Fighting a double stigma

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ST Kevin Rebe INLSA Taking a holistic approach: Dr Kevin Rebe is the head of the Ivan Toms Centre for Mens Health in Woodstock, Cape Town. Picture: Brenton Geach

It’s about doing nice things for people at risk, says Dr Kevin Rebe with a smile.

An infectious diseases expert, Rebe heads a unique service that is looking after people who would otherwise either delay seeking health care until it is too late or not go in search of help at all – men who have sex with men and transgender women.

Men who have sex with men (MSM) are not, as many believe, necessarily gay, but are often in long-term heterosexual relationships with a wife with whom they have children, but have sex with men when the opportunity arises.

Trans-women are what many describe as a “woman trapped in a man’s body” or in a few cases men who have undergone a gender reassignment or sex change.

And while both groups are viewed as high risk when it comes to HIV infection – both biologically and behaviourally – very little is targeted at them in the form of HIV prevention messaging or making healthcare services available that serve their unique and often complex needs.

Not surprisingly, their more regular or long-term sexual partners are also at high risk.

It is widely known that the transgender community is one of the populations most vulnerable to HIV, with high rates of infection.

Research has shown that the risk of HIV infection from anal sex is 18 times higher for the receptive partner than vaginal sex.

“There are many cases which illustrate why it is often hard for these groups to seek health care at our run-of-the-mill health services – in the public and private sector,” says Rebe.

Shaking his head, Rebe recalls one gay couple who went to a community health centre in Cape Town where they were asked: “Who is the man and who is the woman”?

“They walked out and the one needing the health care almost died as he flatly refused to go back to a clinic or hospital. There is lots of discriminatory talk at health-care institutions and in doctors’ rooms where more than 60 percent of their clients are women and they feel more comfortable talking about breast-feeding and Pap smears than anal warts,” says Rebe, whose fashionable hairstyle and dress sense blows the stereotypical conservative doctor image out the window.

Discriminatory behaviour by health providers and the humiliation of being called a male name in front of other patients discourage many transgender women from seeking health services.

Outright denial of service by health-care providers is also commonplace.

“Kevin is like a friend. He listens to us and trusts us completely, you can share anything with him and he will not be shocked and think that you are weird,” says one of the Health4Men patients at the Ivan Toms Centre for Men’s Health in Woodstock.

“I could never do that with any other doctor.”

Health4men is a special interest project of the Anova Health Institute that receives support from the US President’s Emergency Plan for Aids Relief.

Health4Men is described as a “holistic project targeting the sexual health-care needs of men who have sex with men”.

The Ivan Toms Clinic is one of three clinics nationally that deal with the clinical aspects of the programme.

Named after the late activist doctor and former head of health services at the City of Cape Town, the clinic is focused on making it as easy, simple and painless as possible for these marginalised groups to access lifesaving health-care when they are HIV positive, or if they are negative, access all the information and prevention interventions available to keep it that way.

But Rebe is quick to point out that it is not an antiretroviral, HIV or wellness clinic.

“We are a clinic with special skills dealing with men who have sex with men and sexual health.”

Rebe points out that these special skills often involve dealing with complex mental health issues, alcohol and drug abuse, much of which, he believes, is driven by the reality of living in a highly stigmatised society.

“Men who have sex with men face enough stigma, so in the clinic we make sure that the moment they walk through that door they don’t face double stigma.”

According to Rebe, the groups most at risk are those who don’t identify as gay.

“They could have children, a wife in the Eastern Cape and once a week they have sex with a man behind the shebeen.

“This group is the most vulnerable as they are at high risk of contracting HIV and in turn infecting their wives back at home.”

Rebe is scathing of the ABC message that was the backbone of the HIV prevention messaging for many years.

“Abstain? You want to tell this to two testosterone-driven men in a club? They are not hearing this message, it’s useless. Be faithful? It’s stupid, because who must they be faithful to? Condoms? We all know use is inconsistent and low and for transgender women, they don’t have the social capital to negotiate condom use. It’s simple, ABC ignores this group,” he says.

Rebe believes it is critical to be able to individualise the approach for each patient when it comes to treatment and prevention.

For now, he would like to see more female condoms being made available for use when anal sex is involved, the distribution of “bucketloads” of lubrication (not yet on the government’s list) and making these products easily available in shebeens, MSM-friendly spaces and other places frequented by these marginalised groups.

“We need the stuff at the front of the clinics and bars, not hidden at the back,” says Rebe.

When asked why he thinks HIV incidence is on the increase again in the gay community, Rebe is quick to reply.

“I think for the young generation the loss of friends and lovers in the 1980s is a foreign concept. For the youngsters, HIV is a treatable disease and they don’t have that consciousness of the illness that the older generation has. I also believe there is message fatigue.”

Rebe also believes that today’s younger generation is much more “sexualised” with the advent of the internet, where finding a willing sexual partner is a click away.

“There is no doubt that the opportunities for sex are more and then of course drugs have changed the whole scene.

“People are having sex on crystal methamphetamine (tik), which increases the risk of HIV by up to 400 percent.

“It makes the user much less discriminating about who they take home, there is evidence that you increase your biological susceptibility to HIV and it makes you ditch safe sex,” he says

“I guess at the end of the day it’s a case of acknowledging that the groups we target have different needs, but equal rights to quality service and information.” – Health-e News Service


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