health centers 12 31
Partners 2 3
Note: Respondents could give more than one response.
16

Meeting the Sexual Health Needs of MSM
Conclusions and Next Steps
This study provides important insights about the sexuality of MSM, their risk of HIV/STIs, and the
role of violence and stigma in their lives. The findings also highlight the lack of sexual health
services and information available to meet their particular needs.
Research conducted among MSM in Madagascar revealed similar vulnerabilities (Célestine 1998).
Respondents in this study identified a number of strategies for meeting the needs of MSM for
prevention and care, including training peer educators, holding community workshops, making
condoms available in places frequented by MSM, and reducing the stigmatization and
discrimination among health professionals through sensitivity training. A recent meta analysis of
nine controlled studies evaluating the effects of interventions for MSM in the United States
concluded that community-level interventions and small group efforts can substantially reduce
sexual risk in this population (Johnson et al. 2002). Given our findings, such intervention strategies
are applicable to the Senegalese context as well.
The findings from this study were disseminated at a meeting held in April 2001 in Dakar and have
catalyzed awareness of the public health importance of developing non-stigmatizing interventions
for MSM. As a result, a task force of NGOs and the USAID Mission, under the auspices of the
CNLS, has been formed to develop and coordinate services for MSM in Dakar. Potential
intervention components include behavior change communication, capacity building of MSM
leaders, training of peer educators, sensitizing service providers to the health needs of MSM,
creation of spaces that are safe and comfortable where MSM can gather to exchange information,
and liaising with police to reduce violence against MSM.
17

References
Célestine, R. 1998. Etude du Comportement des Hommes Ayant des Relations Sexuelles avec
d’autres Hommes en Matière de Prévention des MST/SIDA à Antananarivo, Madagascar.
Unpublished medical thesis.
Crowder, M. 1959. Pagans and Politicians. London: Hutchinson.
Diop, A.B. 1981. La société Wolof- Les systèmes d’inégalité et de domination (“Wolof Society:
Systems of Inequality and Domination”). Editions Karthala. Paris: IFAN, René Descartes.
Evans-Pritchard, E.E. 1929. Witchcraft (Mangu) among the A-Zande. Sudan Notes and Records
XII: 163-249. Khartoum: McCorquodale.
Foreman, M., editor. 1998. AIDS and Men: Taking Risks or Taking Responsibility. London: Panos
Institute.
Herdt, G. 1997. Same Sex, Different Cultures. Boulder: Westview Press.
Johnson, W.D. et al. 2002. “HIV Prevention research for men who have sex with men: A
systematic review and meta-analysis.” Journal of Acquired Immune Deficiency Syndrome 30:
S118-S129.
McKenna, N. 1996. On the Margins: Men Who Have Sex With Men and HIV in the Developing
World. London: Panos Institute.
Orubuloye, I.O., O.P. Omoniyi, and W.A. Shokunbi. 1995. “Sexual networking, STDs and
HIV/AIDS in four urban gaols in Nigeria.” Health Transition Review, Supplement to Vol. 5: 123-
130.
Panos Institute. 1991. “Unsung heroes in the south.” WorldAIDS (Nov.): 5-8.
Simooya, O.O. et al. 2001. “ ‘Behind walls’: a study of HIV risk behaviors and seroprevalence in
prisons in Zambia,” AIDS 15(13): 1741-1744.
Tauxier, L. 1912. Le noir du soudan, pays Mossi et Gourounsi : Documents et Analyses (“The
Blacks of Sudan: Mossi and Gourounsi Country, Documents and Analysis”). Paris: Emile Larose,
Librairie – Editeur.
Teunis, N. 1996. “Homosexuality in Dakar: Is the Bed the Heart of Sexual Subculture?” Journal of
Gay, Lesbian and Bisexual Identity 1(2): 153-169.
UNAIDS. 1998. “AIDS and Men who Have Sex with Men.” Best Practices: Point of View.
Geneva: UNAIDS.
18

Meeting the Sexual Health Needs of MSM
19
UNAIDS. 2000a. “AIDS and Men who Have Sex with Men.” Best Practices: Technical Update.
Geneva: UNAIDS.
UNAIDS. 2000b. Résultats de recherche – action, Projet Migration et SIDA, IOA/ONUSIDA.
(“Action Research Results, Migration and AIDS Project”). Abijan: UNAIDS Inter-Country Team
for West and Central Africa.
Werner, D. 1987. Human Sexuality Around the World. Unpublished manuscript of the Human
Relations Area Files. www.yale.edu/hraf.

Horizons is a global operations research
program designed to:
·Identify and test potential str ategies to
impro ve HIV/AIDS prevention, care, and
suppor t programs and service delivery.
·Disseminate best pr actices and utilize
findings with a vie w toward scaling up
successful inter ventions.
For more information, please contact:
Horizons Program, Communications Unit
4301 Connecticut Avenue, NW Suite 280
Washington, DC 20008 USA
Tel: 202-237-9400
Fax: 202-237-8410
Email: horizons@pcdc.org
www.popcouncil.org/horizons
Horizons is implemented by the
Population Council in collaboration with
· International Center for Research on
Women (ICRW)
· International HIV/AIDS Alliance
· Program for Appropriate Technology in
Health (PATH)
· Tulane University
· Family Health International (FHI)
· Johns Hopkins University
Y E A R S
1 9 5 2 –2 0 0 2