In-depth interviews were conducted with 25 participants, 12 of whom identified as MSM (48%) and 13 as TW (52%). The median age of IDI participants was 23 years (range 18–42) and 16 (64%) were aged between 18 and 25. The majority of participants were single (n = 10), while 4 and 7 participants reported a current relationship with a casual and regular partner(s) respectively. Sixteen participants were HIV negative (64%), eight were HIV positive (32%) and one was HIV status unknown or undisclosed (4%). Five FGDs were also held with 35 participants; two with service providers (n = 8 and 6), one with MSM and TW community leaders (n = 9), one with hidden MSM community leaders (n = 6) and one with TW community leaders (n = 6) (Table 1).
“I HAVE NEVER ADMITTED I’M A MSM BECAUSE I AM HIDDEN”: CHARACTERIZING THE LIVED EXPERIENCE OF HIDDEN MSM IN MYANMAR
Participant responses highlighted the perceived interconnectedness between sexual and gender identities in Myanmar, with participants expressing a belief that men who are sexually oriented towards other men share an inherent desire to dress and present in a feminine form:
When we become gays … also the hiddens who become gays... we want to look or behave like girls. Forget about the rules. As soon as we realize we are not straight, we want to look/behave like girls...
- Participant 1, FGD 2, Hidden MSM
Transgender women were therefore regarded as those who successfully embraced this desire while those who repudiated it were typically regarded as ‘hidden’ due to their efforts to maintain heteronormative behavior and presentation. As the following participant notes, expression of gender and sexual identity was often related to the external environment:
There are environments where hidden MSM cannot dress like Apwints… So they take hidden forms…
- Participant 3, FGD 2, Hidden MSM
These ‘hidden forms’ enabled MSM to conceal their sexual preferences by maintaining gender-confirming appearances and behaviors. As the above participant suggests, disclosure and concealment of sexuality was often contextual and tied to specific environments. This quote, and the one that follows, points to a fluidity of sexual and gender expression among MSM and TW in Myanmar:
Interviewer: First, have you heard of the words Apone, Apwint, etc?
Participant: Yes, I know
Interviewer: Which type would you identify yourself with?
Participant: I am more like Apwint
Interviewer: More Apwint?
Participant: Yes, because I am no longer Apone.
- IDI 34, TW, age 36.
A key influence on the disclosure of sexual and gender identity was the perception or expectation of stigma and discrimination. Participants directly connected the degree of anticipated or experienced stigma and discrimination to the extent to which sexuality was publicly disclosed or observed. For example, participants who were more ‘visible’ as sexual minorities, such as TW, or MSM who openly had relationships with male partners, more commonly experienced stigma from both significant others and the community. Consequently, concealment of their sexual identity and gender-conforming presentation enabled hidden MSM to avoid similar experiences to those described by this TW participant:
Of course, there are challenges. As I have a husband (long term male partner), I have to face more problems in my neighbourhood. I have to face things like that... Since I started identifying myself as a gay, there has been discrimination from my siblings and community.
- IDI 23, TW, age 22
The extent to which MSM felt the need to conform to traditional gender roles, including in the context of meeting family expectations to marry and have children, also had significant bearing on disclosure of sexuality. Underscoring the primacy of preserving good family relationships was an assumption that families would be disapproving of same-sex orientation. The following quote illustrates a possible consequence of disclosure to families:
To admit openly… that he is MSM, it will be difficult for him to be accepted by his family and community. There is a concern that the family will find out and abandon him.
- IDI 11, MSM, age 22
Participants engaged in a range of negotiated identity practices in order to conceal their sexuality from their family and community and avoid anticipated stigma and discrimination. Many described their general avoidance of other MSM and TW and their beliefs that any association would enable others to identify them as part of the MSM or TW community. While some avoided other MSM and TW all together, others restricted their socialization only to other hidden MSM:
I deny it when my family asked me. I have never admitted I’m a MSM either in the past and now because I am a hidden MSM and not an open type... I don’t know whether they pretend they don’t know about me. But they don’t like my Apwint friends and I choose Apone as my friends
- IDI 26, Hidden MSM, age 23
Other participants described a careful demarcation between their family and social lives, in order to maintain concealment of their sexuality around family, while selectively disclosing in certain social settings:
When I was in 8th or 9th Standard, I met some gays in the neighborhood. They told me “Hey ... Here. You have to dress like this.” and “A gay has to live like this.” …My family did not allow me to live in a gay (feminine) appearance. Even my hair was short like a boy and I wore a longyi (sarong typically worn by men in Myanmar). So, I had to meet them secretly at night.
- IDI 27, MSM, age 24
Selective disclosure also meant that participants' sexual identity and gender presentation was not static; many participants described a fluidity of sexual and gender performance which highlights the situational and contextual nature and application of sexual identity labels in Myanmar. This participant shares their experience of moving between transgender and male forms:
Although I was a gay, I still wanted to live like a boy. I mean – I wanted to dress like a boy. Others dressed like women at night. I did it sometimes. Also these days, as I am working as a dancer in a Zat band (traditional dance band), I dress like a woman. For the time being, as our team disbands for the season … I stay with friends, in places where there are MSM.
- IDI 27, MSM, 24 years old
“HIDDEN MSM DO NOT TRY TO LEARN MUCH [ABOUT HIV] THINKING PEOPLE MIGHT FIND OUT THEIR MSM STATUS”: BARRIERS TO ACCESSING HIV PREVENTION SERVICES AMONG HIDDEN MSM
The behaviors and concerns of potential discrimination and stigma among hidden MSM described above presented a range of barriers to their engagement with HIV prevention services. Most notably, many participants described the perceived threat of disclosure of their sexual identity associated with HIV testing services – either related to the need to disclose or discuss potential sexual risk behaviours, or questions that may be raised following a possible HIV diagnosis:
With hidden MSM, most families don’t know them. Since they are MSM, it will be a bit more difficult for them to test (in case) somebody finds out while he is testing. (Also) If he is hidden and he has it [HIV] and people don’t know his orientation, I think it can hurt him mentally.
- IDI 26, Hidden MSM, age 23
The priority given to concealing sexuality by hidden MSM shaped their preferences for HIV testing locations and providers. Many described the paramount importance of maintaining privacy and confidentiality in relation to their sexual orientation. While many MSM and TW participants expressed a preference for tailored HIV services, hidden MSM tended to weigh the perceived suitability of such MSM and TW-specific services against the threats to their confidentiality that these services were seen to pose. This ambivalence among hidden MSM towards MSM- and TW specific services was compounded by their avoidance of other MSM and TW. This participant describes an example of such avoidance from a fellow MSM waiting for HIV testing:
When I took a blood test in June, there was another Apone and I recognized him as an Apone at a glance. He was using the umbrella with anti-discrimination day label. I knew he was Apone. And he most probably recognized me as well. But he didn’t want me to know he came there for a blood test. He was sitting in a corner silently. He didn’t want me to notice him.
- IDI 24, Hidden MSM, aged 30
Government-provided services were viewed unfavourably by most MSM and TW, often related to past experiences or expectations of stigmatization and discrimination by government staff. This was particularly felt by TW participants and more ‘open’ MSM:
With the NGOs, since we are MSM, they do counselling regarding sexual disease if we have it. They treated us warmly without discrimination. That is the difference. It is difficult for MSM to enter government clinic. They don’t go there. There are many MSM staffs at NGOs. We just go where we are comfortable.
- IDI 33, TW, age 22
While both ‘open’ MSM and TW, and hidden MSM shared this fear of stigmatization by health staff, for hidden MSM, the specific requirements of government services, as described below, and the inherent risk of indiscretion that these requirements carried presented additional barriers to accessing HIV testing at government services:
If an Apone like me went to NAP [National AIDS Programme], there would be a lot of challenges. They insist we bring one family member to their counseling session. And they don’t do history taking and counseling sessions individually. They ask about sexual issues in front of several doctors and female nurses. And they tell us to bring our male partners for blood test.
- IDI 24, Hidden MSM, age 30
In general, health-seeking behavior among hidden MSM was largely influenced by the extent to which services could offer anonymity. Below describes a participant’s recent visit to a HIV testing clinic that served MSM and TW clients as well as the broader community. Service satisfaction was related to the relative anonymity provided by this clinic, coupled with the skill and sensitivity of the service provider towards MSM and TW clients:
Although it was a general clinic, many MSM went there. It was good for me as there were not too many MSMs. Hidden ones can also visit. All kinds of them. It was good because there was an MSM project (also at the clinic) ... I felt more secure and safe. It is better for the clients.
- IDI 24, Hidden MSM, aged 30
The need for anonymity also held important implications for hidden MSM diagnosed with HIV. As this participant describes, hidden MSM may choose to prioritize the concealment of their sexuality over their own health and well-being. For some, a HIV diagnosis would be regarded as an unwelcome intrusion of their private ‘hidden’ life, into their daily, more ‘visible’ lives, such as the need to take daily treatment for example.
I think Apones will face more challenges (with HIV testing). They are hiding themselves and when they get a positive result, they can have more worries and emotional problems. Some don’t want to disclose even if they get a positive result. And you know? They might think “Why should I care about a positive result? I am not going to seek medical care.” Apwints have more guts to disclose and discuss. They will seek medical care if they get a positive result. I think they have more knowledge than Apones do; compared to Apones, many Apwints know about HIV. Apones do not try to learn much (about HIV) thinking people might find out their MSM status.
- IDI 16, MSM, age 23
The need to navigate between these two worlds likely impacts the perceived suitability and appropriateness of HIV treatment and support. The following participant describes the differentiated perspectives of home-based peer-support - a service commonly provided by NGOs to promote adherence to HIV treatment and ensure ongoing psychosocial wellbeing - among hidden MSM and TW:
Interviewer: Was it okay when there were visitors at home?
Participant: For transgender, they mostly spend time outside the home. And those who are accepted by their families, home visits are okay. For hidden MSMs, home visits are not okay.
Interviewer: So, you make appointments and meet him/her in a convenient place?
Participant: They (hidden MSM) just don’t want people around.
- IDI 24, Hidden MSM, age 30
“WE ARE PEERS AND WE KNOW WHAT HIDDEN MSM DO BUT, AT THE COUNSELING SESSION, THEY WOULD SAY THEY ARE NOT THAT KIND OF PERSON … WHAT DO WE DO THEN?” SERVICE PROVIDER AND COMMUNITY LEADER PERCEPTIONS OF BARRIERS TO ENGAGING HIDDEN MSM IN HIV PREVENTION
Data from service providers and community leaders highlighted the ways in which characteristics of hidden MSM presented barriers to effectively engaging this group in HIV prevention. In discussing the challenges, service providers demonstrated an awareness of concerns and inner struggles faced by hidden MSM and recognized the impact this had on their approaches to service provision, as this service provider demonstrates:
Interviewer: How do you identify open and hidden type?
Participant: Hidden type hides himself. It is quite difficult to persuade him to do blood test. The thought is that what if someone sees him if he comes here?
- Participant, FGD 3, Service Provider
Some service providers observed that hidden MSM had low levels of HIV prevention knowledge and were less likely to engage in protective behaviors compared to other MSM and TW:
Hidden MSM don’t admit it (that they have sex with men). They don’t always use condoms. Even if they use condoms, they sometimes don’t know if they are wearing the condoms correctly or inside-out.
- Participant, FGD 1, MSM Community leader
This behaviour may be a result of a deliberate avoidance of the purchase of or access to condoms in order to conceal sexual behaviours, or reflect the limited knowledge of HIV prevention and safe sex practices due to minimal engagement with HIV prevention services and providers. For example, this service provider describes their experience encountering MSM who deny their sexual orientation and therefore their need for HIV-related health promotion during community-based outreach and health promotion:
In hidden types, they don’t even want to be known among themselves. They live with their pride. When you look at them, they look like real men… When you tell them to do blood test, they are scared to death. When you tell them about health education, they told (us) “We are not gays. Since I don’t think of myself as gay, don’t tell me those things.”
- Participant, FGD 3, Service provider
Some participants believed that the constant need among hidden MSM to hide their same-sex preferences and behaviors resulted in negative psychological effects such as feelings of internalized stigma and homophobia. In some cases, these negative feelings led to a sense of antipathy towards other MSM and TW. This hidden MSM reflects on these feelings arising from self-stigma and an ongoing need to conceal their sexual identity:
They (hidden MSM) can’t let the community know at all. And they can’t let their families know at all. So, finally they develop an attitude that they can’t even accept themselves as MSM….They have a gay instinct but they hide themselves so much and try so hard to prove they are not gays .. and then they gradually begin to hate gays.
- Participant 5, FGD 2, Hidden MSM community leader
The denial of same-sex behavior by hidden MSM was seen as a strategy to distance themselves from other MSM and TW as part of their broader attempts to conceal their sexuality. This behavior persisted even in situations where MSM sought HIV testing. Service providers noted how the reluctance of hidden MSM to discuss same-sex behaviors limited the ability of HIV testing staff to accurately assess risk and provide appropriate counseling. As this service provider notes, prevarication from hidden clients during HIV testing was a common experience:
We are peers and we know what hidden MSM do. But, at the counseling session, they would say they are not that kind of person … What do we do then? As we are peers, we know who is doing what. And things were okay when they first talked to us... Then, when they faced the counselor, and when the counselor started explaining, they said “I’m not that kind of person” and come out of the counseling room.
- Participant, FGD 1, MSM Community leader
Service providers also acknowledged the negative ways non-disclosure of sexuality intersected with HIV diagnosis and the impact this had on HIV treatment. As this following quote highlights, the need to keep sexual and family lives separate prevented some HIV-positive MSM from accessing family support. This quote also illustrates the contextualized nature of disclosure of sexuality among MSM as well as the potential impact - such as delayed or disrupted treatment - on access to HIV prevention and care services:
Interviewer: Are there conditions where MSM cannot come for HIV treatment all?
Participant: I have seen one… He is only 22. He lives with his aunt. She discriminates him because he is MSM. He came to our clinic and said he wants to test. He is “out of the closet” type but he lives like “in the closet” type at home in front of his aunt. When tested, his HIV test was positive. When I showed him the long-term plan (for treatment and care) he said that his aunt does not agree with him being an MSM (so) he has to live like a man. She does not like him going out…. The aunt will be worse if he has HIV because she doesn’t like him being MSM.
- Participant, FGD 3, Service provider
In response to these complexities, service providers described the different approaches they adopt to engage hidden MSM, demonstrating an understanding of the characteristics of this group and a level of empathy for their struggles. In particular, many service providers were cognizant of hidden MSM’s need for privacy and discretion. This service provider reflects on how these priorities are reflected in their professional practice:
The one who is doing prevention knows them (hidden MSM). However, they hide. I know I cannot approach them like they are gay. I call them big brother or little brother. They liked to be called like that.
- Participant, FGD 3, Service provider
Conversely, while many service providers and community leaders expressed understanding and empathy towards hidden MSM, others expressed feelings of frustration and impatience in the face of the difficulties they experienced working with this group. Underpinning this frustration was an expectation of responsibility among MSM and TW to prevent the spread of HIV. The following quote assumes a sense of community that underpins this sense of responsibility, however this sentiment is unlikely to extend to hidden MSM. This quote also speaks to the importance of rapport- and trust-building in the HIV prevention work carried out by peers - which is often developed over time and through repeated interactions - and is typically a precursor to longer-term engagement of MSM and TW with HIV prevention services. This community leader reflects on the challenges to engaging with hidden MSM and conveys a sense of frustration:
We want to help them understand such things as HIV prevention. It’s not that we have left the hidden ones out but they have left us. There will be no discrimination if they have open discussions with us… They need to cooperate by doing their part…. They are not interested in how to use condoms to prevent HIV and how to take treatment. We don’t leave them out but they have left us.
- Participant, FGD 1, MSM Community leader
Responses from some service providers and community leaders also conveyed a sense of powerlessness against the numerous influences that prevented MSM from more freely disclosing their sexual preferences and behaviors. These responses also displayed their recognition of the need for supportive and enabling environments if such behaviors were to change:
What can we do when hidden people from the community don’t disclose? … Rather than tell them to take HIV tests, they don’t even know what HIV is and what AIDS is. To face this thing (HIV testing) is something which comes later. From the very beginning, their parents did not accept them being gays. If these problems (like a positive HIV diagnosis) are added, a lot of them will be dead.
- Participant, FGD 1, MSM Community Leader
This quote also hints at recognition by some community leaders and service providers of a hierarchy of priorities for hidden MSM that may supersede the need for HIV testing and prevention. For example, denying or concealing same-sex orientation may enable hidden MSM to maintain family relationships and support, which may be disrupted by an HIV diagnosis that may force hidden MSM to reveal their sexuality and potentially upset family dynamics.