Having sex with a man doesnt make me gay

Needs assessment among men from ethnic-cultural minorities who have sex (also) with men


Having sex with a man doesnt make me gay Needs assessment among men from ethnic-cultural minorities who have sex (also) with men

Sunita Steenbakker Mariek Hilhorst Bouko Bakker In collaboration with: Toni La Tegola (African Gay Youth Foundation, The Hague) Rev. Msizi Dube (Jongeren op Doortocht / Youth on the March, Amsterdam) Iris Shiripinda (STI AIDS Netherlands) Juan Walter (GGD / Amsterdam Municipal Health Authority) Translated from Dutch by Tom Johnston

The title quote is from the interview with Milan, aged 5, who was born in Morocco (see also page 4)

Schorer is the Netherlands national institute for homosexuality, health and well-being. Schorer sees to it that lesbians, gay men, bisexuals and transgenders have access to the information, expertise and facilities they need to bring about an optimal state of health and well-being.

Schorer Postbus 5830 00 NH Amsterdam www.schorer.nl info@schorer.nl 009 Schorer January 009

Content
Acknowledgements Summary Introduction From gay men to MSM Ethnic minorities, people with a non-Dutch background and immigrants/migrants Size of the target group Assessment Research problem Self-identification and coming out Structure of this report Chapter 1 Method and Theoretical Framework The RDS method Informants and respondents The interviews A theoretical exploration Relationships and sexual behaviour Views on (homo)sexuality in the Christian and Islamic cultures Antillean and Surinamese views on (homo)sexuality African religious and cultural views on (homo) sexuality Sexual and cultural identity Results Demographic background Sexual identity Sexual feelings Acceptance and self-acceptance Discrimination and acceptance Information and information-seeking behaviour Sexual behaviour and safe sex Forced sex and paid sex HIV status, HIV testing and testing advice Conclusions and Recommendations Conclusions Needs Difficulties Points for discussion Recommendations Literature and sources 4 5 7 7 7 7 7 7 8 8 9 9 9 9 9 9 0 0   13 3 4 5 5 6 6 7 8 9 20 0 0 0   24 26

Chapter 2

Appendix 1

Questionnaire

Acknowledgements

This needs assessment has been possible thanks to the cooperation of a large number of people whom we would like to acknowledge here. We are grateful to Toni La Tegola of the African Gay Youth Foundation for providing us with information about a specific group MSM of African origin; to Juan Walter (GGD / Amsterdam Municipal Health Authority) and Iris Shiripinda (STI AIDS Netherlands) for their input on the project plan and the interim reports; to Stichting Outway and Embrace Pink for doing the publicity and recruiting the respondents; and to Suzanne Meijer for providing general advice about the setup of an assessment. Our thanks are also due to Irv Sandstra, a Schorer volunteer who helped us in conducting the interviews and provided feedback on the report at various stages. We are grateful to Rev. Msizi Dube (Jongeren op Doortocht / Youth on the March) for the many interesting discussions we had with him about sexuality, masculinity and identity. We thank Mikel Haman (Dutch Suriname AIDS Foundation) for his enthusiasm and for the fieldwork he did among young gays in Amsterdam, and we thank Humanitas for placing an item about this assessment in their newsletter. We are appreciative of Astrid Roggen of Schorer for commenting on this report at various stages and Andrea Vogelsnger and Karen Kraan, likewise of Schorer, for their recommendations about future activities and a follow-up for the assessment. Last but not least, we would like to thank all the young men and boys who took part in the assessment. Without the information they provided, we would never have been able to carry out this assessment. Their cooperation gave us the opportunity to gain insights and knowledge about a world that has until now remained largely invisible. We hope this knowledge of their needs will lead to a broader range of possibilities for each and every MSM in terms of making individual choices that will increase their own sexual health and that of others. Sunita Steenbakker Mariek Hilhorst Bouko Bakker

Acknowledgements

Summary
The most important reason for carrying out this assessment was the need of mainstream organisations such as Schorer to gain more knowledge and insight into the experiential world of those young men who have sex with men (MSM) who belong to one of several different ethnic-cultural minorities in the Netherlands. The objective of the assessment was to gain a better understanding of the perceptions, experiences and needs of these young MSM with regard to HIV and STI prevention and sexual health. That can lead to the development of a more suitable array of prevention interventions for that group. A total of 58 young men and boys took part in this needs assessment. All of them were MSM, all were members of one or another ethnic-cultural minority living in the Netherlands and all were between 5 and 30 years of age. The data for this needs assessment come from two sources. Schorer and various informants approached 38 men and boys who matched those criteria, and 36 of them were ultimately interviewed. At the same time, the African Gay Youth Foundation (AGYF) was conducting a comparable assessment involving a total of  respondents, all of African origin. The aim of both assessments was to take stock of the needs, views and experiences of young, non-Dutch MSM in the areas of prevention, health and sexuality. On account of their similar objectives and the shared intention of both Schorer and the AGYF to jointly develop new interventions, we combined the information obtained through both assessments wherever possible. Both assessments took place in the period from September 007 through May 008. Recruitment of MSM The MSM who took part in the needs assessment were approached via informants and via fieldwork. Boys and young men were also approached within the Safe Haven project and at various bars and clubs in Amsterdam, The Hague and Rotterdam. In addition, notices were posted on Internet sites for young gays-lesbians-bisexuals and various newsletters carried items calling attention to the assessment. Results In terms of identity and behaviour, the most important needs are for: information campaigns dealing with sexual diversity to be carried out within the community in order to promote the acceptance of sexual diversity information campaigns about sexual health and diversity to be carried out in regular elementary and secondary education people from within a particular community to serve as examples and to assume a groundbreaking role in broaching the subject of (diversity in) sexuality women to become involved in attempting to get heterosexual men to accept homosexuality and bisexuality safe environments where younger MSM can meet each other, whether or not they share the same cultural background. In terms of HIV and STI prevention, the most important needs are for: information about HIV and STI to be made available in a persons first or second language, including about how those 5 are transmitted, the symptoms, testing sites and medication an explanatory introduction to the Dutch healthcare system information to be presented in an informal way: personal contact is important in transferring knowledge ways of safeguarding a persons anonymity, for example by deploying health educators who have a different ethnic-cultural background than those who are receiving the information neutral locations that are not generally associated with HIV, STI and sexuality, for example the Internet or someones home information to be presented outside the Schorer contexts of websites and magazines for gay men, since most of the respondents have little or no contact with those sources. Recommendations In this report we give the first step towards developing a prevention method for the target group of MSM from ethnic-cultural minorities. The most important recommendations with regard to better reaching that target group and working together with them more effectively are to: Look for new channels for reaching the target group The general prevention interventions appeal primarily to white, well-educated gay men. Men from ethnic-cultural minorities often do not make use of those sources of information, in part because they do not identify themselves as gay or homosexual. To reach those MSM, information about sexuality and health will therefore need to be communicated and disseminated in other ways. Distinguish between cultural contexts HIV and STI prevention programmes should take into account culturally determined differences in terms of views relating to sexual identity within the target group of MSM from ethnic-cultural minorities. Increase peoples knowledge and skill sets with regard to sexual health The target group has a need for more knowledge about HIV, STI and safe sex, better skills for dealing with sexual health on the individual and group levels, encouragement for choosing responsible behaviour especially in terms of being able to communicate ones desires and boundaries and an explanation of the Dutch healthcare system. Support immigrant self-help organisations in terms of indirect prevention Knowledge and skills relating to sexual health can be developed effectively if immigrant self-help organisations themselves have the knowledge, facilities and motivation they need to set up concrete and structured interventions for the target group of MSM from ethnic-cultural minorities. A strategy of indirect prevention, in which Schorer supports those other organisations and activities, is much more effective than direct interventions since members of the target group are very apt to distance themselves from organisations whose target groups are known to be gay or bisexual.

Summary

Introduction
Schorer began with the long-term project Interventions Aimed at Young MSM from Ethnic-cultural Minorities Aged 5 to 30 Years Old in 007. As an initial step, a plan was set up in collaboration with GGD / Amsterdam Municipal Health Authority and STI AIDS Netherlands to arrive at the present needs assessment and to make recommendations for possible interventions. This introduction deals with the following topics: Using MSM rather than gay men as a way of describing the target group; the terms ethnic-cultural minorities, people with a nonDutch background and immigrants / migrants; the size of the target group; the assessment; the research problem; and self-identification and coming out. Finally, the structure of this report is described briefly below. From gay men to MSM In this report we use the terms men who have sex with men (MSM) and boys who have sex with boys rather than gay men and gay boys. There are various arguments in support of this. First of all, there is a distinction between identity and behaviour in various different communities within the Netherlands, both Dutch and non-Dutch. In those communities, having sex with men is not considered the equivalent of being homosexual. Homosexuality is often not a recognisable framework for people and/or it is a concept that one does not identify with. More and more over the past few years, HIV and STI prevention has been using the term men who have sex with men with its focus on behaviour and developing interventions aimed at behaviour. It is assumed that this will increase the effectiveness of prevention, since no explicit references are made to any personal identity. Ethnic-cultural minorities, people with a non-Dutch background and immigrants / migrants The participants in this assessment included men from a variety of different immigrant groups in the Netherlands. In recent years, a variety of terms referring to those groups have been introduced in the media and elsewhere, including people with a non-Dutch background, ethnic minorities, migrants and nonnatives. Statistics Netherlands (CBS) defines ethnic minorities and immigrants as people who were born abroad or who have at least one parent who was born outside the Netherlands. There are both Western and non-Western immigrants. Western immigrants come from other European countries (excluding Turkey) and various other countries including Canada, Indonesia (or the former Dutch East Indies) and Japan, along with other islands in Oceania. Non-Western immigrants come from countries in Africa, Asia (except for countries like Indonesia or the former Dutch East Indies and Japan), Asia Minor (e.g. Turkey), Latin America and the Caribbean. Immigrants can also include asylum seekers, refugees and illegal aliens. The participants in this assessment were of both Western and non-Western origin; they grew up in a variety of countries and cultures (see Table 7). The difference between ethnic minorities and immigrants on the one hand and migrants on the other is that the latter in fact refer to people who migrate. That term is primarily used for people who move from country to country. Generally speaking, people are considered immigrants if they remain in the new country longer than a year. All but two of the respondents in this assessment were first-generation immigrants. Size of the target group It is not clear how many MSM from immigrant groups between the ages of 5 and 30 there are in the Netherlands. The existing figures often only refer to the entire group of MSM, and statistics about ethnic minorities almost never include any differentiation in terms of homosexual or heterosexual behaviour. On  January 008, there were 05,753 immigrant boys or young men between the ages of 5 and 30 in the Netherlands (CBS). Any estimate of the number of men who have sex (also) with men is necessarily only a very rough one and is dependent on a number of assumptions. The report Trends in seksualiteit in Nederland [Trends in Sexuality in the Netherlands] (RNG, 008) indicated that 3% of all men have had sex with another man at least once in their lives, while 7% of all men call themselves gay or bisexual. For conveniences sake, we assume that 0% of all men have sex with other boys/men on occasion. What do we know about sex between immigrant men? The Amsterdamse Gezondheidsmonitor [Amsterdam Health Monitor] (004) published by the GGD / Amsterdam Municipal Health Authority reports that sex with someone of the same sex is not uncommon among Moroccan men: 5% of them indicated having had sex with a man in the past year. That also held for between % and 3% of Turkish men. Underreporting always remains a possibility. We would therefore estimate the number of men from ethnic-cultural minorities in the Netherlands who have sex (also) with men to be roughly between 5% and 0%, which translates to between 0,000 and 0,000 people. Assessment We opted for a needs assessment for the following two reasons. First, young MSM from ethnic-cultural minorities in the Netherlands are practically invisible for mainstream organisations: by means of a needs assessment we can manage to reach these MSM in a relatively short time and with scientific accountability. Secondly: as a method of collecting data, an assessment is both acceptable for the target group and effective for prevention staff. Research problem There is growing attention within society for issues revolving around sexuality and ethnicity. Homosexuality, in particular, is a hot item even while sex between men is not always easy to discuss and often surrounded by taboos, secrecy and misconceptions. Religious and cultural views about relationships and sex make it difficult for people to talk about their behaviour

Introduction

and feelings. From a health perspective, there is also the question of how to reach those young men and boys that the mainstream organisations have trouble reaching, but who like everyone else run a risk of contracting STI and HIV. MSM from ethnic-cultural minorities are an important target group for HIV prevention in the Netherlands, considering the relatively high prevalence of HIV in this risk group. One of the most important reasons for doing this assessment was the lack of knowledge within and among mainstream organisations in terms of the perceptions, experiences and needs of young MSM from ethnic-cultural minorities in the areas of prevention, sexual health and care. Insight into those areas is of importance for prevention in order to reduce the risk of transmitting HIV and STI and to increase the target groups knowledge about sexual health. There is also only limited knowledge about the target groups experiences with relationships and sex. The assessment of the risk they run of contracting HIV, STI and Hepatitis is not certain. Moreover, studies such as Sex onder je 25e [Sex Below the Age of 5] (Meijer, S. et al., 005) have made it clear that boys from ethnic-cultural minorities generally know less about sexuality and health than girls from ethnic-cultural minorities. That is even truer for those boys from ethnic minorities who have sex with other boys. In that connection it would be interesting to know how MSM get their information about sexuality and health and what their opinions and experiences are in the area of prevention. With this assessment we are attempting to raise the level of knowledge about and insights into those topics. The Internet is often used as a resource for finding sex partners. Using the Internet makes life more dynamic for many young MSM, but it also exposes them to new risks. The focus on young MSM from ethnic-cultural minorities offers the possibility of providing them at a reasonably early stage with the knowledge and skills they will need to make choices about sexual health. Self-identification and coming out MSM from ethnic-cultural minorities in the Netherlands do not constitute a coherent, separate group. As the report Dubbel en dwars [Double and Defiant] (Pierik, C. et al., 008) shows, there are many differences among them in terms of ethnic and cultural background, the degree of integration within Dutch society, the degree of openness about ones sexual identity and the degree to which ones sexual preference is put into practice (Pierik et al., 008). What does exist is a range of diversities in behaviour and identity: self-identified homosexuals, self-identified heterosexuals who have sexual contacts with men and self-identified bisexual men and boys. In looking for boys to take part in this assessment, the choice of words and their interpretation turned out to be very important. As interpreted in its Western European context,

the words gay or homosexual were by no means always appealing. The same holds for the concept of coming out (of the closet). The latter refers to the moment at which a gay man, lesbian or bisexual person chooses to be open about his or her sexuality and implies that there is a single moment of emergence from the proverbial closet, while in fact that is much more apt to involve a longer process. The contrast between being in and out of the closet suggests all or nothing, while in reality it is much more complicated. The act of coming out is the result of a personal decision and takes place at ones own initiative. The decision whether or not to come out of the closet depends strongly on ones environment and on the possible consequences of making such a revelation. The many different identities that MSM from ethnic-cultural minorities take on show that they by no means always find it prudent to come out of the closet. A number of those young men and boys actually prefer to lead a double life in order to avoid the risk of being treated as an outsider. In that sense one can speak of double discrimination: discrimination in Dutch society due to the boys (sub) cultural background and discrimination within his own community due to his sexual preference. Structure of this report The first part of this report provides a description of the method used, a survey of recent literature on sexual and cultural identity, and an overview of how the Islamic, Christian, Antillean/Surinamese and African cultures, respectively, view homosexuality. The second part contains a discussion of the results of the assessment along with conclusions and recommendations. The latter section will also elaborate on the needs, difficulties and points for further discussion.

Introduction

Method and Theoretical Framework

This section begins with a consideration of the method used: the RDS method, the informants and the interviews. Then there is a theoretical exploration of the current ideas about relationships and sexual behaviour and about (homo) sexuality in the Christian, Islamic, Surinamese and Antillean cultures. Finally, we consider a number of African religious and cultural ideas about (homo) sexuality and sexual and cultural identity. The RDS method Besides a study of the relevant literature we also applied the Respondent Driven Sampling (RDS) method, which consists of holding interviews with individuals and groups. The RDS method puts participants from the study group known as seeds or informants to work within their own social network to recruit other participants. This method reduces the dependency on sampling sites/hangouts, since the informants are already familiar with the network concerned. The RDS method was developed by Douglas Heckathorn (997) and is especially suited for hard-to-reach groups and individuals. It is used for groups that are relatively small compared to the general population and for which no exhaustive list of members exists. This method is described in the literature as the gold standard for research on hard-to-reach groups. Informants and respondents The informants in this assessment came from North and Central Africa, Eastern Europe and Suriname. They fulfilled various roles: as interviewers, as facilitators of Focus Group Discussions (FGDs) or as fieldworkers. It was a deliberate choice to use a wide variety of informants for this assessment as a way of making the results representative. Young MSM were approached by informants or key figures from different communities, immigrant self-help organisations, religious and spiritual groups. In addition, presentations were held during activities in which MSM took part or at which professionals who work with MSM were present. Recruitment was also facilitated by means of notices placed in Schorermagazine, the E-Male Nieuwsbrief and the Humanitas Nieuwsbrief. A total of 58 MSM took part in the assessment. One set of data concerning  young MSM, all of African origin, derives from the FGDs held within the African Gay Youth Foundation. A second set of data stems from interviews that Schorer held with 36 young MSM individually. Schorer had approached a larger number of boys, but some of those ultimately decided against participating in the assessment. The latter boys preferred not to discuss the subject, did not wish to be associated with homosexual sex or were afraid they might be recognized. In this assessment, the data from the MSM from the African Gay Youth Foundation group are compared with that from the Schorer group consisting of MSM of varying origins. This allows the differences and similarities to be more readily identified, and that may reveal interesting consequences for possible prevention interventions. The names of the MSM quoted in this report are fictitious.

The interviews An interview was held with each informant. During those interviews, attention was given to Schorers role in HIV and STI prevention, to why an assessment was being conducted and to what an assessment was. The questionnaire was also discussed, as were the topics for the FGDs. The fieldwork was done mainly in Amsterdams nightlife scene. Two of the informants also took part in the assessment as respondents. Due to the sensitive nature of the topic, the individual and group interviews with MSM were not taperecorded. The questionnaire (in Dutch, English and French) was based on the Schorer Monitor questionnaire. A small number of MSM informants (often with an African background) also provided additional information in writing and by telephone after they had been interviewed. A couple of respondents from each of the participating immigrant groups were interviewed more than once; in total, 9 follow-up interviews were held. Extra information was necessary on a number of topics, such as the fact that many young men call themselves heterosexual even though they have sexual contacts with men. It turned out that ones self-identification as heterosexual or homosexual depends on ones reason for having sex with men (including: want to have sex but there are no women around or sex with men is less complicated). A theoretical exploration There is very little scientific data on young MSM from ethniccultural minorities. In this section we first provide an overview of what is known about them until now. Then we give a brief survey of the literature on the themes of identity, masculinity and sexuality. Next we consider how sexuality is viewed in the African, Antillean and Surinamese, Christian and Islamic cultures, respectively. We also look at the differences between personal, cultural and sexual identity according to queer theory. We have opted for the theories of professionals from various professional groups to create a broad framework of perceptions, assumptions and concepts. Relationships and sexual behaviour Earlier studies of young MSM both those with a Dutch background and those with a non-Dutch background have shown that the vast majority never use a condom for oral sex (fellatio): that holds for 90% of them, compared with 78% of young heterosexual males (Richel and De Wit, 007; S. Meijer et al., 005). Also, young MSM in relationships relatively often use condoms for anal sex only at the beginning of a relationship. One-third of the young MSM reported always having used a condom in their most recent relationship, one-third did that occasionally or only in the beginning, and one-third never did that. For consistent condom use, ones attitude towards condoms and the frequency of sex turned out to be important factors. When condom use with ones steady male partner was felt to be important, there was a greater chance of consistent condom use. The chance that one always used condoms for

Method and Theoretical Framework

anal sex with a steady partner declined the more often one had sex with that partner (Hospers et al., 008). Young MSM were less apt to be in a relationship than their heterosexual counterparts, and their most recent relationship also lasted less long. Young MSM have had more experience with forced sex than young heterosexual males (Franssens et al., 007). Young homosexual and bisexual males are more often forced to have sex at some point in their lives than their heterosexual counterparts, also before they reach the age of twelve years. Sexual orientation has a high correlation with coercion, and compared with their heterosexual counterparts, young MSM are also more apt to have had experience with paid sex. The level of knowledge about safe sex, HIV and STI among Moroccan, Turkish and Surinamese youths reveals major differences among those groups. A study done by MCA Communicatie (Blom and MCA, 003) showed that three-quarters of the Surinamese youth knew what the term STI meant, and a small percentage was also able to name a number of specific STI. Only a quarter of the Turkish youth knew what STI stood for, while that was true for nearly a third of the Moroccans; just as many of the Moroccans also managed to mention specific STI (Van der Poel and Hekkink, 005). The level of knowledge of the Surinamese youths corresponded most closely with that of the Dutch youths. In short, Moroccan and Turkish youths knew relatively little about STI. Under the term safe sex the phrase use condoms got the highest score for all three groups. Research done among Antillean and Aruban youths (Kalwij, 000) has shown that their views about the transmission of STI do not always correspond to reality. There were also indications of a low risk assessment. Communication is a factor that has a major impact on the level of knowledge. Language and communication problems can be a disruptive factor in prevention activities and information campaigns. Attitudes regarding condom use vary. Turkish men and Moroccans tend to be more negative about using condoms than Surinamers, mentioning the following reasons for not using them: Its an annoying interruption, I didnt have any at hand, Im embarrassed to buy them (Von Bergh and Sandfort, 000). We can conclude that young MSM run a disproportional risk of contracting STI and HIV because many reported having had unprotected sex (Richel and De Wit, 007; Meijer, 007; Hospers et al., 008). To summarise: young MSM run more of a risk of contracting HIV and STI through unsafe sex, have a negative attitude towards condom use, have opinions that run counter to reality and have cultural and religious views that actually heighten the risk they run. Finally: forced sex and sex for money are more common among young MSM than they are among young heterosexual males.

Views on (homo) sexuality in the Christian and Islamic cultures Many cultures and religions have rules prescribing how people should interact and what is acceptable and what is unacceptable. Over the ages, those rules have been written down and rewritten and are open to interpretation. Differences of opinion can arise even within one and the same cultural or religious group. Among the various religions there are diverse ideas about homosexuality. Much has been written in recent years about what the Bible and the Koran have to say about homosexuality (El Kaka and Kursun, 00; Doppert and Hermans, 006; Nahas, 00). The analysis as far as the passages about Sodom and Gomorrah are concerned is that the word sodomy originally referred to all different kinds of sexual abuse that concerned the inhabitants of Sodom: sexual abuse between men and women, between men among each other and between adults and children. Over the centuries, the meaning of that word changed and came to be applied to homosexuality in general, even in the total absence of abuse, also when it concerns sexual relationships based on love and equality between two men. The Bible and the Koran have very little to say about loving sexual relationships on an equal basis between men or between women. Depending on the type of Christian church and its particular interpretation, homosexuality is looked upon in a more or less negative light. Some Christian denominations ostracise homosexual men and women. Other churches are accepting of gays and lesbians as long as they remain celibate. And there are also churches that find that faithful and loving relationships between two men or two women do not go against their faith and that are also willing to bless those relationships. Within the Islamic community, homosexuality is a much more delicate topic in many cases. Islamic scholars never openly accept homosexuality and most of them shut out any dialogue with homosexual men and women. Muslims who have homosexual feelings are therefore apt to feel forced to distance themselves from their faith or from the ideas of religious leaders. They attempt to sort out their feelings by focusing on their personal relationship with God, reasoning that Allah made me this way, so what I feel cant be wrong. Antillean and Surinamese views on (homo)sexuality Within the Antillean and Surinamese (sub)cultures, machismo plays an important role alongside the religious element, and homosexuality is taboo. There, just as in the Islamic culture, people tend to think that only the passive partners (i.e. those who are penetrated) are homosexual. More than in the Arabic cultures, however, a link is made between homosexuality and femininity. By being open about his homosexuality, a boy will often be identified as feminine and seen as inferior. Gloria Wekker, a professor of gender and ethnicity and being of Surinamese descent herself, therefore suggests that it is

0

Method and Theoretical Framework

high time to start talking about sexuality within the Surinamese and Antillean cultures. Remaining silent about it will lead to high risks of ignorance, STI and unwanted pregnancies. Wekker sees a paradox between on the one hand the existing image of people from the Caribbean as being super talented sexually and extremely gifted in bed a racist legacy from the colonial past and their sense of shame and lack of knowledge on the other hand (Wekker, 006). African religious and cultural views on (homo)sexuality Since a large group of the MSM in this assessment came directly from Africa, we will also consider the African views on heterosexuality and homosexuality here. In many African countries, homosexuality is forbidden and homosexuals are discriminated against. Homosexuality is often seen as a Western concept. Sexuality in general is a theme that people find difficult to talk about and is usually thought to refer only to the sexual act. Governmental policy and everyday reality often diverge dramatically from each other. Even though homosexuality is punishable by death in some countries, there are nevertheless places for gays and bisexual men to go to meet each other in the larger cities of those countries. With the advent of advocacy groups such as the Rainbow Project in Namibia and GALZ (Gay and Lesbians Zimbabwe) in Zimbabwe, the topic of diversity in sexuality is getting a place on the political agenda more and more often (Johnson, 007). The sexual behaviour of the African respondents in this assessment can be explained in part by the notions they were brought up with. People in Africa think in a fundamentally different way about sex, disease and death than people in Western Europe. That also explains the rapid spread of the AIDS virus in many African countries. In Africa, someone doesnt simply become ill. Rather, the illness happens to them: it is seen as a punishment or retribution. In Africa, any form of illness and premature death is seen in connection with the transgression of boundaries, with guilt, negligence and selfishness, and therefore with envy and witchcraft. People know very well what causes the disease, but the real question is: why does that person have it? Which account is being settled here? Who bewitched me? In other words, the virus is nothing more than a biological intermediary within a much grander interplay of forces. But along with that, people in Africa are familiar with death, also when it concerns children and young people. Everyone knows people who died suddenly when they had been in full health. People take into account that life may end suddenly; and that will always have to do with witchcraft. People who have such an attitude towards life are not apt to be very receptive to the warning that a little sexual fun today can lead to death some ten years down the road. Moreover, sex is attributed a much more important role in African culture than it does in Western society. Sex is considered essential for good health. A man is supposed to release his

seed on a regular basis, as it would otherwise become pentup and ultimately damage his entire body from the inside out. Sexual prowess is also invariably associated with masculinity: a man is only really a man if he has sex several times a day. Moreover it is considered taboo to squander seed: it is to be sown where it belongs. Using a condom is therefore hardly a viable option, and the same holds for masturbation. And as for women: they need sex, because the male seed contains substances that will make a woman strong. And a woman with health problems (for example resulting from an HIV-related infection) is considered to be extra needy. Seen from this perspective, using a condom would be counterproductive (AIDS Congress, Windhoek, Namibia, 00; Steenbakker, 004/005; Holland, 00). Sexual and cultural identity We can distinguish various different kinds of identities, including genetic, national, cultural, personal, social and sexual. The personal perception of identity and sexuality varies strongly per person or group, depending on the cultural and religious background concerned. Moreover ones sexual identity, sexual preference and gender identity do not need to coincide, nor are they necessarily static. That is something that we need to take into account when contemplating the development of prevention activities for this target group. Having knowledge about those things is imperative. We will discuss personal, cultural, sexual and gender identity in more detail below. Personal identity concerns a person as a subject with consciousness and with psychological experiences (Marres, 99). Cultural identity arises if a society opts for cohesion as a group a cohesion defined by the society itself on the basis of shared values and norms and grounded in a common past. Cultural identity is a process of attribution that is rooted in an awareness of historical continuity (Hobsbawm, 983; Anderson, 983; Gellner, 983). According to Gloria Wekker (006), sexual identity has to do with both ones sexual orientation (i.e. whom one is sexually attracted to) and ones gender identity (i.e. whether one feels oneself to be male or female). The important thing is the psychological experience people have of how masculine or feminine they are. Wekker therefore prefers to speak of sexual practices rather than sexual identity. As she sees it, sexuality is often wrongly seen as an expression of ones core identity: one is supposed to be born homosexual, heterosexual or bisexual. But sexuality is not fixed. Moreover, sexuality is often seen as being subdivided into male (i.e. active) sexuality and female (i.e. passive) sexuality. That, too, for Wekker, is a simplistic view. Sexual identity is not always unequivocally defined in the literature. It is often seen as a synonym for gender identity: seeing oneself as belonging to one sex or the other, as a man or a woman, according to Leo Van Hove, a social worker and therapist. He defines sexual identity as feeling attracted to a



Method and Theoretical Framework

certain sex. Self-identification plays an important role in this regard. Van Hove maintains that peoples life histories show that sexual orientation is a variable that can change over the course of time. Someone who has lived happily for years as a heterosexual can notice being sexually attracted to someone of the same sex in a subsequent phase of life. Besides this dimension of time, there is also a growing awareness that place and culture are likewise elements that we need to take into account. In the Islamic culture, for example, ones sexual preference is not part of ones sexual identity. Homosexual behaviour is more veiled there because the boundary between honour and scandal runs via the polarity of active-masculine and passive-feminine. Men are allowed to have sex with other men as long as they assume the active role. And the sexual act is only scandalous and shameful for the passive partner if it is talked about. Under the influence of the Western culture, a process is taking place in which individuals are assuming a sexual identity on the basis of sexual preference (Van Hove, 004). Van Hoves view of sexual identity as a construction constrained by time and space has a lot in common with queer theory. The latter school of thought studies the existing definitions regarding gender, visibility and sexuality. Identity is no longer a fixed given, but is considered a construction, a convergence of various different factors that are constantly changing. According to the queer theorist and professor of rhetoric and comparative literature Judith Butler, identity is not a permanent personal characteristic but rather a variable that changes depending on context and time. Butler sees no necessary connection between ones biological sex and ones patterns of thought and expectations. In other words, we should also see identity as a flexible construction that can change depending on individual and societal factors and as an open and flexible possibility for inclusion and exclusion (Butler, 990). The idea of multiple identities is a core concept in the present report. In short, we see major differences between the Western concept of relative openness about sexuality and the Eastern reticence about that topic. According to the Eastern concept, everything in the realm of sexuality takes place behind veils of scandal and embarrassment. Wherever there may be differences in sexual identities, it is the accompanying promiscuity that actually causes the biggest shock. Homosexuality is something that is not openly talked about and that one does not openly acknowledge, although there are certainly exceptions. The social order and ones family honour are important considerations. Everything that takes place in private is tolerated, however. In that context, homosexuality is often not seen as part of someones identity, but rather as something sexual. Sex is very often experienced as being an activity rather than an identity. Environmental factors such as stigmatisation, discrimination and the societal pressure to conform to the generally accepted rules play a role in ones acceptance of oneself and of the other. The designations given to behaviour and identity and the interpretations that stem from those names are important.



Method and Theoretical Framework

Results
A majority of the respondents indicated that the highest level of education they had completed was secondary school (33 persons, see Table 3). Seventeen had had a higher professional (HBO) or university education. Eight respondents had had only a primary education. Most of the men had finished their education in their country of origin. That was less often the case for those men with a higher education, since their university studies were more likely to take place outside their country of origin. Four of the men with a university education were studying Dutch at a recognised educational institution. More than half of those who had had a higher education wanted to have their foreign diploma converted (of upgraded) to a Dutch equivalent. Table 3: Level of education of the interviewees Type of school Number Elementary 8 Secondary education 33 Higher professional education (HBO) 7 University 0 Total 58 Twenty-three of the MSM in the Schorer group were employed. A majority of those men were working below the level for which they had been trained. Two of the university-educated men were unemployed. Of the African Gay Youth Foundation group most of the men had had a secondary school education and did primarily semi-skilled or unskilled labour. The respondents lived for the most part in Amsterdam and The Hague, which corresponds to the locations of Schorer and the African Gay Youth Foundation, respectively (see Table 4). Table 4: Place of residence of the interviewees Number Amsterdam 6 Rotterdam 7 The Hague  Leiden and vicinity 3 Zoetermeer  Total 58 Most of the respondents lived alone, while the rest lived with friends and/or had no steady place to live (see Table 5). As for the reasons for living together with friends, the most important was reported as being that they were the interviewees first contact(s) in the Netherlands or sometimes even from before he had come to the Netherlands. Financial considerations were reported as being the second most important reason. The two MSM without a steady place to live were from Eastern Europe and had not been in the Netherlands very long. They, too, were staying temporarily with friends. Table 5: Living situation of the interviewees Number Live alone 39 Live with friends 7 * No steady place to live  Total 58 3
* (including: no steady place to live)

In this chapter we analyse the responses to the questionnaires and the content of the group interviews. The following topics will pass the revue: the demographic background of the respondents, sexual identity, sexual feelings, acceptance and self-acceptance, discrimination and acceptance, information and information-seeking behaviour, sexual behaviour and safe sex, forced sex and paid sex, HIV status, HIV testing and testing advice, and the needs of the MSM under consideration in this report. As discussed in the introduction, 58 young MSM took part in the assessment. This group comprised two subgroups: the African Gay Youth Foundation group ( persons) and the Schorer group (36 persons). Data from both groups of respondents are included in the analysis, although some information is unknown about the respondents from the African Gay Youth Foundation. In each of those cases, the analysis presented concerns only the 36 Schorer respondents (as indicated each time in the text). Table  gives an idea of the kinds of themes that are dealt with in the questionnaire (see Appendix  for the questionnaire in its entirety). In the analysis below, the clusters D and E will be treated jointly under the heading of sexual health as that conveniently reveals the relationship between factors. Table 1: Character of the questions Clusters of questions A Demographic background B Coming out/coming in C Information and seeking behaviour D Sexual health E Experiences with sex and relationships Total

Number of questions 0 7 (including  open question) 4 (including 6 open questions)  6 69

Demographic background The range in age of the respondents is reasonably balanced (see Table ). The youngest MSM at the time of the assessment was 7 years old; the oldest was 30. There were 3 MSM aged 8. Table 2: Age range of the interviewees Age Number 7  8  9  0 0  5  4 3 6 4 5 5  6 7 7 5 8 3 9 5 30 4 Total 58

Results

The religious background of the respondents was primarily African local-indigenous or Islamic (Table 6). The men from Eastern Europe and some of those from African countries had a Christian background. The precise religious background of the men in the group from the African Gay Youth Foundation is not known, as that was not among the things asked during the group interviews. Nevertheless it is clear that a religious local African reference system was part of the upbringing of most of the men. That held also to more or less the same degree for the African men from the Schorer group. They often failed to give a clear answer to the question about this in the questionnaire. Less than one-tenth of the total group of respondents called themselves religious at the time of the assessment. Table 6: Religious background of the interviewees Number Christian 6 Islamic 7 African and Surinamese indigenous religions 35 Total 58 The nationalities and countries of birth of the respondents were for the most part African (see Table 7, which refers only to the respondents from the Schorer group; the  respondents in the AGYF group were all from Africa). All of the 58 respondents were born outside the Netherlands except for one Turkish and one Moroccan man. Table 7: Nationalities of the interviewees Southern Africa: Zimbabwean  Central Africa: Kenyan  Somali  Sudanese  Cameroonian  North Africa: Egyptian 3 Tunisian 3 Lebanese  Moroccan 4 Middle East /Turkey: Iraqi  Turkish 3 Caribbean: Antillean 4 Surinamese  Eastern Europe: Serbian  Polish 3 Rumanian  Total 36 These data apply only to the Schorer group For 49 of the men, the employment opportunities in the Netherlands at the time were the primary reason for them to come

to the Netherlands. An application for asylum was the reason for seven men. Other reasons mentioned were: a Dutch boyfriend, in combination with having a job in the Netherlands, or the fact that there is more freedom in the Netherlands for MSM. The latter reason held for four men in combination with an application for asylum. Sexual identity It is remarkable that a very large majority of the MSM call themselves heterosexual: 4 out of 58, which is over two-thirds (Table 8). Only 7 of the 58 young men and boys reported being openly gay or bisexual, which is less than one-third. Of the  MSM from the Africa Gay Youth Foundation, only six men reported being openly gay, which is a little over one-quarter. We let a few of those who were interviewed speak briefly for themselves here about their reasons for not choosing to selfidentify as gay. The Netherlands has a large, open gay scene. A number of my friends know that I sometimes have sex with men. My parents also know that now. But it is never discussed, and that is okay with me. I dont have a boyfriend at the moment. I have sex with men and women. Sex with a woman is also very exciting for me, but very different. I know there has been a long struggle to get to the point where people are able to say who or what they think they are. What I dont understand is that so many man are convinced that they only want to be with men. And then go and make that public. As if sexuality were the only important aspect of a persons identity. Not at all. Plus, I believe that your sexual feelings can change as the years go by. The media present it as a fixed thing, so that a lot of people actually start believing that you will always be the same person. I dont think so. Having sex with a man doesnt make me gay. Why would I want to put a label on myself? I do see a problem with some boys. They have defined themselves. I agree with them that you should do what you want to do, but I think you should look further into the future. Maybe someone is interested in men now, but in a couple of years he may want a wife and children. That will be easier if you dont talk about certain feelings with everybody. I really dont think I need to choose. How can something that feels good be bad? I like it the way it is. (Milan, 25 years old, Moroccan) I have sex with men and women. Its easier with men: no hassles, no long discussions and no problems afterwards. Thats freedom, isnt it? I live for myself and not for anyone else. I came to the Netherlands to work. I have work not what I want, but that can always change. For now I am having a nice time, lots of choices I didnt have at first, different contacts and I travel quite a bit within Europe. And thats how I notice that the gay world is pretty small. On the other hand: sex with women is often just in order to have children. I can always do that later. (Baltazar, 27 years old, Rumanian)

4

Results

Table 8: Self-identified sexual identity of the interviewees Number Heterosexual 4 (of which 6: other*) Bisexual  Homosexual 5 Total 58 * Other: no label for sexual activities  sex with whomever is available 4 Sexual feelings Of the 58 MSM participating in this assessment, 4 or twothirds reported (also) feeling attracted to boys while as we have seen 4 likewise two-thirds reported being heterosexual. That means that one-third call themselves hetero-sexual, although they are also attracted to boys. Clearly we can therefore establish that sexual preference and self-identified sexual identity are not always unequivocal, considered from a Western European perspective. Most of the men felt attracted to other boys for the first time when they were between ten and fourteen years old (Table 9). The respondents from the Schorer group had their first voluntary sex between their 3th and 7th year. No one reported being 8 or older when that happened (see Table 0). There are no comparable data for the MSM from the African Gay Youth Foundation group.

for their sexual identity. The status of the remaining 6 men of this group is not known in that regard. Of the 58 respondents in total, 7 were openly gay or bisexual. Nevertheless, these 7 men also indicated that they sometimes have difficulty accepting their sexual activities with boys (Table ). This is evident from, among other things, the comments they added to the answer categories sometimes and usually not: I only have sex with boys if no woman is available, Sex with boys is easier than with a woman, I know that what I do isnt right, but sometimes I just want to have sex with a boy and As long as not everyone I know knows about it, its okay. Five of the 36 men in the Schorer group reported that they sometimes found it problematic to have sex with men. Six indicated that that applied only very occasionally. This has to do with the level of acceptance that one experiences in ones social environment and that affects the level of self-acceptance. The interviews revealed that experiences with discrimination have a major impact on ones self-acceptance. There is social pressure and discrimination and that makes it difficult to openly call yourself gay. On the one hand you could decide to ignore most of that, but on the other hand, you can get so much negativity dumped on you that life isnt fun anymore. Sometimes Im jealous of my Dutch friends here in Amsterdam. (Faridoon, 30 years old, Iraqi) I am religious, officially still married and have three children. My wife and sons live on Aruba. Its a beautiful island that attracts many vacationers. During the high season, you cant help but notice all those beautiful, tight bodies on the beach. My wife knows that I have sex with men and that Ive also occasionally fallen in love with men in the past, but does that make me bisexual? Its mainly about the contact between man and woman: if there is acceptance and thats there in our case then I dont see the point of being known as bi or gay. Not everyone is open-minded. As long as you take the responsibility to have safe sex, theres no problem. (Stephen, 28 years old, Aruban)

Table 9: Age when interviewees first felt attraction to boys Number 5-9 years old 3 0-4 years old 5 5-9 years old 5 0 years old and older 3 Total 36 These data apply only to the Schorer group Table 10: Age when interviewees had their first voluntary sex with a boy Number 3 years old 5 4 years old 8 5 years old 9 6 years old 7 7 years old 5 Dont know  Total 36 These data apply only to the Schorer group Acceptance and self-acceptance The degree of self-acceptance stands in relation to whether the MSM in this assessment reported being openly gay or bisexual or identified themselves as heterosexual. Six of the  men from the African Gay Youth Foundation group had no problems with their sexual behaviour; they come out openly

Table 11: Do you accept your sexual activities with boys? Number No, usually not 5 Sometimes 6 Yes 5 Total 36 These data apply only to the Schorer group The vast majority of the men had told friends about their sexual activities with other men (Table ). Some had also told their family. No one had kept it completely to himself, not having told anyone in his circle of family and friends. All of the respondents were receiving emotional support. That support

5

Results

usually came from friends and very occasionally from family members. No one reported having received no emotional support whatsoever. Table 12: Have you told others about your sexual activities with other men? Number Yes, friends 46 Yes, family and friends 8 Yes, someone else * 4 No 0 Total 58 *For someone else a counsellor at some religious group or immigrant self-help organisations was mentioned Table 13: Do you receive emotional support? Number Yes, from friends 45 Yes, from family  Yes, from family and friends 7 Yes, from others 4 Total 58 Discrimination and acceptance Nearly all of the respondents mentioned examples of discrimination (see Table 4). Roughly the following categories can be distinguished: subtle rejection (e.g. the way people look at me, whisper to each other and chuckle), being called names, hate mails and getting beat up. No one had taken the trouble to go to the police. In general, the men felt unsupported by the police. They also had little confidence in the team of gay police officers Roze in Blauw (Pink in Blue), although some of the respondents indicated that they thought it was a good initiative. Especially the men of African origin said they often felt threatened by the police. They mentioned having had negative experiences with the police in their country of origin and fearing for problems with their residency status. The number of times the respondents had felt discriminated varied from ten times to having heard remarks almost weekly for years on end. A number of different men felt they were in a doubly difficult position: for having sex with other men and for being coloured. They reported that many people see that combination as a reason for ridicule. Table 14: Have you ever experienced discrimination in connection with your having sex with other men? Number Yes 56 No  Total 58 All of the respondents reported going out to bars and discos once a week on average, usually on Fridays or Saturdays. It is not known how often they visited cruising areas such as parks or rest areas alongside a motorway.

The large number of respondents who said they did not feel welcome in the white gay scene is striking. Only six of the 58 reported always feeling welcome; the other 5 felt welcome only sometimes if ever (see Table 5). They mentioned the following reasons for that: The scene is generally made up of mainly white people who have their own codes. The communication takes place on a one-on-one basis, not on a group basis. That makes it more difficult for me to make contact, which gives me the idea that Im an outsider. I feel constrained by the fact that others look at me from a different perspective. People are not very understanding when someone is not (or not fully) out of the closet, which is often the case. The respondents also considered it to be a disadvantage that the Dutch gay scene seems primarily oriented towards sex. The men from the African Gay Youth Foundation group reported regularly organising meetings at each others homes, where sex might take place. That holds to a lesser extent for the men from the Schorer group as well. Since all the participants in the needs assessment reported looking for and finding their sex partners more and more often on dating sites on the Internet, they were going out less often. Table 15: Do you feel welcome in the white Dutch gay scene? Number No 3 Sometimes  Yes 6 Total 58 Information and information-seeking behaviour Based on the answers given, the term information can best be divided into information about sexual health (including HIV and STI prevention) and information about dating/going out. The respondents looked for information primarily on the Internet (see Table 6). As reasons for doing so they indicated: The Internet is anonymous, I can look there at my convenience, No high costs, Direct and quick. The topics mentioned most often in the area of HIV and STI prevention were: HIV and AIDS, What are STI, Where can you go to get tested for HIV and STI, and When should you get tested?. It is known for both the Schorer group and the African Gay Youth Foundation group which websites they visit and which magazines they read. Of the 58 MSM, 34 reported regularly looking for digital information on HIV and STI, which is to say surfing the Web at least once a week. The other 4 men looked for such information less often. Only one person in the African Gay Youth Foundation group did not use the Internet. The respondents not only looked for and found information about HIV and STI prevention via the Internet (particularly on English-language websites); they also discussed those things at gatherings of men at someones home. All but one of the 58 MSM visited specific Internet sites for men. By far the most important reason for doing so was dating (see Table 7). Forty-nine of the 58 men had a personal profile on a site. The sites mentioned in this context included GayRomeo, BelloBoy, Gaydar.date and Gaydate. 6 Results

Various respondents, especially those of African origin (in both the Schorer group and the African Gay Youth Foundation group) mentioned that the transfer of information in an informal atmosphere at someones home was considered the most valuable. A number of men called this form of information transfer reliable and pleasant. Looking for information in an unfamiliar setting in a foreign language presented obstacles, especially since many of the respondents did not want to be seen in a context that was in any way associated with HIV, STI and sexuality. Anonymity in prevention activities is of great importance in terms both of the location where and the persons through whom the necessary information is provided. The target group has a need for a neutral place where they can get information, which is to say a place that has no connotation with HIV, STI or sexuality. The Internet or meetings at someones home are good examples of such places. But there is no real consensus as to who the right people might be as providers of the necessary information. Thirty-one men preferred someone with a different (ethnic) background than their own; 33 men said they would have more confidence in a woman than a man. Women are experienced as being more understanding and less judgemental than men. A large group of the MSM in this assessment thought that someone with a different (ethnic) background and of the opposite sex would be less apt to pass on confidential information, and that would give those men an added sense of security. Especially the respondents with a Surinamese or Antillean background mentioned that aspect. Table 16: Where do you find information about HIV and STI? Number Internet 57 Magazines (English-language) 8 Forums on websites 9 Gatherings at someones home 34 Total 8 Multiple answers were possible Table 17: What is your most important reason for visiting specific sites for men? Dating 5 Information over HIV and STI 3 Both 7 Total 0 Multiple answers were possible Sexual behaviour and safe sex A large majority of the respondents was unfamiliar with the concept of sexual health. Once it was explained, however, most of the boys thought that it went without saying that both they and their sex partner carried responsibility for their sexual health (see Table 8). The members of the African Gay Youth Foundation group were not asked this question. Later enquiries made it clear that they were not familiar with the concept of sexual health.

Table 18: Who is responsible for your sexual health? Number Myself 0 Myself and my sex partner  Dont know 5 Total 36 These data apply only to the Schorer group All but one of the men from the Schorer group reported having sex with casual partners. Those MSM who had steady partners also had casual sexual contacts. Three of them had more than one steady partner; those also included paid-sex relationships. Twenty-six of the 58 men had also had sex with a girl/woman one or more times in the previous six months. Only a small minority of the respondents reported practicing safe sex. Of the 58 men, 37 indicated having had the intention to use a condom and lubrication, but 5 men reported not using condoms and lubrication (see Table 9). Various MSM reported regularly having had intercourse without a condom because they or their sex partners did not like using condoms. I have to admit that I do recognise the importance of having safe sex. I mean, who doesnt? But sometimes it just doesnt happen. A lot of guys dont want to use a condom. I agree with them that sex is different with a condom. Like its less real, more artificial. But also with a condom all kinds of things can go wrong. (Sevgi, 26 years old, Moroccan) Only eight of the 58 respondents reported having had an HIV test in the previous six months (see Table 5), and six of those eight were HIV positive. Only one of those six reported telling that to every sex partner he has had a test (Table 0). One of the eight said he had not yet heard the test results. All six HIV positive MSM said they would tell a steady partner of their positive status. While two-thirds reported having the intention to use condoms and lube, one-third reported not using them and only six men said they always used condoms and lube. Also the HIV-positive men did not always use condoms and lube. The reasons they gave for that were: I dont always have them with me, I dont always remember to use them, As long as I dont have any physical symptoms it isnt necessary. Table 19: Do you always use a condom and lubrication whenever you have sex? Number Yes, I always use a condom and lube 6 No, I do not use a condom or lube  I dont have sex with positive men  No penetration 5 I have the intention to use one 34 Total 58

7

Results

Table 20: Do you tell your sex partners about your HIV status? Number Yes, only my steady partner 4 Yes, every partner  No 48 If he asks  If I think about it 4 Total 58 As Table  shows, the respondents from the Schorer group had extremely limited knowledge of PEP, a treatment with HIV medications that can potentially prevent an HIV infection shortly after a risky sexual contact. One man had known what PEP was before he was infected with HIV, but he did not know that he could have received it at the GGD / Amsterdam Municipal Health Authority. PEP was sometimes confused with the morning-after pill: two of the respondents thought that PEP was a contraceptive. Those who had had more experience with the Dutch healthcare system were more apt to have heard of PEP. None of the men in the Schorer group had ever had a PEP treatment. It is not known whether or not the men from the African Gay Youth Foundation were familiar with PEP. In a telephone call, one of the informants indicated that the knowledge of PEP was sure to be minimal within that group. Table 21: Have you ever heard of PEP? Number Yes 9 No 7 Total 36 These data apply only to the Schorer group Many of the men knew nothing of Hepatitis B. Four of the 6 men from the Schorer group had been vaccinated against Hepatitis B; all four of them were HIV positive. More than half didnt know if they had ever been vaccinated against it. The MSM in the African Gay Youth Foundation group were not asked for that information. The respondents use drugs and alcohol very often when they are out at bars and discos. All  men from the African Gay Youth Foundation group reported using both soft drugs (especially marihuana and hash) and alcohol on a weekly basis; 7 of the 36 men from the Schorer group reported doing that as well. For several years now, the Schorer Monitor has noted a relationship between drug use prior to and during sex on the one hand and unprotected anal sex with casual partners on the other hand. Drug use is thus an important risk factor for unprotected sex with casual partners. More research on this is necessary, also with an eye to the target group of this needs assessment. Forced sex and paid sex A remarkably large number of respondents have had experience with forced sex: no less than one-third of the Schorer

group (see Table ). No data on this are known for the African Gay Youth Foundation group. Three men from the Schorer group did not answer the question on that topic. None of the men said they had ever reported such an event to the police. Studies by the Nederlands Centrum Buitenlanders and the Rutgers Nisso Groep reveal that only % of the sexual offences against immigrant boys or young men are reported to the police (Kooistra, 006; Rutgers Nisso Groep, 008). Just as with their experiences with discrimination, their limited confidence in the police in their country of origin is a reason for this, but negative experiences with the police in the Netherlands could also be a reason. The young men or boys are also often afraid of reprisals by those who used violence against them in the first place. Table 22: Have you ever had to have sex against your will / without your consent*? Number Yes 4 No 9 Unknown 3 Total 36 These data apply only to the Schorer group
* against your will / without your consent includes things like being touched (also naked body parts) or kissed involuntarily, as well as forced oral or anal sex.

The respondents from the Schorer group also tend to have had considerable experience with paid sex. About one-third had paid someone else for sex at least once and nearly onethird had been paid to have sex at some point (see Tables 3 and 4). The men of Polish and Rumanian origin reported having accepted money for sex relatively more often than the others. Some of them reported sometimes also working temporarily as prostitutes or escorts. Payment sometimes occurs in kind: cell phones and clothing were mentioned more than once. Several men indicated by way of explanation that being paid for sex was not a good thing, but paying someone else for sex was okay. Table 23: Have you ever paid someone for sex? Number Yes 9 No 5 Not filled in  Dont know  Total 36 These data apply only to the Schorer group

8

Results

Table 24: Have you ever been paid for sex? Number Yes 9 No 7 Not filled in 3 Dont know 7 Total 36 These data apply only to the Schorer group HIV status, HIV testing and testing advice The Schorer Monitor 008 showed that 34% of the men who identified themselves as homosexual had still never been tested for HIV. The reasons given for that were fear (of the consequences, of having to take medications, of the side effects, of social exclusion), shame (for having sex with another man) and underestimation of the medical need for early detection of HIV (Its early enough for treatment once any symptoms appear, and I dont have any symptoms). Those reasons were also mentioned by respondents in this needs assessment: particularly the fear of negative reactions from ones environment. They also wrote: I dont want to know when I will die, My life will end if I know that I am HIV positive, I dont want to be dependent on others, I will be completely alone and Why should I know? I will notice it when the time comes. Only eight of the 58 participants in the needs assessment had been tested for HIV and for STI in the previous six months (see Tables 5, 6 and 7). That is nearly three times fewer than the numbers the Schorer Monitor 008 reported for its own respondents, although the figures are not easily comparable. Only two men reported having followed the national recommendations for testing frequency (twice a year for STI and at least once a year for HIV); both had been tested in the previous six months. What probably plays a role in the remarkably low testing figures of this group of MSM is the fact that many of the men of African origin have other ideas about health and sexuality than Western Europeans commonly do. They often see the chances of HIV transmission not primarily as the result of unsafe sex, but rather emphasize the role of the supernatural in this regard. The underlying idea is that there is no point to safe sex, since you will get HIV anyway if that is your fate. One of those who were interviewed remarked: How can you get sick if you are a good person? In Africa we have other ideas about health than here in Europe. Being sick has a purpose. A disease tells you: something went wrong. Ultimately its a positive thing that you change your life, so that you will have less misfortune. I think that people in the West dont always take African ideas completely seriously. Life is about more than just knowledge. After all, dont you people also have situations that can only be explained from a supernatural perspective? You can see that for example from the popularity of some Dutch TV programmes about that sort of thing. (Kato, 22 years old, Zimbabwean)

Table 25: Have you been tested for HIV in the past six months? Number Yes 8 No 50 Total 58 Table 26: What is your current HIV status? HIV negative HIV positive Still waiting for the results Not known Total Number  6  50 58

Table 27: Have you ever been tested for STI? Number Yes 9 No 49 Total 58

9

Results

Conclusions and recommendations

Conclusions These are our principle conclusions on the basis of the assessment conducted among 58 young MSM from ethnic minorities in the Netherlands. Our conclusions are partially based on a subset of this group (i.e. 36 MSM from the Schorer group). Condom use among members of the target group is low. A vast majority has the intention to use condoms and lubrication but often fails to do that in practice. They rarely get tested for STI and especially for HIV. The vast majority of the respondents dont know their own HIV status. Their own assessment of the risk they run of contracting STI and HIV is optimistic. Many MSM also have sexual contacts with women. A majority of the young MSM call themselves heterosexual. The Internet forms by far the most important source of information about HIV, STI and dating. Drug and alcohol use while the young MSM are out at night is high. Many MSM know nothing about PEP and Hepatitis B. Experience with forced sex is more common than has been reported in earlier studies. Experience with paid sex is more common than has been reported in earlier studies. We now have a clearer idea of the needs of these MSM: both in relation to homosexuality in general and to the area of STI and HIV prevention (see below). Needs In terms of homosexuality in general, the MSM in this needs assessment primarily have a need for: education within their own community about diversity in sexuality education in places like schools and neighbourhood/community centres role models and groundbreakers from their own community women from their own community to be involved in this process; women are seen as being more understanding and less judgemental than men. In terms of HIV and STI prevention, the primary needs of the MSM in this needs assessment are: information presented in their own language information beyond the Schorer framework of websites and magazines for gay men, since most of the respondents rarely if ever come into contact with those personal contact in the transfer of knowledge a guarantee of anonymity, for example by means of a health educator who has a different ethnic-cultural background than the MSM in question a neutral location that has no association with HIV, STI and sexuality, for example the Internet or someones home an explanation about the Dutch healthcare system a basic knowledge about HIV and STI.

The respondents suggested the following solutions of their own: role models: to have one or even to be one with the support of others information transfer in a way that fits with their own cultural background: informal and taking place in a trusted setting, for example during gatherings at someones home that revolve around a certain theme a greater role for immigrant self-help organisations in education and the transfer of knowledge. Difficulties It is evidently very difficult to develop a method that will allow young MSM from ethnic-cultural minorities to gain the right knowledge and skills to be able to make healthy choices about their sexuality. Why is that? The problems faced by the target group are underestimated. There are various major problems in the area of sexual health, but those have hardly been identified and described. Since the social and care professionals have failed to make itself visible to the target group and as a consequence the target group has not been able to articulate its needs the problems of this group of MSM have largely gone unheeded. Invisible and difficult-to-reach target group. It is difficult to come into contact with these young men and boys. The target group is practically invisible and often prefers to remain that way. Recruiting counsellors from among the target group itself is also difficult, due to loyalty conflicts and the fear of social exclusion, among other things. The media are often interested in projects, but only want to talk with the young men or boys themselves, who for their part are not at all interested in doing that. Difficult collaboration with the target group. Collaborative projects with the target group do not go easily. There are often differences of opinion between the organisations that set up such projects. People are not always sure about who is supposed to do what, and the objectives and planning are often unclear as well. Some projects suffer from being overambitious. The intrinsic motivation of the collaborative parties often decreases because things end up going more slowly than expected. Turnover of professional staff can also cause problems. Finally, informal care and help are often difficult to organise and maintain, especially because many immigrant selfhelp organisations work with volunteers. Effectiveness of projects is difficult to measure. The effectiveness of the often-informal methods and ways of working of immigrant self-help organisations, where the focus is on community development and empowerment, is difficult to measure, which rules out structural funding. At the same time, some immigrant self-help organisations have a very fragile structure and are sensitive to instable internal and external factors. Moreover boys from ethnic minorities are often very mobile and flexible: one creates oneself and associates oneself with groups according to ones needs (Walter and Dankmeijer, 00).

0

Conclusions and recommendations

Points for discussion Based on the results of our research as well as the literature we would like to propose the following points for discussion in the context of the development of HIV and STI prevention for MSM from ethnic-cultural minorities in the Netherlands. Relatively late identity-forming. This needs assessment aimed at MSM from ethnic-cultural minorities between the ages of 5 and 30, but no boys aged 5 or 6 were reached. The average age of the respondents was 8. It is possible that very young MSM do not yet refer to themselves as such but rather see themselves as being exclusively heterosexual. At a young age, experimenting with men is often not a problem. It is only when they are a bit older and need to find a marriage partner that those boys are fully confronted with the values and standards of their environment. As a result, their identity-forming and identification get a relatively late start as seen from a Western European perspective. Often many years will pass between their first sexual contact and the point at which they come out (if ever). What risks can that bring about in the context of HIV and STI prevention? Doubly different. For respondents who have no family ties in the Netherlands and who socialise with other young MSM, the perception or awareness of being different can bring about substantial psychological disquiet. Some of the views with which they were brought up abroad can inhibit them; the situation and opportunities for young MSM in the Netherlands are often very different from those in their country of origin. But they may also feel themselves to be outsiders in the Netherlands due to their ethnic background. It can be shocking for them to realise that besides their being of a different origin they are also different in another way and both ways often have negative connotations. So it takes inner strength and perseverance to take part in a survey (even anonymously). In the prevention of HIV and STI, too, we need to take these feelings of the target group into account. HIV and STI prevention in a heterosexual environment. A considerable segment of the respondents reported also having had sexual contacts with women and identified themselves as heterosexual. That entails a danger of spreading HIV and STI in a substantially larger group. In which ways can HIV and STI prevention respond to the consequences of that behaviour on a larger scale? Uncertain future perspective. A very large segment of the respondents had still never been tested for HIV and STI or had been tested longer than six months before the needs assessment was conducted. Not knowing ones own status with regard to HIV and STI is not only risky for the person in question (having an STI increases ones chances of contracting HIV), but also for ones sex partners. It is important to know the reasons why someone

does not get tested. What in any case seems to play a role is the unclear and uncertain future of many MSM from ethniccultural minorities. This ties in closely with their often weak socio-economic position and means that sexual health and the possible risks in the short and longer term do not always have the first priority. Their position in society makes it difficult to address some MSM from ethnic-cultural minorities about the consequences of their unsafe sexual behaviour for themselves and for others. This can stand in the way of an effective approach to HIV and STI prevention and means that, here too, much work still needs to be done in preventing HIV and STI. Discrimination. Nearly all of the participating MSM have experienced discrimination in relation to their having sex with men and boys. For most of the respondents the form of discrimination they experienced was no reason for reporting it to the police. The general perception is that there is no point in reporting it. Many MSM from ethnic-cultural minorities live in a world of men (separated from women) that is secret and not openly discussed. But there is also a lack of trust in the police, which has to do with their experiences with the police in their country of origin on the one hand and with their experiences in the Netherlands as asylum seekers or scapegoats on the other. Which measures can we take on the regional and national levels that would make young MSM from ethnic-cultural minorities think it was worth reporting such discrimination? What is the role of anti-discrimination offices and the Roze-in-Blauw team of the police force in this connection? Forced sex, sex for pay. A large number of the men who took part in the assessment has experienced forced sex and/or sex for pay. Although paid sex is not synonymous with forced sex, we are treating them together here since the division between them can be fragile. A small number of MSM live illegally in the Netherlands and earn their living as prostitutes. For them, sex is a way of providing for themselves. This way of working is sometimes experienced as being something of their choosing, but sometimes also not. Knowing who you are and what you want and being able to indicate your boundaries and to say what you want are essential skills in order to be able to properly stand up for yourself and to offer resistance to coercion and involuntary sex for pay. The weak socio-economic position of many of the participating respondents plays a major role in this regard. On the other hand, there are also MSM who occasionally earn extra money through paid sex. They have regular jobs but find it exciting, enjoyable or sexually arousing to have quick, anonymous sex while earning money in the process. Customised response for multiple steady partners. Some MSM in this assessment had multiple steady sex partners at the same time, which is something different than serial monogamy. Most of the behavioural recommendations (including those given by Schorer) make a distinction between prevention advice intended for MSM with casual sex partners



Conclusions and recommendations

and that intended for MSM with steady sex partners. There are nevertheless many different ways of interpreting the words casual and steady and the one does not exclude the other. What are the criteria for recommendations and when does a general message become a specific, customised or tailored piece of advice, so that the safe-sex message will still come across? Also among MSM from ethnic-cultural minorities, there are numerous possible versions of casual and steady. Recommendations We make a number of recommendations here for better reaching the target group and for working together more effectively. We also provide a first impulse for the development of a prevention methodology for the target group of MSM from ethnic-cultural minorities. Look for new channels to reach target group. General prevention interventions appeal primarily to welleducated white gay men. These kinds of prevention interventions are apparently insufficiently compatible with the experiential world of men with a different cultural background. What is more, many of those men identify themselves as heterosexual and also have sex with women. This fact has consequences for the information campaigns, as those men by no means all read the sources of information that are aimed at gay men. To reach young MSM from ethnic-cultural minorities, the information about sexuality and health will need to reach further than the standard sources, such as gay websites and printed materials found in the bars, parties and sex saunas that white gay men frequent (Walter and Dankmeijer, 00). The fact that the men of this target group also have sex with women also needs to be included in the content of any preventive message aimed at them. Make distinctions according to the cultural context. Ethnic minority men with bisexual and homosexual contacts and feelings must not be seen as forming a single, homogenous group. Their interpretation of those feelings and contacts can differ per cultural context (Walter and Dankmeijer, 00). If HIV and STI prevention is to be effective, we will need to take (sub)culturally different views about sexual identity into account. Involving the cultural context in HIV and STI prevention also means giving attention to the fact that the ideas that MSM have about health are culturally bound. The largest group of MSM in this assessment was of African origin. In the future collaboration with the African Gay Youth Foundation, with the COC, with youth websites such as Sense and Maroc.nl, and with STI AIDS Netherlands, among others, it will be important to take specific African aspects into account in the prevention messages that will be communicated. Those are first of all African views about sexual health, for example the fact that many men with an African background dont consider it masculine to use a condom, as well as the significance they attach to the supernatural in the event of an HIV infection.

In the second place, those aspects include the African experience of identity and sexuality. Many African societies have a group culture. Beliefs and opinions are part of a cultural frame of reference and form a strong indication for identity-forming and behaviour. The views of an individual are subordinate to those of the group, and environmental factors have an enormous influence. As STI and HIV prevention is usually based on the principle that a person sees and experiences himself as an individual with his own views, preferences and realm of possible choices, this will be a difficult road filled with many obstacles. It is not yet clear to what extent all of this can be achieved. Based on the men who took part in this assessment, it is clear that a personal approach and close collaboration with role models and/or prominent individuals can effect a response to the many complex aspects in this comprehensive whole. Increasing knowledge and skills relating to sexual health. Members of the target group not only need more knowledge about HIV, STI and safe sex; they also need to improve their skills in connection with sexual health, both at the individual level and the group level. Stimulating responsible behaviour is important, especially ones being able to communicate what he wants and where his boundaries lie. An explanation of the Dutch healthcare system should also be included along with the knowledge and skills that are needed. With more knowledge and skills in the area of sexual health, young MSM from ethnic-cultural minorities will be better capable of making their own choices. Among other things that includes: knowing what you want and how you can achieve that, getting people to talk about choices such as condom use, not giving in to social, cultural and/or religious pressure, knowing which factors can play a role in terms of having unsafe sex, daring to say no to forced sex. The core is becoming aware of ones own self and ones own will and being able to make responsible choices on the basis of that. Being self-aware / self-confident and making independent decisions needs to be the main focus, considering that these boys sometimes find themselves in difficult situations, both economically and socially. Indirect prevention: supporting immigrant self-help organisations. Knowledge and skills involving sexual health can be developed effectively if immigrant self-help organisations themselves have the knowledge, facilities and motivation to set up concrete and structured actions for the target group of MSM from ethnic-cultural minorities. Schorer can provide more structural support to other organisations and activities in the process. This strategy of indirect prevention is much more effective than direct interventions, since those men are very apt to distance themselves from organisations whose target groups are known to be gay or bisexual. Those labels are problematic for male respondents. However, via local



Conclusions and recommendations

organisations, immigrant self-help organisations and educators working within the subjects own language and culture, the target group can be reached. That makes it essential to involve the community of the group in question when broaching the subject. Collaborative partners need to develop a well-considered policy on the technical and substantive approach of this indirect prevention. Important aspects in that regard include: stimulating the collaboration between organisations and activities, guiding the setup, carrying out and evaluating projects, and encouraging the staff of local organisations by celebrating successes. As many immigrant self-help organisations only have a short-term planning, Schorer can contribute to structuring and stimulating interventions. The benefits of this indirect prevention or coaching approach, where Schorer and other organisations are active in the background, include: empowerment takes place from the inside out, since boys participate in projects and in the longer term also in the development of those projects boys can turn to people they already know in a relatively safe setting key figures in communities are encouraged to get people to talk about diversity in sexuality in an open and neutral setting projects and organisations are reinforced in terms of both content and process emphasis on personal contact (written material is less effective) no outsiders who set the course input on a continual basis. Strategies and methods for prevention: training and/or support of key figures within immigrant selfhelp organisations and from the communities themselves in getting people to talk about sexual diversity and health, and designing/ setting up small-scale prevention activities for the communities themselves (= indirect prevention) offering information about HIV, STI and sexuality on websites in different languages using interventions that have been proven effective for ethnic minorities, such as educators who speak the groups own language, living room projects, etc. organising discussions and debates via radio, local television and conferences having women play a role in getting heterosexual men (especially fathers and brothers) to talk about the theme involving religious, community and spiritual leaders in the topic creating and using teaching packages about health and sexuality in lower, secondary and continued education, in neighbourhood centres and in youth organisations.

3

Conclusions and recommendations

Literature and Sources

AIDS Congress, organised by AIDS Law Unit. Windhoek, Namibia, 4-8 July 00 (congress papers). Anderson, B., Imagined Communities: Reflections on the Origins and Spread of Nationalism. London, Verso Books, 983. Bergh, M.Y.W. von & T.G.M. Sandfort, Veilig vrijen en condoomgebruik bij Turkse, Marokkaanse, Surinaamse en Antilliaanse jongeren en jong-volwassenen. Een vergelijking met autochtone Nederlanders. Utrecht, NISSO/Universiteit Utrecht, 000. Blom, C. & MCA Communicatie Utrecht, Inventarisatie aidsbestrijding onder allochtonen in Nederland. Amsterdam, Aids Fonds, 003. Breeman, L. et al., Jongeren en hun seksuele zelfbeeld: implicatie voor seksuele gezondheidsbevordering. Soa Aids Magazine, vol. 3, no. 4, 006, pp.-5. Butler, J., Gender Trouble. Feminism and the Subversion of Identity. New York/London, Routledge, 990/999. CBS Bevolkingsstatistieken. Voorburg/Heerlen, CBS, 003. Dekkers, T., Homoseksualiteit en religie. Schorermagazine, Dec. 005, pp. -4. Doppert, M. & M. Hermans, Haat en liefde. Homoseksualiteit in multicultureel Nederland. Kampen, Ten Have, 006. Forum, Masterplan homoseksualiteit bespreekbaar maken in etnische kring. Utrecht, Forum, Instituut voor Multiculturele Ontwikkeling, 005. Franssens, D., M. Koning & H. Hospers, Outcomes, lopende cohortstudie jonge homos. Deelrapport . Universiteit Maastricht, 007. Uitenbroek D.G. et al. (eds), Gezond zijn en gezond leven in Amsterdam. Amsterdamse Gezondheidsmonitor 2004. GGD Amsterdam, 006. Gellner, E., Nations and Nationalism: New Perspectives on the Past. Oxford, Basil Blackwell, 983. Graaf, H. de et al., Seks onder je 25e. Seksuele gezondheid van jongeren in Nederland anno 2005. Rutgers Nisso Groep/ Soa Aids Nederland, Delft, Eburon, 005. Heckathorn, D.D., Respondent-Driven Sampling: A New Approach to the Study of Hidden Populations. Social Problems, vol. 44, no. , May 997. Hermans, M., Jongens en hiv. Schorermagazine, April 006, pp. 8-0.

Hobsbawm, E., Introduction: Inventing Traditions. In E. Hobsbawm & T. Ranger (eds), The Invention of Tradition. Cambridge: Cambridge University Press, 983, p. -4. Holland, H., African Magic: Traditional Ideas That Heal a Continent. Penguin Viking, SA, 00. Hospers, H.J. et al., Schorer Monitor 2006, 2007 and 2008. Schorer and Universiteit Maastricht. Huurman, J.G.J., Gezond leven. Onderzoeksmethoden en meetinstrumenten voor de evaluatie van de communitybenadering. Nationaal Instituut voor Gezondheidsbevordering en Ziektepreventie (NIGZ), 003. Johnson, C.A., Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa. International Gay and Lesbian Human Rights Commission, 007. Kaka, I. el & H. Kurun, Mijn geloof en mijn geluk. Islamitische meiden en jongens over hun homoseksuele gevoelens. Amsterdam, Schorer Boeken, 00. Kalwij, M. Amor Salu. De seksuele gezondheid onder Antillianen en Arubanen in Rotterdam, GGD Rotterdam, 000. Kerksi, N., Internet belangrijke bron voor homojongens, Hogeschool Groningen, 004 (Masters thesis). Klein Tank, M., Als preventiewerker moet je een beetje een entertainer zijn. Soa Aids Magazine, vol. 3, no. 4, 006, pp. 6-7. Kooistra, O., Jongens huilen niet. Seksueel geweld tegen allochtone jongens. Amsterdams Centrum Buitenlanders, 006. Marres, R., Persoonlijke identiteit na het verval van de ziel. Muiderberg, Coutinho, 99. Meijer, I., Prejudice as Stress: Conceptual and Measurement Problems. American Journal of Public Health. Vol. 93, No . 003. Meijer, I. et al., The Trouble with MSM and WSW: Erasure of the Sexual Minority Person in Public Health Disclosure. American Journal of Public Health. Vol. 95, No 7. 005. Meijer, S., Jongeren en condoomgebruik. Soa Aids Magazine, vol. 4, no. , 007. Nahas, O., Islam en homoseksualiteit. Amsterdam/Utrecht, Bulaaq/Yoesuf, 00. Pierik, C. et al., Dubbel en dwars. Naar hulpverlening op maat voor allochtone jongeren (m/v) met homoseksuele gevoelens. Utrecht, Movisie, 008.

4

Literature and Sources

Poel, F. van der & C. Hekkink, Tien jaar soa/aids-bestrijding allochtonen: review. Woerden, NIGZ, 005. Richel, C. et al, Seks onder je 5e: homo- en biseksuele jongens. Soa Aids Magazine vol. 4, no. 5, 007 Rutgers Nisso Groep, Trends in seksualiteit in Nederland. Wat weten we anno 2008? Utrecht, RNG, 008. Steenbakker, S., Gesprekken met vrouwen in Buma Bwesi Health Care Centre. Kashakishi, Zambia. 004/5, (internal report). Veen, M.G. van et al., Hiv-survey onder Surinamers, Antillianen en Kaapverdianen in Rotterdam. Bilthoven, RIVM 006. Vriens, P. et al., E-dating needs assessment. Schorer, Amsterdam & GGD Rotterdam, 004. Vries, E. de, Niet alleen horen, maar ook luisteren. Schorermagazine, Aug. 006, pp. 8-. Walter, J. & P. Dankmeijer, Een verkenning van het niemandsland tussen homo en hetero, in: P. Vera (red.), Kansen en belemmeringen van een homospecifiek hulpverleningstraject voor vluchtelingen, immigranten en illegalen met lesbische, biseksuele of homoseksuele gevoelens. Reader, Amsterdam, Schorer, 00. Wekker, G., The Politics of Passion. Womens Sexual Culture in the Afro-Surinamese Diaspora. New York, Columbia University Press, 006.

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Literature and Sources

Appendix 1: Needs Assessment Questionnaire

Boys and Young Men of Ethnic Minorities in the Netherlands who Have Sex with Men Schorer 008

9. In which cultural background were you raised? A Dutch B Mixed (Dutch and .................................) C Non-Dutch, namely.................................................. Within which religious background were you raised? A None B Within...................................................................... Are you religious yourself? A No B Yes

A. Identity and background . How old are you? A. 5-9 years B 0-4 years C 5-30 years . How do you describe/see yourself? A Boy/(young) man B Transgender (male to female) C Transgender (female to male) 3. What is the highest level of education you have completed? A Elementary school B Secondary school C University D Post graduate (e.g. PhD) E Other... 4. Do you have a job? A No, I am attending school / studying B Yes, part time C Yes, full time D No, I am unemployed 5. Where do you live? (Please fill in the first three digits of your postal code) ..... 6. What is your living situation? A I live alone B I live with family C I live with friends D I live in a shelter/ group home E I have no steady place to live F Other..................... 7. Were you born in the Netherlands? A No, I was born in ............. (country), and I came to the Netherlands in ............(year). B Yes (please go to question 8) 8. What was for you the most important reason for coming to the Netherlands? A Work B Study C To seek asylum D To be re-united with your family E Other.......................

B. Coming out/coming in . How do you see yourself? We identify three main categories: heterosexual or straight (if you are sexually attracted to females only), bisexual (if you are sexually attracted to both males and females), homosexual or gay (if you are sexually attracted to males only). A fourth category is different from the first three: If you feel that you dont fit into any of the other categories but are different. The numbers indicate the level of agreement or disagreement:  = I disagree completely and 5 = I agree completely. A B C3 D4 E5

A Heterosexual B Bisexual C Homosexual D Different...

. According to yourself: how do others see you? A B C3 D4 A Heterosexual B Bisexual C Homosexual D Different...

E5

3. Have you told other people about your sexual orienation? A No B Yes, only friends C Yes, only family D Yes, friends and family E Someone else 4. Do you receive support? (e.g. Do you have someone to talk to?) A No B Yes, (some) friends C Yes (some) family members D Yes, (some) friends and family members E Others...... 5. Have you ever experienced hatred or violence because of your sexual orientation? A No B Yes

6

Needs Assessment Questionnaire

6. Do you ever visit commercial venues for males only (e.g. bars, saunas, parties)? A No B Sometimes C Yes D Dont know 7. Do you feel welcome and at ease in the Dutch gay scene? A No B Sometimes C Yes D Dont know

7. For the prevention of HIV and STIs, we would like to provide information that will reach men like you. How should we do that? 8. What kinds of information or tools do you need / miss in terms of the prevention of HIV and STIs?

D. Sexual health Perhaps you have already heard of the concept of sexual health. Sexual health is everything you do to keep sex as healthy as possible, in order to try to decrease the risk of contracting HIV and STIs. . Who is responsible for your sexual health? A I am B Myself and my partner(s) C My partner D No one E Dont know . Have you ever been tested for HIV? A No (Please go to question 5) B Yes, in the last 6 months C Yes, in the last  months 3. What was the result of your most recent HIV test? A HIV negative (HIV) B HIV positive (HIV+) C Im still waiting for the results D Not known: I never got the results 4. Where did you have the HIV test done? A At the STI clinic B At my family doctors office C At home D Somewhere else.................................... 5. Have you ever been tested for STIs other than HIV? A No (Please go to question 7) B Yes 6. Where did you have the STI test(s) done? A At the STI clinic B At my family doctors office C At home D Somewhere else.................................... 7. In the Netherlands, men who have sex with men are advised to get tested once a year for HIV and twice a year for other STIs. Did you know this? A No B Yes

C. Information and seeking behaviour . Where do you find information about sex, HIV and STIs? (multiple answers are possible) A Magazines like......................................................... B Newspapers C Friends D Family E Leaflets and booklets F Gay magazines G Web sites H Forums on the Internet I Radio and television J Your family doctor (GP) K Schorer website L SOA-STI Netherlands (Soa-Aids Nederland) M Switchboard N STI clinic (Soa-poli) O HIV Vereniging P Other...... . Do you visit web sites for males only? A No (Please go to question 5) B Sometimes, e.g. (fill in the frequency, if known) C Yes 3. What kind of sites are those? A Dating B Information on prevention issues C Both D Other..... 4. Do you have your own profile on specific sites for men only? A No B Yes C I will in the near future 5. What do you think of the information about HIV and STIs that is currently available? 6. For the prevention of HIV and STIs we would like to get into contact with men like you. How should we do that?

7

Needs Assessment Questionnaire

8. Did you ever been diagnosed with Hepatitis B? A No B Yes 9. Have you been vaccinated against Hepatitis B? A No B Yes C Dont know 0. If you ever happen to have unsafe sex (e.g. by accident). What do you do? A Seek help from a healthcare institution B Seek help from friends C Nothing D Other.... . Have you ever heard of PEP (Post Exposure Prophylaxis)? A No B Yes C Dont know

6. Do you use condoms and lubricant with a casual (one-time) partner? A No B Only a condom C A condom and sometimes lubricant D I have the intention to do so E Yes 7. Why do you use or not use condoms (and lubricant) with a casual partner? A It is important to take care of myself and my casual partner B It is important to take care of myself C I dont take care of my casual partner D I dont take care of myself and my casual partner E Dont know 8. Have you ever had to have sex against your will / without your consent? A No B Yes C Dont know 9. Have you ever paid for sex? A No B Yes C Dont know 0. Have you ever been paid for sex? A No B Yes C Dont know .Who do you have sex with? A Men/boys from my own cultural background B Men/boys from other cultural backgrounds C Mixed D Dont know . Is there anything else that you would like to mention? This is your chance! Thank you very much for your co-operation.

E. Experiences with sex and relationships . Have you had sex with females during the last six months? A No B Yes . Have you had sex with males during the last six months? A No B Yes 3. Do you tell your sex partner(s) about you HIV status? A No B Yes, if I think of it C Yes, steady partner(s) only D Yes, every sex partner 4. Do you use condoms and lubricant with a steady partner? A No B Only a condom C A condom and sometimes lubricant D I have the intention to do so E Yes 5. Why do you use or not use condoms (and lubricant) with a steady partner? A It is important to take care of myself and my steady partner B It is important to take care of myself C I dont take care of my steady partner D I dont take care of myself and my steady partner E Dont know

8

Needs Assessment Questionnaire