While the persistence of homophobia in South African society negatively impacts the ability of all MSM to access non-stigmatizing health services, the specific sexual health seeking strategies individual MSM employ to avoid homophobia depends on how they present their sexual and gender identities to HCWs, and how HCWs perceive them. Gay-identified men, many of whom are gender non-conforming, were more likely to confront HCW homophobia in the health care setting when they could not access non-stigmatizing health services. NGI MSM, who identified as bisexual or straight, were likely to emphasize a masculine gender identity and avoid disclosing same-sex sexual behavior when presenting for sexual health services. The split between gay and NGI MSM's experiences with HCWs appears to follow the gendered construction of STIs in South Africa described by Shefer et al., by which HCWs stigmatize the sexuality of women who contract STIs as “promiscuous”, but not men, who may sometimes receive positive reinforcement about their presumed multiple partnerships from HCWs as well as their peers.[21
] With MSM in this study, the sexuality of openly gay-identified and gender non-conforming men was further stigmatized by HCWs' homophobia; knowing this, NGI MSM who were not open about their sexuality and were able to emphasize their masculinity could escape such degrading and “feminizing” treatment.
Goal 16.3 of South Africa's NSP is to “Ensure a supportive legal environment for the provision of HIV and AIDS services to marginalized groups,” and to “Develop and distribute information and materials on rights to HIV prevention, treatment and support that responds to the special needs of … MSM.”[4
] This is an important goal that must be pursued in light of South Africa's constitutional guarantees of non-discrimination. However, the experience of MSM in this study was not simply a lack of information about the right to health care; rather, that access to sexual health care in the public sector was complicated by the perception, based on actual experience, that they are likely to encounter homophobic verbal harrassment from HCWs. As one participant suggested, HCW homophobia may lead MSM to delay or avoid treatment for STIs or HIV. It may also be the case that only exceptionally self-confident gay-identified men who are knowledgeable about the larger struggle for LGBT equality in South Africa are able to confront homophobia in health care settings. Yet the enmity gay men incur by defending themselves is not conducive to forming patient-provider relationships that encourage adoption of health-promoting behaviors. Further research should explore these hypotheses.
Although experiences of homophobia among NGI MSM were less direct or severe than gay men's, their strategy of not discussing same-sex behavior with HCWs may place them at a greater disadvantage than “out” gay men in their ability to access appropriate advice on STI and HIV prevention and treatment. LGBT CBOs reach out to openly gay-identified men, and many NGI MSM may feel uncomfortable accessing services that are associated with gay men. Therefore, NGI MSM who avoid these services and act on the assumption that public sector HCWs are hostile to same-sex sexuality effectively deny themselves any source of appropriate HIV and STI prevention information. It is uncertain how widespread these experiences are, but it may be the case that NGI MSM's strategy of avoiding homophobia in health care settings inadvertently causes these MSM to continue to compromise their own sexual health as well as the health of their male and female partners.
These findings have important implications for intervention. Promoting awareness of sexual health services for MSM must be accompanied, at a minimum, by sensitization training for public sector HCWs. This training needs to increase HCW awareness of the sexual health challenges that all same-sex practicing men face. HCWs will need to build skills that encourage and enable them to offer non-stigmatizing sexual health and HIV services to gender non-conforming MSM. In addition, it should increase HCW awareness that not all MSM identify as gay, or are gender non-conforming, and that NGI MSM may be reluctant to discuss their same-sex behaviors. Such an intervention would not by itself remove homophobia from public health services, but by affirming a commitment to non-discrimination on the basis of sexual orientation, it would be an important step towards ensuring a supportive environment for all South Africans seeking sexual health services. South Africa's LGBT CBOs and health professionals can provide valuable assistance to these efforts. In addition, the efforts of LGBT CBOs to provide sexual health services for MSM, and to identify and develop networks of “gay-friendly” health service providers, should be strengthened and expanded.
This study has several limitations. This research was explicitly focused on the experiences of MSM in two communities in a single South African province, and may not be generalizable to the entire country. However, Gauteng is the wealthiest, most urban, and most cosmopolitan of South Africa's provinces, where an LGBT CBO is active in promoting LGBT rights in township communities, including rights to sexual health care and HIV prevention and treatment. It is possible that the visibility and assertiveness of LGBT persons in Gauteng elicits strong homophobic reactions among a minority of HCWs; but it is also possible that these experiences may represent the best-case scenario for South African township MSM at present. While the research team made every effort to recruit MSM from all known MSM sub-groups, our sampling methodology favored the recruitment of gay men, and a smaller number of bisexual and straight MSM who were comfortable discussing their sexuality and social lives. All participants were likely more knowledgeable about accessing health services and comfortable with the risks of participating in socially sensitive research than others in their communities or in South Africa more generally. Nonetheless, the evidence presented here suggests that MSM who are less socially visible or comfortable discussing sexuality would have particular difficulty accessing appropriate health care. Finally, this research did not directly address the experiences of HCWs in meeting the sexual health care needs of MSM, which would be an important component of the development of a comprehensive and effective strategy to combat homophobia in the health services.
The South African constitution's prohibition of discrimination on the basis of sexual orientation provides a necessary precondition for realizing the NSP's goal of increasing awareness of the rights of all South Africans to HIV and STI prevention and treatment. However, these findings suggest that a focus solely on increasing awareness is insufficient. Gay-identified men seem well aware of their rights—and that their rights are being violated—while few NGI MSM seem inclined to claim or enforce their rights. MSM's collective experiences suggest an urgent need for HCWs to be made aware of the rights of all MSM to non-stigmatizing sexual health services, and receive training that more appropriately equips them to care for all same-sex practicing individuals.