This gendered identity framework of male-to-male sex is mainly common among low-income populations, both rural and urban, which are plagued by poverty, low levels of literacy and economic disempowerment. Another category of men who have sex with men (MSM) involves English-speaking, middle and upper class males who identify themselves as gay. Then there are hijras, biological males who cross-dress regularly. They are often castrated and belong to a socio-religious community with its own rules and regulations. They draw their sexual partners from the general male population. Finally, there are men and boys who approach other males to relieve their sexual urge (referred to as "reducing body heat") and may include friends having sex with friends for mutual pleasure and males in all-male institutions such as boarding schools.

In the South Asian context, male-to-male sex is seen primarily within a gendered dynamic, rather than in terms of sexual orientation or identity. This means that many who could be categorised as MSM would not define themselves as such because they perceive themselves as normative penetrative males or as penetrated "not-men". Categorization is further complicated by the traditional demand that every man marries a woman. Many MSM, of whatever gender identification or sexual orientation, are either married or planning to marry, even kothis. Many MSM have concurrent relationships – with men and women at the same time.

Male to male sex and HIV/AIDS

Very little is known about HIV prevalence among MSM in the region. The National AIDS Control Organisation (NACO) in India has several sentinel sites which target MSM separately. In 2002, NACO reported a 23.6% rate of HIV infection among MSM in Mumbai. However, two sentinel sites located in rural areas in Tamil Nadu State reported much lower figures, that is 1.2 and 3.6% respectively. The exact contribution of male-to-male sex to HIV infection is unknown, as no studies have been undertaken on the subject. From the observed high-risk behaviour and vulnerability of the kothis, it can be assumed that the impact is significant. The various situational assessments conducted by the Naz Foundation International indicate the following risk and vulnerability factors:¹

-Feminization within a dominant masculinity that sees such males as less than men, and thus susceptible to abuse, violence and rape

-Receptive anal sex and low levels of condom and lubricant use

-High levels of multiple partners and sex work

-Significant levels of reported STIs and low levels of treatment.

Stigmatization and disempowerment

The Naz Foundation International (NFI) is an international NGO, whose primary aim is to improve the sexual health and human rights of marginalized males who have sex with males, and their partners and families in South Asia. Research conducted by NFI shows that men who are anally penetrated by other men are highly stigmatized, both by penetrators, as well as the general society.¹ Those who are perceived to be recipients of penetration are usually treated with contempt. Such stigmatization leads to human rights abuses, blackmail, violence, and male-on-male rape by local men, thugs and even the local police. As reported by several members of the Network of Indian People with Alternate Sexualities living with HIV/AIDS (NIPASHA), MSM living with HIV/AIDS are stigmatized by other men who are also living with HIV/AIDS because men in heterosexual relationships deem their routes of HIV infection "normal".

Many kothis also face harassment, sexual violence and rape from former friends in schools and colleges, and from those in positions of trust such as relatives, neighbourhood elders and teachers. Gang rape is common, along with violence and abuse from sexual partners. Such forced sex is always unsafe and often results in serious physical injury such as a ruptured rectum, internal haemorrhage and even HIV infection.

One of the central issues that have arisen from NFI research is that often it is effeminacy (acting or looking like a woman) and not the factual knowledge of male-to-male sexual behaviour that leads to harassment and violence. This effeminacy is expressed through body language, and at times, through cross-dressing, wearing make-up and use of effeminate language. Harassment and sexual violence result from the fact that many kothis do not live up to the expected normative standards of masculine behaviour. It is this belief that leads to the notion that those who are feminized can be exploited and abused and that being feminized somehow weakens the person, a notion often harboured by the kothis themselves.

The disempowerment of kothis has been found to create significant levels of suicidal impulses and self-damage, an expression of self-hatred and despair. This increases their vulnerability to STI/HIV as well as impeding successful implementation of risk-reduction strategies.

What needs to be done

Accepted notions around effeminacy are, therefore, one of the major factors that lead to disempowerment and opens kothis to abuse and assault. The fact that kothis themselves have internalized these notions so strongly, means that specific tools need to be developed for them to enable them to value their lives, enhance their self-respect and reduce their risks of contracting HIV. These tools would include gender-sensitivity training programmes that address differing sexualities, targeting the judiciary and law enforcement agencies² and education and vocational training programmes for kothis, to make them less economically dependent on their partners. Examples drawn from female sex workers projects, such as the Sonagachi Project in Calcutta, India, indicates this could be a viable process for enhancing self-esteem, increasing other sources of income, and more effective risk management.

Also, the legal, socio-cultural and economic impediments to MSM sexual health interventions urgently need to be understood and addressed. An NFI study in Bangladesh (Against the odds, 2002, 2004) clearly identifies this as a major concern. Empowering MSM to develop their own self-help services will be central because community-based organizing is often the best approach to sustaining behaviour change. NFI has assisted in the development of 28 such community-based service providers in Bangladesh, India, Nepal and Pakistan, who are showing the way. There are several other organizations in the region which have arisen from networks of MSM and developed as self-help providers, including Humsafar Trust in Mumbai, MANAS Bangla in Calcutta, Sahodaran in Chennai, Blue Diamond Society in Kathmandu, and Bandhu Social Welfare Society in Bangladesh. While these, and others, are providing excellent services, in a region of 1.5 billion people there is still a lot more that can be done, and should be done. Some of the issues that need to be addresses are:-Repeal of legislation that impedes sexual health promotion among MSM

-Address human rights violations of MSM and reduce sexual violence, harassment and abuse

-Empower local networks of self-identified MSM to develop their own services

-Address the risks of unprotected anal sex in all HIV/STI education programmes for the general population

-Include MSM in policy and decision-making at all levels

-Ensure that appropriate STI treatment centres are available, accessible and sympathetic to the needs of the many differing sub-populations of MSM.

Since 1996, NFI, along with several other MSM agencies in the region, has been strongly advocating for change, and for ensuring that appropriate services for at-risk populations of MSM are available and accessible. Donors, governments and NGOs in South Asia are now beginning to recognize the real risks of the HIV epidemic spreading through the various MSM sub-populations, and into the general population. However, such advocacy needs to be maintained, strengthened, and upstreamed, so that more funds can be leveraged to develop new services, and those most at risk can be ensured equity, social justice and well-being.

1. Resources located on the NFI website (www.nfi.net): e.g., Situational Assessment Report for Hyderbad, 2000; NFI Briefing Paper No. 7: Social Justice, human rights and MSM; and Against the odds – a report on the impact of legal, socio-cultural, legislative and socio-economic impediments to effective HIV/AIDS interventions with males who have sex with males in Bangladesh. NFI also publishes the quarterly newsletter Pukaar on HIV/AIDS, sexual health and Asian masculinities and sexualities (available online).