The sex genie is out of the bottle when it comes to male students who engage in sex with men (MSM) in South Africa.
The study, the first of its kind in South Africa, was conducted by the Higher Education and Training HIV/AIDS Programme (HEAIDS) and the Networking HIV/AIDS Community of South Africa (Nacosa) in 2014 at 14 higher education institutions in the country and released this May.
A total of 8 869 participants completed the sexual health survey, which aimed to investigate MSM and lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) students’ knowledge, attitudes, perceptions and behaviours relating to sex, HIV and alcohol and substance use.
Quiz: Test your STI knowledge
"The knowledge, attitudes and behaviour in terms of HIV prevention and related factors among South African students in sexual minorities including MSM have never before been studied," Dr Ramneek Ahluwalia, who is the director of HEAIDS, told Health24.
A diversity of sexual orientations
Although 10% (896) of the students identified as MSM, the survey suggests that same-sex practices are not confined to those who identify themselves as homosexual.
“Among the men who engage in same-sex behaviour, almost three-quarters (71.2%) identified as homosexual, one out of five (20%) said he was bisexual, fewer than one in 10 (7.4%) said he was heterosexual and fewer than two percent selected another sexual orientation,” the study stated.
The study revealed a surprising finding - despite the sample of student MSM having a high basic HIV knowledge, they still engage in sexual behaviours that put them at a bigger risk of contracting HIV and other sexually transmitted diseases (STIs). These include:
- Unprotected anal and/or vaginal sex;
- Low rates of lubricant use during penetrative anal sex;
- Multiple sexual partners and multiple concurrent sexual-partners;
- Having sex for the first time at a young age;
- Meeting partners through the Internet; and
- Transactional sex.
The survey also indicated that belonging to the MSM group of students was statistically associated with a number of variables including:
- A very strong association with ever having found a sex partner through the internet;
- A moderate association with use of alcohol and/or drugs during the most recent sexual experience;
- A strong association with having offered transactional sex to someone;
- A strong association with having threatened someone with force in order to have sex.
Dr Ahluwalia said the findings would help campus-based health initiatives to improve HIV prevention among students, including MSM students.
Filling the gaps in HIV programmes
"We needed this student sexual health survey in order to have empirical evidence to fine-tune HIV responses on campuses and make them more inclusive and relevant to specific needs among MSM and LGBTQI student populations."
The study also serves a useful awareness-raising and advocacy purpose, he said. "It will allow us to pay attention to and initiate dialogue on an issue that has, to a large degree, been marginalised within health and support programmes for students," Ahluwalia said.
Dr Maureen van Wyk, the Executive Director of Nacosa, told Health24 that a major risk factor for MSM students was failure to properly “manage their body fluids when having sex".
She said men who have “receptive” anal sex are far more at risk than men who mostly do the penetrating.
"This increases the risk for transmission or contracting HIV when a condom is not used or when water-based lubrication is not used," said Van Wyk. "So when MSM have unprotected sex they also engage in sex with their female partners."
Debunking sexual behaviour myths
Despite these examples of risky behaviour, Van Wyk dismissed the commonly held perception that sexual minority groups are generally reckless about intercourse.
“Sexual minority groups are not more ‘reckless’ compared to heterosexual persons. This is once again a perception, myth and skewed view to MSM/LGBTI persons.”
She said the study showed that heterosexual identifying students had the same perceptions, behaviour and knowledge as LGBTI/MSM students when it came to sex, sexuality and HIV knowledge.
But, sexual minorities, “are certainly more vulnerable and at risk,” she said, particularly because nearly all sexual “messaging” was aimed at heterosexual people. Sexual minorities also, “don’t have free access to sexual health care”.
Van Wyk said the broader public was still ignorant when it comes to sex and sexuality in general and prejudiced and discriminatory when it comes to sexual minorities.
“It is far too easy to... lay the blame at the feet of LGBTI/MSM/WSW persons by saying they isolate themselves, or struggle with self-acceptance, or should disclose and out themselves in order to elicit support and acceptance from the broader public.”
She said the study should be used as a springboard for further discussions across the board, “to dispel harmful myths and stigmatisation, and to educate the public about sexuality, sexual diversity and sexual behaviour in general”.
A helping hand to MSM and LGBTQI students
Deputy Minister of Higher Education Mduduzi Manana told Health24 that the department, through HEAIDS, intends to use the survey findings to understand and address issues that affect student MSM and LGBTQ populations.
“HEAIDS will be working in partnership with other role-players including students, staff and leadership at higher education and training institutions, NGOs and the Department of Health department to use the findings of this survey and to refine responses in order to address existing gaps.”
Manana said the department would also collaborate with human rights advocacy groups, the Department of Health and other government departments, civil society and the LGBTI and MSM community to work towards fostering an attitude of tolerance in the higher education sector.
Here are some insights from the survey:
HIV testing behaviour
Most MSM participants (73%) had been tested for HIV at least once in their lifetime and four percent of those who had undergone testing reported that they were HIV positive.
Eight respondents who had been tested declined to answer the question on their HIV status, and seven said they were not sure of their HIV status
History of STIs other than HIV
In the MSM sample, 14.2% of participants reported having had STIs (other than HIV). However, 19.8% of MSM reported having had genital sores, nine percent had experienced a discharge (or unexplained fluid) from the genitals and/or anus, while 26.5% reported the past experience of burning while urinating.
A look at sex partners
Among student MSM, 54.5% reported having had at least one female sex partner in the past year and 47.9% reported having had at least one male sex partner in the same period.
One out of five (21.3%) sexually active MSM in the study reported having had only one male sex partner in the past year, while 13.9% had between two and three sex partners and 12.7% reported having four or more sex partners.
Almost five percent of sexually active student MSM reported more than nine male sex partners in the preceding year.
More than a third (36.6%) of MSM participants reported they had not used condoms during their last sexual encounter, while two-thirds (63.4%) had used condoms the last time they had penetrative sex.
The survey notes that this implies that they use condoms inconsistently or not at all.
One-third (32.4%) of student MSM reported having had penetrative anal sex without the use of condoms at least once in the past 12 months and 37.9% of MSM reported having had penetrative vaginal sex without the use of condoms during the past year.
One-third of MSM (34.3%) stated that they used condoms “all of the time” when having sex while another third (31.9%) said they used condoms “most of the time”.
One-third of MSM (31.1%) reported having had oral sex with semen in their mouths and 44.5% had had oral sex without semen in their mouths in the last year.
The role of alcohol and drugs
One in five student MSM reported using alcohol and/or drugs the last time they had sex, while 52% indicated that they had at some point used alcohol and/or drugs when having sex.
Only 1.3% said they always used alcohol and/or drugs when having sex, while 5.1% said they did so “most of the time” and 18% said “sometimes”.
About two percent of MSM participants reported that they or a sex partner had used needles to inject drugs at some point in the past year.
Sexual coercion, violence and use of force
More than one in 10 students in the MSM group reported that they had been forced to have sexual intercourse against their will, while three percent indicated that they had threatened to use force to get someone to have sex against his or her will.
A total of 10.6% of the MSM sample had experienced abuse and/or violence on campus due to their sexual preference; and 8.9% said they had been hit by a sex partner.
On the subject of transactional sex, 5.6% of student MSM reported having accepted material benefits in exchange for sex and 10.1% said they had offered some benefit in exchange for sex. More than a third (36.4%) indicated that they had met a sex partner through the internet.
Sexual health services
Despite three-quarters of student MSM indicating they were comfortable using sexual health services on campus, only one-third reported having actually used these services in the preceding 12 months.
The study noted that more than 40% had used off-campus sexual health services in the past year.
"Students’ perceptions suggest there is scope for improvement in the role played by university management and student leadership in addressing LGBTQI issues," the study stated.
Moderate levels of confidence were expressed (around 50% for both MSM and non-MSM participants) that cases of discrimination based on gender, sexuality and race would be well investigated by the staff at tertiary institutions. But many students were unsure how issues relating to the broader experiences of LGBTQI students would be managed.
About the participants
Of the total group of MSM participants, 61% were black students, 20% were white, 12% coloured and 2.7% of Indian origin. Just 1.3% said they belonged to “other” groups and 3.7% chose not to answer this question.
More than a third (37.7%) were aged 18 to 20 years, and another third (33.7%) were 21 to 23 years of age.
isiZulu, English, Afrikaans were the most common mother-tongue languages among student MSM, followed by isiXhosa.
Of the student MSM, 4.6% indicated that they had children and 4.6% were married.
The following higher education institutions were invited to participate: Central University of Technology, Durban University of Technology, Mangosuthu University of Technology, Nelson Mandela Metropolitan University, Stellenbosch University, Tshwane University of Technology, University of Cape Town, University of the Free State, University of KwaZulu-Natal, University of Limpopo, University of South Africa, University of Venda, University of the Western Cape and Walter Sisulu University.
Download the full study here
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