41 year old married kothi

“I don’t tell anybody that I am married”:
Understanding the vulnerabilities and associated
HIV risks of Indian men having sex with men who are
married to women
Sandeep Mane, Matthew J. Mimiaga, Steven A. Safren,
Murugesan Sivasubramanian, Patricia Case,
Carey V. Johnson, Vivek Raj Anand, Ashok Row Kavi, Arun
Risbud, Raman Gangakhedkar, Kenneth H. Mayer
Formative, qualitative
Examining experiences
and HIV sexual risk
 20 MSM who are married
to women
 20 MSM who are not
married to women
MSM in India Constitute a Core HIV Risk Group
National AIDS Control Organization (NACO)
2007 HIV prevalence estimates:
 7.4% for MSM
 0.34% for general population
Other HIV prevalence estimates among MSM in
India range from 9 to 18%:
 12% at The Humsafar Trust VCT clinic Mumbai
 13% Tamil Nadu state; 9% Chennai
 18% in Andhra Pradesh
NACO, 2008; Kumta et al., JAIDS 2010; Solomon et al., AIDS Behav 2010; Sravankumar et al., IAS 2006
MSM in India: Gay sexual identity and sexual
behavior not necessarily linked
 Kothi – Feminine
acting/appearing, predominantly
receptive sex partner
 Panthi – Masculine appearing,
predominantly insertive sex
 Double Decker – Both insertive
and receptive sex partner
 Gay – Similar to the identity of
“out” gay men in the U.S.
 Bisexual – Sexual behavior with
men and women
 Hijra (Arivani) – Male-to-female
transgenders, not MSM identified
Asthana and Oostvogels, Social Science and Medicine 2001
Pressure to marry is high in India
Additional stressors for MSM in India
 Social recognition: a person is not
recognized in society unless they are
 MSM are a stigmatized group
 MSM are hidden, including married MSM
 If not married, loss of family property rights
 Potential HIV risk to self, to wife, to children
 Psychosocial stressors
Harassment / assault
Fear of rejection from friends and family
Many MSM Get Married
 2009 Mental Health Study of
MSM at Humsafar Trust (N=150)
 21% of sample reported that they were
married to women
 2003-04 Humsafar VCT study (N=831)
 23% married to a woman
 Being married to a woman was a risk factor for being HIV
infected (AOR = 1.59; 95% CI = 1.27-2.78)
 This is likely an underestimate of the percent of MSM who are
 These are MSM presenting at Humsafar
Sivasubramanian et al., IAS 2010, paper in progress; Kumta et al., JAIDS 2010
Study Design
 Qualitative interviews & brief survey
 20 married MSM and 20 non-married MSM
 Voluntary counseling & testing for HIV
 Analysis: content analysis using NVivo qualitative
Descriptive Data
 Percentage sexual identities
 25 kothi
 20 bisexual
 20 gay/other
 23 panthi
 10 double decker
 2 unspecified
 Married participants were older than unmarried
(mean 28 vs. 24 years, p<0.03)
 3 married, 2 unmarried were HIV+
 Sex with women in past 12 months:
 100% of married MSM
 70% unmarried MSM
 Married and unmarried MSM were similar with respect to:
 Education
 Income
 Sexual risk behavior
Theme: Stigma and Pressure to Marry
 65% of MSM described experiences of stigma and
harassment from family members and other social influences,
particularly the pressure to marry:
 “No, nobody knows this [sex with men] so far, I have hidden all these
things from them…No one will respect me, they will condemn me, this
kind of things will happen.”
21 year old unmarried MSM, unspecified sexual identity
 “Four to five days before marriage my mother had locked me in a
room with one pair of clothes as I had said her that I would flee as I do
not want to get married…I don’t like it. I feel that I should become a
wife of other [men].”
23 year old married double decker
Theme: Childhood Sexual Abuse
 22% respondents described childhood sexual abuse
(CSA) experiences that were traumatic and/or unwanted
 This abuse was generally by older men in the community, family
members or teachers:
 “I was going to school for studying, and teacher only did sex with
me. He used to make me sit next to him and he was asking me to
hold is organ. Hence I left studies…That time my age was 9.”
26 year old married kothi
 Although CSA does not cause homosexuality, a few
respondents described these experiences as formative to
their being MSM
 “Had he not done sex with me, I wouldn’t be in this state today. I
wouldn’t be kothi or panthi today. I became kothi because he did
sex with me.”
41 year old married kothi
Theme: Concealment of Marital
Status to other MSM
 55% respondents reported that an individual’s marital
status is not discussed or disclosed among other MSM
 Married MSM conceal their marital status from their
sexual partners to maintain their identity as single and to
remain sexually desirable:
 “I don’t tell anybody that I am married. I ask my partner whether
he is married or not! Some of them say yes, some deny.”
28 year old married gay
 While respondents knew several terms to describe MSM
and same-sex behavior, there was only one term to
describe married MSM: “Paav Bhattewala”
Theme: Concealment of MSM Behavior
to Family, Friends, and Social Circle
 75% of respondents reported conscious concealment of
their MSM behavior from their wives and/or other family
 “I am always having tension whether somebody is watching me,
and by chance if they see me I have to tell my wife [a] lie.”
41 year old married kothi
 “My family is broadminded, but…I can’t expose my things to
them because they won’t accept it. I never hurt them for any
reason so I can’t hurt them by revealing this truth to them about
me. My bhabhi [sister in law] is God for me. I don’t want to tell
her all these things about me and make her sad.”
28 year old unmarried bisexual
 MSM in India face unique, complex, and culturally specific
stressors – HIV risk behaviors occur in this context
 Important psychosocial factors to consider in future
interventions may include:
Stigma and pressure
Childhood sexual abuse
Concealment of marital status to other MSM
Concealment of MSM behavior to family, friends, and social circle
 HIV interventions may benefit from an increased awareness
of this population and their specific prevention and treatment
 Future quantitative studies understanding the networks of
married MSM are warranted
 Findings have been used to develop a larger, quantitative
study (N=300) examining the social and sexual network
characteristics of married MSM in Mumbai, currently in
Thank you
Kamini Walia
Willo Pequegnat
Brown CFAR and
Fogarty AITRP Program
Harvard CFAR
Kalpita Langekar Patil
Jesse Ripton
Rodney VanDerwarker
Girish Kumar P
Study participants and
Humsafar Research Team

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