A qualitative study by Dr Adam Bourne and colleagues published in Global Public Health highlights the stigma and discrimination experienced by men who have sex with men (MSM) and trans women when accessing sexual health services in Nairobi, Kenya. Most participants preferred community run services and did not want to be referred to another clinic or public hospital. Trans interviewees emphasised the need for trans-run clinics.
The Kenyan AIDS Strategic Framework, published in 2014, prioritises HIV care and treatment services that are welcoming to ‘key populations’. However, as in many other African countries, LGBTI+ people are criminalised in Kenya. Currently, same-sex sexual activities are illegal, and sex between men is criminalised with a penalty of up to 14 years imprisonment.
Dedicated services for MSM in Nairobi are primarily delivered by community organisations supported by international funding, some of which establish partnerships with the public hospital system for referrals or complex care. MSM may also seek sexual health care from private providers offering dedicated services for MSM, or instead from public hospitals and clinics.
In-depth interviews were conducted with 30 participants in 2017 to collect their experiences and opinions related to sexual health services in Nairobi. Participants were aged between 19 and 56 years; six identified as trans women and twenty-four as men who have sex with men. Eight had female as well as male sexual partners.
All participants, except one, had previously visited a sexual health clinic. Ten said they accessed community-based sexual health services run by gay and bisexual men. Eight of the participants have visited a state-run or private clinic to access sexual health services in the past 12 months.
Professionalism, safety, and the standard of clinical care
During the interviews, participants mostly talked about the safety and professionalism of services. Only a small number of participants described clinical care experiences that were affirming of their sexual orientation and gender identity.
Almost all interviewees were concerned about confidentiality. These concerns were more pronounced among participants living with HIV who expressed the need for privacy and wanted to be able to talk openly with clinical staff in a safe environment. One participant shared his experience visiting a public clinic with his partner to have genital warts treated:
“They came in just to look at us and they yelled at us as we moved out. ‘Hey, those are homosexuals, those are partners.’ It was that bad and I think that was the worst experience have ever had and from that day I said I will never go to any clinic that is not friendly.” [Aged 27, HIV negative]
Affirming and professional care experiences were more common among those visiting private hospitals, community-run clinics, and community-oriented non-governmental organisation (NGO) programmes.
“The provider is the same gender as me. Like when you start from the receptionist to the nurse to the director. They are all MSM. So you feel comfortable you feel at home, yes is good. The information you share with the people... they are confidential.” [Aged 28, living with diagnosed HIV]
Trans participants had especially challenging experiences due to hostile attitudes and poor understanding of their identities. One participant shared her experience at a public hospital where she felt unsafe.
“I was sick and then they asked me, ‘Are you pregnant?’... They wanted to put things in there [gestures to genital region] and at that point I decided to tell them that am not a woman am a transgender and the doctor asked me, ‘What!’ You are a transgender? What is a transgender?’ And I say a transgender is a man who wants to become a woman or a woman who wants to become a man. And now the doctor went outside and called other doctors. ‘Come and see. There is a patient in my office, is a man, I don’t know whether is a man or is a woman but is telling me she doesn’t have a vagina’. I told them let me go to the toilet and I didn’t come back... I was feeling embarrassed and so many questions.” [Aged 28, HIV negative]
A common concern among participants was the disclosure of their sexual orientation or gender identity to third parties, especially in public hospitals, which were perceived as an extension of the government. This concern made accessing health services provided by NGOs safer and easier.
Comfort and cultural affinity in service provision
Many participants expressed a clear preference for services run by MSM, where they found it easier to talk openly and explain what they need.
“Now mostly [the staff] who are there are men. And even when they are men, you don’t fear anything. They told when I went now to be tested; they told me everything. ‘Even when we test you here even if we find out that you have HIV, nobody will know that you are MSM. No that is just our secret’. Even those people, that is they have that welcoming heart for people. You just reach there and you are greeted nicely, you are talked to nicely, there are seats there and you can just sit there and watch TV, yes even you just share stories. Yes even you just like going there.” [Aged 19, HIV negative]
However, trans participants also shared the need for trans-run clinics.
“So if me, I want to be served [at a clinic] I will want to go to the transgender somebody who will understand me. We will talk one language we will tell each other what the problem is and so forth... With MSM they like to ask lots of questions... Like if a met a trans woman and is the one assisting me I will feel comfortable.“ [Aged 28, HIV negative]
Participants living with HIV, who attend sexual health clinics regularly for HIV treatment, felt they were subject to harassment more often. In many cases, they needed to out themselves in order to educate the clinical staff.
“The idea I have is if the government can sensitize all nurses and all doctors about don’t mention ‘do you have a girlfriend’. That is the main topic. Yes ‘do you have a wife’ they will always ask ‘do you have a wife do you have a girlfriend’. Why can’t they ask ‘do you have a sex partner’ do they have to use such language? Every time I have to explain.” [Aged 33, living with diagnosed HIV]
Capacity and accessibility of services
Many NGO clinics for MSM are only able to screen and treat infections on the basis of common symptoms, without access to diagnostic tests. Most participants expressed the necessity of providing enhanced STI testing, diagnosis and treatment in all types of clinics. Interviewees wanted to be treated at the point of diagnosis, instead of being referred to a different clinic or other sections of the hospital due to concerns of stigma and discrimination.
“HIV testing, HTC, STI screening, treatment as well, for STIs for those who are infected and also counselling for those infected or affected by AIDS should be in same place. And also it should be welcoming more or less like it should be ample, should be you feel like you are at home [...] If it turns out that they have to go to another clinic they are not supposed to tell them to go to that other clinic or just refer you to another clinic, things will be bad. They are supposed to have all the equipment to treat and to guide the person.“ [Aged 20, HIV negative]
When it came to the location of the clinics, there were different opinions. Some participants wished to have the clinics in the city centre to be easily accessible, while some were concerned about being seen entering the clinics, especially community-run clinics, and preferred discrete locations.
The researchers conclude that gay and bisexual men and trans women “continue to receive substandard or unprofessional sexual health care. This paper documents numerous overt experiences of stigma, discrimination, and hostility within clinical contexts in public hospitals. Such experience, or indeed the fear of having such an experience (shaped by report from others), significantly impacted the accessibility and effectiveness of clinical care for many of those we interviewed.”
They note: “As exciting as PrEP and U = U are as epidemic-changing interventions, their potential will not be realised without addressing prevailing stigma directed towards [gay and bisexual men and trans women] and without taking steps to earn the trust of those who have grown accustomed to ill-treatment in the healthcare settings upon which deliver of these interventions depend”.
Bourne A et al. Experiences and challenges in sexual health service access among men who have sex with men in Kenya. Global Public Health, online ahead of print, 10 October 2021.