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There is concern that the tremendous economic, social, and political upheavals that the Republic of Georgia has undergone in the years since the fall of the Soviet Union may have created an environment fertile for HIV transmission. Notably absent from official statistics and HIV-related research in Georgia is discussion of men who have sex with men (MSM) and, therefore, little is known about the MSM population or its potential to acquire or transmit HIV. Data were collected from 30 MSM recruited through a testing and counseling center in Tbilisi, the capital of Georgia. Two focus groups with six men each and 18 individual in-depth interviews were conducted between October 2006 and February 2007. The study participants described a Georgian culture that is largely intolerant of sexual contact between men. In describing the various forms of discrimination and violence that they would face should their sexual identities be discovered, the MSM in this sample described a variety of behaviors that they and other Georgian MSM undertake to conceal their sexual behavior. Many of these could put these men and their partners at risk for HIV. Although official HIV rates in Georgia are still low, results from this qualitative study indicate that efforts to educate and to provide unobtrusive and anonymous testing and counseling services to MSM may be critical to the deterrence of an HIV epidemic in the Republic of Georgia.
In most Eastern European countries, official HIV surveillance reports indicate injection, drug use and heterosexual contact as the primary means by which HIV is being spread. Unlike the West, men who have sex with men (MSM) appear to be a population at minor risk in the HIV epidemic in this part of the world (UNAIDS & WHO, 2006). Concern is increasing, however, that the epidemic may be hidden among MSM in these countries (Hamers & Downs, 2003; UNAIDS, 2003; UNAIDS & WHO, 2006).
In the Republic of Georgia, official HIV rates are less than 1%. Surveillance is poor, however, and the UNAIDS/UNICEF/WHO HIV/AIDS working group estimates HIV prevalence to be nearly five times higher than the official estimates (UNAIDS, UNICEF, & WHO, 2006). Indeed, there is concern that the tremendous economic, social, and political upheavals that Georgia has undergone in the years since the fall of the Soviet Union may have created an environment fertile for HIV transmission. A dramatic rise in both sexually transmitted infections (STIs) and injection drug use, high rates of unemployment, large populations of internally displaced persons, a burgeoning commercial sex industry, and rising HIV incidence in neighboring countries are all noted as significant factors which could contribute to the rapid spread of HIV in Georgia (Tkeshelashvili-Kessler, del Rio, Nelson, & Tsertsvadze, 2005; UNAIDS & WHO, 2006).
Notably absent from official statistics and HIV-related research in Georgia is discussion of MSM. Homophobia is deeply engrained in both the society and the state and MSM remain a largely hidden and stigmatized population. As recently in 1999, homosexual relations were a criminal offense under Sovietera Article 113. Since declaring their independence from the atheist Soviet Union in 1991, Georgia has experienced a religious renaissance. Nearly 85% of the population is now Georgian Orthodox (CIA_World_Factbook, 2007). Family and marriage are strong tenets of the Orthodox faith, contributing to high rates of early marriage and low rates of divorce and the Church condemns same-sex relationships (Collin, 2007; Zolotov, 1997). Furthermore, although homosexuality is no longer illegal under Georgian law, the Georgian Constitution does not specifically prohibit discrimination based on sexual orientation (Inclusive_Foundation, n.d.). To date, Georgia’s gay community remains largely hidden and, therefore, little is known about the MSM population or its risk for HIV.
In this paper, we report findings from the qualitative component of an HIV-risk assessment undertaken in Tbilisi, the capital of Georgia, which we named the Tbilisi Urban Health Study. The study was conducted in collaboration with Union Alternative Georgia, a local independent health policy research center focused on drug abuse and HIV-prevention research. The purposes of this qualitative study were to assess the prevalence and context of homosexuality and HIV risk among Georgian MSM as well as to determine the feasibility of conducting HIV-prevention research with MSM in an environment where the behavior is so highly stigmatized.
Two focus groups with six men each and 18 individual in-depth interviews were conducted with MSM in Tbilisi between October 2006 and February 2007. Participants were recruited through Tanadgoma, a local NGO that has been providing anonymous, free testing and counseling for STIs and HIV since 2000.1 A Tanadgoma social worker who specializes in MSM outreach recruited participants from among clients at the testing and counseling center. He informed potential participants about the goals of the study and screened them for eligibility after obtaining verbal consent. In addition to being male, eligibility criteria included being age 18 or older and self-reporting sex with another man in the past year. Because the recruiter was already familiar with each of the participants prior to contacting them about the study, he was able to select individuals for the focus groups who already knew one another, thereby alleviating potential concerns about discussing sensitive issues in a group setting. Because of his personal relationship with the men that he chose to recruit, none of the individuals that he approached for either the focus groups or individual interviews refused to participate.
A focus group discussion format was chosen for our first stage of data collection for several reasons. Focus groups allow researchers to collect information from conversations between individuals knowledgable about a particular subject, particularly from individuals who may be reluctant to engage in one-on-one interviews or who may initially feel that they have only limited knowledge of the topic (Kitzinger, 1995). Focus groups are often used in the collection of pilot data where third-person information helps to develop broad impressions which can then be elaborated upon through personal, one-on-one interviews (e.g. Sawyer, Wechsberg, & Myers, 2006). In our focus groups we asked participants to speak from general knowledge regarding MSM, emphasizing that they were under no obligation to reveal anything about their own activities. The discussion themes that emerged from our MSM focus groups were used in turn to determine the domains of inquiry for in-depth individual interviews, as described below.
The in-depth interviews and focus groups were conducted in Georgia and were audio-taped by Georgian staff members of Tanadgoma and Union Alternative Georgia. All of the interviewers and focus group facilitators were trained in qualitative interviewing techniques. Taped interviews were transcribed in Georgian and then translated into English for analysis. Georgian and American members of the team worked closely to ensure that the translations accurately reflected the speakers’ intended meanings.
Informed consent was obtained from each participant prior to data collection. Focus groups lasted from one to two hours. Individual interviews lasted approximately 45 minutes. Participants received US$20 for participation. All study materials were approved by RTI International’s Office of Research Protection and Ethics and by the Institutional Review Board on Bioethics of the HIV/AIDS Patient Support Foundation in Tbilisi.
Focus group interview guides were developed with input from staff members of local organizations working with the MSM population. Topics covered in the focus groups included general characteristics and life experiences of MSM, prevalence of MSM, general risk behaviors and strategies for collecting data among MSM.
Focus group transcripts were read by all members of the analysis team in order to identify discussion themes to be investigated in the individual interviews. Analysis of focus group data revealed three main discussion themes among participants: perceptions of social acceptability of MSM, issues establishing MSM relationships and sexual risk and protective behaviors. These themes were used to develop an individual interview guide that expanded on these topics by asking about them in the context of each participant’s own current sexual behaviors and past sexual and drug use histories.
More than one team member reviewed each of the focus group and in-depth interview transcripts in order to come up with a list of overall discussion themes. Once this list was generated and agreed upon by the team, NVivo (QSR International Pty., Cambridge, MA) – a qualitative analysis package – was used to search the transcripts for quotes related to these themes. Identified quotes were reviewed by all members of the team to ensure that they had not been taken out of context and to select those which were thought to best reflect a view expressed by a majority of participants.
In total, 30 men participated in this qualitative study. Table 1 shows demographic characteristics of these participants.
The study participants described a Georgian culture that is largely intolerant of MSM. Several of the older men talked about what it was like when homosexuality was outlawed by the Communists. Others talked about how Soviet-era prejudices have continued into the present and liken homosexuality to “a pathology or a disease for which one should be taken to a mental hospital.” Many of the respondents said that they and their peers live in fear that their sexualities will be revealed. More specifically, they fear the social and physical consequences of such disclosure. Men reported suffering discrimination in a number of forms, including insults, ostracism, loss of jobs, rejection by families, and outright physical violence:
As soon as a man is being gossiped about as a homosexual or bisexual, no one will talk to him. His family is ruined, his parents deny him, [and] he is ignored at work.
There are only a few men who admit [their homosexuality] in public. Such relations are generally concealed. A man admitting it loudly may find a fist in his face.
If I said in my village that I was gay, they would gather together and kill or burn me.
Discrimination and violence against MSM were described as being deeply embedded in society and even supported by the media and the police:
… the mass media reproaches homosexuality more and more often. They are aware of every little thing; making statements and writing articles. Articles and statements of this nature, criticizing homosexuality, are very popular.
Even if [people] are beating you for being a homosexual and you call the police patrol, don’t be too sure that after learning what’s going on the patrol won’t spare one or two extra fists for you. It’s better to be quiet when they are beating you.
After explaining the various forms of discrimination and violence faced when MSM sexual identity is discovered, participants went on to describe a variety of strategies that they and other MSM undertake to conceal their sexual behavior. Many of the strategies could put these men and their partners at risk for HIV.
Several participants reported that marriage and female sexual partners are commonly used by MSM to “camouflage” or “mask” their sexual orientation:
It is common to get married to conceal one’s homosexuality … When they have the problem of their friends or colleagues at work gossiping about them as homosexuals, the only way they can get out of it is by getting married.
Several study participants expressed a desire to have a regular sexual partner but talked about how the need for secrecy and anonymity makes this difficult, resulting instead in frequent anonymous and one-time sexual encounters:
I have just one sexual encounter with a man and then I never see him again. I am ashamed to have sex with him again. What if someone notices the two of us together very often?
I loved a man who left me because I talked to him in the street and he had a complex. He thought the others would guess who he was.
Such “complexes” tied up with the desire to stay hidden may lead some MSM to exhibit open homophobia against their peers. Study participants discussed homophobic speech by MSM themselves and cases of physical violence perpetrated on MSM by other MSM:
[I]f he shows aggression towards sex among men, no one in society will think of him as gay. So, by being aggressive, he tries to conceal his sexual deviation from the people around him.
Of note, however, was the fact that despite the majority of men being unemployed none of them attributed their unemployment to homophobia or discrimination.
A further difficulty is the general lack of openly gay and bisexually oriented venues in Tbilisi. Study participants seemed dubious that such a venue could exist in Tbilisi, both because the authorities would make it difficult to operate the establishment and because most MSM wish to hide their sexuality and would avoid the place. Consequently, informal locations serve as meeting places for Georgian MSM. These include railway, bus, and metro stations, bathhouses, the circus, public toilets and bridges where the unemployed wait for day work. Several participants indicated visiting these locations but described them as places where they would not wish to be seen:
… there is such a place at the circus where women [i.e. female commercial sex workers] gather. Many are ashamed to stand there. So are the men. They may want to meet other men, but are ashamed to go to such “fag joints.”
Many participants reported engaging in some form of sex trading. Sex trading among MSM was reported to be common, particularly among economically disadvantaged men, many of whom come to Tbilisi in search of work:
For example, imagine a man arrives from some village and doesn’t know what to do. Then he is offered food, clothes, and a place to spend the night by someone. After drinking a little, he is offered sex. The poor guy thinks this is the city life and not wanting to lose benefits, agrees to such contact. Then, gradually, he gets used to it and does it regularly with no problem. There are many students and children driven out of or running away from their families among them.
Those arriving in Tbilisi start with this stuff. It is a source of income for them. Poor parents send their children to Tbilisi to study and they make money through sex. Then, after trying it a bit, they start liking it and can’t give it up.
When participants talked about sex trading they seemed to associate it with higher numbers and even greater anonymity of partners. Furthermore, they seemed to think that sex traders rarely have a say in whether condoms are used. In general they agreed that in a sex trading situation, “the payer sets the rules”:
Sometimes a man does not want to lose a partner and he may agree not to use a condom … [Such cases] are quite frequent among newcomers who are still “virgins.” They have no stable clients and agree to do everything to have them.
With the exception of marijuana, participants felt that drugs were not widely used by MSM. Both injecting and non-injecting drugs – including subutex (i.e. buprenorphine), vint (i.e. homemade methamphetamine), cocaine, ecstasy, and poppers – were mentioned by respondents, however. Several of the men reported the use of these drugs by MSM with sex partners or in order to facilitate approaching other men for sex. Many expressed the opinion that people in their social circles cannot afford drugs, but that wealthier MSM can – and often do – use them:
[The elite] may inject drugs and meet their requirements for everything. They have more to do with drugs. As for [the lower classes], this is not the case among them. I think it will never be the case … They have no financial standing and so drugs are also out of the question here.
As in Georgian culture generally, alcohol is far more widespread than drugs among MSM. Many participants talked about using alcohol as a way to feel less inhibited about male-to-male sex:
You may drink so much that you don’t remember with whom you had sex or what kind of sex you had with him. You don’t remember a condom or personal hygiene.
There was considerable variation in participants’ opinions regarding the acceptability and frequency of condom use among MSM. A few men described condoms as if they were a routine part of their sex lives. Other participants, however, admitted that condoms are used only if they happen to be available when a sexual opportunity arises. Participants cited a variety of reasons for inconsistent condom use, including the perception that condoms interfere with sexual pleasure, break frequently, decrease trust among partners, and are difficult to obtain. Many participants stated that condom use was particularly rare in rural areas, and among younger, more economically disadvantaged MSM, many of whom have emigrated from these rural areas:
Many [poor MSM] … don’t even know what a condom is. Half of them at the Railway Station have learned about it from [Tanadgoma] for the first time. They thought it was a balloon. [laughing] Anyway, many don’t use a condom even now.
Yes, [homosexuals are characterized by high-risk sexual behavior] … and this is particularly true with the youth. They don’t fear anything and don’t use condoms at all. They have oral, anal, and every kind of sex. They sometimes drive themselves to bloody sex.
Many participants recognized the infection risks posed by MSM sex. Others, however, were less aware or had misconceptions regarding HIV and other STIs. Several, for instance, seemed to believe that only the receptive MSM partner is at risk for HIV acquisition. Other participants talked about being able to judge a partner’s disease status by his appearance (i.e. “neat” and “clean” tended to be synonymous with “disease-free”).
Many participants reported a reluctance to seek STI testing and treatment for fear of betraying their sexual behavior. Unemployment and the cost of health care were also described as barriers to seeking services. One participant expressed the following opinion regarding the service needs of MSM:
They don’t have sufficient information about venereal and infectious diseases and they are asking for more information. They want to get together and discuss the problems that concern them. They lack human relationships. It would be good if HIV testing were free. They get three condoms a day, but it is not enough for them … Everyone tries to look after themselves in various ways. It would be good if there were health centers for them where nothing is recorded and they could be provided advice on how to look after themselves.
Although official HIV rates in Georgia are still low and MSM are not considered a high-risk population for HIV transmission, results from this study suggest that many MSM in Tbilisi engage in behaviors that put them and their partners at risk for HIV. The majority of participants described an environment of such extreme intolerance to homosexuality that they felt compelled to hide their sexual tendencies. Efforts of men to hide their sexual activities with other men seemed to lead to more one-time anonymous sexual partners as well as more unplanned and unprotected sexual liaisons in public places. The need for secrecy may interfere with the formation of monogamous, long-term partnerships between men and contribute to increased partner turnover, bisexual activity and concurrent sexual relationships.
In the West, there is concern that bisexually active men may serve as a bridge between populations at high and low risk for HIV (Hightow et al., 2006; Montgomery, Mokotoff, Gentry, & Blair, 2003). In a recent review article, Hamers and Downs (2003) noted that even though the literature on MSM in Central and Eastern Europe is sparse, MSM populations that have been studied in the region suggest a high number of bisexually active individuals. Our data suggest that if HIV were to enter the MSM community in Georgia, the sexual bridge is in place for it to move from MSM to their female partners.
US-funded HIV behavioral interventions are currently required to encourage the ABC’s (abstinence, being faithful and condom use) of reducing sexual HIV risk (USAID, 2002). Unfortunately, abstinence does not appear to be an acceptable option for the men in this sample, and the pressure to conceal their MSM activity makes it difficult to form long-term monogamous partnerships with other men. Under these circumstances, consistent condom use may be the only realistic option for reducing HIV and STI risk. According to the men in this sample, however, condom knowledge is not uniform and use is inconsistent even among those who are informed.
Particularly troubling is the implication from these interviews that the men who have the most limited knowledge of correct condom use and access to HIV testing and counseling are those who support themselves through sex trading. Respondents indicated that younger and more economically disadvantaged men may support themselves through sex trading, at least in part, as a response to Georgia’s severe economic conditions and high rates of unemployment. Throughout the former Soviet Union (Dudwick, 1999; Renton & Borisenko, 1998), the political and economic upheaval of the past two decades, has been linked to a rise in prostitution.
Georgia’s high rate of unemployment and troubled political economy also appeared to influence where MSM meet their partners and where MSM encounters occur. It has become common for men to meet potential partners at a particular bridge in Tbilisi where the unemployed wait for work. It is likely that public sites such as these are also the location of MSM sexual encounters. A substantial literature indicates that sex in public places tends to incur greater risk for the participants (Frankis & Flowers, 2005).
As with most qualitative studies, this sample is relatively small and these results may not be generalizable. Despite these limitations, this study is among the first to focus on the current social situation for Georgian MSM and to raise issues related to HIV risks and human rights that need further research.
Although HIV prevalence is currently low in Georgia, a rising trend in new HIV cases has been observed; the number of infections recorded in 2005 is more than double that reported in 2002 (UNAIDS & WHO, 2006). In addition, there is concern that increasing tensions between Georgia and Russia could lead to a sudden expulsion from Russia of the many thousand ethnic Georgians currently residing there (HRW, 2007). Such a large forced population movement from an area of high HIV prevalence is certain to lead to an influx of HIV-positive individuals. These individuals could be the catalysts for an epidemic in Georgia. Indeed, if the sudden onset and rapid increase of HIV in the neighboring countries of Russia and Ukraine serve no other positive purpose, they provide a tragic lesson about insufficient early prevention.
Although the majority of findings in this study paint a bleak picture of the situation faced by MSM in Georgia, there are some encouraging signs. The fact that all men in this study sample had a personal connection with a staff member at Tanadgoma, the anonymous testing and counseling site, is one positive sign. Another is the fact that all of the MSM in our study were willing to talk openly with each other, knew at least some other MSM and shared common knowledge about where to meet sexual partners. This shared common knowledge suggests that an MSM subculture may be forming, which could facilitate access to these men. For instance, our access to and success in recruiting these men was facilitated by a “gatekeeper”, in the form of a social worker with established connections to other MSM.
While the results of a recent study suggest that young Georgian adults are more tolerant of male homosexuality than their parents (Sumbadze & Tarkhan-Mouravi, 2003), the arrival of a clearly visible, easily accessible and accepted gay community may still be a decade or more away. In the meantime, efforts to reach, to educate and to provide unobtrusive and anonymous testing and counseling services to MSM are likely to be critical to the deterrence of an HIV epidemic in the Republic of Georgia. Misperceptions, fears and financial concerns were all noted by these men as barriers to seeking services. Anonymity of information and service provision seemed to be their most salient concern. In light of these concerns, it seems obvious that campaigns promoting counseling and testing services cannot yet be targeted directly to MSM regardless of assurances of confidentiality. In the meantime, in a society where men appear to be the sexual decision makers, a promising alternate strategy might be promotion of counseling and testing services for Georgian men in general.
1It should be noted that Tanadgoma focuses on HIV testing and psychological counseling for a number of different populations, including MSM but also injecting drug users, prisoners, and female commercial sex workers. Tanadgoma estimates that MSM currently account for 20–25% of its clientele. The NGO was chosen to collaborate on this project because, while MSM are in the minority among the people it serves, this is perhaps the only organization in Tbilisi to openly address MSM needs. Furthermore, Tanadgoma had already demonstrated its ability to recruit MSM into research projects – albeit in relatively small numbers – through respondent-driven sampling (UNGASS, 2008), a technique shown to be effective in the recruitment of otherwise-hidden populations (Heckathorn, 1997, 2002).