Abstract: In Ghana and other countries, heightened social stigma and discrimination towards gay men and other men that have sex with men (MSM) is compounded by the criminalisation of homosexuality. These are factors that influence them to avoid in-person peer-networks and settings where HIV prevention and care services are available. Yet in Ghana, and more globally, these same populations are increasingly using online social media networking practices to connect with people and information. This is because it is perceived to be safer and more anonymous. From an HIV prevention and care perspective, this makes online social media—particularly Facebook—uniquely well suited for connecting these at-risk populations to sexual health interventions and services. Drawing on findings from an ethnographic study, I outline how CBOs and NGOs delivering sexual health services could possibly improve HIV prevention and care outreach within these subpopulations of gay men and MSM by mimicking how they use social media. Such an approach entails ambitious and undercover methods for leveraging these subpopulations’ use of social media networks in order to connect them to localised HIV prevention and care services. However, the approach of mimicking how sexual minorities use social media presents new ethical dilemmas. I consider these ethical dilemmas. Then I outline a number of logistical considerations and specific methods sexual health CBOs and NGOs could implement using social media for HIV prevention and care, arguing they have the potential to improve outreach to underserved subpopulations of gay men and other MSM in contexts where discrimination, fear and stigma prevent them from accessing these vital resources.
Keywords: social media, Facebook, gay, MSM, sexual minorities, sexual health, HIV, NGOs, Ghana
Sexual health organisations, sexual minorities and social media
At the 2014 International AIDS Conference in Melbourne, it was made clear that those who provide sexual health services to gay men and other MSM need to rethink the intersection between sexual health organisations, sexual minorities and social media in “stepping up the pace” to address HIV. It is critical to better understand how sexual minorities’ use of social media can inform sexual health interventions targeting these populations. Gay men, other MSM and transgender women are sexual minorities targeted by sexual health organisations because they are at a disproportional risk for contracting and transmitting HIV and other STIs (UNAIDS, 2014; Wilson et al., 2013, Baral et al., 2013). These sexual minorities, as well as people involved in sex work and people who inject drugs comprise the “key populations” framework for targeted HIV/AIDS interventions by USAID (2014).
In this article, I argue nongovernmental organisations (NGOs) and community-based organisations (CBOs) who focus on sexual health could broaden their reach within and to subpopulations of gay men and other MSM by mimicking how these populations use social media. Such an approach entails more ambitious and undercover methods for leveraging these populations’ use of social media networks, like Facebook, to better connect them to localised HIV prevention and care services. In what follows I review a number of successful HIV programs to highlight successful examples of NGOs and CBOs using social media to provide HIV services to gay men, other MSM and transgender people to underscore the potential benefit of integrating similar approaches to strengthen HIV efforts into the future. Then, drawing on an ethnographic study with sexual minorities in Ghana, I describe specific methods and logistical considerations used to successfully reach underserved populations using Facebook. Drawing on data sets across participants from urban areas in six regions in Ghana, I illustrate how many gay men and other MSM in Ghana reported having little or no knowledge of local sexual health services. Findings highlight the need to expand the reach of sexual health interventions on offer in Ghana targeting gay men and other MSM. This led me to explore the potential benefits of using Facebook to broaden and diversify the reach of HIV services to gay men and other MSM, as well as other sexual minorities disproportionately at risk to HIV. However, new ethical dilemmas arose as a result of my “when in Rome, do as Romans do” approach of mimicking how sexual minorities’ use social media. I conclude by examining these ethical dilemmas and then outline how they influenced my recommendations for approaches sexual health NGOs and CBOs can implement. I argue these methods have the potential to better reach underserved subpopulations of gay men and other MSM in Ghana and more globally to provide contextualised HIV prevention and care.
Outreach to sexual minorities through social media
The increasing ubiquity of online social media corresponds with a surge in numbers of sexual minorities engaging these platforms (Jones & Fox, 2009; Martinez et al., 2014; Oosterhoff, 2014). Furthermore, the recent and dramatic politicisation of homosexuality and high levels of stigma and discrimination in many Sub-Saharan African countries not only influence some sexual minorities to avoid public interaction, but also negatively affects the provision of HIV care and prevention services (Corey-Boulet, 2012, Currier, 2014, Epstein et al., 2004; IRIN, 2006; Walsh, Laskey, Chiayajit and Morrish, 2010). Over the past decade, Ghana has witnessed not only a proliferation of more affordable information communication technologies (ICTs) (Frempong, 2012; infoDev 2014), but also the politicisation of homosexuality and increased instances of human rights abuses directed at sexual minorities (Eveslage, 2015; Essien & Aderinto, 2009; PANA, 2011; Citi FM Online, 2010; Daily Guide, 2010; Mac-Darling Cobbinah, 2015). In this context, online social media networking becomes increasingly attractive for sexual minorities seeking sexual partners. It also provides unexplored platforms to maintain anonymity and discretion in accessing health services and information. Importantly, this also potentially opens up new avenues of exploitation (O’Mara, 2013) and violence (Wood, 2014; Avari 2014).
HIV prevention and care interventions in various regions – from North and Central America (Allman et al., 2012; Rivas et al., 2014) to Africa (Henry et al., 2012; Scheibe et al., 2012) and Asia (Avery et al., 2014; Chaiyajit & Walsh, 2012; Dasgupta 2012) – have highlighted the ways sexual minorities use social media to better inform the practice of HIV prevention and care (also see Kahema et al., 2014; Beck et al., 2012; Young & Jaganath 2013). These research studies highlight the importance of understanding how and why sexual minorities use social media in order to improve outreach into the virtual locations where they connect and communicate (Hanckel et al., 2014, p. 183-185). The available ICT resources range in their ability to directly reach gay men and other MSM. For example, designing a new website for sexual health education as Muessig et al. (2014) describes may allow for more tailored messages and service delivery, but will likely be encumbered with getting their target population engaged on their platform. Instead, Rivas et al. (2014) and Chaiyajit and Walsh (2012) document projects that more directly reached sexual minorities through chat rooms and social media websites already in use by sexual minorities. Specifically, the Sexperts! project, developed by RFSL (2009) in Stockholm and deployed by Mplus+ Thailand and TLBz Sexperts!, included two CBOs in Thailand that engaged on social media to reach populations of MSM and transgender women (Walsh, 2008; 2011; Walsh, Chaiyajit & Thepsai, 2010). In Thailand, the TLBz Sexperts! Program is “a low-cost, transgender-led, community project offering accurate online transgender-specific sexual health information, social support and legal advice” (Chaiyajit, 2014). With 10 years of experience, the Sexperts! projects serves as example of directly reaching key populations to connect them to HIV and broader STI education.
In Ghana, Green et al. (2014) detailed the experience of USAID-funded HIV prevention and care efforts for key populations under the SHARPER project. In 2012 they reached less than 50% of the estimated number of MSM in Ghana when using traditional means of reaching MSM through “peer educators” (p. 210; Aberle-Grasse et al., 2013). However, peer educators within their project “were aware of other MSM networks – particularly those that were older or discreet about their sexuality, and who were not interested in being directly contacted by a peer educator” (p. 210). To incorporate these un-reached populations SHARPER invested in new efforts to reach MSM through social media (including Facebook and dating websites), increasing their coverage to 92% of the estimated population of MSM in Ghana (ibid.).
These studies evidence that sexual health CBOs and NGOs are capitalising on expanding ICT resources and social media used by sexual minorities. However, there remain large populations out of the reach of current HIV programming for various reasons. For one, many of the population size estimates of gay men and other MSM – which are used to measure the success of HIV reach, prevention, care and treatment services – are typically based on biased starting points such as respondent driven sampling or a “wisdom of the crowds” approach (Paz-Bailey et al., 2011; Quaye et al., 2015). While there are methods that attempt to control for this bias (Lane, 2009, p. 73), they tend to overlook subpopulations not connected to peer-networks whatsoever. Furthermore, there remain issues of how researchers and demographers understand sexual identities and how they conceptualise the impact of these identities on sexual behaviours (as discussed in Lane, 2009, p. 71; Sandfort & Dodge, 2009, p. 55; Nel, 2009).
The current approaches harnessing social media and ICTs to reach subpopulations of gay men, other MSM and transgender women to connect them to HIV services have room for growth. The goal of my research, reported below, is to add to and augment these methods by describing a study that could also be used to connect an at-risk population in Ghana to sexual health interventions and services. In what follows, I describe an independent field study conducted in Ghana that leverages subpopulations of gay men and MSM’s use of Facebook—by mimicking how they use social media—to:
- broaden the reach of sexual health CBOs and NGOs to currently un-reached sub populations of gay men and other MSM on Facebook in Ghana;
- to bridge the gap from online to in-person CBO and NGO contact with gay men and other MSM (e.g. to connect them to research studies or HIV prevention, care and treatment); and
- to successfully navigate and address ethical dilemmas that arise when using such an innovative approach in a context where social stigma and discrimination towards gay men and other men MSM is severe.
Detailing my field study experience in Ghana will provide a deeper context for how sexual minorities use social media in Ghana and how sexual health CBOs and NGOs can learn from and mimic sexual minorities’ use of social media to develop methods to reach largely hidden subpopulations of gay men and other MSM who have little to no knowledge of sexual health services available to them.
Using Facebook to reach gay men and other MSM
Background and review of the study
To provide a background to my research, my use of the phrase “when in Ghana, do as sexual minorities do” is a reflection of my own experience as a sexual minority, and within broader sexual minority populations in Ghana. Over a 10-month period between 2009 and 2010 I became acquainted with sexual minority populations in Ghana as well as a number of sexual health NGOs targeting key populations at disproportionate risk to HIV. Unquestionably, I operated from a position of privilege being a white, male foreigner while in Ghana. However, my methods of making contacts and developing friendships within these populations were similarly shaped by the apparent risks that sexual minorities experience when connecting with others and disclosing sensitive information about sexuality. I also learned about methods of networking within sexual minority populations by interacting within sexual minority communities, taking their advice, and learning from their strategies. The experience integrally shaped my understanding of how sexual minorities interacted, connected and socialised on Facebook in the context of heightened stigma and discrimination.
My field research in Ghana was conducted in 2014 for my Masters degree at the School of Oriental and African Studies, University of London. The field study was designed to gather a broad range of data to address the research question: “How have the politicisation of homosexuality and the transcultural production of sexual orientation and gender identity impacted people with non-normative sexual orientations and gender identities in Ghana?” Preparation for the field study began in January 2014 including obtaining ethical clearance and designing field research methods. Beginning in March, and spanning till the end of the field study in August, I reached out to 400 gay men and other MSM on Facebook to recruit research participants (Facebook recruitment methods are described in the following section). From mid-June to mid-August I was located in Ghana to collect data from participants recruited from Facebook, as well as through respondent driven sampling (i.e. snowballing) and gatekeeper referrals that brought in some lesbian women participants.
Participants predominantly included sexual minorities, including 113 gay men and other MSM and five lesbian women. A small number of participants recruited described themselves as heterosexual during interviews (N=9). Additional interviews included staff of human rights and sexual health NGOs and other business, civil society and community leaders that impact sexual minorities (N=9). While my field study sought to speak with a diversity of sexual minorities, this chapter specifically focuses on how I identified and recruited gay men and other MSM using Facebook. Data collection with the larger group of gay men and other MSM included in-depth interviews (N=70), focus group discussions (N=36) and participant observation (N=7). Gay men and other MSM recruited using Facebook only participated in-depth interviews, while some recruited through snowballing, gatekeepers and sexual health NGOs participated in focus groups. Of the 113 gay men and other MSM who participated in the study, Facebook recruitment methods recruited 64 participants, while 49 other participants had been identified through traditional strategies. In-depth interviews lasted between 30 minutes to three hours, with an average of about 90 minutes. An interview discussion guide was used in all interviews and focus groups, which included a list of standard open-ended questions (see Appendix 1), divided between these eight sections:
1) Social-demographic profile (age, religious/ethic background and family details);
2) Economic profile (means of livelihood, education and future plans);
3) Sexuality profile (description of sexuality, sexual behaviours/dating life, and any economic factors related to sexual relationships);
4) Globalisation and perception of sexuality (Connectedness to ICT resources and friends located globally, means of learning about sexuality, perceived marginalisation/agency that comes with their sexuality);
5) Politicisation of homosexuality (Understanding of the politicisation of homosexuality in Ghana and how this has impacted their life);
6) Societal norms (perception for how societal norms and others’ expectations impact their gender performivity and their relationships including marriage and having children);
7) Religious/spirituality profile (Role/impact of religion in life, marginalisation experienced and agency demonstrated through participation in religious activities/organisations or spirituality); and
8) Sexual health knowledge (knowledge of sexual health services/NGOs, health seeking behaviour, and suggestions for organisations working with sexual minorities in Ghana).
Analysing this data took the form of transcribing interviews, where I categorised responses into themes that I then codified and tallied. However, the data collection was not administered uniformly across participants. Some concepts and questions were added to interviews after participants identified them as important. At times, participants commanded the direction of the interview, addressing many of the questions on their own, while at other times, I led the conversation and adapted the wording and order of questions to maximise continuity and depth of conversation. At the conclusion of interviews, I typically sought to clarify any unclear responses or address skipped questions. Yet, in some instances not all sections or questions were answered, resulting in a number of incomplete interviews.
Methods for identifying gay men and other MSM on Facebook as potential research participants
Three methods were used to identify gay men and other MSM on Facebook as potential participants for my research project. Some of these methods are distinguished from others employed by other NGOs because they reached populations whose status as gay or MSM was not assured before contacting them, leading to both an imperfect but also widely cast sample. These methods included:
- Adding friends-of-friends: I reached out to my previous contacts and friends in Ghana who I knew as gay men or other MSM by requesting their “friendship” on their Facebook profile. From this initially small group of Facebook contacts, I requested friendship with their friends, and friends of their friends (and so on).
- Joining Facebook groups for gay men and other MSM: I searched for and joined Facebook discussion groups for gay men and other MSM. To connect with the members of these groups, I posted a short research description in the discussion board indicating that interested members could reach out to me directly to participate and I directly contacted and requested friendship with some members.
- Searching for “men interested in men”: I used Facebook’s search box to find “men interested in men”. Using this last method, I searched for “men who are interested in men from [name of city]“. Entering these search criteria returned profiles on the basis of the details that Facebook users entered on their profiles, such as their gender, who they are “interested in” (which can include “men, women, or both”), and their current location and hometown.
Each method had unique strengths and weaknesses for identifying gay men and other MSM as potential participants. For instance, those I identified using methods two and three created additional entry-points for the first method to be used again to deepen and broaden to friends-of-friends. However, the first method’s accurate identification of gay men and other MSM was predicated on the assumption that my initial contacts (and their friends) used their Facebook profile primarily to connect with similar men. This appeared especially true for those who used an anonymous Facebook profile (i.e. containing no personally identifiable information or photos), which allowed them to connect with other gay men and MSM and openly discuss matters related to sexuality and sexual interests while avoiding exposure. However, some individuals reached using this method did not only use Facebook for these reasons, some had friends who were heterosexual or others were pretending to be gay or MSM to in order to exploit/blackmail or direct violence towards these groups. Others used their real name and photo to connect with gay men and other MSM among a range of other people including friends and family.
Many Facebook groups for gay men and other MSM are openly accessible, which allowed me to view the list of group members and communicate with members directly. The openness of these groups also indicated they were particularly high risk, as they were open to any Facebook user including people interested in finding other gay men for financial gain (e.g. commercial sex work, blackmail or and theft/violence). Accurately identifying potential participants by searching for “men interested in men” on Facebook was predicated on the assumption that “interested in” meant a sexual interest. Many people I identified using this method appeared to use Facebook profiles that were not anonymous, meaning that some gay men and other MSM used the “interested in” section of their profile to discreetly communicate sexual interests to other gay men and MSM who could interpret this. For example, some participants I identified using this method, and later interviewed, described that their Facebook friends who are neither gay nor MSM would understand “interested in men” on their profile to mean an interest in friendship with other men. Using this method allowed me to identify potential participants located in regions where I had little success with other methods. However, this method also identified a number of “straight” or heterosexual Facebook users (as was revealed during interviews).
In each of these methods, I targeted Facebook profiles that I judged as being more likely to be owned by gay men or other MSM, such as profiles with a high number of mutual friends with me or those who used their Facebook to discuss topics about gay men or other MSM.
Interview recruitment strategies
Knowing how gay men and other MSM use social media not only guided my methods for identifying potential participants on Facebook, but also my strategies to recruit these contacts into in-person interviews. I focused the use of these recruitment strategies on contacts with interest to participate in the research. Conducting my research in Ghana as an independent researcher required that I build my credibility as a legitimate researcher to those I reached on social media. For instance, because Facebook is commonly used as a dating website among gay men and other MSM in Ghana, it was important that I first clarified the goals of my study to those I reached using plain language and inviting a wide range of participants to join the study. In order to protect the privacy and non-disclosed sexuality of possible participants recruited using Facebook, my project description was authored in such a way that it avoided narrowly targeting sexual identities with admittedly quite vague wording. An example of the standard messages sent to those identified on Facebook as possible research participants are included in the graphic below. (The image was edited to blur the profile photo and the named was changed).
Figure 1: Screenshot of Standard Recruitment Messages on Facebook
Being an independent researcher allowed me to travel alone and remotely in order to meet with participants in a variety of locations and settings comfortable to them. Being a gay man who also used social media to connect with other gay men and MSM, meant I assumed additional risks when meeting with participants for interviews. I believe this context offset the typical unequal power relationship between researcher and participant, providing for a friendlier two-way discussion by showing that (in some ways) we had our queer sexuality in common.
For many potential participants identified on Facebook, my positionality facilitated the process of building trust and setting up interviews. Most notably, I am referring to being an “out”, gay, white male researcher who is not from Ghana. Many participants indicated they would not have met with me had I been Ghanaian, or even black. Being seen as an outsider (and my whiteness being evidence of that) but also an insider as a sexual minority, meant many of the contacts I made on Facebook felt more comfortable meeting with me to discuss issues related to their sexuality.
Obtaining informed consent and addressing other ethical considerations
My methods and strategies of reaching gay men and other MSM on Facebook led to unique ethical dilemmas. Here, I account for how participants’ informed consent was obtained, anonymity ensured, confidentiality of personally identifying information secured and the chance for undue harm reduced.
Obtaining participants’ informed consent
To obtain participants’ informed consent, I sent those I reached on Facebook who were interested to participate in the research a “participant consent form” (see Appendix 2 & 3), which detailed the purpose of the study, procedures, ethical considerations, benefits, duration and a statement of confidentiality. I asked each participant to review the participant consent form through Facebook (where possible) before deciding to meet for an interview. Further, I reviewed the participant consent form fully with all individuals who met me for an interview by asking them to read it or, where that was difficult, I read it to participants. Before moving into an interview, I addressed any remaining questions and confirmed their voluntary participation with a verbal consent (to avoid any names being written on paper for anonymity purposes). All of those who met with me consented to participation in the research, while a few opted for informal discussion instead of a formal interview.
Ensuring anonymity and confidentiality of personally identifying information
At the point when my contacts on Facebook indicated an interest to participate, I noted their details into a password protected key file, which included their Facebook name, a link to their Facebook profile and additional contact information provided (e.g. email and phone numbers). I commonly made note of their city or neighbourhood location to schedule interviews by geographic location. I never asked for real names, but rather asked for a name they preferred to use. During audio-recorded interviews the participant and I used a completely new pseudonym that no one knew the participant by. All notes and files associated with participants’ interview responses were linked to their pseudonym and a 4-digit code and only linked to their other names and identifying information in the key file. All field study data, including the key was encrypted before backing up to Google Drive.
Interviews were held in various public and private locations, but never in designated, interview sites or rooms where former participants could find me interviewing later participants.
Reducing chance of undue harm
Even before a participant agreed to participate, those I reached on Facebook could be adversely impacted. For instance, there remained chances that my Facebook ‘friends’ could see whom I was connected to on my Facebook and might suspect these contacts as sexual minorities. For these reasons, I hid my list of friends from others and was sure to invite a wide range of participants (and not narrowly target sexual minorities) so others could not assume that I only connected with sexual minorities on my Facebook account. Further, I depended on those I reached and recruited to recognise and mitigate their own risk when using Facebook, such as using privacy settings, or preventing others from viewing their communication with me on their phone, laptop or public computer.
Minimising risks to participants also resulted from me acknowledging participants’ level and manner of communication and matching this, commonly using less than straightforward language that preserved discretion and plausible deniability for their participation in my research or any basis for them to receive undue harm.
Data and results
Knowledge of sexual health services
Of the 64 interviews with gay men and other MSM recruited through social media, 55 completed the interview discussion guide section on sexual health services. Data from these interviews revealed a very low level of knowledge about sexual health services. Of these 55 men, 24 (44%) had no knowledge of sexual health services for gay men or other MSM in Ghana, while 14 people (25%) merely knew of their existence, but could not name the organisation or what their activities were. A remaining 17 people (31%) were familiar with these organisations and their services (see Figure 2).
Figure 2: Knowledge of Sexual Health NGOs/Services for Gay Men & MSM in Ghana
Another series of questions asked participants about their knowledge of, connection to, and interest in “peer educators” and their services. 40% of participants recruited through social media (N=23) had no knowledge about peer educators. The remainder knew about peer educators (25%), had peer educators as friends (24%) or was either a peer educator himself or had been previously (4%). Slightly more participants were aware of the kinds of services that peer educators provide (N28), while 26 participants (44%) had no knowledge about their service (See Figure 3).
Figure 3: Knowledge of Peer Educators for Gay Men & MSM in Ghana
After confirming that participants were familiar with peer educators (or after I told them about the kinds of services they provide), 34 participants indicated that at some point they would have wanted to speak with a peer educator about issues they were facing. These participants demonstrated unmet needs for peer educators’ services because 15 people indicated both that they did not know about peer educators, but would have liked to speak with one had they known. However, 10 participants who were aware of peer educators did not want to speak to one. An additional 8 participants similarly felt no need to speak to a peer educator even after learning about their services (see Figure 4).
Figure 4: Demand for Peer Education Services
A number of these individuals explained that they felt no need to speak with a peer educator because they already received education on sexual health or felt more confident using the Internet or books to find reliable sexual health information. Some of these respondents did not face many barriers to accessing commodities provided by peer educators (i.e. condoms and lubricant). However, a few indicated that they actively disassociated themselves from sexual health services for gay men and other MSM (e.g. peer educators). For instance, a participant called “Michael” indicated awareness that peer educators provided services to gay men and other MSM in Ghana. “So I know these things are there,” Michael said. “I think I have made a conscious effort not to be a part of them”. Like Michael, there were other participants who shared his sentiments, indicating a self-distancing from sexual health organisations and services targeting sexual minorities – not due to their lacking awareness, but because they wanted to avoid compromising the confidentiality of their sexuality by affiliating with such organisations.
Despite successfully gathering a broad range of participants both demographically and geographically (see Appendix 4-6), my methods proved unsuccessful or insufficient for including some groups of gay men and other MSM (e.g. those older than 45 years old, those located in rural areas or outside the six regions where I conducted fieldwork). Furthermore, my positionality as a white, gay researcher likely complicated the participation of gay men/MSM who engage in blackmail against others because it would be financially non-remunerative (I offered no incentive for participation) or they could feel morally vexed by being interviewed by a queer researcher and may be afraid to discuss how they exploit other gay men/MSM for financial gain. My use of social media also did not help me to reach those not using social media (or those not using it for same-sex sexual interests) and those who cannot speak or read English (due to my own language limitations). For a number of these gay men and other MSM who remain unreached, they likely face added factors making them vulnerable to sexual health concerns (e.g. economic vulnerability) and are distanced from the NGOs who provide sexual health prevention and care services. These sub-populations are a new frontier for future research and service delivery methods in the field of sexual health.
Discussion and conclusion
My field study in Ghana is relevant to sexual health organisations because its methods facilitated outreach and recruitment of gay men and other MSM who are not being reached by the sexual health services targeted for them. I argue this offers a new and innovative approach that sexual health CBOs and NGOs, who are possibly struggling to reach gay men and other MSM, could leverage to provide their services. Furthermore, my participants’ knowledge of, and attitudes towards, available local HIV services can also usefully inform programmatic options to address the sexual health needs of more diverse groups of gay men and other MSM.
Improving sexual health CBOs and NGOs’ outreach to gay men and other MSM
I argue my approach of mimicking how sexual minorities use social media—specifically Facebook—is a timely approach that sexual health CBOs and NGOs could possibly implement to improve outreach to subpopulations of gay men and other MSM in Ghana and elsewhere where homosexuality is criminalised (or where gay men, other MSM and transgender person face extreme stigma and discrimination). CBOs and NGOs could also possibly appoint a social media peer “champion” from the community tasked with mimicking how sexual minorities use social media to improve and augment their outreach programs. Such a peer champion could connect with other gay men/MSM by accumulating contacts and by snowballing through his contacts’ Facebook “friends”, by joining and contacting members of Facebook discussion groups for gay men and other MSM, and by directly searching for “men interested in men” on Facebook.
By using these methods, along with traditional recruitment methods, my research project included the experiences and opinions of 121 sexual minorities; 113 of whom identified as gay men or other MSM. With nearly 70% of participants recruited on social media having little to no knowledge of sexual health services for MSM, it struck me that not only were existing CBOs and NGOs still struggling to connect to sexual health services to these populations in Ghana, but also that outreach strategies, similar to those outlined in this study, could help address this issue. Furthermore, outreach in this manner could connect individuals to sexual health services that they want but don’t know exist (27% of social media-recruited participants indicated this). While some participants did not want to be associated with these sexual health organisations and services, the larger number who did gives cause for sexual health services to continue rethinking how they provide outreach to gay men and other MSM.
Ethically integrating methods into sexual health CBOs and NGOs
While my methods for reaching gay men and other MSM and strategies to recruit participants worked well for my study, they may not be entirely suitable or appropriate for implementation by CBOs and NGOs. Mimicking gay men’s and other MSM’s use of Facebook is a complicated task for sexual health organisations, namely in how they integrate the methods that I was able to employ as an independent researcher into their organisational structure given the many ethical and political dilemmas that may arise.
The specific strategies I chose for identifying participants on Facebook were relatively simple and could be adopted by sexual health CBOs and NGOs. If sexual health CBOs and NGOs do not need to recruit sexual minority participants for studies or have them meet with their staff in-person, these social media recruitment strategies could be implemented quite easily. For instance, the peer educators of some sexual health CBOs and NGOs already use social media to increase their outreach to broader sexual minorities populations, as noted by the SHARPER project in Ghana (Green et al. 2014). However, more ambitious methods could seek those left un-reached by other methods by extending beyond the networks of gay men and other MSM on social media that peer educators are already in contact with. They could diversify the entry points into these virtual networks by incorporating contacts well beyond their circle of friends, by adding friends of friends, including 3rd, 4th, and 5th degree connections. They could also join social media groups meant for sexual minorities or simply search for “men interested in men”.
Because these strategies cast a wider net, and are based on assumptions about how gay men and other MSM use social media, it means many “straight” or heterosexual people may be included in those who are contacted. This sort of recruitment and outreach by sexual health CBOs and NGOs should be encouraged while also tailoring the language of sexual health messages for relevance to both broader audiences as well as to sexual minorities. Broadening the language of sexual health services to avoid messages targeting only gay men and other MSM would help prevent ostracising some audiences who would not want to be associated (on social media or otherwise) to organisations or people known to have this focus. This is particularly important for social media outreach to gay men and other MSM who are using a Facebook with personally identifying information.
However, peer educators and sexual health CBOs and NGOs using these approaches may be placed at increased risk, because they will likely reach audiences that are beyond the safety and trust that is developed within in-person peer-networks. Peer educators may not be open about their sexuality beyond small groups of friends or the sexual health CBO or NGO may be discreet about their outreach efforts. Maintaining a balance between methods that seek to reach people who are more likely to be gay men or MSM, while at the same time mainstreaming the communication and messages for general audiences may help to reduce these risks. Additionally, it may help for peer educators to conduct outreach in cities, regions or even countries different than their own and where they feel comfortable with the risks. Alternatively, peer educators could also use anonymous Facebook profiles to conduct outreach if it is not important for sexual health organisations to recruit the gay men and other MSM for in-person meetings.
When sexual health CBOs and NGOs seek to recruit sexual minority populations into physical meetings for research or to deliver sexual health services, there are more pronounced ethical and logistical considerations. Many sexual health NGOs are not well suited to employ the tactics I used to successfully bridge the gap between social media outreach and recruitment for in-person interviews. I was successful in this regard due to the manner of my fieldwork and my own positionality. For the most part, my fieldwork was conducted in isolation from sexual health CBOs and NGOs and as an independent researcher. I chose this manner of fieldwork to distance myself from the stigma that many participants feared when associating with groups who target gay men and other MSM. Operating independently in the field also allowed me to be more vulnerable and accessible to potential participants, meeting them in contexts and in manners convenient to them. This helped reduce the inhibitions of some participants to meet me. Furthermore, my positionality as a white, gay, foreigner who was not working for sexual health CBOs or NGOs was especially important for securing in-person interviews.
My experience demonstrates a case for sexual health CBOs and NGOs to consider employing independent consultants or even including foreigners into social media outreach in addition to their domestic peer educators and researchers. Many of my research participants only met with me because I was a foreigner. However, when dealing with sexual minority populations and marginalised populations generally, there are heightened concerns for sexual health CBOs and NGOs who may want to employ independent researchers. The lacking ability for these CBOs or NGOs to oversee these researchers’ operations is one concern, as well as reconciling their specific policies and ethics procedures that detail how to engage with marginalised populations. This is not to mention the prohibitively high cost of hiring foreign staff by these CBOs and NGOs. Striking a balance between researchers whose positionality and experience will grant them preferential access to sexual minority communities is integrally important. My positionality and experience was helpful for my participants to feel comfortable to talk with me on social media as well as in-person during interviews. However, it is unlikely that any single researcher will be capable of adequately accessing all sub-populations. Even with my preferential access, I was also disadvantaged in accessing other subpopulations.
Targeting gay men and other MSM for HIV prevention and care
My research sought to improve outreach of HIV prevention and care to gay men and other MSM, however it also brings into question the logic of targeting these groups in the first place. While 44% of those I recruited through social media had no knowledge of sexual health services in Ghana for gay men and other MSM, this should not be construed as an overwhelming desire for such services among these participants. For participants recruited through social media, 18% (N10) were aware of peer educators and the sexual health services for gay men and other MSM, but were not interested in their services. Another 15% (N8) were not aware of these services, and even after being informed about peer educators and their services, were not interested. Some of these participants indicated that they did not experience any barriers to accessing sexual health services, but others avoided sexual health services targeting gay men and other MSM specifically because they targeted gay men and other MSM.
My research found that some gay men and other MSM feared the stigma of being associated with these organisations. Recognising this, I argue that complementary efforts should be employed by sexual health CBOs and NGOs to better reach those who actively avoid them. This is important because these populations are still at a high risk to HIV, yet social circumstances and personal preferences place them at odds with accessing the currently available services directed to them. These additional efforts should include stigma reduction through nurses and doctor trainings within the public health services and offering more affordable private health services that can meet the health needs of gay men and other MSM. Human rights organisations may be well suited for this mandate, including the broader work of educating the public about sexual minorities and addressing misconceptions and stigma that exacerbate health outcomes for these populations. While the targeting of HIV care and treatment to key populations is certainly a frontier worth furthering, especially for the sake of populations who are denied health services on the basis of sexual orientation or gender identity, other methods will be necessary for those who would avoid these organisations’ targeted services.
Allman, D., Meyers, T., Xu, K., & Steele, S. J. (2012). The social technographics of gay men and other men who have sex with men (MSM) in Canada: Implications for HIV research, outreach and prevention. Digital Culture & Education, 4(1).
Avari, J. (2014, August 20). Alleged Grindr security flaw exposes exact location data, endangers users. NDTV. Retrieved from http://gadgets.ndtv.com/apps/news/alleged-grindr-security-flaw-exposes-exact-location-data-endangers-users-1-579031
Avery, M., Meng, G., & Mills, S. (2014). Two internet-based approaches to promoting HIV counselling and testing for MSM in China. Digital Culture & Education, 6(3). Retrieved from http://www.digitalcultureandeducation.com/volume-6/avery_et_a/
Baral S. D., Poteat T., Stömdahl S., Wirtz A. L., Guadamuz T. E., & Beyrer C. (2013). Worldwide burden of HIV in transgender women: A systematic review and meta-analysis. Lancet Infect Dis. 13(3): 214–222. doi:10.1016/S1473-3099(12)70315-8.
Beck, J., Catanes, L. M., Herbert, P., Negelev, G., & Ayala, G. (2012). Local languages, global exchange: Digital networking, communication and collaboration for the health and human rights of men who have sex with men. Digital Culture & Education, 4(1). Retrieved from http://www.digitalcultureandeducation.com/volume-4/thehive_3002/
Chaiyajit, N., & Walsh, C S. (2012). Sexperts! Disrupting injustice with digital community-led HIV prevention and legal rights education in Thailand. Digital Culture and Education, 4(1): 146-166. Retrieved from http://www.digitalcultureandeducation.com/cms/wp-content/uploads/2012/04/theHIVe_3012.pdf
Chaiyajit, N. (2014). TLBz Sexperts! Using information and technology to get to zero HIV infections among Thai transgender people. Digital Culture and Education, 6(3): 243-253.
Citi FM Online. (2010, June 4). Thousands attend first anti-gay protest in Ghana. Citi FM Online. Retrieved from http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=183484
Corey-Boulet, R. (2012, December 1). Anti-gay stigma hinders bid to lower Cote d’Ivoire’s HIV rate. Inter Press Service. Retrieved from http://www.ipsnews.net/2012/12/anti-gay-stigma-hinders-bid-to-lower-cote-divoires-hiv-rate/
Currier, A. (2014). Arrested Solidarity: Obstacles to Intermovement Support for LGBT Rights in Malawi. Women’s Studies Quarterly 42(3), 146-163.
Daily Guide. (2010, May 28). Gays, lesbians go gospel. GhanaWeb. Retrieved from http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=182960
Dasgupta, R. K. (2012). Digital media and the Internet for HIV prevention, capacity building and advocacy among gay, other men who have sex with men (MSM), and transgender (TG): Perspectives from Kolkata, India. Digital Culture & Education, 4(1). Retrieved from http://www.digitalcultureandeducation.com/volume-4/thehive_3006/
Epstein, D., Morrell, R., Moletsane, R. & Unterhalter, E. (2004). Gender and HIV/AIDS in Africa south of the Sahara: interventions, activism, identities. Transformation: Critical Perspectives on Southern Africa 54(1), 1-16.
Essien, K. & Aderinto, S. (2009). ‘Cutting the head of the roaring monster’: Homosexuality and repression in Africa. African Study Monographs 30(1): 121-135. Retrieved from http://repository.kulib.kyoto-u.ac.jp/dspace/handle/2433/85284
Eveslage, B. (2015). Sexual health or rights? USAID-funded HIV/AIDS interventions for sexual minorities in Ghana. In J. Gideon and M. Leite (Eds.), Gender and Health Handbook. Cheltenham, UK and Northampton, USA: Edward Elgar.
Frempong, G. (2012). Understanding what is happening in ICT in Ghana: A supply and demand-side analysis of the ICT sector. Evidence for ICT Policy Action, Policy Paper 4.
Green, K., Girault, P., Wambugu, S., Clement, N. C. & Adams, B. (2014). Reaching men who have sex with men in Ghana through social media: A pilot intervention. Digital Culture & Education, 6(3). Retrieved from http://www.digitalcultureandeducation.com/volume-6/green_et_al/
Hanckel, B., Garcia, L., Santos, G. & Manalastas, E. J. (2014). Assessing needs and capabilities: Towards an ICT resource to support HIV-positive gay men and other MSM in Southeast Asia. Digital Culture & Education, 6(3). Retrieved from http://www.digitalcultureandeducation.com/volume-6/hanckel_et_al/
Henry, E., Yomb, Y., Fugon, L. & Spire, B. (2012). The use of the Internet in male sexual encounters by men who have sex with men in Cameroon. Digital Culture & Education, 4(1). Retrieved from http://www.digitalcultureandeducation.com/volume-4/thehive_3003_/
infoDev. (2014). Mobile at the Base of the Pyramid: Ghana. Washington, DC: World Bank.
IRIN. (2006, Oct 26). Zimbabwe: Homophobia raises HIV risk for gays. IRIN. Retrieved from http://www.irinnews.org/report/62628/zimbabwe-homophobia-raises-hiv-risk-for-gays.
Jones S, & Fox S. (2009). Generations online in 2009. Pew Internet and American Life Project. Retrieved from http://www.pewinternet.org/Reports/2009/Generations-Online-in-2009.aspx
Kahema, C. M., Kashiha, J., Mbote, D. K. & Mhando, M. R. (2014). Bambucha media: Using social media to build social capital and health Seeking behaviour among key populations. Digital Culture & Education, 6(3). Retrieved from http://www.digitalcultureandeducation.com/volume-6/kahema/
Lane, T. (2009). From social silence to social science: HIV research among township MSM in South Africa. In V. Reddy, T. Sandfort, & L. Rispel (Eds), From Social Silence to Social Science: Same-Sex Sexuality, HIV & AIDS and Gender in South Africa. Edited by. Cape Town: HSRC Press
Mac-Darling Cobbinah. (2015, February 16). Mob justice, not homosexuality, at root of society’s evils. Modern Ghana. Retrieved from http://www.modernghana.com/newsthread1/598875/50/283964
Martinez, O. et al. (2014). Still a hard to reach population? Using social Media to recruit Latino gay couples for an HIV interventions adaptation study. Journal of Medical Internet Research, 16(4).
Muessig, K. E., Baltierra, N. B., Pike, E. C., LeGrand, S., & Hightow-Wiedman, L. B. (2014). Achieving HIV risk reduction through HealthMpowerment.org, a user-driven eHealth intervention for young Black men who have sex with men and transgender women who have sex with men. Digital Culture & Education, 6(3). Retrieved from http://www.digitalcultureandeducation.com/volume-6/muessig_et_al/
Nel, J. (2009). Same-sex sexuality and health: Current psychosocial scientific research in South Africa. In V. Reddy, T. Sandfort, & L. Rispel (Eds), From Social Silence to Social Science: Same-Sex Sexuality, HIV & AIDS and Gender in South Africa. Edited by. Cape Town: HSRC Press
O’Mara, K. (2013). LGBTI community and citizenship practices in urban Ghana. In S.N. Nyeck and M Epprecht (Eds. ), Sexual Diversity in Africa: Politics, Theory, and Citizenship (188-207). McGill-Queen’s University Press.
Oosterhoff, P. 2014. Research Methods and Visualisation Tools for Online LGBT Communities. IDS Evidence Report, No. 89. Retrieved from http://www.ids.ac.uk/publication/research-methods-and-visualisation-tools-for-online-lgbt-communities
PANA. (2011, June 4). Gay concerns, bloody accident played up by Ghanaian media. PANA. Retrieved from http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=210119
Paz-Bailey, G., Jacobson J. O., Guardado, M. E., et al. (2011). How many men who have sex with men and female sex workers live in El Salvador? Using respondent driven sampling and capture-recapture to estimate population sizes. Sexually Transmitted Infections, 87:279-82.
Quaye, S. et al. (2015). Critique and lessons learned from using multiple methods to estimate population size of men who have sex with men in Ghana. AIDS Behaviour, 19(Supplement 1):S16-23.
RFSL. (2009). We are the Sexperts! A Manual on How to use Internet Chatrooms and Communities to Promote Sexual Health and Condom Use. Stockholm. Sweden. Retrieved from http://www.rfsl.se/halsa/public/RFSL_sexperterna_rapport.pdf
Rivas, J., Wheeler, J., Rodas, M., & Lungo, S. (2014). “Hidden on the social media”: HIV Education on MSM through Cyber-educators in Central America. Digital Culture & Education, 6(3). Retrieved from http://www.digitalcultureandeducation.com/volume-6/rivas/
Sandfort, T. & Dodge, B. (2009). Homosexual and bisexual labels: The need for more clear conceptualisation operationalisations and appropriate methodological designs. In V. Reddy, T. Sandfort, & L. Rispel (Eds), From Social Silence to Social Science: Same-Sex Sexuality, HIV & AIDS and Gender in South Africa. Edited by. Cape Town: HSRC Press
Scheibe, A., Brown, B., & Bekker, L. (2012). ICT & HIV prevention: Experiences from a biomedical HIV prevention trial among men who have sex with men (MSM) in Cape Town, South Africa. Digital Culture & Education, 4(1). Retrieved from http://www.digitalcultureandeducation.com/volume-4/thehive_3004/
UNAIDS. (2014). Services for Transgender People, Guidance Note. Retrieved from http://www.unaids.org/sites/default/files/media_asset/2014unaidsguidancenote_servicesfortransgenderpeople_en.pdf
USAID. (2014). Key populations: Targeted approaches toward ad AIDS-free generation. Retrieved from http://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/key-populations-targeted-approaches-toward#section3
Walsh, C. S. (2008). Producing animations to educate MSM and MSW to fashion safe sex practices and address low perceptions of personal risk. IADIS Multi Conference on Computer Science and Information Systems 2008, Amsterdam. July, 2008, pp. 99-102. Retrieved from http://oro.open.ac.uk/19576/
Walsh, C.S., Laskey, B., Chaiyajit, N., Morrish, W. (2010). Producing animations to teach victims of sexual violence how to access legal rights. O IADIS e-Democracy, Equity and Social Justice Conference 2010. Freiburg, Germany.
Walsh, C. S. (2011). Mobile and Online HIV/AIDS Outreach and Prevention on Social Networks, Mobile Phones and MP3 Players for Marginalised Populations. In S. Barton, J. Hedberg & K. Suzuki (Eds.), Proceedings of Global Learn 2011 (pp. 1858-1866). Association for the Advancement of Computing in Education (AACE). Retrieved from http://www.editlib.org/p/37412
Walsh. C, S., Chaiyajit, N., & Thepsai, P. (2010, January 22). Mplus Thailand produces animations for HIV/AIDS outreach and prevention. Fridae. Retrieved from http://www.fridae.asia/gay-news/2010/01/22/9575.mplus-thailand-produces-animations-for-hiv-aids-outreach-and-prevention?n=aut
Wilson, E. C., et al. (2009). Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS and Behavior, 13(5): 902–913.
Wood, Stephen. (2014). Digital Battlegrounds: the growing struggle to contest LGBT online spaces. IDS Blog. Retrieved From https://participationpower.wordpress.com/2014/10/15/digital-battlegrounds-the-growing-struggle-to-contest-lgbt-online-spaces/
Young, S. D. & Jaganath, D. (2013). Online social networking for HIV education and prevention: A mixed methods analysis. Sexually Transmitted Diseases, 40(2): 162-7.
The chapter is based upon the author’s Master’s dissertation submitted to the School of Oriental and African Studies in September 2014 titled, “The Transcultural Production of Sexual Orientation and Gender Identity (SOGI), Securitisation and the Politicisation of Homosexuality in Ghana”. For the support, feedback, comments and criticism spanning the planning, fieldwork and multiple drafts of this research, he would like to thank Dr Christopher Walsh, Dr Colette Harris, Dr Rahul Rao, Kwame Edwin Otu, the participants at Oxford University’s Researching Africa Day 2014 and Birkbeck University’s Re-Writing Homophobia conference in 2014, and all participants and informants in Ghana, particularly John David Dupree, Mac Darling Cobbinah and Nana Fosua Clement.
Benjamin Eveslage is a consultant to FHI 360 on the LINKAGES project. He holds an MSc in Research for International Development from the School of Oriental and African Studies, University of London. His research focuses on analysing the experience of marginalised populations within processes of transcultural change and international development practice. He has taken on a number of capacities during his 15 months in Ghana from 2008 to 2014, including fieldwork with sexual minorities, key populations and sexual health organisations. From these experiences and research endeavours he hopes to highlight the tensions and prospects for joint health and human rights approaches in international development.