Culture, Health & Sexuality, 2015 Vol. 17, No. 8, 977–989, http://dx.doi.org/10.1080/13691058.2015.1018948
How do community-based HIV prevention programmes for men who have sex with men ‘travel’? Lessons from the Ukwazana/Zwakalani journey in South Africa Andrew Tuckera,b*, Glenn de Swardtb, James McIntyreb and Helen Struthersb a Centre for Gender Studies, University of Cambridge, Cambridge, UK; bAnova Health Institute, Johannesburg, South Africa
(Received 30 May 2014; accepted 10 February 2015) Research reveals how homophobia and stigma link closely to HIV among men who have sex with men in sub-Saharan Africa. This paper considers the varying impact of homophobic stigma on HIV prevention programmes among men who have sex with men in South Africa. It explores how a community-based HIV prevention programme based in the peri-urban townships of Cape Town was ‘translated’ to peri-urban Johannesburg. Drawing on interviews with volunteers and programme facilitators in Johannesburg, it argues that an altered homophobic environment to that found in Cape Town gave different opportunities to engage both with other men who have sex with men and the broader community. It also argues that programme facilitators should be mindful of how varying degrees of homophobic stigma may relate to broader theoretical debates about sexual binary relationships, which can help us understand why particular programmes choose to focus on certain activities rather than others. Keywords: South Africa; men who have sex with men; HIV prevention; homophobia; community interventions
Introduction Men who have sex with men have historically been marginalised in African HIV prevention programmes (McIntyre 2010; Smith et al. 2009). Work specifically in relation to groups such as peri-urban men who have sex with men in South Africa has, however, begun to highlight key issues that need to be addressed to confront HIV prevalence figures that are significantly greater than those of the general population (Lane et al. 2011). Research has also shown how risk activities such as condomless sex are associated with various behavioural factors, including alcohol use, the number of sexual partners and relationship type (Baral et al. 2009; Lane, Shade et al. 2008; Sandfort et al. 2013). Work is also exploring how social factors such as homophobic stigma1 are directly related to the HIV epidemic among men who have sex with men. Homophobic stigma has been documented in South Africa (and the broader region) as having serious implications with regard to schooling and employment opportunities, family support and physical safety (Msibi 2009; Nel and Judge 2008; Wells and Polders 2006). Research has documented how the power and endurance of such stigma relates to factors such as the misguided belief that homosexuality is unAfrican (Vincent and Howell 2014), which has remained closely aligned to particular renderings of post-colonial nationalism (Epprecht 2013; Stychin 2004). With regard to HIV, studies conducted in Kenya (van der Elst et al. 2013) and South Africa (Lane, Mogale et al. 2008) have highlighted how homophobic stigma on the part of
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healthcare workers can significantly inhibit men from accessing clinic services. Research also suggests that experiences of homophobic stigma lead to increased risk of engaging in sexual practices such as condomless sex (Tucker et al. 2014). More broadly, homophobic laws inhibit safer-sex information dissemination among men who have sex with men (McIntyre 2010). One further key way in which homophobic stigma has impacted on the HIV epidemic among men who have sex with men is through its ability to limit HIV prevention programme success. For example, men have sometimes felt unable to take part in community-based programmes that require them to become known locally as engaging in same-sex behaviour (Tucker, de Swardt et al. 2013). Volunteers for such community-based programmes have also at times felt unwilling to take part if programmes do not acknowledge the existence of, and find ways of tackling, homophobic stigma within their design. Taken together these findings help us understand the many ways homophobic stigma in the region can impact on endeavours to reduce HIV transmission among men who have sex with men. However, while it is now understood as important to address homophobic stigma with regard to the HIV epidemic among men who have sex with men, it is also important to consider the variability of such stigma, especially as it relates to HIV prevention. Sociological and anthropological research has pointed to diverse manifestations of homophobic stigma in South Africa (and across southern Africa) (Epprecht 2007, 2013; Hoad 2007; Sandfort and Reddy 2013). Different histories of gender- and sexuality-based oppression, often tied to different political histories, have given rise to differences in the way stigma impacts on men who have sex with men. It is important to take account of such variability when looking at other HIV prevention programming among marginalised groups. For example, research in community-based HIV prevention with marginalised communities has revealed how women can sometimes strategically engage with patriarchal structures necessary for programme success, while at other times in other places finding the possibility of engagement far harder (Campbell and Cornish 2010; Cornish and Ghosh 2007). While a comparative lens has been used to successfully explore some of the particularities related to the way gender-based discrimination can inhibit community-based HIV prevention programmes, there exists far less research on how variations in other social forces, such as homophobic stigma, may be implicated in opportunities for success as programmes ‘travel’. This paper therefore explores what happened when an HIV prevention programme focused on men who have sex with men, which had attempted to overcome barriers associated with homophobic stigma in peri-urban Cape Town, was taken to peri-urban Johannesburg. We begin by describing the rationale for the development of the Cape Town-based Ukwazana programme and highlighting how it relates to the Zwakalani programme in Johannesburg. Drawing on interviews with programme facilitators and volunteer outreach workers (the programme’s ‘township ambassadors’), we argue that there are important lessons to be learned by considering how programmes can adapt to different degrees of self-reported homophobic stigma.2 This can impact on how a programme goes about attracting men’s participation. Concurrently, it can also affect how a programme challenges homophobic stigma itself. We then relate these issues to broader theoretical concerns regarding the regulative power of sexual binaries, and the impact this may also have on HIV prevention among men who have sex with men. Translating programmes The Ukwazana3 programme in the peri-urban townships of Cape Town was a new type of HIV prevention programme for South African men who have sex with men. It was
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designed to work in structured and frequent collaboration with a team of township volunteers or ‘ambassadors’, who were themselves men who have sex with other men, to uncover and confront community-level factors associated with sexual risk taking (Tucker, de Swardt et al. 2013). Research into prior HIV prevention programmes in peri-urban Cape Town aimed at such men had shown they often struggled to work collaboratively with targeted groups to explore and challenge HIV risk factors. There was therefore less than sustained interest and engagement by such men (Gevisser 1995; Tucker 2009). Informed by work with other at-risk populations (see Campbell 2003), Ukwazana was therefore designed to facilitate direct communication, structured discussion and collaboration between township men who had sex with other men, township ambassadors and programme facilitators in the exploration of risk factors and the implementation of measures to address these factors (Jobson 2011). Significant effort was made to attract the interest of local men who had sex with men to the programme and to highlight this collaborative ethos (Tucker, de Swardt et al. 2013). Ukwazana was a partnership between Health4Men, an initiative of the Anova Health Institute, and the University of Cambridge Centre for Gender Studies. Prior to the Ukwazana programme, research had documented reports of severe and sustained sexuality-based discrimination in Cape Town’s townships (Salo et al. 2010). Research and popular reporting also described the beating and even murder of same-sex attracted individuals (Burrell et al. 2008; Moisan 2014). Research from the Ukwazana programme supported these findings and suggested how homophobic stigma impacted on diverse aspects of HIV prevention. For example, quantitative research conducted among local men who have sex with men highlighted a significant association between the experiences of homophobic stigma and likelihood of engaging in condomless sex (Tucker et al. 2014). It also revealed that over the preceding six months, 78% of men in the survey had been verbally insulted, 59% had been threatened with physical violence, 46% had been physically attacked and 28% had lost a place to stay due to their sexuality. Such factors were associated with psycho-social concerns such as depression and a lack of selfefficacy, which were also associated with condomless sex (Tucker, Liht et al. 2013). Qualitative research also pointed to ways in which homophobic stigma had to be acknowledged and confronted by Ukwazana. Prior research had described how this factor could limit men’s participation in the programme due to fear of wider community censure (Tucker 2009). Because of this, a decision was made by Ukwazana’s programme facilitators that township ambassadors should be men who had already reached relative positions of safety within the community and were relatively open about their same-sex interests and desires (Tucker, de Swardt et al. 2013). Qualitative interviews with these township ambassadors confirmed the quantitative findings and also revealed how homophobic stigma was seen to result in isolation among men and a lack of peer support, inhibiting solidarity networks (Tucker, de Swardt et al. 2013). These issues were of such significance in the lives of township men that their decision to take part in Ukwazana as a township ambassador was in part dependent on the programme being willing and able to find ways of challenging homophobic stigma and associated concerns such as isolation within the community. Tackling such issues in partnership with township ambassadors therefore became important to help sustain the very premise of the Ukwazana programme itself – namely to work collaboratively with local men. In 2012, Health4Men implemented a similar programme in the peri-urban township locations surrounding Johannesburg (predominantly in Soweto, home to approximately 30% of the city’s inhabitants). This programme, termed Zwakalani,4 followed a similar brief to Ukwazana. It included attracting the sustained interest of a cohort of volunteer
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outreach workers and structured and accountable mechanisms for communication and action between ambassadors and programme facilitators (Motswagae 2013). Care was taken not to assume that the earlier Ukwazana initiative should necessarily be replicated in its entirety in the new location. For example, while it was appreciated that certain similar factors such as homophobic stigma were previously of concern in Johannesburg (Reid and Dirsuweit 2002), it was not assumed that their relationship to HIV prevention programming would necessarily be the same. At the end of 2013, after the programme had been running for over a year, 13 Zwakalani ambassadors were interviewed by the first author, who had not been involved in the development of the programme (but had earlier assisted with research processes associated with Ukwazana). Interviews were also conducted with the five Zwakalani programme facilitators employed by Health4Men who came from local peri-urban communities. An inductive methodology initially explored the success (or otherwise) of collaboration with the target population and awareness of local context. Interviews were semi-structured and, to allow for comparison with Ukwazana, covered the same topics, including why men volunteered their time, how well the programme was functioning and how it engaged with the broader township community. Analysis subsequently drew from what Tilly (1984) might refer to as variation-finding comparison, an approach that has been appropriated within fields such as urban studies to theorise differences across ostensibly similar units (Robinson 2011). Interviewees provided written informed consent and were informed that their comments would be kept anonymous. Interviews lasted between 20 and 60 minutes. Interviews were recorded, transcribed and thematically coded. Ethics review boards at the University of Witwatersrand and the University of Cambridge approved the research process. Below, township ambassadors’ quotations are listed with the letters TA and a randomly assigned number used for all of that particular ambassador’s quotations, for example TA2. Programme facilitator’s quotes follow a similar pattern, for example PF3. Soweto: a changed environment Interviewees saw several benefits to Zwakalani over and above issues related to challenging homophobic stigma. While, as previously discussed, Ukwazana’s ambassadors in Cape Town saw the need to challenge homophobic stigma as a condition for their participation, this issue appeared absent in discussions with Zwakalani’s ambassadors. Of importance for the latter was the more straightforward desire to provide education on safer-sex, condoms and HIV testing to other men who have sex with men. As the following quotations highlight, the provision of (previously lacking) safer-sex information and materials for such men was a key reason why ambassadors volunteered with Zwakalani: I’m gay, I need to know some things, ja. It’s important so I can share this safer-sex information in the township. [Gay] people need to know . . . . So I give condoms to my friends and tell them to protect themselves each and every time when they have sex. (TA6) I should say every friend of mine [gets condoms]. Because I make sure I do have from Health4Men so I can give them to [my friends]. So every friend of mine if they don’t have, then they actually ask me as an ambassador and then I’ll bring [condoms] for them. (TA7)
Ambassadors described this ability to pass on safer-sex information and provide the methods by which their peers could protect themselves as also helping to create a sense of personal positive affirmation. This in turn helped reinforce a desire for involvement in the programme. For example, when asked why they volunteered their time, men responded:
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Well, I like working with people. It’s been my passion since I was young. Interacting with people, especially others in the gay community. It’s so very great to get out there to talk to people, to educate them about HIV and testing . . . . For me that’s so fulfilling on a personal [level]. (TA2) I do it because I want to do it. I think that, it was a personal thing that I always wanted to do. Because I personally have never had that support. And because of that, my decisions were bad. And there were consequences . . . . For example, I didn’t know about the lubricant [used with condoms for anal sex] and I would go on and use oil-based lubrication [which degrade latex], which I didn’t know you were not supposed to use it. So that is why I decided to go and help. You can help people by going to be an ambassador. (TA12)
For many township ambassadors, the desire to assist other men who have sex with men in directly looking after their own health was the primary reason for their participation in Zwakalani. The almost urgent need to find ways of challenging homophobic stigma and address associated factors such as social isolation (as was the case with Ukwazana’s ambassadors) appeared in Soweto not to be a prerequisite for Zwakalani ambassadors’ participation in the programme. This is not, however, to suggest that consideration of such issues was unimportant for Zwakalani’s ambassadors. As the following ambassadors describe, homophobic stigma continued to be perpetrated by members of the wider community against men who have sex with men in Soweto: There’s homophobic people in Soweto. We get criticised [by such people]. There’s that stuff. (TA8) It’s still there [homophobia]. So there are those who still does not have the full understanding, maybe. I can say the full understanding about the homosexuals. And mostly it is the straight boys who are homophobic. (TA10)
And as one programme facilitator explained in relation to the barriers homophobic stigma can create when conducting community workshops that included heterosexual members: I mean, yes, especially when we were doing the workshops. And we get there and we ask ‘Who are MSM?’ and they [snaps fingers] fly out ‘stabane [a derogatory term], what, what.’ ‘This is not biblical . . . ’ (PF1)
It is important to situate such statements within broader emerging dynamics related to men who have sex with men from Soweto. Important here was the feeling expressed by interviewees that homophobic stigma in Soweto was not as uniformly in evidence to the extent encountered by Ukwazana in Cape Town. For example, in Cape Town, homophobic stigma was considered both to be widespread and to inhibit community building and the development of peer support networks. Ambassadors in Soweto, on the other hand, presented a more complex picture of men’s social worlds (while not negating the existence of homophobic stigma) describing a more ambivalent relationship to it and its negative consequences: I might say it’s like [homophobic] people don’t have any choice. You can control me, but until when? So they actually let it go. ‘Cause this is who we are and no one can change us. So they [homophobic people] don’t have any choice . . . . Well in Soweto, it’s actually a place where you feel free . . . (TA7) I think the people who are homophobic are less than the people who does understand the whole homosexual thing. And we are gay people, we tend to be friends [with] a lot [of people that] are more free to understand the whole thing and spread the word to those homophobic guys and stuff. (TA10)
In further support of these views is recent research into the somewhat unique opportunities afforded to men who have sex with men from Soweto to openly socialise
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compared to men from other peri-urban spaces in the country. Livermon (2014), for example, has described how there exists a vibrant and visible nightlife or ‘party culture’ for men who have sex with men in Soweto. There are also a variety of public events for the local lesbian, gay, bisexual and transgender community, which are unique in South Africa. As de Waal and Manion (2006) have documented, Soweto Pride has run in the township for over a decade. There has also been a well-attended cross-dressing pageant in Soweto since 2000 (Tsouroulis 2014). This is very different to peri-urban Cape Town, which, prior to Ukwazana, has not been able to develop similar events in size, scope or scale (Meersman 2014). Several Zwakalani ambassadors who had spent time living in Cape Town identified key reasons they saw as contributing to the variation between the two cities. In particular, they highlighted a history of far greater cultural mixing in the Johannesburg area, which had allowed for a greater degree of understanding and tolerance of diversity: I think that cultural diversity, somehow, it plays a role in the sense that, lets say in Cape Town, it’s a Xhosa community, they have their own beliefs and their rituals and so on. So if they see one gay man telling the community they are gay, they feel somehow they are insulting their culture and their tradition. But we [in Johannesburg] are very diverse as people . . . . we’ve got Xhosas, we’ve got Zulus here in Joburg, we’ve got Pedis . . . People think, ok, we’ve got Pedi’s who are gay . . . . Everybody can be gay. I think that can play a role in that kind of thing. (TA2) Life this side is very, very fast. In terms of looking at people who are coming from outside, provinces like KwaZulu-Natal, countries like Lesthoto, Botswana, coming this side. This is why people say, when you come to Joburg, it’s a fast place. It’s a place where you see everything . . . people that always [ask] questions . . . . I would say in the yard where I live, there’s a lot of cultures . . . . There’s Zulu’s there’s Pedis, there’s Tsongas. So when we all come together in the yard and make a fire or have a braai [BBQ] they ask ‘why don’t we see you with a girl?’, I will explain . . . (TA1)
Such views also have historical precedent. Research documenting the acceptance of ‘coloured’ homosexual communities in South Africa during the mid-twentieth century has shown how those designated as coloured by the apartheid state came from a wide variety of locales (Chetty 1995). Coloured heritage included the first Europeans, their slaves (from places including Indonesia, Mozambique and South India) and the Cape’s original inhabitants, the Khoisan. Such hybridity of coloured life may have helped protect coloured men who had sex with other men from any one discriminating social or moral doctrine gaining prominence (Gevisser 1995). Ethnic diversity between black African groups has also been well documented in South Africa, with apartheid planning limiting black African migration to the Cape (Western 1997). The results of these policies are still evident in the 2011 South African Census. While Johannesburg and Cape Town each report a principal black African language group (in Cape Town isiXhosa makes up 29.2% of the population and in Johannesburg isiZulu makes up 23%), other variability is stark. While isiNbebele, Sepedi, Sesotho, Setswana, Tshivenda and Xitsonga speakers combine make up 37% of the population in Johannesburg, they make up only 2.2% of speakers in Cape Town.5 There may well be other explanations as to why homophobic stigma and its effects present differently and in a less intractable manner in Soweto compared to Cape Town’s townships.6 One additional explanation has been put forward by Donham (1998) in relation to Johannesburg’s close proximity to the country’s mines (and migrant labour). Historically, mines were understood by Soweto residents as locations in which male samesex practices were at least partially accepted, which may continue to influence understanding of same-sex desire today in the area (Donham 1998).
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Such a situation is not, however, to suggest that challenging homophobic stigma was unimportant for the Zwakalani programme. As the township ambassador below describes, it is impossible to discuss an HIV prevention programme in a place like Soweto without appreciating the importance of addressing homophobic stigma: It’s connected because when you go into the community and advise people . . . the word homophobia, it can’t be left out. It just can’t be left out. It’s something that has to be said. Because when you go to people to start talking . . . what the person, heterosexual, homophobic individual, they will be like, ‘ah, we don’t want this gay stuff!’ it’s when you will start talking . . . (TA1)
Expanding Zwakalani’s scope As described above, Zwakalani’s ambassadors did not appear to see the need to directly tackle homophobic stigma in the same way as those at the Ukwazana programme. Zwakalani’s ambassadors also did not frame their participation as ambassadors as contingent on the programme directly tackling homophobic stigma. Furthermore, other men who have sex with men from Soweto did not necessarily feel unable to partake in Zwakalani events or activities due to such stigma. As two Zwakalani ambassadors explained: Since we have this programme we’ve had [events such as] netball tournaments here in Soweto. I was actually surprised and I was actually impressed that older people, they came to support their children. Even straight people, they came. [They] were asking so many questions and so forth. We were very open about everything. (TA2) We’ve been going to taverns and we distribute condoms and [conduct HIV] testing and telling them about sickness and everything. So, it’s working. Others are listening when we [are] reaching out to them. Ok, you put the gazebo tent there. It’s not like we stand in the street and ask people to come. They just come to the table and they ask the information. And you tell them everything . . . (TA3)
In an environment where the participation of men (both generally in programme events and as ambassadors) did not appear so directly tied to the need to address homophobic stigma, Zwakalani was able to reconsider how it approached serving the health needs of men it targeted. One key issue was finding ways of encouraging men’s participation in the programme. The strategy deployed by Zwakalani to do this not only differed significantly from that deployed by Ukwazana, it also provided a different approach to tackling the homophobic stigma that was in existence in Soweto. Zwakalani expanded to include a small new group of individuals who had been largely absent from Ukwazana – namely, heterosexual men who undertook the same outreach activities as ambassadors who were men who had sex with men. This new group, who comprised fully 25% of those interviewed, self-identified and were understood by other interviewees not to be men who had sex with other men. When asked why these men had been included within the programme, interviewees described two felt needs: first, was the need to engage as broad a cohort of men as possible with the programme; second, was a need to challenge homophobic stigma by helping create dialogue with the wider community. In relation to the first of these needs, there was a clear awareness by interviewees that the category men who have sex with men includes a rich diversity of men – from men who openly report having sex with other men, to more clandestine men. Programmes can too readily focus only on one group of men who overtly indicate their sexual attraction to other men, which can limit the participation of others (Benoit et al. 2012). Similar issues had emerged at one of Health4Men’s earliest clinical services, the Simon Nkoli clinic, which also operated in Soweto but predated the Zwakalani
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programme. A decision was made early on to describe this clinic (and all the other clinics operated by Health4Men) as a ‘Men’s Clinic’, rather than as a clinic for men who have sex with men (Sjolund 2011). There were three interconnected rationales for this decision (Rebe et al. 2013). First, men who have sex with men (be they overt or clandestine) are unlikely to visit a space that could potentially lead to social censure (for example, if community members saw them entering it). Second, labelling a space as ‘gay’ or for men who have sex with men may limit the participation of clandestine men for whom such identity labels are incongruent with their self-understanding or image. Third, it is not in the interest of clinical services to attempt to screen whether a man has sex with another man prior to treatment. Problematically, as the following ambassador describes, such a strategy of branding a clinical space as a ‘men’s space’ did not work at first in Soweto: Actually I have a straight friend who once asked me about [the Simon Nkoli clinic] because he wanted to go but then he heard this thing that it was for homosexuals only and they would say he’s also gay . . . there was that stigma. (TA10)
Interviewees also highlighted this concern in relation to Zwakalani. In the following example, one programme facilitator describes how, had Zwakalani decided to focus solely on including openly identified men who have sex with men (often referred to, as in the following quotation, as ‘gay’ men), it might have suffered similar problems to those initially encountered at the Simon Nkoli clinic: If [Zwakalani ] is all open MSM [men who have sex with men] that then is where the problem lies . . . that is why we ended up balancing [including heterosexual men in the programme] . . . . I remember that when we started [Zwakalani ] we were sitting with 71 people. Like the [Simon Nkoli] clinic enrolled only 71 MSM, your gay[-identified] people. So we asked what is the problem? We called those 71 people and we had a focus group with them . . . . We asked ‘is it because the [clinical] services are useless, or what?’ They said, ‘no, you are stigmatising the project. Because [when] people go there, [other] people are already saying “he’s MSM.” Even if he doesn’t want to be [open].’ So you are already disclosing to people that he’s an MSM, so you are stigmatising them . . . (PF1)
For Zwakalani therefore, the inclusion of heterosexual men within the programme aimed to help broaden the scope of its work by framing the programme as not being overly focused on only one group of men who were open about their sexuality (‘gay’ in the quotation above). By way of comparison, Ukwazana in its initial stages had focused on attracting a small number of overtly visible men who had sex with other men who had reached positions of safety within the community. Such a shift in attempting to affect community perception can also be appreciated in another aspect of the programme’s work: namely, the way it went about challenging homophobic stigma. While, as already discussed, this focus was not such a central aim of Zwakalani, it was still noted as an issue of concern by interviewees. As the interviewees below explain, a Zwakalani approach towards this issue again centred on including heterosexual men as volunteers within the programme: But we also have straight men, they’ve got wives, but they go out and go to work and spread the word ‘guys, lets come together and support gay people’. I think for the community it works, in accepting us. Because if I am gay and I’ve got a straight friend and he’s also my colleague he’s going to take me to his straight friends and they will get to know me outside of my sexuality. ‘Ok, he’s gay but he’s just a person like the rest of us’. So I think it makes a very big difference to the community if we are a mix of people. (TA2) Gay and straight ambassadors, I believe [is better]. Because if ever there are those [homophobic] people, [they are] hard to crack. But if you got a straight person and they are
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a peer and then they will see them and then they will explain to them about, ‘this is how it is’. Yes, it changes their mind . . . (TA13)
This strategy of including heterosexual men to speak on behalf of men who have sex with men should not be seen as substituting for the role that men who have sex with men themselves can play in challenging homophobic stigma. However, it offered an important additional element in this regard. Significantly, the lessened homophobic environment in Soweto compared to Cape Town meant Zwakalani could consider additional ways of engaging the interest and participation of men within the programme. It also allowed Zwakalani to find other ways of challenging the homophobic stigma that did exist locally. Sexual binaries and HIV prevention The different paths taken by the two programmes can be understood in terms of the interface between sexual minorities and heterosexual majorities, and their relationships to power. Such concerns may need to be taken into consideration in future HIV prevention programmes that exist in communities with varying levels of homophobic stigma. They may help us hypothesise why only one of the two programmes discussed in this paper initially engaged heterosexual men as ambassadors, despite the potential benefits of doing so. As Derrida (1982) and Foucault (1978) highlight, social binaries (sexual or otherwise) often function such that a dominant group on one side of a binary (in this instance, a heterosexual majority) can maintain its ability to name and keep separate that which they see as different (in this instance, all that which is sexually ‘Other’ and beyond the bounds of heteronormativity, the minority). By doing this, power remains with the majority, even if minority groups attempt to challenge discrimination (Fuss 1991). Within such a hegemonic framing, while it may be possible and fruitful to challenge discrimination from the perspective and position of the minority, power remains with the majority precisely because such a challenge still takes place within the confines of the binary dictated by the majority (Connell 1995). If we conceptualise homophobic stigma in townships as an element of power that can be potentially wielded by the heterosexual majority, we can see a variant of this formation in the way Ukwazana functioned and hence a possible reason why it did not initially focus on including heterosexual men as ambassadors. As described earlier, Ukwazana initially encouraged the inclusion of men who had already reached positions of relative safety in society and who were open to the wider community about their same-sex interests and desires to take part as ambassadors. Severe stigma could have potentially limited the participation (and safety) of other men who have sex with men in the initial stages of the programme. Ukwazana’s ambassadors, it transpired, wished then to challenge homophobic stigma themselves (due to its severity) and this became important for their continued participation in the programme. The ability and mechanism by which the programme came to understand how it was possible to challenge homophobic stigma was therefore in part dictated by its very severity to begin with. By focusing on the most visible and open group of men who have sex with men, the programme could then also be seen to exist very much on the minority side of the binary relationship. Volunteers’ own desire to challenge homophobic stigma from the perspective of the minority against the majority not only solidified this position, but also helped to entrench the binary. While ostensibly there was little to stop Ukwazana from also encouraging the participation of heterosexual men, such did not take place precisely because Ukwazana had come to exist on the side of the sexual binary that was most oppressed.
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Such a framing is, however, premised upon a hegemonic rendering of power, whereby, at one extreme, there are those with the power to regulate and position sexual binaries and, at the other, those with far less power. As Hall (1996) and Hart (2007) highlight, such a framing need not exist in all places at all times; a hegemonic position is not necessarily fixed, but instead is historically and geographically contingent. We can consider this in relation to the opportunities that afforded Zwakalani to operate in a different way to Ukwazana, in part due to less severe local forms of homophobic stigma and a generally less inequitable sexual binary in Soweto.7 Zwakalani, it would appear, did not have to initially position itself on one side of a sexual binary relationship. By strategically including the active participation of heterosexual men, it also moved away from reinforcing sexual difference. Such a positioning made it easier for diverse groups of men who have sex with men to take part in the programme. It also helped diminish the way in which homophobic stigma manifests itself as a form of Othering directed against those who are positioned as different to the heterosexual majority. Conclusion This paper has examined how variations in homophobic stigma across different locales affected HIV prevention programmes targeted at men who have sex with men, both in relation to engaging the targeted groups and with respect to the way in which such programmes concurrently tackled homophobic stigma itself. Previous HIV prevention research among marginalised groups in places including South Africa has discussed the need to consider the variable impact of factors such as gender-based discrimination on the ability of different HIV programmes to function. This paper has highlighted how it is important to also consider variation in other forms of social inequality. This should be remembered as further community-based HIV prevention programmes, targeting men who have sex with men, emerge within the region. Disclosure statement No potential conflict of interest was reported by the authors.
Notes 1.
2. 3. 4. 5. 6. 7.
The term ‘homophobic stigma’ is deployed in the text to encompass negative and discriminatory behaviors (including verbal abuse, physical abuse, the threat of such abuse) enacted against individuals marked as non-heteronormative by heteronormative majorities (Neilands et al. 2008; Tucker et al. 2014). This is not to discount other potential influences. For example factors noted as influencing the degree of ambassador participation in Cape Town (e.g. volunteer training on bonding social capital) were not such an issue for Zwakalani interviewees. isiXhosa for ‘bringing people together’. isiZulu for ‘bringing people together’. Cape Town’s remaining languages are English (28%) and Afrikaans (35%). Several influential African National Congress apartheid-era political activists who were openly gay also came from Soweto, including Simon Nkoli. This is not to negate the fact that Ukwazana’s ambassadors also found ways to critically engage and challenge homophobic stigma in original ways (Tucker, de Swardt et al. 2013).
References Baral, S., G. Trapence, F. Motimedi, E. Umar, S. Iipinge, F. Dausab, C. Beyrer, and L. F. P. Ng. 2009. “HIV Prevalence, Risks for HIV Infection, and Human Rights among Men Who Have Sex with Men (MSM) in Malawi, Namibia, and Botswana.” PLoS One 4 (3): e4997.
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Benoit, E., M. Pass, D. Randolph, D. Murray, and M. J. Downing. 2012. “Reaching and Engaging Non-Gay Identified, Non-Disclosing Black Men Who have Sex with both Men and Women.” Culture, Health & Sexuality 14 (9): 975– 990. Burrell, E., S. Baral, R. Wood, and L.-G. Bekker. 2008. “Exploratory Study to Determine Rights Violations and HIV Prevalence Among Township MSM in Cape Town, South Africa.” Paper presented at XVII International AIDS Conference Mexico City 3-8 August. Campbell, C. 2003. Letting Them Die: Why HIV Prevention Programmes Fail. Oxford: James Currey. Campbell, C., and F. Cornish. 2010. “Towards a Fourth Generation of Approaches to HIV/AIDS Management: Creating Contexts for Effective Community Mobilisation.” AIDS Care 22 (sup2): 1569– 1579. Chetty, D. 1995. “A Drag at Madame Costello’s.” In Defiant Desire, edited by M. Gevisser and E. Cameron. London: Routledge. Connell, R. W. 1995. Masculinities. Cambridge: Polity. Cornish, F., and R. Ghosh. 2007. “The Necessary Contradictions of ‘Community-Led’ Health Promotion: A Case Study of HIV Prevention in an Indian Red Light District.” Social Science & Medicine 64 (2): 496– 507. de Waal, S., and A. Manion. 2006. Pride: Protest and Celebration. Johannesburg: Jacana. Derrida, J. 1982. The Margins of Philosophy. Brighton: Harvester Press. Donham, D. L. 1998. “Freeing South Africa: The “Modernization” of Male-Male Sexuality in Soweto.” Cultural Anthropology 13 (1): 3 – 21. Epprecht, M. 2007. Hungochani: The History of Dissident Sexuality in Southern Africa. London: McGill-Queen’s University Press. Epprecht, M. 2013. Sexuality and Social Justice in Africa: Rethinking Homophobia and Forging Resistance. London: Zed Books. Foucault, M. 1978. The History of Sexuality Volume 1: An Introduction. London: Allen Lane. Fuss, D. 1991. “Inside/Outside.” In Inside/Outside: Lesbian Theories: Gay Theories, edited by D. Fuss, 1 – 10. London: Routledge. Gevisser, M. 1995. “A Different Fight for Freedom: A History of South African Lesbian and Gay Organisation from the 1950s to the 1990s.” In Defiant Desire, edited by M. Gevisser and E. Cameron. London: Routledge. Hall, S. 1996. “On Postmodernism and Articulation: An Interview with Stuart Hall.” Journal of Communication Inquiry 10 (2): 45 – 60. Hart, G. 2007. “Changing Concepts of Articulation.” Africanus: Journal of Development Studies 37 (2): 46 – 65. Hoad, N. 2007. African Intimacies: Race, Homosexuality and Globalisation. Minneapolis: University of Minnesota Press. Jobson, J. 2011. “Ukwazana Programme.” Anova Health Institute. Accessed September 15. http:// www.anovahealth.co.za/resources/entry/ukwazana_programme/ Lane, T., T. Mogale, H. Struthers, J. McIntyre, and S. M. Keels. 2008. “‘They See You as a Different Thing’: The Experiences of Men Who Have Sex with Men with Healthcare Workers in South African Township Communities.” Sexually Transmitted Infections 84 (6): 430– 433. Lane, T., H. F. Raymond, S. Dladla, J. Rasethe, H. Struthers, W. McFarland, and J. McIntyre. 2011. “High HIV Prevalence Among Men Who have Sex with Men in Soweto, South Africa: Results from the Soweto Men’s Study.” AIDS & Behavior 15 (3): 626– 634. Lane, T., S. B. Shade, J. McIntyre, and S. F. Morin. 2008. “Alcohol and Sexual Risk Behavior Among Men Who Have Sex with Men in South African Township Communities.” AIDS & Behavior 12 (S1): 78 – 85. Livermon, X. 2014. “Soweto Nights: Making Black Queer Space in Post-Apartheid South Africa.” Gender, Place & Culture 21 (4): 508– 525. McIntyre, J. 2010. “The Need for HIV Prevention Interventions for Men Who have Sex with Men in Africa.” Sexually Transmitted Infections 86 (2): 82 – 83. Meersman, B. 2014. “Where to for Cape Town Pride.” GroundUp, April 15. http://www.groundup. org.za/content/where-cape-town-pride Moisan, D. 2014. “Life on the Run from Homophobia.” Mail and Guardian online. http://mg.co.za/ article/2014-05-16-life-on-the-run-from-homophobia Motswagae, D. 2013. “Ukwazana/Zwakalani: An Innovative Outreach Model.” Paper presented at Top2Btm – Keeping up: What’s trending with MSM Johannesburg, April 23.
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Msibi, T. 2009. “Not Crossing the Line: Masculinities and Homophobic Violence in South Africa.” Agenda: Empowering Women for Gender Equity 23 (80): 50 – 54. Neilands, T. B., W. T. Steward, and K.-H. Choi. 2008. “Assessment of Stigma Towards Homosexuality in China: A Study of Men Who have Sex with Men.” Archives of Sexual Behavior 37 (5): 838– 844. Nel, J. A., and M. Judge. 2008. “Exploring Homophobic Victimisation in Gauteng, South Africa: Issues, Impacts and Responses.” Acta Criminologica 21 (3): 19 – 37. Rebe, K. B., G. de Swardt, H. Struthers, and J. McIntyre. 2013. “Towards ‘Men Who have Sex with Men-Appropriate’ Health Services in South Africa.” Southern African Journal of HIV Medicine 14 (2): 52 – 57. Reid, G., and T. Dirsuweit. 2002. “Understanding Systemic Violence: Homophobic Attacks in Johannesburg and its Surrounds.” Urban Forum 13 (3): 99 – 126. Robinson, J. 2011. “Cities in a World of Cities: The Comparative Gesture.” International Journal of Urban and Regional Research 35 (1): 1 –23. Salo, E., M. Ribas, P. Lopes, and M. Zamboni. 2010. “Living our Lives on the Edge: Power, Space and Sexual Orientation in Cape Town Townships, South Africa.” Sexuality Research and Social Policy 7 (4): 298– 309. Sandfort, T., and V. Reddy. 2013. “African Same-Sex Sexualities and Gender-Diversity: An Introduction.” Culture, Health & Sexuality 15 (sup1): 1 –6. Sandfort, T., H. Yi, J. Knox, and V. Reddy. 2013. “Sexual Partnership Types as Determinant of HIV Risk in South African MSM: An Event-Level Cluster Analysis.” AIDS and Behavior 17 (S1): 23 – 32. Sjolund, Y. 2011. “Soweto Clinic Reaches Out to Men Who have Sex with Men.” MSMGF: The Global Forum on MSM & HIV. Accessed September 2014. http://www.msmgf.org/index.cfm/id/ 11/aid/3425/lang/en Smith, A. D., P. Tapsoba, N. Peshu, E. J. Sanders, and H. W. Jaffe. 2009. “Men Who have Sex with Men and HIV/AIDS in Sub-Saharan Africa.” The Lancet 374 (9687): 416– 422. Stychin, C. F. 2004. “Same-Sex Sexualities and the Globalisation of Human Rights Discourse.” McGill Law Review 49: 951– 967. Tilly, C. 1984. Big Structures, Large Processes, Huge Comparisons. New York: Russell Sage Foundation. Tsouroulis, E. 2014. “Drag Kings & Beauty Queens: Gay Glamour in Soweto.” Out Africa Magazine 18 (Autumn): 3. Tucker, A. 2009. Queer Visibilities: Space, Identity and Interaction in Cape Town. Chichester: Wiley-Blackwell. Tucker, A., G. de Swardt, H. Struthers, and J. McIntyre. 2013. “Understanding the Needs of Township Men Who have Sex with Men (MSM) Health Outreach Workers: Exploring the Interplay Between Volunteer Training, Social Capital and Critical Consciousness.” AIDS and Behavior 17 (S1): 33 – 42. Tucker, A., J. Liht, G. de Swardt, G. Jobson, K. Rebe, J. McIntyre, and H. Struthers. 2013. “An Exploration into the Role of Depression and Self-Efficacy on Township Men Who have Sex with Men’s Ability to Engage in Safer Sexual Practices.” AIDS Care 25 (10): 1227– 1235. Tucker, A., J. Liht, G. de Swardt, G. Jobson, K. Rebe, J. McIntyre, and H. Struthers. 2014. “Homophobic Stigma, Depression, Self-Efficacy and Unprotected Anal Intercourse for PeriUrban Township Men Who have Sex with Men in Cape Town, South Africa: A Cross-Sectional Association Model.” AIDS Care 26 (7): 882– 889. van der Elst, E. M., A. D. Smith, E. Gichuru, E. Wahome, H. Musyoki, N. Muraguri, G. Fegan, et al. 2013. “Men Who have Sex with Men Sensitivity Training Reduces Homoprejudice and Increases Knowledge Among Kenyan Healthcare Providers in Coastal Kenya.” Journal of the International AIDS Society 16 (Suppl 3): 18748. Vincent, L., and S. Howell. 2014. “‘Unnatural’, ‘Un-African’ and ‘Ungodly’: Homophobic Discourse in Democratic South Africa.” Sexualities 17 (4): 472– 483. Wells, H., and L. Polders. 2006. “Anti-Gay Hate Crimes in South Africa: Prevalence, Reporting Practices, and Experiences of the Police.” Agenda: Empowering Women for Gender Equity 20 (67): 20 – 28. Western, J. 1997. Outcast Cape Town. 2nd ed. Berkeley, CA: University of California Press.
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Re´sume´ La recherche a re´ve´le´ comment le stigma homophobe est e´troitement lie´ au VIH chez les hommes qui ont des rapports avec des hommes en Afrique subsaharienne. Cet article se penche sur les incidences variables de l’impact du stigma homophobe sur les programmes de pre´vention du VIH qui ciblent les hommes qui ont des rapports avec des hommes en Afrique du Sud. Il examine comment un programme de pre´vention du VIH a` assise communautaire base´ dans les townships pre´urbains de la ville du Cap a e´te´ « traduit » pour la zone pre´urbaine de Johannesburg. En se basant sur des entretiens conduits avec des volontaires et des animateurs du programme a` Johannesburg, l’article soutient qu’un environnement homophobe diffe´rent de celui du Cap a offert des opportunite´s de collaboration a` la fois avec d’autres hommes qui ont des rapports avec des hommes et avec la communaute´ en ge´ne´ral. Il soutient aussi que les animateurs du programme doivent eˆtre conscients de la fac on dont divers degre´s de stigma homophobe peuvent se rapporter a` des de´bats the´oriques plus larges sur les relations sexuelles binaires, qui peuvent nous aider a` comprendre pourquoi certains programmes de´cident de se concentrer sur des activite´s spe´cifiques plutoˆt que sur d’autres.
Resumen ´ frica subsahariana han revelado que el estigma Ciertas investigaciones llevadas a cabo en el A homofo´bico se vincula estrechamente con la transmisio´n del vih entre hombres que tienen sexo con hombres (hsh). El presente artı´culo examina el impacto diferenciado que dicho estigma tiene en los programas de prevencio´n del vih entre hsh de Suda´frica. Asimismo, analiza el traslado de un programa comunitario de prevencio´n del vih ejecutado en los municipios del a´rea metropolitana de Ciudad del Cabo a la zona urbana de Johannesburgo. A partir de las entrevistas realizadas a voluntarios y a facilitadores del programa en esta ciudad, el artı´culo concluye que el entorno homofo´bico presente en Johannesburgo, distinto al que se encuentra en Ciudad del Cabo, permitio´ que surgieran distintas oportunidades para involucrar a otros hsh y a la comunidad en general. Sostiene, adema´s, que los facilitadores del programa deben prestar atencio´n a los distintos matices con que se presenta el estigma homofo´bico, ya que estos podrı´an vincularse con debates teo´ricos ma´s amplios en torno a las relaciones sexuales binarias, los cuales pueden llevar a comprender las razones por las cuales ciertos programas se centran en algunas actividades y no en otras.
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How do community-based HIV prevention programmes for men who have sex with men ‘travel’? Lessons from the Ukwazana/Zwakalani journey in South Africa Andrew Tuckera,b*, Glenn de Swardtb, James McIntyreb and Helen Struthersb a Centre for Gender Studies, University of Cambridge, Cambridge, UK; bAnova Health Institute, Johannesburg, South Africa
(Received 30 May 2014; accepted 10 February 2015) Research reveals how homophobia and stigma link closely to HIV among men who have sex with men in sub-Saharan Africa. This paper considers the varying impact of homophobic stigma on HIV prevention programmes among men who have sex with men in South Africa. It explores how a community-based HIV prevention programme based in the peri-urban townships of Cape Town was ‘translated’ to peri-urban Johannesburg. Drawing on interviews with volunteers and programme facilitators in Johannesburg, it argues that an altered homophobic environment to that found in Cape Town gave different opportunities to engage both with other men who have sex with men and the broader community. It also argues that programme facilitators should be mindful of how varying degrees of homophobic stigma may relate to broader theoretical debates about sexual binary relationships, which can help us understand why particular programmes choose to focus on certain activities rather than others. Keywords: South Africa; men who have sex with men; HIV prevention; homophobia; community interventions
Introduction Men who have sex with men have historically been marginalised in African HIV prevention programmes (McIntyre 2010; Smith et al. 2009). Work specifically in relation to groups such as peri-urban men who have sex with men in South Africa has, however, begun to highlight key issues that need to be addressed to confront HIV prevalence figures that are significantly greater than those of the general population (Lane et al. 2011). Research has also shown how risk activities such as condomless sex are associated with various behavioural factors, including alcohol use, the number of sexual partners and relationship type (Baral et al. 2009; Lane, Shade et al. 2008; Sandfort et al. 2013). Work is also exploring how social factors such as homophobic stigma1 are directly related to the HIV epidemic among men who have sex with men. Homophobic stigma has been documented in South Africa (and the broader region) as having serious implications with regard to schooling and employment opportunities, family support and physical safety (Msibi 2009; Nel and Judge 2008; Wells and Polders 2006). Research has documented how the power and endurance of such stigma relates to factors such as the misguided belief that homosexuality is unAfrican (Vincent and Howell 2014), which has remained closely aligned to particular renderings of post-colonial nationalism (Epprecht 2013; Stychin 2004). With regard to HIV, studies conducted in Kenya (van der Elst et al. 2013) and South Africa (Lane, Mogale et al. 2008) have highlighted how homophobic stigma on the part of
*Corresponding author. Email: [email protected] q 2015 Taylor & Francis
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healthcare workers can significantly inhibit men from accessing clinic services. Research also suggests that experiences of homophobic stigma lead to increased risk of engaging in sexual practices such as condomless sex (Tucker et al. 2014). More broadly, homophobic laws inhibit safer-sex information dissemination among men who have sex with men (McIntyre 2010). One further key way in which homophobic stigma has impacted on the HIV epidemic among men who have sex with men is through its ability to limit HIV prevention programme success. For example, men have sometimes felt unable to take part in community-based programmes that require them to become known locally as engaging in same-sex behaviour (Tucker, de Swardt et al. 2013). Volunteers for such community-based programmes have also at times felt unwilling to take part if programmes do not acknowledge the existence of, and find ways of tackling, homophobic stigma within their design. Taken together these findings help us understand the many ways homophobic stigma in the region can impact on endeavours to reduce HIV transmission among men who have sex with men. However, while it is now understood as important to address homophobic stigma with regard to the HIV epidemic among men who have sex with men, it is also important to consider the variability of such stigma, especially as it relates to HIV prevention. Sociological and anthropological research has pointed to diverse manifestations of homophobic stigma in South Africa (and across southern Africa) (Epprecht 2007, 2013; Hoad 2007; Sandfort and Reddy 2013). Different histories of gender- and sexuality-based oppression, often tied to different political histories, have given rise to differences in the way stigma impacts on men who have sex with men. It is important to take account of such variability when looking at other HIV prevention programming among marginalised groups. For example, research in community-based HIV prevention with marginalised communities has revealed how women can sometimes strategically engage with patriarchal structures necessary for programme success, while at other times in other places finding the possibility of engagement far harder (Campbell and Cornish 2010; Cornish and Ghosh 2007). While a comparative lens has been used to successfully explore some of the particularities related to the way gender-based discrimination can inhibit community-based HIV prevention programmes, there exists far less research on how variations in other social forces, such as homophobic stigma, may be implicated in opportunities for success as programmes ‘travel’. This paper therefore explores what happened when an HIV prevention programme focused on men who have sex with men, which had attempted to overcome barriers associated with homophobic stigma in peri-urban Cape Town, was taken to peri-urban Johannesburg. We begin by describing the rationale for the development of the Cape Town-based Ukwazana programme and highlighting how it relates to the Zwakalani programme in Johannesburg. Drawing on interviews with programme facilitators and volunteer outreach workers (the programme’s ‘township ambassadors’), we argue that there are important lessons to be learned by considering how programmes can adapt to different degrees of self-reported homophobic stigma.2 This can impact on how a programme goes about attracting men’s participation. Concurrently, it can also affect how a programme challenges homophobic stigma itself. We then relate these issues to broader theoretical concerns regarding the regulative power of sexual binaries, and the impact this may also have on HIV prevention among men who have sex with men. Translating programmes The Ukwazana3 programme in the peri-urban townships of Cape Town was a new type of HIV prevention programme for South African men who have sex with men. It was
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designed to work in structured and frequent collaboration with a team of township volunteers or ‘ambassadors’, who were themselves men who have sex with other men, to uncover and confront community-level factors associated with sexual risk taking (Tucker, de Swardt et al. 2013). Research into prior HIV prevention programmes in peri-urban Cape Town aimed at such men had shown they often struggled to work collaboratively with targeted groups to explore and challenge HIV risk factors. There was therefore less than sustained interest and engagement by such men (Gevisser 1995; Tucker 2009). Informed by work with other at-risk populations (see Campbell 2003), Ukwazana was therefore designed to facilitate direct communication, structured discussion and collaboration between township men who had sex with other men, township ambassadors and programme facilitators in the exploration of risk factors and the implementation of measures to address these factors (Jobson 2011). Significant effort was made to attract the interest of local men who had sex with men to the programme and to highlight this collaborative ethos (Tucker, de Swardt et al. 2013). Ukwazana was a partnership between Health4Men, an initiative of the Anova Health Institute, and the University of Cambridge Centre for Gender Studies. Prior to the Ukwazana programme, research had documented reports of severe and sustained sexuality-based discrimination in Cape Town’s townships (Salo et al. 2010). Research and popular reporting also described the beating and even murder of same-sex attracted individuals (Burrell et al. 2008; Moisan 2014). Research from the Ukwazana programme supported these findings and suggested how homophobic stigma impacted on diverse aspects of HIV prevention. For example, quantitative research conducted among local men who have sex with men highlighted a significant association between the experiences of homophobic stigma and likelihood of engaging in condomless sex (Tucker et al. 2014). It also revealed that over the preceding six months, 78% of men in the survey had been verbally insulted, 59% had been threatened with physical violence, 46% had been physically attacked and 28% had lost a place to stay due to their sexuality. Such factors were associated with psycho-social concerns such as depression and a lack of selfefficacy, which were also associated with condomless sex (Tucker, Liht et al. 2013). Qualitative research also pointed to ways in which homophobic stigma had to be acknowledged and confronted by Ukwazana. Prior research had described how this factor could limit men’s participation in the programme due to fear of wider community censure (Tucker 2009). Because of this, a decision was made by Ukwazana’s programme facilitators that township ambassadors should be men who had already reached relative positions of safety within the community and were relatively open about their same-sex interests and desires (Tucker, de Swardt et al. 2013). Qualitative interviews with these township ambassadors confirmed the quantitative findings and also revealed how homophobic stigma was seen to result in isolation among men and a lack of peer support, inhibiting solidarity networks (Tucker, de Swardt et al. 2013). These issues were of such significance in the lives of township men that their decision to take part in Ukwazana as a township ambassador was in part dependent on the programme being willing and able to find ways of challenging homophobic stigma and associated concerns such as isolation within the community. Tackling such issues in partnership with township ambassadors therefore became important to help sustain the very premise of the Ukwazana programme itself – namely to work collaboratively with local men. In 2012, Health4Men implemented a similar programme in the peri-urban township locations surrounding Johannesburg (predominantly in Soweto, home to approximately 30% of the city’s inhabitants). This programme, termed Zwakalani,4 followed a similar brief to Ukwazana. It included attracting the sustained interest of a cohort of volunteer
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outreach workers and structured and accountable mechanisms for communication and action between ambassadors and programme facilitators (Motswagae 2013). Care was taken not to assume that the earlier Ukwazana initiative should necessarily be replicated in its entirety in the new location. For example, while it was appreciated that certain similar factors such as homophobic stigma were previously of concern in Johannesburg (Reid and Dirsuweit 2002), it was not assumed that their relationship to HIV prevention programming would necessarily be the same. At the end of 2013, after the programme had been running for over a year, 13 Zwakalani ambassadors were interviewed by the first author, who had not been involved in the development of the programme (but had earlier assisted with research processes associated with Ukwazana). Interviews were also conducted with the five Zwakalani programme facilitators employed by Health4Men who came from local peri-urban communities. An inductive methodology initially explored the success (or otherwise) of collaboration with the target population and awareness of local context. Interviews were semi-structured and, to allow for comparison with Ukwazana, covered the same topics, including why men volunteered their time, how well the programme was functioning and how it engaged with the broader township community. Analysis subsequently drew from what Tilly (1984) might refer to as variation-finding comparison, an approach that has been appropriated within fields such as urban studies to theorise differences across ostensibly similar units (Robinson 2011). Interviewees provided written informed consent and were informed that their comments would be kept anonymous. Interviews lasted between 20 and 60 minutes. Interviews were recorded, transcribed and thematically coded. Ethics review boards at the University of Witwatersrand and the University of Cambridge approved the research process. Below, township ambassadors’ quotations are listed with the letters TA and a randomly assigned number used for all of that particular ambassador’s quotations, for example TA2. Programme facilitator’s quotes follow a similar pattern, for example PF3. Soweto: a changed environment Interviewees saw several benefits to Zwakalani over and above issues related to challenging homophobic stigma. While, as previously discussed, Ukwazana’s ambassadors in Cape Town saw the need to challenge homophobic stigma as a condition for their participation, this issue appeared absent in discussions with Zwakalani’s ambassadors. Of importance for the latter was the more straightforward desire to provide education on safer-sex, condoms and HIV testing to other men who have sex with men. As the following quotations highlight, the provision of (previously lacking) safer-sex information and materials for such men was a key reason why ambassadors volunteered with Zwakalani: I’m gay, I need to know some things, ja. It’s important so I can share this safer-sex information in the township. [Gay] people need to know . . . . So I give condoms to my friends and tell them to protect themselves each and every time when they have sex. (TA6) I should say every friend of mine [gets condoms]. Because I make sure I do have from Health4Men so I can give them to [my friends]. So every friend of mine if they don’t have, then they actually ask me as an ambassador and then I’ll bring [condoms] for them. (TA7)
Ambassadors described this ability to pass on safer-sex information and provide the methods by which their peers could protect themselves as also helping to create a sense of personal positive affirmation. This in turn helped reinforce a desire for involvement in the programme. For example, when asked why they volunteered their time, men responded:
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Well, I like working with people. It’s been my passion since I was young. Interacting with people, especially others in the gay community. It’s so very great to get out there to talk to people, to educate them about HIV and testing . . . . For me that’s so fulfilling on a personal [level]. (TA2) I do it because I want to do it. I think that, it was a personal thing that I always wanted to do. Because I personally have never had that support. And because of that, my decisions were bad. And there were consequences . . . . For example, I didn’t know about the lubricant [used with condoms for anal sex] and I would go on and use oil-based lubrication [which degrade latex], which I didn’t know you were not supposed to use it. So that is why I decided to go and help. You can help people by going to be an ambassador. (TA12)
For many township ambassadors, the desire to assist other men who have sex with men in directly looking after their own health was the primary reason for their participation in Zwakalani. The almost urgent need to find ways of challenging homophobic stigma and address associated factors such as social isolation (as was the case with Ukwazana’s ambassadors) appeared in Soweto not to be a prerequisite for Zwakalani ambassadors’ participation in the programme. This is not, however, to suggest that consideration of such issues was unimportant for Zwakalani’s ambassadors. As the following ambassadors describe, homophobic stigma continued to be perpetrated by members of the wider community against men who have sex with men in Soweto: There’s homophobic people in Soweto. We get criticised [by such people]. There’s that stuff. (TA8) It’s still there [homophobia]. So there are those who still does not have the full understanding, maybe. I can say the full understanding about the homosexuals. And mostly it is the straight boys who are homophobic. (TA10)
And as one programme facilitator explained in relation to the barriers homophobic stigma can create when conducting community workshops that included heterosexual members: I mean, yes, especially when we were doing the workshops. And we get there and we ask ‘Who are MSM?’ and they [snaps fingers] fly out ‘stabane [a derogatory term], what, what.’ ‘This is not biblical . . . ’ (PF1)
It is important to situate such statements within broader emerging dynamics related to men who have sex with men from Soweto. Important here was the feeling expressed by interviewees that homophobic stigma in Soweto was not as uniformly in evidence to the extent encountered by Ukwazana in Cape Town. For example, in Cape Town, homophobic stigma was considered both to be widespread and to inhibit community building and the development of peer support networks. Ambassadors in Soweto, on the other hand, presented a more complex picture of men’s social worlds (while not negating the existence of homophobic stigma) describing a more ambivalent relationship to it and its negative consequences: I might say it’s like [homophobic] people don’t have any choice. You can control me, but until when? So they actually let it go. ‘Cause this is who we are and no one can change us. So they [homophobic people] don’t have any choice . . . . Well in Soweto, it’s actually a place where you feel free . . . (TA7) I think the people who are homophobic are less than the people who does understand the whole homosexual thing. And we are gay people, we tend to be friends [with] a lot [of people that] are more free to understand the whole thing and spread the word to those homophobic guys and stuff. (TA10)
In further support of these views is recent research into the somewhat unique opportunities afforded to men who have sex with men from Soweto to openly socialise
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compared to men from other peri-urban spaces in the country. Livermon (2014), for example, has described how there exists a vibrant and visible nightlife or ‘party culture’ for men who have sex with men in Soweto. There are also a variety of public events for the local lesbian, gay, bisexual and transgender community, which are unique in South Africa. As de Waal and Manion (2006) have documented, Soweto Pride has run in the township for over a decade. There has also been a well-attended cross-dressing pageant in Soweto since 2000 (Tsouroulis 2014). This is very different to peri-urban Cape Town, which, prior to Ukwazana, has not been able to develop similar events in size, scope or scale (Meersman 2014). Several Zwakalani ambassadors who had spent time living in Cape Town identified key reasons they saw as contributing to the variation between the two cities. In particular, they highlighted a history of far greater cultural mixing in the Johannesburg area, which had allowed for a greater degree of understanding and tolerance of diversity: I think that cultural diversity, somehow, it plays a role in the sense that, lets say in Cape Town, it’s a Xhosa community, they have their own beliefs and their rituals and so on. So if they see one gay man telling the community they are gay, they feel somehow they are insulting their culture and their tradition. But we [in Johannesburg] are very diverse as people . . . . we’ve got Xhosas, we’ve got Zulus here in Joburg, we’ve got Pedis . . . People think, ok, we’ve got Pedi’s who are gay . . . . Everybody can be gay. I think that can play a role in that kind of thing. (TA2) Life this side is very, very fast. In terms of looking at people who are coming from outside, provinces like KwaZulu-Natal, countries like Lesthoto, Botswana, coming this side. This is why people say, when you come to Joburg, it’s a fast place. It’s a place where you see everything . . . people that always [ask] questions . . . . I would say in the yard where I live, there’s a lot of cultures . . . . There’s Zulu’s there’s Pedis, there’s Tsongas. So when we all come together in the yard and make a fire or have a braai [BBQ] they ask ‘why don’t we see you with a girl?’, I will explain . . . (TA1)
Such views also have historical precedent. Research documenting the acceptance of ‘coloured’ homosexual communities in South Africa during the mid-twentieth century has shown how those designated as coloured by the apartheid state came from a wide variety of locales (Chetty 1995). Coloured heritage included the first Europeans, their slaves (from places including Indonesia, Mozambique and South India) and the Cape’s original inhabitants, the Khoisan. Such hybridity of coloured life may have helped protect coloured men who had sex with other men from any one discriminating social or moral doctrine gaining prominence (Gevisser 1995). Ethnic diversity between black African groups has also been well documented in South Africa, with apartheid planning limiting black African migration to the Cape (Western 1997). The results of these policies are still evident in the 2011 South African Census. While Johannesburg and Cape Town each report a principal black African language group (in Cape Town isiXhosa makes up 29.2% of the population and in Johannesburg isiZulu makes up 23%), other variability is stark. While isiNbebele, Sepedi, Sesotho, Setswana, Tshivenda and Xitsonga speakers combine make up 37% of the population in Johannesburg, they make up only 2.2% of speakers in Cape Town.5 There may well be other explanations as to why homophobic stigma and its effects present differently and in a less intractable manner in Soweto compared to Cape Town’s townships.6 One additional explanation has been put forward by Donham (1998) in relation to Johannesburg’s close proximity to the country’s mines (and migrant labour). Historically, mines were understood by Soweto residents as locations in which male samesex practices were at least partially accepted, which may continue to influence understanding of same-sex desire today in the area (Donham 1998).
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Such a situation is not, however, to suggest that challenging homophobic stigma was unimportant for the Zwakalani programme. As the township ambassador below describes, it is impossible to discuss an HIV prevention programme in a place like Soweto without appreciating the importance of addressing homophobic stigma: It’s connected because when you go into the community and advise people . . . the word homophobia, it can’t be left out. It just can’t be left out. It’s something that has to be said. Because when you go to people to start talking . . . what the person, heterosexual, homophobic individual, they will be like, ‘ah, we don’t want this gay stuff!’ it’s when you will start talking . . . (TA1)
Expanding Zwakalani’s scope As described above, Zwakalani’s ambassadors did not appear to see the need to directly tackle homophobic stigma in the same way as those at the Ukwazana programme. Zwakalani’s ambassadors also did not frame their participation as ambassadors as contingent on the programme directly tackling homophobic stigma. Furthermore, other men who have sex with men from Soweto did not necessarily feel unable to partake in Zwakalani events or activities due to such stigma. As two Zwakalani ambassadors explained: Since we have this programme we’ve had [events such as] netball tournaments here in Soweto. I was actually surprised and I was actually impressed that older people, they came to support their children. Even straight people, they came. [They] were asking so many questions and so forth. We were very open about everything. (TA2) We’ve been going to taverns and we distribute condoms and [conduct HIV] testing and telling them about sickness and everything. So, it’s working. Others are listening when we [are] reaching out to them. Ok, you put the gazebo tent there. It’s not like we stand in the street and ask people to come. They just come to the table and they ask the information. And you tell them everything . . . (TA3)
In an environment where the participation of men (both generally in programme events and as ambassadors) did not appear so directly tied to the need to address homophobic stigma, Zwakalani was able to reconsider how it approached serving the health needs of men it targeted. One key issue was finding ways of encouraging men’s participation in the programme. The strategy deployed by Zwakalani to do this not only differed significantly from that deployed by Ukwazana, it also provided a different approach to tackling the homophobic stigma that was in existence in Soweto. Zwakalani expanded to include a small new group of individuals who had been largely absent from Ukwazana – namely, heterosexual men who undertook the same outreach activities as ambassadors who were men who had sex with men. This new group, who comprised fully 25% of those interviewed, self-identified and were understood by other interviewees not to be men who had sex with other men. When asked why these men had been included within the programme, interviewees described two felt needs: first, was the need to engage as broad a cohort of men as possible with the programme; second, was a need to challenge homophobic stigma by helping create dialogue with the wider community. In relation to the first of these needs, there was a clear awareness by interviewees that the category men who have sex with men includes a rich diversity of men – from men who openly report having sex with other men, to more clandestine men. Programmes can too readily focus only on one group of men who overtly indicate their sexual attraction to other men, which can limit the participation of others (Benoit et al. 2012). Similar issues had emerged at one of Health4Men’s earliest clinical services, the Simon Nkoli clinic, which also operated in Soweto but predated the Zwakalani
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programme. A decision was made early on to describe this clinic (and all the other clinics operated by Health4Men) as a ‘Men’s Clinic’, rather than as a clinic for men who have sex with men (Sjolund 2011). There were three interconnected rationales for this decision (Rebe et al. 2013). First, men who have sex with men (be they overt or clandestine) are unlikely to visit a space that could potentially lead to social censure (for example, if community members saw them entering it). Second, labelling a space as ‘gay’ or for men who have sex with men may limit the participation of clandestine men for whom such identity labels are incongruent with their self-understanding or image. Third, it is not in the interest of clinical services to attempt to screen whether a man has sex with another man prior to treatment. Problematically, as the following ambassador describes, such a strategy of branding a clinical space as a ‘men’s space’ did not work at first in Soweto: Actually I have a straight friend who once asked me about [the Simon Nkoli clinic] because he wanted to go but then he heard this thing that it was for homosexuals only and they would say he’s also gay . . . there was that stigma. (TA10)
Interviewees also highlighted this concern in relation to Zwakalani. In the following example, one programme facilitator describes how, had Zwakalani decided to focus solely on including openly identified men who have sex with men (often referred to, as in the following quotation, as ‘gay’ men), it might have suffered similar problems to those initially encountered at the Simon Nkoli clinic: If [Zwakalani ] is all open MSM [men who have sex with men] that then is where the problem lies . . . that is why we ended up balancing [including heterosexual men in the programme] . . . . I remember that when we started [Zwakalani ] we were sitting with 71 people. Like the [Simon Nkoli] clinic enrolled only 71 MSM, your gay[-identified] people. So we asked what is the problem? We called those 71 people and we had a focus group with them . . . . We asked ‘is it because the [clinical] services are useless, or what?’ They said, ‘no, you are stigmatising the project. Because [when] people go there, [other] people are already saying “he’s MSM.” Even if he doesn’t want to be [open].’ So you are already disclosing to people that he’s an MSM, so you are stigmatising them . . . (PF1)
For Zwakalani therefore, the inclusion of heterosexual men within the programme aimed to help broaden the scope of its work by framing the programme as not being overly focused on only one group of men who were open about their sexuality (‘gay’ in the quotation above). By way of comparison, Ukwazana in its initial stages had focused on attracting a small number of overtly visible men who had sex with other men who had reached positions of safety within the community. Such a shift in attempting to affect community perception can also be appreciated in another aspect of the programme’s work: namely, the way it went about challenging homophobic stigma. While, as already discussed, this focus was not such a central aim of Zwakalani, it was still noted as an issue of concern by interviewees. As the interviewees below explain, a Zwakalani approach towards this issue again centred on including heterosexual men as volunteers within the programme: But we also have straight men, they’ve got wives, but they go out and go to work and spread the word ‘guys, lets come together and support gay people’. I think for the community it works, in accepting us. Because if I am gay and I’ve got a straight friend and he’s also my colleague he’s going to take me to his straight friends and they will get to know me outside of my sexuality. ‘Ok, he’s gay but he’s just a person like the rest of us’. So I think it makes a very big difference to the community if we are a mix of people. (TA2) Gay and straight ambassadors, I believe [is better]. Because if ever there are those [homophobic] people, [they are] hard to crack. But if you got a straight person and they are
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a peer and then they will see them and then they will explain to them about, ‘this is how it is’. Yes, it changes their mind . . . (TA13)
This strategy of including heterosexual men to speak on behalf of men who have sex with men should not be seen as substituting for the role that men who have sex with men themselves can play in challenging homophobic stigma. However, it offered an important additional element in this regard. Significantly, the lessened homophobic environment in Soweto compared to Cape Town meant Zwakalani could consider additional ways of engaging the interest and participation of men within the programme. It also allowed Zwakalani to find other ways of challenging the homophobic stigma that did exist locally. Sexual binaries and HIV prevention The different paths taken by the two programmes can be understood in terms of the interface between sexual minorities and heterosexual majorities, and their relationships to power. Such concerns may need to be taken into consideration in future HIV prevention programmes that exist in communities with varying levels of homophobic stigma. They may help us hypothesise why only one of the two programmes discussed in this paper initially engaged heterosexual men as ambassadors, despite the potential benefits of doing so. As Derrida (1982) and Foucault (1978) highlight, social binaries (sexual or otherwise) often function such that a dominant group on one side of a binary (in this instance, a heterosexual majority) can maintain its ability to name and keep separate that which they see as different (in this instance, all that which is sexually ‘Other’ and beyond the bounds of heteronormativity, the minority). By doing this, power remains with the majority, even if minority groups attempt to challenge discrimination (Fuss 1991). Within such a hegemonic framing, while it may be possible and fruitful to challenge discrimination from the perspective and position of the minority, power remains with the majority precisely because such a challenge still takes place within the confines of the binary dictated by the majority (Connell 1995). If we conceptualise homophobic stigma in townships as an element of power that can be potentially wielded by the heterosexual majority, we can see a variant of this formation in the way Ukwazana functioned and hence a possible reason why it did not initially focus on including heterosexual men as ambassadors. As described earlier, Ukwazana initially encouraged the inclusion of men who had already reached positions of relative safety in society and who were open to the wider community about their same-sex interests and desires to take part as ambassadors. Severe stigma could have potentially limited the participation (and safety) of other men who have sex with men in the initial stages of the programme. Ukwazana’s ambassadors, it transpired, wished then to challenge homophobic stigma themselves (due to its severity) and this became important for their continued participation in the programme. The ability and mechanism by which the programme came to understand how it was possible to challenge homophobic stigma was therefore in part dictated by its very severity to begin with. By focusing on the most visible and open group of men who have sex with men, the programme could then also be seen to exist very much on the minority side of the binary relationship. Volunteers’ own desire to challenge homophobic stigma from the perspective of the minority against the majority not only solidified this position, but also helped to entrench the binary. While ostensibly there was little to stop Ukwazana from also encouraging the participation of heterosexual men, such did not take place precisely because Ukwazana had come to exist on the side of the sexual binary that was most oppressed.
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Such a framing is, however, premised upon a hegemonic rendering of power, whereby, at one extreme, there are those with the power to regulate and position sexual binaries and, at the other, those with far less power. As Hall (1996) and Hart (2007) highlight, such a framing need not exist in all places at all times; a hegemonic position is not necessarily fixed, but instead is historically and geographically contingent. We can consider this in relation to the opportunities that afforded Zwakalani to operate in a different way to Ukwazana, in part due to less severe local forms of homophobic stigma and a generally less inequitable sexual binary in Soweto.7 Zwakalani, it would appear, did not have to initially position itself on one side of a sexual binary relationship. By strategically including the active participation of heterosexual men, it also moved away from reinforcing sexual difference. Such a positioning made it easier for diverse groups of men who have sex with men to take part in the programme. It also helped diminish the way in which homophobic stigma manifests itself as a form of Othering directed against those who are positioned as different to the heterosexual majority. Conclusion This paper has examined how variations in homophobic stigma across different locales affected HIV prevention programmes targeted at men who have sex with men, both in relation to engaging the targeted groups and with respect to the way in which such programmes concurrently tackled homophobic stigma itself. Previous HIV prevention research among marginalised groups in places including South Africa has discussed the need to consider the variable impact of factors such as gender-based discrimination on the ability of different HIV programmes to function. This paper has highlighted how it is important to also consider variation in other forms of social inequality. This should be remembered as further community-based HIV prevention programmes, targeting men who have sex with men, emerge within the region. Disclosure statement No potential conflict of interest was reported by the authors.
Notes 1.
2. 3. 4. 5. 6. 7.
The term ‘homophobic stigma’ is deployed in the text to encompass negative and discriminatory behaviors (including verbal abuse, physical abuse, the threat of such abuse) enacted against individuals marked as non-heteronormative by heteronormative majorities (Neilands et al. 2008; Tucker et al. 2014). This is not to discount other potential influences. For example factors noted as influencing the degree of ambassador participation in Cape Town (e.g. volunteer training on bonding social capital) were not such an issue for Zwakalani interviewees. isiXhosa for ‘bringing people together’. isiZulu for ‘bringing people together’. Cape Town’s remaining languages are English (28%) and Afrikaans (35%). Several influential African National Congress apartheid-era political activists who were openly gay also came from Soweto, including Simon Nkoli. This is not to negate the fact that Ukwazana’s ambassadors also found ways to critically engage and challenge homophobic stigma in original ways (Tucker, de Swardt et al. 2013).
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Re´sume´ La recherche a re´ve´le´ comment le stigma homophobe est e´troitement lie´ au VIH chez les hommes qui ont des rapports avec des hommes en Afrique subsaharienne. Cet article se penche sur les incidences variables de l’impact du stigma homophobe sur les programmes de pre´vention du VIH qui ciblent les hommes qui ont des rapports avec des hommes en Afrique du Sud. Il examine comment un programme de pre´vention du VIH a` assise communautaire base´ dans les townships pre´urbains de la ville du Cap a e´te´ « traduit » pour la zone pre´urbaine de Johannesburg. En se basant sur des entretiens conduits avec des volontaires et des animateurs du programme a` Johannesburg, l’article soutient qu’un environnement homophobe diffe´rent de celui du Cap a offert des opportunite´s de collaboration a` la fois avec d’autres hommes qui ont des rapports avec des hommes et avec la communaute´ en ge´ne´ral. Il soutient aussi que les animateurs du programme doivent eˆtre conscients de la fac on dont divers degre´s de stigma homophobe peuvent se rapporter a` des de´bats the´oriques plus larges sur les relations sexuelles binaires, qui peuvent nous aider a` comprendre pourquoi certains programmes de´cident de se concentrer sur des activite´s spe´cifiques plutoˆt que sur d’autres.
Resumen ´ frica subsahariana han revelado que el estigma Ciertas investigaciones llevadas a cabo en el A homofo´bico se vincula estrechamente con la transmisio´n del vih entre hombres que tienen sexo con hombres (hsh). El presente artı´culo examina el impacto diferenciado que dicho estigma tiene en los programas de prevencio´n del vih entre hsh de Suda´frica. Asimismo, analiza el traslado de un programa comunitario de prevencio´n del vih ejecutado en los municipios del a´rea metropolitana de Ciudad del Cabo a la zona urbana de Johannesburgo. A partir de las entrevistas realizadas a voluntarios y a facilitadores del programa en esta ciudad, el artı´culo concluye que el entorno homofo´bico presente en Johannesburgo, distinto al que se encuentra en Ciudad del Cabo, permitio´ que surgieran distintas oportunidades para involucrar a otros hsh y a la comunidad en general. Sostiene, adema´s, que los facilitadores del programa deben prestar atencio´n a los distintos matices con que se presenta el estigma homofo´bico, ya que estos podrı´an vincularse con debates teo´ricos ma´s amplios en torno a las relaciones sexuales binarias, los cuales pueden llevar a comprender las razones por las cuales ciertos programas se centran en algunas actividades y no en otras.
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