The Health Impacts of Violence Perpetrated by Police, Military and Other Public Security Forces on Gay, Bisexual and Other Men Who Have Sex with Men in El Salvador

CULTURE, HEALTH & SEXUALITY https://doi.org/10.1080/13691058.2019.1582801

The health impacts of violence perpetrated by police, military and other public security forces on gay, bisexual and other men who have sex with men in El Salvador

Dirk A. Davisa,b , Giuliana J. Moralesa , Kathleen Ridgewaya , Modesto Mendizabalc, Michele Lanhama , Robyn Daytona, Juana Cooked, Karin Santid and Emily Evensa aFHI 360, Durham, North Carolina, USA; bDepartment of Health Behavior Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA; cAsociacion Dikede Personas Transgenero y LGBTIþ, San Salvador, El Salvador; dRegional HIV, Health and Development Team, United Nations Development Programme, Panama City, Panama

ABSTRACT ARTICLE HISTORY Gay, bisexual and other men who have sex with men face both Received 9 August 2018 high levels of violence and a disproportionate burden of poor Accepted 11 February 2019 health outcomes. We explored violence perpetrated against Salvadoran gay, bisexual and other men who have sex with men KEYWORDS by public security forces; perceived motivations of violence; and Violence; men who have sex with men; police; impacts on health. We conducted structured qualitative interviews military; El Salvador with 20 participants and used systematic coding and narrative analysis to identify emergent themes. Nearly all participants described the physical, emotional, sexual and/or economic violence by public security forces. Most attributed being targeted to their gender expression and/or perceived sexual orientation. The most common impact was emotional distress, including humiliation, fear and depression; lasting physical injuries were also widely reported. Study participants felt unable to report these incidents for fear of retribution or inaction. Men reported feelings of helplessness and distrust, avoidance of authorities and altering when, where or how often they appeared in public spaces. Programmes and interventions should focus on providing mental health services for LGBTI (lesbian, gay, bisexual, transgender and intersex) who have sex with men victims of violence, educating public security forces on the legal rights of Salvadorans and expanding current LGBTI-inclusive policies to all public security forces.

Introduction Gay, bisexual and other men who have sex with men around the world face both high levels of violence and a disproportionate burden of poor health outcomes, including mental disorders and suicide, substance use, and HIV and other sexually transmitted infections (STIs), among others (Healthy People 2020 2016; Global Forum on MSM & HIV and OutRight Action International 2017; MPact: Global Action for Gay Men’s Health and

CONTACT Dirk A. Davis [email protected] ß 2019 Informa UK Limited, trading as Taylor & Francis Group 2 D. A. DAVIS ET AL.

Rights 2018). According to the World Health Organization (WHO), interpersonal violence may include physical abuse (such as slapping, hitting, kicking and beating), sexual abuse (including forced sexual intercourse and sexual coercion), emotional abuse (insults, belittling, humiliation, intimidation, threats of harm) and economic abuse (blackmailing and taking earnings) (World Health Organization 2002). Until recently, data on the relationship between violence and other health outcomes among gay, bisexual and other men who have sex with men have been limited. There is now a growing body of research documenting violence against this group and its correlations with other health outcomes. The literature identifies associations with mental health issues such as suicidal behaviours, depression and social isolation; behavioural risk factors for HIV such as multiple sex partners, coerced sex, substance use and unprotected sex; poor access to health services; acute physical trauma and injury; chronic pain and self-reported poor health; and homicide (Wheeler et al. 2014;deSantisetal.2008; Dunkle and Decker 2013; Siemieniuk, Krentz and John Gill 2013;Lietal.2012; Herek and Sims 2008). As explained by both social dominance theory and Goffman’s work on stigma, disparities in violence and other health outcomes experienced by gay, bisexual and other men who have sex with men are likely the result of them possessing what the social majority believes is a negative attribute, in this case their sexual orientation, and there- fore they are considered members of an inferior social group (Goffman 1963; Pratto, Sidanius and Levin 2006). Social dominance theory describes how some members of society are awarded resources and power based on the social group to which they are assigned (typically cisgender, heterosexual white men in the Americas). In contrast, individuals who are not part of this group disproportionally suffer from less political and economic power, and are relegated to substandard employment, health and wellbeing, among others (Pratto, Sidanius and Levin 2006). Goffman and others have posited that these stigmatised attributes make certain groups more vulnerable to various forms of violence, including structural violence (Goffman 1963; Araujo et al. 2009). Padilla, Vasquez del Aguila and Parker (2007, 210) define structural violence as ‘the ways by which social inequalities and political-economic systems place particular persons or groups in situations of extreme vulnerability’. While we explore interpersonal violence perpetrated by public security forces against gay, bisexual and other men who have sex with men in El Salvador, we recognise that this interpersonal violence is part of the larger structural violence from which all sexual and gender minorities suffer. Interpersonal and structural violence is widespread throughout Central America, and especially high in El Salvador, which has some of the highest violent crime rates in the world (Institute for Health Metrics and Evaluation 2018). Much of this violence is attributed to residual effects from El Salvador’s 12-year civil war that ended in 1992 and claimed over 75,000 lives (Georgetown University Law Center 2017). Since the end of this war, high levels of violence have persisted and have been attributed to gangs and the public security forces fighting them. Although El Salvador is the only Central American country that has never criminalised homosexuality and has some of the most progressive protections for sexual and gender minorities in the region (Georgetown University Law Center 2017), lesbian, gay, bisexual, transgender and intersex (LGBTI) activists have documented more than 500 hate crimes against sexual and gender minorities between 1996 and 2015. Salvadoran authorities explain that CULTURE, HEALTH & SEXUALITY 3 rates and types of violence experienced by LGBTI communities are similar to those of the general population (Georgetown University Law Center 2017); however, a lack of available data makes this impossible to prove. The existing literature on violence among gay, bisexual and other men who have sex with men in El Salvador is limited, with three studies documenting a prevalence, among this group, of psychological violence at 25.9% (Wheeler et al. 2014), physical violence at 12.9% (Wheeler et al. 2014), ever being forced to have sex at 33% (Kim et al. 2013) and general abuse or mistreatment due to their sexual orientation at 21.6% (Andrinopoulos et al. 2014). No research focusing specifically on violence against gay, bisexual and other men who have sex with men in El Salvador has reported the perpetrators of violence or focused specifically on public security forces, the most commonly reported perpetrators of violence in anecdotal reports from LGBTI civil society groups. This dearth of literature has been highlighted in recent years after several high-profile reports of extreme physical and sexual violence against sexual and gender minorities at the hands of public security forces (Georgetown University Law Center 2017; University of California, Berkeley 2012; United States Department of State 2017; Asociacion Salvadorena~ de Derechos Humanos “Entre Amigos’ 2010”.InEl Salvador, public security forces include the national civil police (Policıa Nacional Civil, PNC), city police (Cuerpos de Agentes Metropolitanos, CAM; police who operate in the capital, San Salvador), military personnel and prison guards. In many settings, public security forces, while meant to protect the population, are often perpetrators of violence against gay and bisexual men and other gender and sexual minorities (Kennedy et al. 2013;Lietal.2017; Schneiders and Weissman 2016). Several studies across settings have documented the negative impacts of prejudiced police practices and high levels of violence perpetrated by police on key populations liv- ing with HIV, including sexual and gender minorities (Crofts and Patterson 2016;Footer et al. 2016; Lunze et al. 2016). This evidence supports targeting public security forces for interventions to decrease violence experienced by LGBTI communities and improve their protection. The objective of this study was to document violence experienced by gay, bisexual and other men who have sex with men in El Salvador from public security forces, including the perceived motivations behind it and the types of violence committed by each security force. The need to examine the violence perpetrated by public security forces against this group was identified as a priority by the study’snational advisory group, including several gay and bisexual men civil society organisations (described below). Such data are needed to inform interventions for each public security force and galvanise a broader coalition, including public health institutions, on the importance of engaging with uniformed security forces to improve the health and wellbeing of Salvadoran gay, bisexual and other men who have sex with men.

Methods Parent study

This study was conducted in San Salvador and was part of a larger study conducted by the United Nations Development Programme (UNDP) and the USAID- and PEPFAR-supported LINKAGES project (led by FHI 360). UNDP and LINKAGES partnered 4 D. A. DAVIS ET AL. with key populations affected by HIV, including gay, bisexual and other men who have sex with men, transgender women and female sex workers in El Salvador, Haiti, Trinidad and Tobago and Barbados to learn about their experiences with gender- based violence across their lifespan (Evens et al. forthcoming;Lanhametal.2018). In El Salvador, UNDP and LINKAGES worked with two local civil society partners that provide services to gay, bisexual and other men who have sex with men, the Asociacion Entre Amigos and the Asociacion DikedePersonasTransg enero y LGBTIþ, to identify four gay men to be trained as peer data collectors. Regional and national advisory groups, that included civil society organisations, United Nations agencies, USAID, government representatives and the study team, were formed. The peer data collectors, civil society groups and regional and national advisory groups guided the technical content of the research, interpreted and prioritised results, identified strategies to disseminate the results and identified actions to translate the results into policy and programming.

Sample and recruitment

A purposive sample of participants was recruited based on inclusion criteria of being at least 18 years old and a cisgender man who reported having sex with other men, regardless of if they identified as gay or bisexual. Asociacion Entre Amigos recruited 20 participants by sharing information about the study using a recruitment flyer at events, including contact information, provided by the study team. Men who were interested in participating contacted the study team directly or left their contact information for a study team member to follow up with them. Participants received US$15 for their participation in interviews.

Data collection

Twenty structured qualitative interviews were conducted in Spanish during August 2016 by peer data collectors. All interviews took place in the Asociacion Entre Amigos office and lasted between one and four hours. Data collectors were trained in qualitative research, interviewing skills, study procedures and research ethics, and were supervised by the local researcher. Structured interview guides were used to conduct the interviews and asked about experiences of violence in a variety of contexts, including with public security forces. The interview guide included closed-ended questions to identify the types and frequency of violence experienced by participants in each of the contexts. Participants who reported experiencing violence were then asked open-ended questions about that experience. This paper focuses only on experiences of violence by national civil police, city police, the military and prison guards. Separate papers present overall study results (Evens et al. forthcoming) and explore the experiences of transgender women from this study (Lanham et al. 2018). The interview guides were informed by existing research on violence experienced by gay, bisexual and other men who have sex with men and developed in conjunction with the study’s regional technical advisory group. The guides were piloted with individuals from the MPact Global Action for Gay Men’s Health and Rights as well CULTURE, HEALTH & SEXUALITY 5 as with men in El Salvador who met the study eligibility criteria and updated as appropriate. Participants were asked: ‘As a gay or bisexual man, can you tell me about any violence or discrimination you have experienced from the national civil police, military or city police?’ If participants responded yes, they were then probed on the details of the incident, including impacts on their health and whether they shared the experience with any- one or sought any services. Continuous debriefing between peer data collectors and the supervising researcher occurred in which he provided suggestions for improvement in interviewing skills. All participants were given a referral list of local organisations that provided LGBTI-friendly psychological and other types of support. All participants provided oral informed consent before the interview, and all interviews were audio recorded and transcribed verbatim in Spanish, then translated into English for analysis. The study received ethical approval from both the FHI 360 Protection of Human Subjects Committee and the El Salvador National Ethics Committee on Health Research.

Data analysis

Data analysis was conducted in English. The field team was consulted to discuss key themes and obtain feedback on analytic products and drafts. We conducted a content analysis using a data-driven approach (Hsieh and Shannon 2005). We began by listening to a portion of audio-recordings in Spanish and reading all transcripts. We wrote memos based on emerging themes, including: differences in violence perpetrated by national civil police, city police, the military and prison guards; gender expression; demonstrations of power and authority; health impacts on participants; and support received. Based on these memos, we developed a codebook that contained both deductive, topical codes that reflected the structure of the interview guide (e.g. source of violence, perceived reasons for violence, location of violence) and inductive codes that were based on participant responses (e.g. power and authority, emotional wellbeing, interruption of violence). The 31 codes were systematically applied to all transcripts using QSR NVivo qualitative data analysis software program (QSR Software 2015). Code reports from this programme were used to develop matrices to further reduce data into three main categories: experiences of violence, perceived reasons of violence and impacts of violence. These matrices, along with continual revisiting of transcripts, were used to identify themes within each category and compare and contrast across individuals.

Results Our findings are presented in three sections: experiences of violence at the hands of public security forces; perceived motivations of this violence; and the impact that this violence had on men’s lives. For the purpose of confidentiality, pseudonyms are used when referring to participants.

Description of participants

As shown in Table 1, study participants ranged in age from 20 to 47 years old (mean: 32 years). Over half (n ¼ 11) had completed secondary school, and nearly a third 6 D. A. DAVIS ET AL.

Table 1. Participant characteristics. Mean (range) or n (%) n ¼ 20 Age (years) 32.3 (20–47) Highest level of education Primary 3 (15.0) Secondary 11 (55.0) University/technical 6 (30.0) Has paid employment 2 (10.0) Ever engaged in sex work 6 (30.0)

(n ¼ 6) had completed university or technical training. One-third (n ¼ 6) had engaged in sex work at some point in their lives.

Experiences of violence

Nearly all participants (n ¼ 19) described experiencing emotional, physical, sexual and/or economic violence by public security forces. Emotional violence was the most widely reported type, followed by physical, economic and sexual violence. Most participants had experienced violence at the hands of the national civil police (n ¼ 15), although many also suffered violence committed by city police (n ¼ 7), the military (n ¼ 8) and prison guards (n ¼ 4). Unique attributes of the violence perpetrated by national civil police, city police, soldiers and prisons guards are described in detail below.

National civil police (policıa nacional civil, PNC) The majority of incidents that resulted in violence by the national civil police began as unwarranted stops and searches. Twelve participants reported being searched without reason, most commonly in public spaces, like streets, markets and in parks, often while walking to or from work or while hanging out with friends. During these searches, police would ask participants for their government identification and to spread their legs with their hands above their head. When they asked why they were being searched, national civil police often cited recent crimes committed in the area and that they were looking for drugs or weapons. Participants reported that national civil police often stopped men for searches because of their perceived sexual orientation, including how they were dressed or if they were with a group of gay friends. Eduardo described a recent incident while hanging out with his gay friends: Well, we were sitting with my friends, at my business. Not doing anything. The police arrived and, well, they made us get up. They started to search us, and they even wanted to take us away in the police car. Without us doing anything. They only did it to mess around. They had us standing there for almost half an hour, with our hands on our heads. (Eduardo) These searches often escalated to include verbal and emotional violence by national civil police, calling participants ‘maricones’1 and accusing them of stealing or other crimes without any evidence. If participants resisted in any way or mentioned reporting the incident, the national civil police would often threaten to beat them with batons or arrest them. In two extreme cases, participants reported being physically attacked by the national civil police as Alfonso describes: One time we were all sitting around, and I don’t know how they knew that we were gay, maybe because we were all men, but the police stopped us, and they searched us to see CULTURE, HEALTH & SEXUALITY 7

if we had drugs or anything else. They didn’t find anything, but they wanted to take our money [ … ] he kicked us all on the leg, and I ended up with bruises on my leg. One of us got hurt pretty badly. He was on the curb, so when he got kicked, he fractured his leg, and the police officer almost broke it in two. (Alfonso)

City police (cuerpo de agentes metropolitanos, CAM) Exchanges with city police were similarly violent. Much like with the national civil police, many participants described being stopped and searched, being verbally and physically assaulted, being threatened with beating or arrest by city police. Gay, bisexual and other men who have sex with men were often forced to leave public spaces by the city police, who are responsible for patrolling public spaces such as parks, markets and transport terminals in the capital. Osmin described being told ‘we don’t want to see you again around this place’ and being called vulgar names by city police as he was walking through a public park. Another participant, Kelvin, was kicked out of a movie theatre frequented by gay men for allegedly smoking, although he had no cigarettes on him. They threatened me, practically at gunpoint to leave the theatre. This happened when I refused to show my ID because I didn’t have my ID on me at the time. I felt threatened by them. (Kelvin) Participants also described how city police robbed them of money and their cell phones. Some participants experienced this so frequently that they came to expect it. Erick described how every time he planned on going to a gay club in drag, he also planned on being robbed by city police: So anyways, we would be looking for taxis, and most of the time an agent would stop us and look through our purses and they would always rob our cell-phones or our money. It was very common. Common, common, common. I knew that every Sunday for me meant getting my phone stolen. So, people take advantage of the situation that they see you in. [ … ] They didn’t like us walking around with high heels, and a big wig. So yeah, honestly the authority of this system sometimes fails us. (Erick)

Military Participants in this study also described how soldiers performed unwarranted searches, verbally assaulted them using derogatory name-calling and threatened arrest or physical assault. Osmin described his first time attending a gay club that ended in a raid by the military: After an hour and a half, the military came in and carried out a raid. And they asked us for our IDs. They made a list and suddenly we were in a line for getting onto a military truck. They took us to the prison cells. For me it was aggression. I didn’t see any justification for it. That just for being in a gay nightclub I was going to be imprisoned. (Osmin) This experience had a lasting impact on Osmin, who lived in fear of security forces. In general, military interactions with gay, bisexual and other men who have sex with men ended in more physical violence. Five participants describe some sort of physical assault by soldiers. While Osmin’srun-inwiththemilitaryhappenedin1991,Eduardodescribed being physically assaulted by the military just one week prior to being interviewed for the study, indicating the ongoing nature of the violence perpetrated by soldiers: 8 D. A. DAVIS ET AL.

The last time was really harsh, what happened with them, because they put us all like this, in a line, the soldiers did. They opened, they really made us spread our legs as much as we could. One of my friends who is underage, they made him pick up stones … and they pushed him to the ground, and they threw the stones at him for half an hour. For the others [ … ] they only hit us a few times in the chest, then they started to search our phones, and they took one of my friends’ phone, they took it with them. (Eduardo)

Prison guards While only four participants spent time in prison, all four reported experiencing emotional violence, including name-calling, by prison guards, and three also reported physical and sexual assault. Sexual violence was reported more often in prisons than any other setting. Diego described being threatened with sexual assault by a prison guard while he was incarcerated for eight days: So, one of the guards that was in charge of the inmates threw me in one of the cells where there were other gay men. So, the guy who was in charge of us, wanted me to have sex with him [ … ] by force, but I didn’t want to. (Diego) Prison guards also verbally assaulted family members of gay, bisexual and other men who have sex with men who visited them in prison. Fernando describes his treatment compared to that of other inmates: I was arrested and convicted and was sent to prison for four years and the discrimination in there is even worse than it is with the police. I think they don’t get any training so that you could ask them for assistance, so that they understand that homosexuals are equal to other human beings, but they see it differently, they discriminate against you, they beat you when they search you, they hit you even more if you’re gay, right? They made some comments to my mother on various occasions like why is she visiting me knowing that I had probably been a bad son, especially because I was gay. Like I said before, guards always follow their own ideology, they can’t stand gay people and they always discriminate against them. (Fernando) While gay, bisexual and other men who have sex with men described experiencing emotional, physical, sexual and economic violence by all public security forces, notable patterns emerged. National civil police were more commonly involved in unwarranted searches, while city police often removed these men from public spaces. Participants identified soldiers as the most common perpetrators of physical violence and prison guards as the most common perpetrators of sexual violence compared to other public security forces.

Perceived motivations of perpetrators

Participants described that the most common perceived motivation of violence was non-normative gender expression. Several participants connected persistent machismo and homophobia in El Salvador to public security forces feeling the need to exert their authority and power over gay, bisexual and other men who have sex with men through violence. Many participants described how using what was perceived as ‘feminine’ clothing or accessories often drew unwanted attention from public security forces while out in public. In one example, while Ariel was returning home and CULTURE, HEALTH & SEXUALITY 9 walking through a public park, he was detained by the national civil police and searched. He describes the exchange with the police officer who was accusing him of stealing: ‘You people come here to steal’. So, then I went and told him, ‘look, how do you know that I’m one of “those people”?’ First, he told me ‘because of the way you dress’. Then he said, ‘I’m a policeman and we know these things pretty well’. (Ariel) In a similar case, Pablo was walking down a street in his neighbourhood and was stopped by national civil police because they noticed he was carrying a woman’s purse: So, then they searched the money purse, where I usually carry my coins and my dollar bills tightly rolled inside the coin purse, I was carrying a 10-dollar bill and some coins, and my documents were in the wallet, all of my ID documents. ‘What are you doing with 10 dollars and your coins?’, he asked, ‘Who did you steal this from? … no, this money you stole is from a woman, this is a lady’s coin purse’, he said to me. I told him, ‘no, I need my wallet, that’s where all of my documents are’. Then he searched me and they didn’t find anything. ‘Go on’, he said, he gave me my ID, then they gave me my wallet back, but they only left me with my keys and my wallet. ‘But that is mine’, the coin purse, I said. ‘No, this you’ve stolen’, and they were insisting that I had stolen it when that wasn’t true. (Pablo) While Pablo’s incident with the national civil police resulted in a loss of income, in some extreme cases interactions with public security forces led to severe physical and emotional assault. Mario described being approached by a group of soldiers while hanging out with friends and being targeted because of his tight clothing and long finger nails: I was sitting where I have my business [ … ] and all of a sudden, the soldiers arrived … they made many of us who were seated there get up, they got us to put our hands up and, they hit one of my feet [ … ] so that I would spread my legs. So, I told him that I couldn’t open my legs very wide because of my tight pants, because the pants didn’t let me spread my legs any further, so he came and told me [ … ] ‘and who are you, asslicker, to go around with long nails?’ He said, ‘chew off your nails’, he said, and he made me bite all of them off [ … ] I bit them off and he said that I had to swallow them. (Mario) After forcing him to chew off his nails, the soldiers beat Mario and his friends. Other participants described being targeted by police and soldiers for kissing a male friend on the cheek or walking a certain way. Eduardo discussed how any action that is perceived as going against what it means in typical Salvadoran culture to be a man becomes a target for the public security forces: ‘They start to yell at you, they embar- rass you, they tell you that you’re not a man, that you have to behave like a man, all of that’. Other perceived deviations from gender norms were believed to be the cause of violence experienced by gay, bisexual and other men who have sex with men in El Salvador. Many participants described how public security forces intensified their attacks once they found what was seen as ‘proof’ of their sexual orientation. Several men described experiencing violence while hanging out with a group of gay friends in the park, at a business or other venues known to serve gay men. Others, like Manuel, described how the national civil police became even more violent with him after searching his cell phone and discovering messages from his boyfriend: 10 D. A. DAVIS ET AL.

Well, one night when I was coming back from work and they stopped me just for a routine search, [ … ] one of them came up to me and asked for my cell phone, and the cell phone had a message in it from my ex-partner saying things like ‘how did your work go, my love?’ Then the policemen came, and he asked me if it was a woman or a man who I was messaging with. And so, I told him that I was a bisexual or gay person and then they started to make fun of me and started to say that I liked sex a certain way and things that are always offensive that they say to a gay person. They kept on mocking me and saying vulgar stuff. (Manuel) As Manuel described events, what may have started as a routine stop by police quickly escalated to verbal assault after police assumed he was gay. This example challenges the common narrative that public security forces are just preventing crime and doing their jobs while routinely searching all Salvadorans.

Impact of violence

Emotional distress Participants reported lasting emotional trauma from the violence they experienced at the hands of the public security forces. Men described feeling humiliated and afraid at the time of the violent incidents and later feelings of insecurity, depression and suicidal ideation for some. Osmin described the impact of being rounded up by the military during a raid conducted on a gay club: Well it was frustrating. Humiliating at the same time. I had never experienced anything like it. Much less being in the cells. I thought that I hadn’t done anything wrong for me to be arrested or that I hadn’t broken any law for me to be imprisoned. It was humiliating, frustrating [ … ] a lot of fear. Because I thought that at every moment that I had to tell people that I am gay. Or that those same people would know I was gay. I felt that the police and the military were already after me. It was horrible. For me it wasn’t negligence, but aggression. For me, it was premeditated. That’s to say it was abuse. It was not so much physical violence, but it was mental, emotional violence. (Osmin) Osmin feared that his run-in with the military would ultimately lead to being forced to disclose his sexual orientation to family and friends and his alienation by Salvadoran society. Nelson describes being similarly impacted after multiple violent interactions with the national civil police near his home. After they searched his phone and found ‘gay material’, they verbally assaulted him with vulgar name-calling and detained him at the police station. After he refused to pay a bribe to be released, they called his mother to disclose his sexual orientation and attempted to extort her. After finally being released, he continued to receive verbal insults from the national civil police and threats of being physically beaten on his daily walk home. Nelson described how this has impacted him: Well, [I feel] disappointed, feeling like I want to die, and well, taking my life. Sometimes, when I’m depressed, I don’t know, I start to feel bad, and well yes, I start to talk to myself …‘I would be better off dead’. (Nelson)

Distrust of authorities One of the most common themes that emerged during interviews was the feeling of helplessness due to the authority and power that public security forces have in El CULTURE, HEALTH & SEXUALITY 11

Salvador. Although participants knew that the violence they experienced by public security forces was morally wrong and illegal, they felt unable to report the incidents. Some chose not to press charges because they assumed that nothing would be done since the authorities to which they were required to submit the complaints were often the same perpetrators of the violence. As Cesar described it, ‘I was fuming, but what can one say to them if they are supposed to be the authority?’ Others feared that reporting the incident would lead to more violence, as most acts of violence occurred in the neighbourhoods where participants lived, and security forces knew the location of their homes. Manuel described how national civil police threatened him after he mentioned that he had memorised their police badge numbers and was going to report them for searching his phone and verbally assaulting him: Then they started to hassle me. Like, why was I going to do something like that? And that supposedly I was the one who would end up losing out, because in any case, if I pressed charges, well they already knew where I lived. Because it happened pretty near my house and almost every night they were always in the same place [ … ] it was a threat. So, I mean I didn’t make a big deal out of it, because if I were to press charges that could start to cause trouble for me and you know, you go face to face with certain people or act like that, and then it’s already a little bit more dangerous. (Manuel) Many participants reported similar feelings as Manuel – wanting to report the incidents of violence to higher authorities – but often deciding against it after thinking about the potential consequences of even more violent assaults by public security forces.

Discussion Our findings highlight the extreme distrust that gay, bisexual and other men who have sex with men have of public security forces because of the violence they perpet- rate and the ways in which gender norms motivate this violence. Respondents reported that public security forces often felt it necessary to exert their power and authority over participants, often to punish them for deviating from gender norms as they relate to both gender expression and sexual behaviour. These observations are supported by social dominance theory and other research that has posited that in societies with more militarised security forces, like El Salvador, public security forces more commonly act to protect what they perceive to be ‘their’ community, or those in conformance with the dominant social group (Crofts and Patterson 2016; Pratto, Sidanius and Levin 2006). These experiences of violence force some gay, bisexual and other men who have sex with men to live in a constant state of fear. The most widely reported impact of this violence on study participants was emotional distress, including feeling depressed, afraid, anxious and suicidal. This is consist- ent with existing literature that links violence victimisation and emotional wellbeing (Blashill, Perry and Safren 2011; Finneran and Stephenson 2013; Gonzalez-Guarda, Florom-Smith and Thomas 2011). To combat the negative impacts of stigma and structural violence that gay, bisexual and other men who have sex with men experience in El Salvador, our findings support an increase in mental health service provision for LGBTI victims of violence. Specialised, government-sponsored LGBTI-friendly HIV/STI prevention and treatment clinics, known locally as Vigilancia Centinela de las Infecciones de Transmision Sexual (Sexually Transmitted Infection Surveillance) or 12 D. A. DAVIS ET AL.

VICITS clinics, may provide an opportunity for increasing mental health services for the LGBTI community. Additionally, our team’s work throughout the region has found that other sexual and gender minority victims of violence reported telling friends and family members about these experiences, highlighting the opportunity for social support interventions (Lanham et al. 2018; Evens et al. forthcoming). For example, health navigation services, which use a social support model to improve HIV/STI testing and linkage to care at VICITS clinics throughout the region, may be an opportunity to provide additional emotional and informational support for victims of violence (Centers for Disease Control and Prevention 2018; Loya-Montiel et al. 2018). Given the extensive and severe nature of the violence perpetrated by law enforcement and its impacts on gay, bisexual and other men who have sex with men, we recommend that future programmes and interventions include the training of public security forces not only to sensitise them to the unique needs and vulnerabilities of the LGBTI community caused by their membership in less dominant social groups, but also on their legal rights (Pratto, Sidanius and Levin 2006). The Ministerio de Justicia y Seguridad Publica (which oversees the national civil police), in collaboration with the Salvadoran LGBTI Federation, has begun this difficult work by creating and launching a policy in April 2018 to improve the services its institutions provide to the LGBTI community in El Salvador (Ministerio de Justicia y Seguridad Publica 2018). As our findings suggest, the implementation of this new policy should focus on reducing unnecessary stop and searches of gay, bisexual and other men who have sex with men based on their gender expression. It should also work to explore and transform the harmful gender norms at the root of much of this violence, including educating law enforcement officers to recognise their position of power. A similar programme with police in India resulted in significant decreases in female sex workers reporting being arrested. There, a structural intervention with police involved advocacy work with senior police officials, sensitisation workshops and the integration of HIV and human rights topics in pre-service curricula (Bhattacharjee et al. 2016). While creating an LGBTI-inclusive policy is an important first step, successful operationalisation of the proposed activities will be vital in reducing violence experienced by gay, bisexual and other men who have sex with men. Previous policies developed by the Ministry of Public Health and Social Assistance and by presidential decree to reduce discrimination and violence experienced by LGBTI Salvadorans demonstrate that political will for this work exists; however, close oversight and enforcement of these policies is essential to reducing violence perpetrated by state actors. Our findings also suggest that all other institutions involved in providing public security should adopt similar policies and actions as those created by the Ministerio de Justicia y Seguridad Publica to sensitise their forces and cadets to the specific needs of gay, bisexual and other men who have sex with men and the Salvadoran laws that protect their rights. In other settings, community-based organisations have had success in working with police academies to provide pre-service training to cadets and continuing in-service training to veteran public security forces (Thomson et al. 2016; Scheibe et al. 2016). Beyond rights education, we recommend that training uses champions from each public security force and covers core knowledge topics such as gender versus sex, gender norm formation and the harms of rigid norms, CULTURE, HEALTH & SEXUALITY 13 sexual orientation and gender identity and core skill-building topics such as how to respond to and document incidents of violence reported by LGBTI community members using a trauma-informed, client-centred approach. Trained public security officers should also be involved in referral networks. Our findings support the creation of a system that trains and empowers gay, bisexual and other men who have sex with men and other LGBTI community members to file complaints against public security forces, including ensuring that complaints are investigated, and sanctions are given as appropriate.

Limitations

There were some limitations to our study methodology. The study used a purposive sample selected by organisations and peers providing services to gay, bisexual and other men who have sex with men. As such, the participants in this study may be more connected to LGBTI-specific social services and peer networks than other men and, as a result of these connections, may be more empowered or feel more support than those not connected with the LGBTI community. Conversely, men not connected to these services may feel more isolated and unable to report violence. Additionally, our findings are not readily generalisable because of the convenience sampling approach and limited number of participants.

Conclusion The gay, bisexual and other men who have sex with men in El Salvador who partici- pated in this study experienced pervasive, frequent violence by public security forces because they are perceived as violating gender norms regarding dress, behaviour and sexual orientation. The violence participants experienced caused emotional distress, physical injuries, an inability to seek justice and the avoidance of authorities. Future programmes and interventions should focus on providing mental health services for LGBTI victims of violence, educating all public security forces on the legal rights of LGBTI Salvadorans, the expansion of current LGBTI-inclusive policies to all public security force institutions and the creation and utilisation of a system to file complaints against public security forces, including ensuring that complaints are investigated and sanctions are given as appropriate. Such measures could improve HIV prevention efforts, as well as the health and quality of life of gay, bisexual and other men who have sex with men in El Salvador.

Note 1. A derogatory term for gay men, equivalent to ‘fag’ in US English.

Disclosure statement No potential conflict of interest was reported by the authors. 14 D. A. DAVIS ET AL.

Funding This publication is made possible by the support of US Agency for International Development (USAID) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) through the LINKAGES project, cooperative agreement number AID-OAA-A-14-00045, as well as through support from the United Nations Development Programme (UNDP). The contents of this publication are the sole responsibility of FHI 360 and do not necessarily reflect the views of USAID, PEPFAR, the US Government or UNDP.

ORCID Dirk A. Davis http://orcid.org/0000-0002-7056-427X Giuliana J. Morales http://orcid.org/0000-0001-7986-4810 Kathleen Ridgeway http://orcid.org/0000-0003-0839-2830 Michele Lanham http://orcid.org/0000-0003-3012-5683 Emily Evens http://orcid.org/0000-0002-7369-458X

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