Bringing the Invisible to Light

BRINGING THE INVISIBLE TO LIGHT

Researching the homosexual community in India and cutting through the social stigma

Pallavi Dhall

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Publication Date: October 2014 ESOMAR Publication

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YOUNG RESEARCHER OF THE YEAR AWARD WINNER 2014

BRINGING THE INVISIBLE TO LIGHT

Researching the homosexual community in India and cutting through the social stigma

Pallavi Dhall

INTRODUCTION

‘’I have been raped so many times that I have lost count. The police tells me that if I intend to indulge in such ‘wrong things’, then I am bound to be treated this way’’- said a 19-year-old boy during a focus group discussion in New Delhi, the capital of my country, India. I was not surprised, disheartened but not surprised. The ‘wrong’ that the police was referring to was that the boy is a homosexual; he has sex with other men. Just when we as individuals, communities and a nation begin to believe that we have moved past such blatant bigotry, instances and narratives like these burst our bubble. Although the existence of homosexuality is evident in the Indian culture since pre-historic times, as seen in different forms of art like paintings and carvings in temples, homosexuals are in reality depicted more as an anomaly. Therefore, the MSM (Men who have Sex with other Men) are highly stigmatized and those who are engaged in this type of sexual behaviour are usually treated with social contempt. Furthermore, the inequality arising from our normative constructions of masculinity, social attitudes towards feminized males and their ‘unusual or unnatural’ sexual practices, instances of sexual abuse, assault and rape, poverty and disempowerment, alongside legal prejudice impacts their identity in particular and life in general.

The MSM are one of the ‘hard-to-reach’ population groups among various others, such as female sex workers, transgender, drug users, etc. The fear of prejudice, mockery, stigma and discrimination has isolated this group from the rest of the society and consequently made them inaccessible. The endeavor was to reach this section of hard-to-reach population through this research project. The target group was sexually active men who have sex with men and who were not taking services from any Targeted Intervention (TI) projects being implemented in the country by NGOs with support from the Department of AIDS control.

In a country where even the existence of the MSM population is not acknowledged, the attitude with which they are faced with is among the least of our concerns. The vulnerabilities among men who have sex with other men are well established across the public health arena, especially with reference to HIV/AIDS and other sexually transmitted infections. Low rates of condom usage, multiple sex partners and inconsistent lubricant use make them more susceptible. Although the efforts of prevention and support in care have been going on for a while now, the Government records point out that the reach of such interventions has not been quite successful. The seclusion and society’s aversion to their acceptance has become one of the most significant impediments against the HIV/AIDS programmes in India. A major cause being that till late men-with-men sex was seen as immoral and unnatural, not just by the general public but also by the legal system, which has resulted in keeping these communities at bay from all the government initiatives and programs aimed towards HIV prevention and care as most of the MSM population remains hidden and ‘hard-to-reach’.

In India, there is a cultural categorization of MSM population; Kothis (men who tend to be the ‘receptive’ male partner in anal and oral sex and typically have effeminate mannerisms), Panthis (men who tend to be the ‘insertive’ male partner in anal and oral sex) and double-deckers (men who are both ‘receptive’ and ‘insertive’ partners). The Panthis are usually ‘masculine’, which makes it easier for them to blend and align with the societal norms, consequently making them ‘harder-to-reach’.

The proposal to carry out this research study to understand the HIV-related risk behaviours among the MSM community, apart from operational difficulties, also presented a fundamental complexity: how do we reach them? MSM groups generally do not disclose their identity to others due to the fear of social seclusion that they might face if their identity is revealed and make it difficult even for the NGOs/CBOs to contact them. So, the Page 5 – YOUNG RESEARCHER OF THE YEAR AWARD WINNER 2014 Copyright © ESOMAR 2014

challenge of the study was to identify and test a methodology to approach this inaccessible, dark and hidden section of the society.

METHODOLOGY

Probability sampling methods do not work with hard-to-reach groups since there is no sampling frame to choose from, there are no defined boundaries and most importantly there are strong privacy concerns. The MSM population is hard-to-reach and harder-to-sample. The plausible way to tap the hard-to-reach MSM seemed to be through the peers or their close networks and thus the use of Respondent Driven Sampling (RDS) was arrived at. RDS, in the past, has been studied and carried out to reach hard-to-reach groups, however, this study was the first of this scale to use it: across three states and with a sample size of 1650.

RDS is a chain-referral system where current respondents recruit their friends/peers for the study to be future respondents. It employs a dual system of structured compensation: a reward for being interviewed and a reward for recruiting peers to be interviewed. Broadly, it combines snowballing sampling with the mathematical model that weighs the sample to compensate for the fact that the sample was collected in a non-random way. However, the selection of the initial respondents referred to as our ‘seeds’ provides an opportunity for making it representative across age, education and geographical area. Each of the selected seed is given three unique, non-replicable coupons which they further distribute among their peers for participation in the study. Furthermore, each of the eligible participants is given three coupons and so on. In this manner, RDS overcomes the biases of other chain referral methods such as snowball sampling, which tends to oversample participants with larger personal networks.

Ethical considerations are at the core of research studies that require the participation of human subjects and more so if the human subjects belong to a marginalized and stigmatized sections of the society. To keep the identity of the respondents confidential it was essential not to ask for any kind of identification information like name, address and mobile number. Hence, the research study designed an innovative way to experiment with measuring the change by creating a cohort with social anonymity. The study included collection of fingerprints to serve as biomarker for the study. An optical scanning device was used to collect the fingerprint of the participants. Each fingerprint was given a unique ID and no other personal information was recorded.

With respect to the implementation of respondent-driven sampling, it was crucial to collaborate with the community-based organizations working with MSM in and around the study sites and set up centres for interviews in their proximity. Since, these organizations work closely with MSM, they have gained their trust to a certain extent and their cooperation became crucial for the successful implementation of this sampling method. The director of an NGO working with MSM and the transgender asserted that their community would never trust an outsider and would not cooperate. I wondered who could blame them. When our judiciary declares homosexuality as criminal and unconstitutional, expecting homosexuals to reach out or letting others to reach out to them does not seem quite reasonable.

RESULTS

The use of respondent driven sampling proved to overcome the barriers of suspicion and helped us penetrate into this community. The study met its sample size of 1650; it reached out to 1650 hard-to-reach men who have sex with men. Kothis, the ‘penetrative’ partners, as discussed earlier, are harder to reach within the community of MSM. The non-random selection of ‘seeds’ enabled us to reach a large number of Kothis, making the sample representative. RDS is a robust midway between probability and non-probability sampling, which allows for a more probable sample selection. Considering the experimental nature of methods used for the study, there were a couple of unanticipated interruptions, such as the rate of distribution of coupons which was less than expected and led to the extension of field work beyond what was initially scheduled. This was a learning, which can be useful in other research done with hard-to-reach group using respondent-driven sampling.

Analytically, respondent-driven sampling gives the opportunity and control to look at the data in a more organized manner as the common characteristics such as network size, educational background, sexual identity etc. can be better tracked. The concept of ‘homophily’ is central in RDS; it is a measure of preference for connections to one's own group. Basically, the tendency to recruit peers with characteristics similar to those of Page 6 – YOUNG RESEARCHER OF THE YEAR AWARD WINNER 2014 Copyright © ESOMAR 2014

the recruiters. It varies between -1 (completely heterophilous) and +1 (completely homophilous). For example, if HIV-positive respondents recruited no other HIV-positive respondents they would exhibit complete heterophily. The data was analysed across sexual identity, age, use of intoxicants, knowledge on HIV/AIDS among various others, with the results showing that the majority were found to be homophilous.

RECOMMENDATIONS

The hostility towards homosexuals and the social stigma attached to them is something that our country is yet to deal with and has a long way to go. However, reaching out to them, penetrating their community can be facilitated by respondent-driven sampling. The challenges of designing programmes and implementing them for other sections of the society are quite different to those of the hidden population. The major challenge with the hard-to-reach is, well, that they are hard-to-reach. The inaccessibility of individuals, organizations and even the government to these communities is a difficulty that the Indian society needs to overcome. RDS as a methodology makes this possible to a great extent, it makes these invisible groups visible and once they are visible the possibilities are limitless. In a society like India, where there is an amalgam of different cultures, ideas and beliefs, evolution becomes complex. There are plans, policies and programmes; there are budget allocations and all of these fail to reach where they should. Accessing these communities is the ‘challenge of society’- and RDS is the response to bring these silent communities alive.

THE AUTHOR

Pallavi Dhall Indian Market Research Bureau, India