Rethinking MSM, Trans* and other Categories in HIV Prevention

Amaya G. Perez-Brumer, Richard Parker, Peter Aggleton, Amaya G. Perez-Brumer, Richard Parker, Peter Aggleton

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138557758
• eBook ISBN: 9781351365475
• Edition: 1
• Topic: Medizin
• Subtopic: Gesundheitsversorgung

As the HIV epidemic moves into its fourth decade, it is clear that the global response has failed to adequately address the needs of a wide range of vulnerable populations and groups. Chief among these are gay, bisexual and other men who have sex with men, and transgender persons, who globally face the disproportional burden of HIV infection.

This volume rethinks HIV prevention and health promotion for sexual and gender minorities – in both the industrialised societies of the West, as well as in the developing nations of the Global South. The chapters it contains offer a critical analysis of past and present HIV research employing categories to designate gay and other men who have sex with men, transgender persons, and/or other persons and communities with diverse gender and sexual identities.

Contributors question the politics of many of the existing classifications and categories in HIV research and argue for a more sophisticated analysis of gender and sexual diversity in order to tackle the social and political barriers that impede the design of successful HIV prevention and health promotion approaches. This book was originally published as a special issue of Global Public Health.

In the name of brevity: The problem with binary HIV risk categories

Rachel L. Kaplan, Jae Sevelius and Kira Ribeiro

ABSTRACT

According to the ‘Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations’ there are five groups of people at elevated risk of HIV, including ‘transgender women or transgender men who have receptive anal sex with men’. Although cost effectiveness strategies and best practice lessons recommend targeting specific populations for HIV prevention, existing risk categories lack specificity, and may in fact cause further confusion. Existing categories of risk often perpetuate notions of gender and sexuality that can erroneously exclude, alienate, and stigmatise those who are at the highest risk and thus should be prioritised. We review the troubled history of the MSM category and the problematic conflation of trans feminine individuals and MSM in much of the existing HIV literature, and how this practice has stymied progress in slowing the HIV epidemic in the most at-risk groups, including those who do not fit neatly into binary notions of gender and sex. We draw from examples in the field, specifically among trans feminine people in Beirut and San Francisco, to illustrate the lived experiences of individuals whose identities may not fit into Euro-Atlantic constructs of HIV prevention categories.

Defining categories, erasing bodies: the troubled history of ‘MSM’

The seeming self-evidence of the phrase ‘men who have sex with men’ and its acronym ‘MSM’, could easily lead one to think that it constitutes a purely descriptive category, whose meaning is simple, well defined, and stable. However, exploring the history of this category rapidly reveals how its uses and meanings are frequently questioned and continuously shifting. In the paper ‘But do not identify as gay: A proleptic genealogy of the MSM category’, Boellstorff (2011) illustrates how the MSM category underwent successive transformations to anticipate its own failure and stabilise a definition that continues to face crises. By examining how the meaning of ‘MSM’ has shifted throughout the years to the point where it now sometimes refers to an identity or a community, Boellstorff points out how ‘MSM’ is more than an acronym describing a simple and easily identifiable behaviour.

According to Young and Meyer (2005), the terms MSM and WSW, though sometimes useful and accurate, can also render invisible important information on identity, community, and sexual culture. By separating people from their contexts in order to define them solely by their practices, the MSM acronym can actually prevent health professionals from reaching communities at risk for HIV. The lived experiences of people self-identifying as gay are not the only ones that fail to be captured by the use of the MSM category. In the same vein, others (Namaste et al., 2007) have pointed out that though ‘MSM’ aims to include all kinds of men – independent of their sexual orientation or identity – it does so by effectively erasing the specificities of bisexual lives. By only focusing on sex bisexual men have with men, the MSM category does not account for the complexity of HIV transmission and prevention for bisexual men.

The trouble with ‘MSM’ does not only lie in the way this category excludes certain men, certain communities, and certain identities. It also lies in the way it includes, by force, certain populations by defining them as ‘men who have sex with men’. According to Khan and Khan (2006), it may be inappropriate to talk about ‘men who have sex with men’ in some non-Euro-Atlantic contexts. In fact, many organisations prefer the phrase ‘males who have sex with males’ to account for a myriad of male identities – ‘man’ only being one of them. By taking a look outside of the Euro-Atlantic context from which the MSM category emerged, it is possible to see how the word ‘men’ is far from being a neutral term. Khan and Khan (2006) note that, though the phrase ‘males who have sex with males’ may seem less problematic, it still cannot account for people who do not fit within the male/female binary and their sexual partners.

These critiques reveal that the apparent explicitness of the MSM category relies on three main erroneous assumptions: (1) the assumption that ‘men’ is not an identity; (2) that we know the bodies we are talking about – that is, that the bodies of ‘men’, the ‘male body’ is something homogeneous, stable, and easily identifiable; and (3) that we know the sexual practices in which these bodies are engaged – that is, that the phrase ‘men who have sex with men’ is enough to describe a sexual behaviour.

Young and Meyer (2005) addressed and criticised the idea according to which ‘men who have sex with men’ could, in and of itself, appropriately describe sexual behaviour. As Patton (2002) notes, ‘MSM’ often supposes anal intercourse between men, even though those men may not engage in anal intercourse, especially in non-Euro-Atlantic contexts (Moody, 1988). By producing a largely implicit association between male–male sexuality and anal intercourse, the MSM category acts as a way to produce and naturalise homosexuality. Khan and Khan (2006) pointed out that the term ‘men’ – as well as ‘male’ – is far from being free of any notion of identity. In this paper, we draw on these critiques to analyse further the question of the body assumed by the MSM category. We argue that, by assuming a body without naming it, the use of the MSM category has stymied progress in slowing the HIV epidemic in some of the most at-risk groups, including those who do not fit neatly into binary notions of gender and sex.

Numerous works from anthropologists and feminist scholars have shown the variability of gender roles and norms throughout ages and cultures. Following the research of American sexologists John Money and Robert Stoller on intersex and transsexual individuals, Oakley (1972) introduced the distinction between sex and gender into Feminist Studies. Separating biological characteristics from identities, roles, or notions of femininity and masculinity allowed feminists to reveal the absence of causality between biology and [social norms regarding sex. However, as early as the 1980s some feminists critiqued the way the distinction between sex and gender tended to reinforce the idea that gender was a social construct that submits to variation while sex was ‘natural’ and ‘stable’ (Dorlin, 2008). As the historicity of sex was being examined (Laqueur, 1990), scientific discourses on sex underwent the scrutiny of historians, philosophers, and social scientists. Feminist studies of science played an important role in demonstrating how the categories of sex constituted an arena of debate and struggle within biomedical sciences (Fausto-Sterling, 2000; Oudshoorn, 2001). Since the seventeenth century, Euro-Atlantic conceptualisations of sex have adopted a binary model. However, throughout history, successive definitions of sex – humeral, gonadic, hormonal, genetic – failed to prove the existence of two, and only two, perfectly distinct sexes. Epistemological changes in the definition of sex aimed to stabilise this binary model even though it cannot account for multiple forms of intersex, as well as for transgender bodies. Far from being an effective and universal concept, the binary of sex constitutes, for biomedical sciences themselves, an ‘epistemological obstacle’ (Dorlin, 2008).

More recently, critiques on the social construction of gender and sexuality have been effectively integrated into works on or with the MSM category, like the work of Young and Meyer (2005). However, critiques on the social construction of sex categorisation has yet to be really taken into account, even though it may help us understand some of the limits and problems related to the use of the MSM category. For example, if the sex binary itself regularly faces definitional crises, it is only logical that the MSM category would face similar issues regarding its own definition. In fact, we would like to argue that MSM’s instability and inaccuracy is largely inherited from the sex categories upon which it is built. If the ability to know what ‘male’ is constitutes a challenge for modern science, it is no wonder that the ability to know whom ‘men who have sex with men’ are appears equally challenging.

This difficulty to define accurately what a ‘man’ is appears clearly in the way trans feminine individuals¹ have been included – or not – within the MSM category. Though excluded from the category at first, trans feminine people have been included because of what Boellstorff calls a ‘biologized understanding of maleness’ (2011, p. 296). Activists and scholars argued that ‘MSM’ didn’t accurately describe trans feminine individuals for, though they were ‘genetically male’ (Kammerer, Mason, Connors, & Durkee, 2001), they did not live as men but as women (Hawkes, 2008). Including them within the MSM category not only negates their identity but also obscures specific issues, especially regarding the role of gender-based violence in HIV risk.

But the problem with defining trans feminine people as ‘men’ or ‘males’ does not only concern the social dimensions of HIV transmission and prevention. It is also about the very physicality and biology of HIV transmission and prevention. To include trans feminine individuals in the MSM category, one does not simply have to adopt a ‘biologized understanding of maleness’, as Boellstorff puts it. Whether we adopt a hormonal, genetic, or gonadic definition of sex – or a combination of these three criterion as it is often the case when it comes to assigning a sex to individuals who do not fit clearly in the sex binary – trans feminine people may, or may not, be considered male. In its 2006 Global Report, UNAIDS (2006, p. 110) defines ‘men who have sex with men’ as people engaging in male–male sex, including trans feminine individuals or, as they put it, ‘transgendered males’. However, what is the definition of ‘male’ adopted here? Could a trans feminine person still be considered ‘biologically male’ while being on hormone replacement therapy? Could a trans feminine person still be considered ‘biologically male’ after an orchiectomy (the surgical ablation of testicles) or a vaginoplasty (the surgical construction of a vulva)? When does one begin or cease to be ‘biologically male’? How does the erasure of surgically modified trans bodies prevent us from having access to accurate evaluation of HIV transmission post genital surgery?

These questions have particularly important implications when it comes to evaluating HIV transmission risk, developing HIV prevention programs, and implementing appropriate prevention tools. By subsuming vastly different bodies under the MSM category, we risk erasing important sexual practices and routes of HIV transmission. For example, by conflating MSM and trans feminine people, it becomes difficult to consider penile–vaginal penetration, thus erasing experiences of some post-operative trans feminine individuals. Similarly, how can we account for penile–vaginal penetration between trans-masculine people and non-transgender men within gay settings while acknowledging the fact that the MSM category implies, not only anal intercourse as Patton and other scholars have stated, but also a specific form of bodies labelled as male?

As specificities of the HIV epidemics within trans communities have become more and more apparent, a shift has appeared in the conflation of MSM and trans feminine people. Examining the more recent UNAIDS Global Reports offers interesting insight on this evolution. While the 2006 Global Report included trans feminine individuals in the MSM category, as they were considered ‘biologically male’, the 2010 Global Report used the phrase ‘men who have sex with men and transgender people’ (UNAIDS, 2010). Another shift appears in the 2013 Global Report as transgender women and MSM constitute two distinct categories (UNAIDS, 2013). As a result, this report extensively addresses challenges faced by transgender women and emphasises that gender inequalities and gender-based violence play an important role in the increased vulnerability of this population regarding HIV transmission. The ‘Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations’ further differentiate risk categories that honour differences in the specification of ‘transgender women or transgender men who have receptive anal sex with men’ (World Health Organization, 2014).

Even though these changes mark an extremely important shift in light of the disproportionate risk of HIV/AIDS among trans feminine people across the globe (Baral et al., 2013), it is essential to remember previous critiques on the use of categories in epidemiological research. Just as ‘gay’, ‘man’, and ‘male’ have raised definitional challenges and epistemological questions, ‘trans woman’ is a specific identity category, situated contextually and culturally in a particular place and time. The term ‘trans woman’ may refer to very different experiences, identities, or forms of embodiment and excludes trans feminine individuals who do not identify as women and/or do not embrace a binary definition of gender. While some people completely identify with the term, others may reject it altogether or use it strategically in order to make sense of their situation. In some non-Euro-Atlantic contexts, as well as some cultures within Euro-Atlantic environments, the category ‘trans woman’ may not make sense at all. Furthermore, attention should be given to the effects of using a category like ‘trans woman’ for the populations we want to reach. Do we – HIV researchers and scholars – effectively reach all parts of the trans community when using such a specific identity term? When we recruit ‘trans women’ as the target population, do we effectively reach trans populations most at risk for HIV, notably migrant trans feminine people engaged in sex work (Giami, Beaubatie, & Le Bail, 2011) who may not identify as ‘trans’ or as ‘trans women’? What realities, narratives, bodies, sexualities, and practices are implied and prioritised by this category? Which ones are excluded or erased? How can we properly address the HIV epidemics among trans women and other trans people assigned male at birth without erasing the experiences of trans men and other trans people assigned female at birth? Answers to these interrogations are unclear and deserve further investigation. Though the use of categories is often challenging and can suffer severe limitations, keeping those interrogations in mind may keep us from erasing the broad diversity of bodies, identities, practices, and sexualities within trans communities and thus enable us to reach people in need of appropriate information, materials, and services.

Throughout the world, the risk of HIV infection among trans feminine individuals is 49 times higher than that of members of the general population (Baral et al., 2013). This staggering figure requires action. However, how is it possible to prioritise and address the health needs of a population with appropriate specificity while at the same time seeking to maximise inclusion and avoid perpetuation of the sex and gender binary? Further, how can health professionals describe and measure risk without reducing individuals to their physical bodies through language and summary? Although we do not yet have answers to these difficult questions, we draw on examples from the field to illustrate these complexities through the lived experiences of individuals whose identities may not fit into the male/female binary or Euro-Atlantic constructs of HIV prevention categories.

Examples from the field

Trans feminine individuals in the Middle East and North Africa: Beirut, Lebanon

To illustrate the complex history of HIV prevention categories that we have outlined and discussed above, we provide examples from the field that highlight some of the challenges associated with existing constructs of definition, recruitment, and description. Challenges in our decisions about expressing HIV risk categories extend beyond a Euro-Atlantic context and the English language. Until recently, HIV research among populations in the Middle East and North Africa (MENA) has often conflated trans feminine individuals and MSM (Mumtaz et al., 2010). In 2011, formative data were collected among a sample of 10 trans feminine people in Beirut, Lebanon to understand their lived experiences and risk behaviour (Kaplan et al., 2015). Recruitment took place through referrals from an LGBT organisation and from study participants. Interviews were then conducted by a social worker who was providing social support services to trans individuals. Unlike ot...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Citation Information
• Notes on Contributors
• Introduction: The trouble with ‘Categories’: Rethinking men who have sex with men, transgender and their equivalents in HIV prevention and health promotion
• 1 In the name of brevity: The problem with binary HIV risk categories
• 2 The conflation of gender and sex: Gaps and opportunities in HIV data among transgender women and MSM
• 3 Towards ‘reflexive epidemiology’: Conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence
• 4 A global research synthesis of HIV and STI biobehavioural risks in female-to-male transgender adults
• 5 ‘Men who use the Internet to seek sex with men’: Rethinking sexuality in the transnational context of HIV prevention
• 6 From marginal to marginalised: The inclusion of men who have sex with men in global and national AIDS programmes and policy
• 7 From MSM to heteroflexibilities: Non-exclusive straight male identities and their implications for HIV prevention and health promotion
• 8 What is in a label? Multiple meanings of ‘MSM’ among same-gender-loving Black men in Mississippi
• 9 Switching on after nine: Black gay-identified men’s perceptions of sexual identities and partnerships in South African towns
• 10 Intersections and evolution of ‘Butch-trans’ categories in Puerto Rico: Needs and barriers of an invisible population
• 11 ‘You should build yourself up as a whole product’: Transgender female identity in Lima, Peru
• 12 HIV vulnerability and the erasure of sexual and gender diversity in Abidjan, Côte d’Ivoire
• 13 Gender identity, healthcare access, and risk reduction among Malaysia’s mak nyah community
• 14 The limitations of ‘Black MSM’ as a category: Why gender, sexuality, and desire still matter for social and biomedical HIV prevention methods
• 15 Sexual identities and sexual health within the Celtic nations: An exploratory study of men who have sex with men recruited through social media
• 16 ‘I am not a man’: Trans-specific barriers and facilitators to PrEP acceptability among transgender women
• 17 ‘Proyecto Orgullo’, an HIV prevention, empowerment and community mobilisation intervention for gay men and transgender women in Callao/Lima, Peru
• Index