MSM Participants.

MSM participants were men drawn from MSM community-based organizations (CBOs) in the aforementioned six regions of Senegal. They were recruited using a non-probability, purposive sampling technique known as network referral. A network of collaborative MSM organizations in Senegal was used to identify potential participants who were then asked to recruit additional participants through messages spread by word-of-mouth. Inclusion criteria for MSM in this study were: born male, 18 years of age or older, and reporting ever having had oral or anal sex with another man.

The sample size for in-depth interviews with MSM included 26 men. Their ages ranged from 18 to 45 years, with an average age of 28 years. Twenty of them had never been married, and eleven had no children. Most men reported having both male and female sexual partners. Their occupations included students, tailors, restaurant workers, street vendors, business men, peer educators, and clinic mediators who provide linkages to care and who help other MSM navigate treatment services. Five participants admitted to paid sex work. All except two participants identified as Muslim and many were actively involved in religious association in their communities. Most of the men belonged to an association of MSM in their region and were recruited through the leader of that organization. Members from seven of the nine MSM CBOs in the country known to the authors participated. While some participants identified themselves as leaders of their local organization, they also clearly identified themselves as MSM and spoke directly of their own experiences and observations.

Interviews were conducted with 3 MSM in each of the six sites, except Mbour where 4 MSM were interviewed. In addition, 7 of the 9 men who had been arrested and imprisoned for acts against nature in December 2008 were interviewed. Six focus group discussions (FGDs) with MSM were held, one in each of the six regions. Each discussion included 6–9 individuals, for a total of 46 focus group participants.

Interviews were conducted in French or Wolof based on the choice of the participant. Each interview lasted between 25 and 120 minutes with an average duration of 60 minutes. The interviews elicited detailed narratives of individual experiences and perceptions. Specifically, each man was asked about his family and social life, sexual identity and practices, and health-seeking behavior before and after the arrests in December 2008. He was also asked to describe how he saw MSM represented in the media and the political and legal environment for MSM in Senegal.

All FGDs were conducted in Wolof and facilitated by experienced Wolof-speaking research staff. Focus group discussions (FGDs) with MSM provided information about community norms and variability. Participants were asked to discuss the family, social, legal, and political environment for MSM as a whole in Senegal, rather their individual experiences. Groups also discussed the impact of the December 2008 arrests on their local MSM association and on the sexual and health-seeking behavior of MSM in their region. The duration of FGDs ranged from 60 to 120 minutes. The average discussion lasted approximately 90 minutes.

Key Informants.

The 14 key informants were drawn from health, legal, media, and academic institutions within the six regions described above. They were recruited by a Senegalese non-governmental organization (NGO) based in Dakar and included the following: 5 staff members from AIDS service organizations (ASOs) that provide services throughout the country; two attorneys who participated in the trial for the arrested men; one journalist from a popular national newspaper who authored articles on MSM during 2008 and early 2009; and one academic sociologist who specializes in research on homosexuality and who had spoken to the press on the issue of homosexuality in connection with the arrest. Each of these key informants was Senegalese and very engaged with issues of homosexuality, human rights, and public health during the arrests and the subsequent months.

Interviews were also conducted with one physician from each of the six regions, except St. Louis. That physician experienced an injury prior to the interview and was unable to participate. Physicians were purposively selected based on their clinical expertise in MSM health care needs, particularly HIV care and treatment.

Interviews with key informants were conducted in French and included questions about the political climate, challenges, and access to services for MSM. IDIs with journalists, academics, and attorneys focused on eliciting a deep understanding of the broad social systems and structural factors effecting MSM, while interviews with physicians and service providers sought to assess changes in both in the uptake of health care services and the ability to provide health care services for MSM since the arrests and subsequent conviction of the nine HIV prevention workers for acts against nature. None of the key informants openly identified as MSM.

Secrecy.

Secrecy emerged as a major theme in response to stigma and discrimination among MSM in Senegal. Findings from both MSM and key informant interviews confirmed generally hostile societal attitudes toward MSM in Senegalese society. Participants described episodes of experienced or observed discrimination ranging from being refused a ride by a taxi driver to being violently attacked. When asked what would happen if a man were openly homosexual in public, the typical response was that he would be attacked and probably killed. Some MSM reported marrying women for the purpose of hiding or suppressing their attraction to men. In the face of such intense stigma, silence and secrecy were the norm. As an MSM participant in Ziguinchor stated:

If my family knows my status as MSM, I think this will be the day I lose my parents, my family and my wife and I will not live long. The family will pray that I die because it is a shame.

The need for secrecy sometimes extended to people who provided services for MSM. Several service providers reported the need to hide the fact that they provided services for MSM, even prior to the December 2008 arrests, because they were concerned about being stigmatized by family and friends.

The attitude of study participants toward criminalization of same sex practices was quite diverse. Some participants disagreed with the law and felt that it led to violence and arbitrary arrest of MSM and prevented them from fully living their lives. In addition, men who worked as clinic mediators and HIV educators found that their effectiveness was limited by this law because it required that they keep their work hidden. One participant stated:

I am a health mediator. I am a father, an educator in the fight against HIV. I do not enjoy any protection from the law in relation to my safety in the exercise of my profession. To carry out our outreach, we are obliged to do so in secret.

However, others felt that the law itself was not the problem, rather the way that it was applied and enforced. According to some participants, Penal Code Article 319 requires that people be caught en flagrant délit (in the act of sex); however, men have been arrested based on reports that they were homosexual without actually being caught having sex. Thus, if the law was correctly enforced, it would only be used against MSM who had sex in public or who were unsuccessful in hiding their sexual activity with men.

Many were concerned that efforts to change this law would lead to heightened attention and increased hostility and violence against MSM. Most felt that Senegal was not ready for such a change due to strong social and religious prohibitions against homosexuality. A few men expressed an internalized hatred for their own sexual desires and feared that decriminalization would mean that men would behave like women or have sex in the streets. Some felt the law was appropriate for a Muslim country and simply required MSM to keep their sexuality secret. A participant from Kaolack demonstrated this sense of internalized homophobia and the need for secrecy:

The law is quite right because we are in a Muslim country. It is true that what is done is not good and therefore it is normal that the law condemns us… Senegal is an Islamic country, there are things you cannot do. And if you stay quiet at home, nothing can happen to you.

Most men expressed the desire to have their sexual privacy respected rather than a desire to decriminalize same sex practices. The right to privacy was of primary importance to them. An MSM participant stated:

I am not for legalization of homosexuality in a country that is 99% Muslim. What I advocate is respect for human rights. That MSM no longer be trapped or beaten in the streets or the victim of arbitrary arrest because of his sexual orientation… . To pass a law where gays have the freedom to do what they want as is the case in Europe is not my wish and that is unthinkable in Senegal… In my opinion, we just limit ourselves to advocate respect for human dignity where we are treated like human beings in our own right.

Negative publicity increased scrutiny and stigma.

According to participants, most people were unaware that MSM existed in Senegal until the February 2008 publication in a local magazine of pictures depicting a marriage between two men in Senegal [46]. This led to significant media attention and MSM found themselves under increased scrutiny by the popular press and the public in general [35]. Publicity surrounding the arrests in December 2008 continued to keep the spotlight on MSM. An MSM participant in Dakar stated: “Young people were afraid and are hiding because of the media who stir up the population against the MSM. If ever you're caught, you risk stoning or death.” One of the men who had been arrested in December 2008 reported homophobia so widespread that he felt more comfortable in prison than on the street:

The fact that you're an MSM and they are talking around your neighborhood. They are always talking on the radio, on TV about MSM and we must kill them. Even we who were in prison are more comfortable than those outside.

Participants reported that press coverage of MSM was universally negative. Pejorative terms such as goordjigen (literally meaning man-woman in Wolof) and “pédé” (derogatory term for homosexual that can be translated as “queer” or “fag”) were commonly used in the popular press to refer to MSM. They felt that inflammatory language was used to sell newspapers. Newspaper articles frequently quoted religious leaders who called for expulsion (at best) and murder (at worst) for MSM in Senegal. During the ten month period between the publication of the article on marriage and the arrest of the nine HIV prevention activists in Dakar, more than 40 articles about MSM appeared in popular press, including those covering stories about men who were violently attacked by members of their communities and about a man whose dead body was twice exhumed and deposited on his family's front steps due to accusations of homosexuality made after his death. Participants who were active in HIV prevention reported resentment about this negative, one-sided portrayal of MSM. One participant in Dakar put it this way:

Always the same language, they speak only on the negative side, never the positive. The MSM have played an important role in the fight against AIDS … but the media only talk about the negative side.

This increased scrutiny and stigma even impacted the men who had been imprisoned. These men reported being singled out from other prisoners for mistreatment. They described being stripped naked, beaten, called insulting names, and prevented from showering because they were homosexual. As described by one former inmate:

We have been tortured. I even think the word [torture] is too weak. I had done everything to hide my sexual orientation, and when I was arrested, the officer took the phone and called “Hello, the goordjigen are here.” Every day we had 10 blows with the baton in the morning and 10 blows in the evening. Other officers who were even from outside the police unit came to beat us. They insulted our mothers, fathers, and they treated us like goordjigen, pédes, etc. We were not entitled to the shower because we were homosexual.

In addition to the physical and psychological mistreatment these men suffered while incarcerated, many described considerable social and mental health consequences of the arrest and subsequent disclosure of their sexual orientation to the public. They discussed being traumatized and considering suicide in the wake of this experience. Most of these men lost relationships with family and friends as well as their jobs and homes. When one man was asked how he handled the events during the arrest and after his release, he said:

My release from prison has been very hard. I preferred even to kill myself. I was humiliated and insulted. In my neighborhood, my older sister was fighting because of the nasty things that were said against me. It was hard. After prison, it is fear I feel. I often think about death, but I never commit suicide… I think often of the day of my death.

Increased fear and hiding.

Participants reported an escalation of widespread fear and hiding among MSM as a result of the December 2008 events. They reported such fear of discrimination, violence, and arbitrary arrest that some MSM left their cities or even the country, which significantly affected sustainability of MSM CBOs. An MSM participant in Mbour noted:

The consequences are many and varied, many men were afraid and this had an impact on operations [of the MSM CBO]. The president of our association has long been abroad, with the assistance of his partner, for fear of being denounced. Most young people wanted to leave the country. It was a very difficult time.

After their release in April 2009, the men who had been incarcerated in December 2008 no longer felt safe providing prevention services and HIV treatment adherence support, thereby reducing access to services upon which their communities once relied. An MSM association leader in Dakar stated, “For security reasons, we were obliged to stop our activities.”

After the arrests, many men no longer felt safe attending meetings where they had previously received HIV education, condoms, and lubricant. They felt that people would recognize them as MSM and they would be subject to violence and detention. In addition to the loss of access to HIV prevention education and materials, this disruption in meetings affected the fledgling social networks among MSM communities. As one association member stated,

MSM dare not receive or go to the talks or to seek condoms. They continue to have unprotected sex and that can bring other problems. Our association fell apart and half of our members are scattered in other regions.

This fear and subsequent hiding also impacted MSM living with HIV being treated with antiretroviral therapy. A service provider in Dakar noted, “This fear has had an impact at all levels. Some no longer even want to take their medicines or meet together for fear of being arrested.” An MSM participant in Ziguinchor noted, “The major impact of these arrests is fear. MSM are so afraid they do not want to leave their homes. They refuse to come to work and even go for treatment.”

Decreased Provision of HIV Prevention Services.

The nine men who were arrested in December 2008 were detained based on the presence of materials they used to provide safer sex education to their peers. One participant described what happened the night of the arrests and his efforts to explain their HIV prevention work to the police:

When the police raided, they asked questions, searched the apartment. Although we justified the presence of certain tools such as counseling cards, condoms, dildos and all other activities we would do such as education and working with the Division of AID, this did not convince the police.

Other MSM noted that prior to the events of December 2008, significant progress had been made in HIV prevention activities by MSM CBOs. Several participants noted that they were unaware of the need to practice safer sex with male partners until they attended sessions sponsored by community-based organizations. After learning about the risk of HIV and STI transmission at these workshops, they reported consistently using condoms with both male and female partners. Participants reported having access to condoms through the MSM CBOs and health care facilities. However, cost was cited as a barrier to use of condoms if they were not available from service providers.

While most of the men reported little difficulty getting condoms, many of them reported difficulty finding water-based lubricant. Even prior to the arrests in December, they often did not have money to buy appropriate water-based lubricants and resorted to the use of petroleum-based beauty products such as shea butter, scalp moisturizers, and body lotion for lubrication during anal intercourse. As a consequence, many men reported that condom breakage was a frequent occurrence. When MSM leaders went into hiding after the arrests in December 2008, MSM had increased difficulty accessing condoms and appropriate lubricants because they were unable to locate the people who had previously provided them.

Even organizations with a decade of experience providing HIV prevention services for MSM in Senegal lost enormous ground during the crisis surrounding the arrests. A service provider in Dakar stated:

We had momentum then. We had established an MSM organization in each regional capital … . But when there were problems, the arrest of the MSM … the networks dissolved. People did no more activities, they did no more activities. They returned 10 years in reverse.

The NGOs that had provided prevention services for these men actually suspended their HIV prevention work with MSM out of fear for their own safety. A service provider described her fear this way: “I've seen programs on TV where religious leaders have called and threatened and I feared at one time to find [our facility] burned.” Another organization reported not only suspending all MSM activities, but also taking down the sign for their organization in order to make it harder for the media to find them.

Decreased Uptake of HIV Prevention Services.

Where prevention services were still available, many MSM were afraid to use them. An MSM participant in Dakar noted,

The consequences are numerous and the MSM have returned underground. This does not mean they have stopped having sex. However, they do not care because they are afraid to pick up condoms.

Service providers consistently reported increased difficulties in finding MSM, even when attempts were made to locate them. One service provider stated,

Evidently, we've lost sight of many MSM despite our active attempts to find them; some have left town to go to the regions and among them were those who are sero-positive.

Several of the service providers discussed the significant work that will be required to rebuild what has been lost in the wake of the crisis. Unlike their work 10 years ago when there was nothing, now they must overcome a new level of fear and loss of trust in organizations that were unable to prevent the crisis. One HIV prevention educator in Dakar put it this way:

We have been involved in the fight against AIDS particularly on behalf of vulnerable groups. We organized sessions of talks, training on AIDS. We had gained positive results and had a grip on this target population up to the day when the events turned everything upside down. Many of the most committed players withdrew from the fight. A significant number of MSM have returned underground… Bisexuality exists among MSM. Even if taboo religiously and culturally, in terms of public health, it can have serious consequences for the spread of the epidemic. Now the MSM are convinced they are not protected despite their commitment.

Decreased Uptake of HIV Care and Treatment Services.

Prior to the events of December 2008, a national NGO had worked, in collaboration with the Senegalese Ministry of Health, with at least one medical provider in most regions to institute programs that facilitate care for MSM. These physicians had established trusting relationships with MSM in their communities and several MSM worked as clinic mediators to help educate their community about services available and to help them navigate the process of getting care from an MSM-supportive facility or provider. Some physicians waived consultation fees for MSM; and in some settings, HIV care and medications were free. These physicians had developed trusting relationships where MSM reported feeling comfortable disclosing their sexual orientation. Health care providers described the importance of knowing if the patient was MSM in order to provide appropriate care, treatment, and prevention counseling and services.

All of the physicians interviewed (representing 5 of the 6 regions studied: Thiès, Mbour, Kaolack, Ziguinchor, and Dakar) noticed a sharp decline in medical visits by MSM beginning in January 2009, after the arrests in December 2008, One doctor noted that many of his patients had left the country and discontinued their medical treatment. Several clinic mediators commented that men were afraid to seek HIV care for fear of violence. An MSM participant in Kaolack stated,

If the hospital people know that you are MSM, you cannot go there for fear of being assaulted. I have a friend who was sick and was afraid to seek treatment from Dr [name withheld] after the events… he was afraid of being assaulted.

A physician in Thiès anticipated the impact these events would have on his MSM patients with HIV. Several MSM participants who lived in the region reported that this physician called his patients and encouraged them continue their treatment and not to disrupt their care. Despite this active effort to retain HIV-infected MSM in care, some men were still too afraid to return to the hospital. In contrast to the fear expressed by MSM, all of the physicians interviewed denied any concerns for their own safety when providing services for MSM. All spoke of their continued commitment to serving the entire community, including MSM.