Sexperts! Disrupting injustice with digital community-led HIV prevention and legal rights education in Thailand

Nada Chaiyajit
Christopher S Walsh
Published Online: April 15, 2012
Full Text: HTML, PDF (476 KB)

Abstract

In addition to growing epidemics of HIV among men that have sex with men (MSM) and transgenders in Thailand, a low awareness of how to access justice increases their vulnerability. This paper presents unique case studies of how two community-based and led organisations used social networking and instant messaging to address this problem. It describes and analyses how online peer-based HIV education and prevention was integrated with access to justice through free university-based clinical legal education (CLE). It argues that re-designing HIV prevention and education through digital technologies with marginalised gay men, other men that have sex with men (MSM) and transgenders is a sustainable community-based and led approach. Furthermore digital media offer strategic opportunities to overcome on-going political violence alongside entrenched stigma and discrimination that disrupt denial of access to justice for populations disproportionately at risk of HIV.

Keywords: clinical legal education (CLE), community research, HIV and AIDS, online peer outreach and prevention (OPOP), gay men, other men that have sex with men (MSM), mobile phones, social justice, transgender, Thailand

The need to disrupt denial of access to justice

Local responses to the global HIV and AIDS epidemic cannot be effective unless the human and legal rights of those infected and affected by HIV are clearly and undeniably addressed (amfAR, 2008). Globally, four decades into the HIV and AIDS epidemic, many countries, including Thailand, have adverse or unfriendly legal environments that potentially undermine the impact of HIV and AIDS outreach and prevention programmes. Thailand has been experiencing an on-going and often violent political struggle between the People’s Alliance for Democracy (‘Yellow Shirts’) and the People’s Power Party (‘Red Shirts’) since 2005. This social upheaval—alongside existing entrenched stigma and discrimination towards gay men, other MSM and transgender communities—is precipitating negative discourses that produce increased risk of HIV infection among gay men, other MSM and transgenders.

As a transgender activist, researcher, peer educator and sexual health counsellor (Chaiyajit) and an openly queer academic and activist (Walsh), we understand all too well that violence, stigma and discrimination are drivers of HIV vulnerability and deny access to prevention, education and care. In our collaborative work around face-to-face and online HIV education and prevention, we are constantly reminded of how gay men, other MSM and transgender individuals struggle against unrelenting social exclusion caused by stigma, discrimination, violence, poverty, lack of access to housing, violations of human and legal rights, homophobia, transphobia and heterosexism. In Thailand specifically, as well as our work in neighbouring Viet Nam, pervasive negative attitudes and violence toward gay men, other MSM, and transgenders are commonly condoned not only by some local police, but also by the state and society in general.

This situation makes it difficult, even impossible, for openly lesbian, gay, bisexual and transgender (LGBT) individuals to find sustainable employment, housing and healthcare outside major cities such as Bangkok, Chiang Mai, Pattaya and Phuket. The situation is particularly dire for transsexuals because they are unable to legally change their gender on state identification cards, even when they have undergone gender reassignment surgery and live as women. This fact alone ‘outs’ them as transgender when they seek employment and housing, something gay men and other MSM do not necessarily have to deal with. Thai media is rife with negative representations of LGBT individuals, with the exception of a few films. Thai cinema and public television often use humour to maintain and reinforce deeply embedded and taken for granted negative stereotypes (Barea, 2012; Jackson and Sullivan, 1999). These media distortions make it difficult for openly gay and bisexual men, other MSM and especially transgenders to identify themselves openly. As a result, a fear of identity disclosure or ‘coming out’ makes it exceedingly difficult to provide LGBT and other MSM with practical HIV education and prevention resources they need on how to access justice when their human or legal rights are violated.

This article describes our work in designing the Mplus Sexpert and the TLBz Sexperts!—two online peer outreach and prevention programmes (OPOP)—that tackle this problem. Putting social justice at the forefront of our work, we examine how two small community-based and led organisations worked in collaboration with strategic partners to integrate contextualised HIV education and prevention alongside access to free university-based clinical legal education (CLE).  First we outline the often-unrecognised situation in Thailand in regards to stigma and discrimination faced by gay men, other MSM, transgenders and sex workers. We then provide background information on HIV prevalence and inconsistent condom use among these communities that was the catalyst for our design of both programmes. We next illustrate how the Mplus Foundation and ThaiLadyBoys.net redesigned peer-based community-led HIV education and prevention using social networking and instant messaging software online and on mobile phones. We highlight how each programme focused explicitly on sexual pleasure as well as health and legal rights. We discuss the key features of both programmes and elucidate implications for quality community-based and led digital interventions. We argue that disrupting denial of access to justice by leveraging digital technologies requires building trust, and continuous stakeholder involvement, to challenge the status quo while reworking and rethinking static biomedical notions of HIV prevention and education.

The land of smiles?

Often referred to ‘as the land of smiles’, Thailand is generally viewed as a tolerant country in regards to its lesbian, gay, bisexual and transgender (LGBT) communities. It is also a popular travel destination for LGBT travellers who experience an open and ‘gay-friendly’ environment that appears absent of stigma and discrimination. Unlike LGBT tourists however, Thai gay men, other MSM and transgenders face extreme stigma and discrimination (Breton, 2009; Brenton and Gonzalez-Figueroa, 2009; UNESCO, 2011; WHO, 2011). This is particularly true for transgender individuals (Nakpor, 2011; UNESCO, 2011). They are also victims of gender-based violence (Egremy, Betron, Eckman, 2009). The authorities often ignore violence against transgenders because they represent a direct challenge to traditional gender norms and roles (Gilles, 2011). The people and government of Thailand tolerate these groups but many certainly do not accept them. In fact, many Thai policymakers and officials believe homosexuality is inappropriate or misdirected (UNGASS, 2010; UNAIDS, 2010).

Stigma and discrimination towards Thai LGBT and other MSM

An overt example of stigma and discrimination against the LGBT community in Thailand was the cancellation of the 2nd Annual Gay Pride Parade on January 21, 2009 (Fridae, 2009; Saunders, 2009). Just before the parade started, organisers and parade participants were locked in a compound and subjected to public harassment and prejudice by the Rak Chiang Mai 51 political group, or ‘Red Shirts’. Parade participants suffered overt discrimination, some were injured, and all were prevented from leaving or entering the compound for over 4 hours while 150 police officers observed (The Nation, 2009). The parade organisers, participants and supporters responded non-violently by sitting in prayer (Figure 1).  The Rak Chiang Mai 51 believes that LGBT individuals and parade participants were destroying traditional Thai Lanna culture by having a Gay Pride parade. They broadcasted this notion via local radio stations calling on Chiang Mai residents to come and block the parade. This overt violence publicly sanctioned and increased homophobia, transphobia, stigma and discrimination towards gay men, other MSM and transgenders.  Seen in the light of the wider on-going political struggle in Thailand, this event highlighted for us that effective HIV prevention and education could only be achieved in a favourable environment where LGBT and other MSM’s rights are fully respected. The harm caused by this experience brought us together to mobilise the community, conceive of, seek funding for, design and launch peer-based online and mobile HIV prevention and education that explicitly integrated access to legal rights.

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Figure 1: Parade participants’ non-violent response to the Chiang Mai Rak 51’s ‘gay parade get out’ public rally to cancel the 2009 Chiang Mai Gay Pride Parade

Standing in solidarity with marginalised groups

Unlike some Thai officials and policymakers, we believe the trite notion of ‘tolerance’ is not helpful for gay men, other MSM, sex workers and transgender individuals who need to understand and navigate personal risk to HIV. Instead it is likely to increase their vulnerability to the virus.  Vulnerability to the virus prior to the moment of exposure takes the form of stigma and discrimination directed at these groups.  These discourses in society can lead to feelings of low self-esteem. These internalised feelings are often symptomatic of other high-risk behaviours, such as substance abuse, transactional sex, or engaging in unsafe sexual practices. As educators and activists, we strongly believed that we needed to transcend the weak and pathetic belief in tolerance that does little to challenge the overt stigma, discrimination and violence faced by gay men, other MSM, sex workers and transgenders in Thailand. This prompted us to rethink and redesign our approach to HIV education and prevention to critically and practically focus on empowering LGBT and other MSM to understand their rights under Thai law and to access justice when they find their rights violated.

“Tolerance” is a word commonly used when speaking about appropriate responses to difference. In fact, practicing “tolerance” is what many educators see as the best indication of a civil and respectful society. (Nieto, 2009, p. 247)

It is important to note that the LGBT community in Chiang Mai did not tolerate the vicious attack on their rights.  The cancellation of the parade galvanised local, national and even international community based groups (CBOs) and non-governmental organisations (NGOs). After two years of constant struggle and persistence, the LGBT community collaborated with other CBOs and NGOs in Chiang Mai to successfully organise a “Peace Walk” in 2011. They were unable to call it a Gay Pride Parade because they were subject to the same kind of public opposition and discrimination they faced in 2009.  A successful peace walk does not mean that LGBT and other MSM do not still face considerable discrimination as well as a forfeiture of their legal and human rights at the hands of police, health care professionals and Thai citizens. Aung Myo Min (2011), the director of the Human Rights Education Institute of Burma (HREIB) and a gay member of the Chiang Mai LGBT community said, in relation to the 2011 Peace Walk:

We are struggling and we still have to try much harder to obtain equality for LGBT people. We can say that it is a struggle within a struggle. It means that the LGBT rights activists are struggling even in the communities which promote democracy and human rights. (Irrawaddy, 2011, ¶ 10)

HIV prevalence among Thai gay men, other MSM and transgenders

Current research clearly indicates that MSM—the term used in the research literature to refer to a wide spectrum of individuals, regardless of stated sexuality or even gender identity—are at a higher risk of contracting HIV in concentrated urban areas such as Bangkok, Chiang Mai and Phuket as well as rural provinces (Avert, n.d.). A 2008 demographic survey found that HIV incidence among MSM in Bangkok increased from 17% in 2003 to 28% in 2005 and 31% in 2007. The rate of new HIV cases in Chiang Mai rose from 15.3% in 2005 to 16.9% in 2007, while rates in Phuket increased from 5.5% to 20% in the same time period (Wimonsate, et al., 2008). The survey also found that half of MSM do not use condoms and that male commercial sex workers (MSW) are at high risk of contracting HIV because they engage in unsafe sexual behaviour. Yet, some progress has been made in terms of reducing new infections:

HIV infection among men who have sex with men (MSM) remains higher and does not show any indication of declining. HIV among MSM is higher in large urban centers and important tourist locations. Nevertheless, the intensified prevention activities among this population over the past two years, especially in Bangkok, are starting to show results in terms of reduced HIV prevalence, from 30.7% in 2007 to 24.7% in 2009. (UNAIDS, 2010, p.3)

Despite the welcome decrease in HIV prevalence, UNAIDS (2010) forecasts a different scenario. Drawing on epidemiological data merged with data from ad hoc serosurveys, this report indicates an overall trend toward a continued spread of HIV. It also indicates the almost certain possibility of a return to an increasing trend among high-risk groups such as gay men, other MSM, male sex workers and transgenders. This trend is consistent with a significant 2010 study of young MSM in Bangkok, Chiang Mai and Phuket. This study found high levels of inconsistent condom use among sexually active young MSM (15-24 years). Of the 837 participants, 33.1% were regular MSM, 37.7% were MSW, and 29.1% were transgenders. 46.7% of MSM, 34.9% of MSW and 52.3% of transgenders reported recent inconsistent condom use (Chemnasiri et al., 2010).

A particular concern we faced alongside the high levels of inconsistent condom use was the increasing use of social networking technologies and mobile phones to potentially access more sexual partners and clients by gay men, MSM, transgenders and sex workers in Thailand. This trend mirrors trends noticed globally in these populations (Liau et al., 2006). There has also been an increasing focus among public health researchers on using online approaches for designing HIV prevention and education among gay men and MSM (Ybarra & Bull, 2007; Rosser et al., 2010). Against these trends however, we were troubled by the lack of attention to the continuing problem of unequal access to justice in community-based and HIV prevention and education. Despite the global push for human rights, gay men, other MSM and transgenders in Thailand are still more likely than heterosexuals to suffer injustice.

Justice, justice, justice

Against a disenabling social and cultural environment and concerns with rising HIV infection, we felt it important to look wider than ‘evidence-based’ biomedical and public health perspectives on online HIV prevention and education (see Rosser et al., 2010). Often, these approaches ignore the need to address human rights and focus on rational behaviour change. They assume gay men, MSM and transgenders exposed to explicit sexual materials, vignettes, reflective journeys, videos, cartoons, and “ ‘hot sex’ calculators” (Rosser et al., 2010, p. 2100) through e-Learning curricula will simply reproduce the tips and tricks they are given by virtual peer educators in forums and chat rooms. However, these ‘safe sex’ messages focus on psychosocial aspects of sexuality and do not teach gay men, MSM and transgenders how to challenge harmful thinking in public spaces in ways that did not put them at harm.  They also do not consider the significance of educating gay men, MSM and transgenders about the importance of knowing and accessing their basic human rights as citizens.

Consequently, we grounded our thinking in how to design and deliver effective HIV education and prevention in affirmation, solidarity and critique (Nieto, 1994) with gay men, other MSM, sex workers and Transgenders. We designed both programmes “on the understanding that culture is not a fixed or unchangeable artefact, and it is therefore subject to critique.  Passively accepting the status quo of any culture is thus inconsistent with this level of…education” (Nieto, 1994, pp. 5-6).  Thus we focused our programmes on educating LGBT, other MSM, sex workers and transgenders about the law and human rights, drawing on the United Nation’s Universal Declaration of Human Rights, as well as their rights under the Thai constitution. We view the generative production of human rights as a necessary element of any HIV prevention and education response to the HIV pandemic in Thailand. As we discuss in the two case studies below, the Sexpert programmes are community-based and led. They are intentional public health and legal rights strategies that deliberately stand in solidarity with LGBT, other MSM and sex workers to reduce stigma and discrimination through digital HIV prevention and legal rights education.  This novel, yet significant, approach is paramount and timely to tactically disrupt injustice in light of increasing HIV infection rates among these groups.

Both programmes we discuss below are examples of critical work aimed at strengthening the rule of law through clinical legal education (CLE) and outreach directed at gay men, other MSM, sex workers and transgenders.  This is pedagogic action that transcends the notion of tolerance.  This is also what led us to work closely with Bridges Across Borders South East Asia Community Legal Education Initiative (BABSEA CLE). Their goal is to provide legal knowledge and legal services to poor, vulnerable and marginalised communities. By collaborating directly with them, we were able to improve access to justice to Mplus and ThaiLadyBoyz’s target populations by providing resources to peer educators that made the system and rules of law in Thailand more transparent. Thus they can simultaneously provide rights-based education alongside HIV prevention and outreach. The right-based education is provided through free clinics housed at universities, as well as through multi-platform online and mobile CLE training materials to raise awareness of rights to Mplus and ThaiLadyBoyz community members and stakeholders.

Sexperts!

A ‘Sexpert!’ is essentially an expert about sex. They specialise in making peers feel comfortable talking about their sexual practices. They provide HIV, sexual health and legal rights education in non-threatening and anonymous virtual environments. A priority for Sexperts is to openly acknowledge the pleasure in having sex while discussing sex with peers online. A Sexpert understands that making a person feel guilty about their sexual practices will sacrifice any viable opportunity to discuss safe sex and personal risk to HIV. Unlike doctors, social workers or therapists, Sexperts are peers recruited from stakeholder communities who receive specialised training, practice and supervision.

The programmes we implemented and currently run were collaboratively designed with the LGBT and sex worker communities in Chiang Mai. This was essential to properly contextualise peer-based HIV prevention and education. These programmes also focus the attention of these communities on understanding the laws and rights that are in the Thai constitution, particularly around access to healthcare, employment and housing.

The first case study we describe details our work with the Mplus Foundation from 2010 to 2011. The second study presents our current work with ThaiLadyBoyz.net. Both organisations are community-based and led. They are dedicated to reducing new HIV infections and battling stigma and discrimination.

Mplus is centrally located in Chiang Mai with a physical drop in centre. It works in and around the city with 12 fulltime staff. It is a recognised community-based organisation (CBO). It is primarily funded by USAID through PACT Thailand. It receives additional funding from the Global Fund to Fight AIDS distributed through Rainbow Sky Association Thailand (RSAT).

ThailadyBoyz.net is entirely Internet based. It runs without any external funding. It serves the transgender community across Thailand. Transgender volunteers staff it. The TLBz Sexperts! programme is currently funded through Bridges Across Borders South East Asia Community Legal Education Initiative (BABSEA CLE) an international non-governmental organisation, that focuses on ethically oriented legal capacity development and community empowerment to enhance access to justice in marginalized communities[i].

The Mplus Sexpert! and TLBZ Sexpert! programmes were designed with funding from amfAR’s MSM Initiative received in 2009. The Swedish Federation for Lesbian Gay, Bisexual and Transgender Rights (RFSL) provided initial training and support to adapt and localise their successful “We are the Sexperts!” programme (Dennermaln and Herder, 2009). BABSEA CLE provided capacity building for collaborative research. It also assisted with continuous community stakeholder involvement in the project.

These efforts produced a 72 pages manual entitled Sexual, human and legal rights for Chiang Mai’s men that have sex with men (MSM), male sex workers (MSW) and transgender (TG) communities[ii] (Figure 1). The manual is an invaluable resource for peer educators and counsellors. It provides them a structured approach to support gay men, other MSM, male sex workers (MSW), transgenders and transgender sex workers understand HIV prevention and their human, legal and sexual rights under Thai law. Twelve peer educators were trained to use this manual for both face-to-face and online support in both programmes. The manual provides a comprehensive listing of references to access local rights and referrals to health services, including free voluntary confidential counselling and testing (VCCT) and university-based clinical legal education (CLE). Both programmes also make use of a number of educational digital animations to help young gay men, male sex workers, transgenders and ‘hidden’ MSM understand personal risk to HIV and how to access justice when an individual finds their rights violated. These animations were designed through behavioural research done by and with these populations. (Walsh, 2011; Walsh, Laskey and Morrish, 2011; Walsh, Chaiyajit, and Thepsai, 2010).

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Figure 2: Sexual, human and legal rights manual produced by BABSEA CLE, Mplus and The Open University

Mplus Sexpert!

Objectives

Mplus implemented the Mplus Sexpert! an online outreach and prevention program (OPOP) from 2010 to 2011 in Chiang Mai (Figure 2). The objective of OPOP is to equip gay men, other MSM, sexworkers and transgenders with the knowledge and skills to tackle the social factors that influence their vulnerability to HIV. OPOP aimed to reduce stigma and discrimination around sexuality, sex work, sexual orientation, gender identity, and legal and human rights. In launching the project, Mplus’ overall goal was to improve and expand its HIV education, prevention and outreach coverage (direct services) with the goal of facilitating the achievement of universal access to appropriate HIV prevention. This commitment was grounded in an ethos to simultaneously promote human and legal rights.

Target Audience

The primary groups targeted by the Mplus Sexpert! programme were:

  • Young MSM who may identify as gay or bisexual and generally tend to be under 25. They missed out on the successful HIV campaigns of the 1990s and often have low perceptions about personal HIV risk. Reports suggest around 85% of Thai youth do not see HIV as something that they should be concerned about, even though 70% of all STI cases in Thailand occur among this group (IRIN, 2006).
  • Transgenders are a diverse group in Chiang Mai. This makes them hard to access for HIV prevention and education. Many are university students, some are everyday workers and others are sex workers. Although HIV prevalence in this group decreased from 17.6% on 2005 to 16.8% in 2007[iii], it is still high. Like many young gay men, transgenders missed out on the successful HIV campaigns of the 1990s and often have low perceptions about personal HIV risk. They also suffer stigma and discrimination.
  • Thai MSM and MSW who work across a variety of venues including bars, saunas, massage parlours, karaoke lounges, and brothels. Additionally, many work independently on the streets, in parks or cinemas, as well as online. Because of the many different kinds of MSW that work across these establishments for different reasons, most work in isolation and many do not fully identify themselves as sex workers. As a result, they have little access to specific sexual health education or services or community legal rights education and are most often underrepresented in current programming and advocacy (UNAIDS, 2007). Data also suggests that the majority of Thai MSM and MSW have sex with men and women, making them a potential “bridge population” as well as an important target for HIV prevention and education (Beyrer, et al., 1998)
  • Hidden MSM, a ‘hidden; subgroup of MSM most likely due to overt stigma who do not identify themselves as gay or bisexual and who are difficult to target HIV prevention outreach towards.  It is believed these men meet secretly online, in parks, restrooms, or other public places with the intention of having sex elsewhere or at the public location. Frequently, the male-to-male sex between these often masculine-identified MSM happens quickly and furtively due to the location and the possibility of discovery by police. This lack of time often leads to unsafe sex (MAP, 2005).

Outreach

Mplus was strategic in advertising its services. Sexperts leveraged social networking sites that Chiang Mai’s gay men, other MSM, sex workers and transgender use to socialise, meet, or engage in sex work.  The most common sites they used to let the intended service users know about the service were Pirch, GayRomeo, Post Jung and MissLadyBoys. An example of an Mplus Sexpert! online advert that was designed and deployed for the project is shown in Figure 2 below:

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Figure 3: Mplus Sexpert! Advert

The approach

The Mplus Sexpert programme, implemented in September 2010, introduced a ‘safe space’ online. This safe space was provided through MSM messenger or the chat function on Pirch, GayRomeo, Post Jung and MissLadyBoys. This gave peers the opportunity to remain anonymous. If using MSN messenger; they could also become return clients to seek additional information.

In this safe space, Chiang Mai’s gay men, other MSM, sex workers and transgender communities could meet, talk openly and receive sexual health and HIV education and prevention. For the first time, this also included information about their rights under Thai law and how to access justice at no cost through clinical legal education at a local university-based clinic. Mplus understood gay men, other MSM, sex workers and transgenders have specific STI-related needs but often feel uncomfortable going to conventional public sector health services. The launch of the Mplus Sexpert! programme thus provided a new viable online option to reach these communities.

From September 2010 until January 2011, Mplus Sexperts conducted more than 1200 peer-education conversations using MSM Messenger and Facebook chat via the Internet and individuals’ mobile phones.  In December 2010 and January 2011, Sexperts logged more than 200 conversations each month. This rapid success increased targeted HIV prevention and education situated in the social and sexual practices of MSM. This responsive approach also proved very useful for generating local community-based knowledge to continually refine and tailor the Mplus’ Sexpert! programme.

One project manager and Mplus’ outreach and prevention staff supervised the OPOP. To preserve confidentiality, each conversation was saved and the peer’s screen name was deleted. The conversations were systematically reviewed to ensure that the peer educators were providing correct information in regards to sexual health and legal rights. Additionally, the number and kinds of referrals to services in the community was documented. Referrals were often also directly provided to Mplus’ outreach team so that individuals could call a number to discuss issues they faced, and receive information about VCCT services in Chiang Mai.

In the next section, we discuss and analyse the chats. We show how Sexperts worked with peers from their stakeholder communities to challenge stigma and change their thinking in small shifts. For us, these shifts represent the increasing ‘sexpertise’ of these marginalised populations. Sexpertise is empowerment that reconnects at-risk gay men, other MSM, sex workers and transgenders with prevention and education grounded in justice, helping them produce new identities as a result of their increased understanding of their legal rights under Thai law.

Online chats on HIV prevention and accessing justice

A qualitative review of the 1200 chats indicates that service users asked Sexperts a diversity of questions. These ranged from questions about how to deal with one’s own sexuality to the availability of antiretroviral (ARV) drugs. The most common topics discussed in the online chats among Mplus Sexperts and peers included:

  1. Risk of sexual behaviour in relation HIV and other sexually transmitted infections (STI);
  2. Penis size, enlargement and appearance;
  3. Love, relationships, loneliness and broken hearts;
  4. Dealing with stigma, discrimination and violence;
  5. Coming out to family and/or gender identity confusion;
  6. Sexual pleasure, premature ejaculation and improved orgasms;
  7. Effects of drugs during sex;
  8. How to access free and confidential counselling and VCCT;
  9. Hormone usage and sex reassignment questions and referrals to transgender friendly doctors;
  10. How to properly use a condom with lubricant; and
  11. People living with HIV (PLHIV) related issues including accessing Antiretroviral (ARV) drugs.

Negotiating risks

Below is a translated sample conversation between an Mplus Sexpert and a peer from the MSM community:

Mplus Sexpert:

A1:

If you have sex, it is better to have safe sex.

Yes I use a condom.

Mplus Sexpert:

A1:

You should use a condom each time you have sex

Of course, I don’t bareback.

Mplus Sexpert:

A1:

Good that is practicing safe sex.

So if we have group sex, is it risky behaviour?

Mplus Sexpert:

A1:

It can be high risk if you don’t practice safe sex and use condoms.

But if everyone uses a condom, it is ok?

Mplus Sexpert:

A1:

Yes, but you must change the condom every time you have sex with a different person.

If someone puts his cock into another guy and then he puts it in me…I should ask him to change to a new condom?

Mplus Sexpert:

A1:

Yes, exactly

Thanks so much for the good information!

The preceding online chat is a telling example of the kinds of situations Sexperts encountered. Sexperts are connecting with the peers’ lived experience without judgement. Here, a peer understands the need to use a condom and not to engage in unprotected sex (‘barebacking’). But, he also does not understand how to properly use condoms to reduce the risk of possible HIV infection and STIs (i.e., changing condoms when changing partners). The ability to ask a Sexpert for clarification about a risky sexual practice (‘group sex’) provided this peer the strategic support needed to shift his frame of reference very quickly.

Access to legal advice

In another chat we analysed, a young gay man confided in the Mplus Sexpert that he had been drugged and raped by multiple men. When Sexperts encounter such a violation, they refer the victim to a free CLE clinic run by the Faculty of Law at Chiang Mai University. They also give the number of someone at Mplus who can talk to them on the phone if they choose. The intention is to help the peer access additional help and resources, particularly post exposure prophylaxis (PEP). At the Chiang Mai University (CMU) Legal Clinic gay men, other MSM, sex workers and transgenders (or anyone else) can get free advice and help. Staff at the legal clinic can also accompany individuals to the police to help them report crimes and provide them with free legal advice. The following translated chat between an Mplus Sexpert and a transgender peer illustrates this point:

Mplus Sexpert:

TG317:

Hello welcome to Mplus Sexpert. Anything I can help you today?

I am studying at Chiang Mai University (CMU) and have problem with a professor who has a problem with me wearing a female uniform. I fell so discouraged from going to class. I need some help will dealing with some senior students and the professor who is against me wearing a female uniform.

Mplus Sexpert:

TG317:

Firstly I have to say that the situation you are facing is not easy and it is challenging to deal with. But you are not alone because you have an Mplus Sexpert beside you who will be available online to discuss this issue with you.  But there is another place that you may try to get some help dealing with this professor and the other students at CMU.

Where?

Mplus Sexpert:

TG317:

The Chiang Mai Legal Clinic at the Faculty of Law. Have you ever heard about this clinic?

Oh yes, I have walked past the office. It located close to Faculty of Social Science.

Mplus Sexpert:

TG317:

Exactly.

But they are willing to help transgender like me? They are Faculty of Law…sound conservative and not welcome to transgender.

Mplus Sexpert:

TG317:

Actually they are very friendly towards transgenders and they provide advice on access to justice and will even go with you to report any injustices you may face that are illegal under Thai Law.  There is an animation you can watch on YouTube that explains how they work and some of the issues they help transgenders with.  Here is the link. Watch and then we can talk some more.

http://www.youtube.com/watch?v=LQ4rBIZo1qk

Ok…Oh Is there this kind of service like this for transgender? Legal clinic friendly with Transgender, Unbelievable!

Mplus Sexpert:

TG317:

Yes but you can truly believe what you just saw. Mplus Sexpert works closely with the CMU Legal clinic and BABSEA CLE and the CLE Thailand Foundation. For more information you can visit www.babseacle.org

I feel really better now. Do you have other clips?

Mplus Sexpert:

TG317:

Yes we have a number of animations, please wait a moment. Here is the link to a story about practicing safe sex, This video has been viewed nearly 100,000 times. It is also about supporting transgenders to live with dignity and take responsibility to practice safe and healthy sexual lives.

http://www.youtube.com/watch?v=2aYGbzt6VeA

Haha, I’m shy. I don’t have boyfriend yet.

Mplus Sexpert:

TG317:

Mplus Sexpert:

That’s ok, even if you don’t have boyfriend HIV prevention knowledge is necessary! That way you be ready to practice safe sex when the time comes or you can share the animation with your friends.

Hopefully I will talk with you again and thanks so much.

You are always welcome to chat with us and you can drop in anytime and say hi.

In 2009, BABSEA CLE worked with Chiang Mai University’s (CMU) Clinical Legal Education Clinic, the Open University and Mplus to produce the animations discussed above. These animations teach transgenders and anyone else who has experienced sexual violence how to access the CMU Legal Clinic. It also explains individuals’ legal rights under the Thai constitution, the importance of reporting crimes to the police, and the availability of free PEP treatment to prevent HIV infection after a sexual assault. Sexperts smartly infused these animations into their online chats with peers. They were widely used in a very short period of time during the OPOP programme. This targeted integration of digital resources and information about access to justice into online chats situated in stakeholders’ lived experience is an indicator of the success of the Sexperts approach. It increased ‘sexpertise’ and enabled the transgender to overcome her anxiety in accessing her rights, built up over years of stigma and discrimination in a harsh climate. We next consider how we strove to widen the impact of Sexperts through another innovative online programme focused on transgenders, the TLBz Sexperts!.

TLBz Sexperts!

The amfAR funding ran out for the Mplus Sexpert programme in 2011. Even though it was extremely successful, it was not continued.  The reasons for this are complex and discouraging, considering its impact and the number of successful chats over six months.  Not wanting to lose the momentum in the Sexperts approach among the community, we lobbied a number of other Thai organisations committed to fighting HIV to see if they would be willing to launch a similar programme. ThaiLadyBoyz, or www.TLBZ.me an online community-based and led Internet community for transgenders agreed. The OPOP received funding through the BABSEA CLE and the Thai CLE foundation to continue a form of the Mplus Sexpert programme hosted on their website. The primary difference was that it was marketed and adapted to meet the needs of male to female (M2F) transgenders across Thailand. This OPOP was named TLBz Sexperts! (Figure 3). The funding is used to pay peer TLBz Sexperts! to run an online peer-counselling service for three hours a day, five days a week.

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Figure 4: TLBz Sexpert! Advert

The TLBz Sexpert! launched in September 2011 and is on-going. Unlike Mplus with over 1400 registered members and an active and public campaign programme, TLBz.me is relatively small and entirely Internet based. To attract transgenders peers, the TLBz Sexperts! programme advertises its peer-counselling programme on three prominent sites: its webpage, Facebook’s open and ‘closed’ Thai transgender groups (450 members across three groups), and the LGBTI Human Rights Thailand Group (1,861 members).

The following diagram outlines how the service was designed and delivered to peers:

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Figure 5: TLBz Sexpert! OPOP design and delivery

Regular advertisements allow members of the 4 Facebook groups know that a TLBz peer counsellor is online and can chat via MSN messenger or Facebook’s chat function on any issue a transgender finds relevant.

A goal of the programme is to use the conversations as a platform for providing information on HIV prevention, sexual health and legal rights. In the next section, we highlight two examples from the online chats that show how TLBz Sexperts! positively shaped the thinking of transgenders on sex and body issues as they came to understand and educate transgenders.

Coping with a sex change operation

TG1-01-02-2012:

TLBz Sexpert!:

Hello TLBz, are you free to chat?

Hello, TLBz Sexpert! always ready to chat?

TG1-01-02-2012:

TLBz Sexpert!:

Any topics I can ask?

Our service provides the sexual health information for transgenders such as hormone use, surgery, general sexual health and safe sex methods. We also provide human and legal rights info and referrals to free Legal Clinics that close to where you are living.

TG1-01-02-2012:

TLBz Sexpert!:

So I had a sex change operation about 3 months ago.

Congratulations! I hope your recovery is going very well.

TG1-01-02-2012:

TLBz Sexpert!:

Yes but it is still swelling and I’m not confident with it because of the smell.

About smell you can handle it. After dilation you have to clean inside with soap free shower gel and rinse with lot of water. During the day you may have to use tampons to absorb the cleaned water that still inside your in neo-vagina.

TG1-01-02-2012:

TLBz Sexpert!:

I am so worried every time that I have to use public toilet. Any suggestion for me?

To use public toilet in a theater or shopping mall, it is a good idea to carry a small sized bottle that is approx. 300-500 cc in your bag soap free shower gel. Wash your hand before and after you urinate. Because we then have to use our hands to widen the labia to clean the neo-vagina with the water in the bottle. It is important to clean each time after you urinate because if you don’t it will cause it to smell. After you clean with the water, then absorb with tissue until dry.

TG1-01-02-2012:

TLBz Sexpert!:

I never thought that post operation life would be difficult like this.

Stay strong!. Please don’t get too discouraged because it’s worth, isn’t it?

TG1-01-02-2012:

TLBz Sexpert!:

Yes I’m so happy to have a pussy.

Any more questions to ask? We are open to talk about anything

TG1-01-02-2012:

TLBz Sexpert!:

Yes I have, but shy to say ha ha ha.

Is it about sex? You can ask, our service is confidential.

TG1-01-02-2012:

TLBz Sexpert!:

I want to know the difference between anal sex and neo-vagina? Any suggestion? I used to have anal sex only.

Before I give the answer can you tell me whether you had skin graft or sigmoid colon technic?

TG1-01-02-2012:

TLBz Sexpert!:

Just skin graft.

Basically skin graft technic reverses the penile skin to create the vagina wall. So human skin can’t produce lubricant, thus when having sex you need to use condom together with water based lubricant. Think about when you have to do dilation, having sex is nearly the same, you just replace from the dilator a human one!

TG1-01-02-2012:

TLBz Sexpert!:

Ha ha so shy.

Of course first time should be exciting! You may have to talk with your partner, persuade him to trying to touch your vagina through foreplay. He needs to know that your pussy is not 100% similar to a genetic female. This will help both of you feel relaxed and ready to move on! So having sex with neo-vagina is different from anal because of different feel between skin graft and rectum tissue and you don’t have to worry too much about the depth when having anal sex :D

[…]

TG1-01-02-2012:

TLBz Sexpert!:

If I really want to try barebacking. I want to feel like real woman!

To feel like woman in term of having sex is about imagination. We don’t know how a woman feels because we were not born female born. Even genetic female, they also have to use condom for safe sex. Thus with or with out condom is not the sign of femininity. But…finally you still really want BB, then take him to have HIV screening with you. Right now there are MSM and transgender sexual health clinic, safe and confidential.

TG1-01-02-2012:

TLBz Sexpert!:

Hmm I’m not ready for screening. So I will invite him to practice safe sex.

That’s fine indeed because screening needs to be voluntary, no one can force us to get tested for HIV. But in the future if you want to go, just get back to us and we will refer you to get free testing services.

TG1-01-02-2012:

TLBz Sexpert!:

Thanks so much. It’s fun chatting but I gain knowledge at the same time.

Your welcome! If you like us please tell your friends or if they use Facebook, please ask them to click “like” to our page TLBz Sexperts! And they will get updates to all kinds of information about transgender life.

In the online chat above, we see the concerns of a transgender struggling with coping with changes to her body as a result of surgery. This significant change in her life provided a basis for the Sexpert to consider how she might use the peer’s lived experience to stimulate a wider discussion about sexual practices. In this online chat, we see how the Sexpert empathises with the peer’s situation without judgement. As the Sexpert became aware of the peer’s specific psychological issues, she went on to suggest a number of practical actions that the peer could take (use tampons, carry a small bottle). In response, the peer begins to feel comfortable enough to ask more questions about having sex. The Sexpert encourages the peer to discuss and negotiate sex with her partner and allays her fears about feeling ‘like a woman’. Instead of teasing and scorn about a sex change operation, the Sexpert speaks of ‘imagination’ and how the ‘first time should be exciting!’ Here, the transgenders’ sexual pleasure and intimacy is valorised and supported by the Sexpert mediating her sexual practice to shift the peer’s frame of references about what is possible with her new body. Finally, the Sexpert draws the peer into HIV prevention; by assuring the peer that free ‘safe and confidential’ HIV testing is available. We thus see how the infusion of a simple online chat using low-cost MSN messenger enabled a Sexpert to share resources, information, and advice to support the transgender maximise the enjoyment of her new body. Importantly, the contact made also provided an opportunity to encourage the peer to engage her friends to access TLBz Sexperts! and build their ‘sexpertise’ through Facebook.

This approach makes sense because it focuses the online chats around issues important to transgenders. As compared to traditional peer support workshops and online peer education, this approach allows for greater customisation and tailoring of the messages to the specific needs of community stakeholders. As we see below, the increased confidence of the Sexperts allowed them to take responsibility for transgenders’ HIV education and prevention.

TLBz Sexpert!:

TG1-18-01-2012

Hello welcome to TLBz Sexpert! services.

I want to know about KY, What is the best lubricant between KY, Vasline and body lotion?

TLBz Sexpert!:

TG1-18-01-2012:

That’s really good question :)

I have a new boyfriend. I used to try Vaseline or body lotion sometimes because it’s easy but have heard KY is better for having sex.

TLBz Sexpert!:

TG1-18-01-2012:

Exactly water-based lubricant is designed for sexual activities. With water based, there is less irritation. Vasline or moisture lotion contains oil that cause condom to break.

[…]

TLBz Sexpert!:

TG1-18-01-2012:

Let’s back to the safe sex issue. From your question about KY, Vaseline and body lotion, do you use with condom?

With the first period of love I use, but with long-term partner I rarely use it.

TLBz Sexpert!:

TG1-18-01-2012:

TG1-18-01-2012:

Let me start with KY and condoms, they are the perfect match! They are like soul mates, always orgasm together! But if we separate condom by using it with Vaseline then…it can be a tragedy because condom will die because of breakage! …

I never realized before, I just know that KY is smoother, non greasy and non irritation. Not much about condom using…

If I don’t want to use condom…

TLBz Sexpert!:

TG1-18-01-2012:

If you are sure that your partner is completely monogamous with to you and he never has sex with anyone accept you! Are you sure? Even yourself, can you have sex with only one guy until the rest of life?

Of course not ha ha ha, so what I should do?

TLBz Sexpert!:

TG1-18-01-2012:

Do you want to get condoms and water-based lubricant for free?

Yes I do! where I can get it?

TLBz Sexpert!:

TG1-18-01-2012:

TLBz Sexpert!:

Where to do you live?

Bangkok, water gate area.

You can get it at Rainbow Sky Association of Thailand.

[…]

TLBz Sexpert!:

TG1-18-01-2012:

Are you interested in blood testing? We can refer you to free services. There are MSM and TG clinic in BKK. All free and confidential…You can go with your partner. Just tell him that you want to get a health check up for free. I suggest Silom Community Clinic
TG1-18-01-2012:

TLBz Sexpert!:

So can I get contact number?

With pleasure! Silom Community Clinic is located at 3rd floor Bangkok Christian Hospital. Very private and peaceful. Open Tuesday-Saturday 16.00-22.00 You can call to check basic info at or 634 2917 or 02 634 2945

Mobile phone: 085 123 8738 email: silom@silomclinic.in.th

TG1-18-01-2012:

TLBz Sexpert!:

Thanks again for suggestion.

Bye! Feel free to get back to us

The preceding chat shows a common misconception encountered by many peer counsellors among transgenders. They often do not know that a water based lubricant is best for use with condoms to avoid breakage.  Furthermore, it is important to stress that in Thailand, like many countries in South East Asia, condoms and lubricant remain expensive for many individuals. Providing knowledge of where to go to get free condoms and VCCT is important. The TLBz Sexperts have information on all of the transgender friendly free clinics and CBOs across Thailand to provide referrals to transgenders near to where they live.

In contrast to static repositories of health promotion information written by health experts, or amateur feedback in online support groups for transgenders, the chat above shows how the social interaction with a legitimate Sexpert provided knowledge infused with fun and excitement. This is evident in the use of terms like ‘ perfect match’, ‘like soul mates together’, which resonate with the kinds of vocabulary used by Thai transgenders in their life. This form of pleasurable engagement between Sexperts and peers is fundamental to our redesigned approach. These are crucial entry points to bring in more sober discussions about HIV testing within the broader framing of access to health and human rights.

Like the Mplus Sexpert chats, all chats are saved, anonymised and reviewed to make sure the peers give correct and accurate information. At the time of writing this article, the TLBz Sexperts! Programme has conducted 155 individual counselling sessions on MSN messenger or Facebook chat. They have made 30 referrals to CBOs and NGOs for VCCT as well as free condoms and lubricant.  As the project gained traction, the TLBz Sexpert! team also collaboratively designed a sexual health online library and hosted 7 topical Q&A forums on www.TLBZ.me.

Conclusion

In this paper, we have presented how two small community-based and led organisations in Thailand strategically deployed digital technologies to disrupt injustice that increased the vulnerability of gay men, other MSM and transgenders to HIV. Our approach has significant implications for CBOs and NGOs who wish to use low-cost technologies in contexts where social stigma and violence prevent MSM and TGs from accessing their rights.

Firstly, the Mplus and TLBz Sexperts programmes we analysed are unique because they show how CBOs can build bridges between disparate HIV and AIDS education, prevention and outreach, legal rights and access to justice.  Both programmes demonstrate the added-value of continuous stakeholder involvement. A collaboration among frontline workers, lawyers, researchers, peer educators, and leaders from an affected community resulted in a greater understanding about each other’s lifeworlds. This reflexive awareness overcame the common negative perceptions of these populations by public health researchers that do not adequately valorise the knowledge of these populations when trying to change their behaviours but ignore understanding the wider social practices which mediate behaviours.

Secondly, our approach shows that it is important for CBOs not to be seduced by the novelty of social media. CBOs need to think critically about how low-cost digital technology available—in this case MSN Messenger, and a variety of social networking sites—can be used to target peer education and counselling, optimise the use of digital resources, and provide access to rights that marginalised people may not know about. In this case, we needed to retaliate against the political and cultural persecution faced by gay men, other MSM and transgenders (and to some extent sex workers) in Thailand. We have found that the use of clinical legal education (CLE) can make a significant contribution to address the specific localised needs of a community around accessing justice under Thai law. We recommend this approach to other organisations who are keen on incorporating a rights based approach into online HIV education and prevention programmes.

Thirdly, our approach shows that modelling non-colonising culturally appropriate educational practices is vital to sustaining meaningful and relevant connections with individuals at risk. Unlike dominant public health approaches to online HIV prevention and education with marginalised communities such as MSM (Rosser et al., 2009), our approach framed the problem of HIV around the broader issue of access to justice. This framing is important for community organisations. This is because the scientific interests and motives of public health researchers and practitioners often do not cater for pleasure, intimacy, sexual and legal rights as important signifiers of perceptions of access to justice among individuals such as gay men, other MSM and transgenders. We thus argue that public health researchers would do well to serve the cause of access to justice so as to enable marginalised communities to move outside deficit assumptions about ‘vulnerability’ and innovate broader interventions that make a difference not only to traditional behaviour change outcomes (although these in themselves are important), but also to the quality of justice experienced by stakeholders.

The Sexpert! programmes developed, implemented and piloted online and mobile resources that offer new avenues to protect public health and promote human rights. However, as the loss of funding from amfAR revealed, it remains a challenge to launch a sustainable and reinventing community-owned response with stigmatised populations disproportionately at risk of HIV infection: gay men, other men that have sex with men (MSM), male sex workers (MSW) and transgenders and transgender sex workers. The success of such innovations is not guaranteed, given the relentless push to ‘biomedicalise’ the AIDS response (Auerbach, this issue). The projects, while small in scale, can have a larger impact only if the connections built through digital technologies continue to engage communities in addressing social, legal and educational barriers through each and every affected individual, without forcing them into workshops or support groups. The chats we have analysed in this paper show how this is possible with trained online peer educators, but we know that these individuals will continue to face stigma and discrimination relating to housing, employment, religion, and accessing justice.

Moving forward, we argue that involving CBOs and individuals in designing online safe spaces for inquiry and sharing offers funders, researchers and practitioners unique opportunities to address important questions of health and well being to reduce HIV risk at low-cost. Although the Sexperts online approach is distinctive and has wider applicability across contexts to circumvent barriers to learning in countries which exclude gay men, other MSM and transgenders, the approach also has raised new questions and unexpected insights for us. Justice is now more than ever at the forefront of our design when we work with the daily experiences of ordinary gay men, other MSM and transgenders in their digital lives, rather than dominant calls for ‘treatment as prevention’ or ‘structural interventions’.

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Acknowledgements

The authors would like to thank Gurmit Singh for his feedback on this paper.

Biographical Statements

Nada Chaiyajit is a Research Development Officer with Bridges Across Borders Southeast Asia Community Legal Education Initiative (BABSEA CLE), a not-for-profit grass roots human rights organisation. She is also the Audience Council Secretary for LGBT and transgender rights for the Thai Public Broadcasting Service (Thai  PBS). Nada is also a founding member of the ‘Thai Transgender Alliance’, a fellowship network that promotes understanding and equality for transgender people in Thai society. The Thai Transgender Alliance is using the Internet to compile a database of human and sexual rights violations against transgender people to prove to the authorities that this gender-based violence (GBV) is a violation of their human rights and a major public health issue. Nada has lobbied individually and collectively to modernize the Thai criminal law on rape, advocating for a specific equality provision for both men and women. Drawing on funded research and her experiences as advocate for human rights, Nada has worked collaboratively with marginalised and stigmatised populations in initiatives to promote democracy, social justice and equity by strengthening their capabilities and promoting their involvement in online communities of practice. Nada was the keynote speaker at the 2010 IADIS International Conference on E-democracy, equity and justice, and also presented her work at the AIDS 2010 Conference in Vienna.

Email: nada.chaiyajit@babseacle.org

Christopher S Walsh is a Senior Lecturer of Educational ICT and Professional Development in the Department of Education at The Open University (UK). He specializes in digital technologies, literacy, multimodality, international development and HIV and AIDS education and prevention. Walsh was central researcher on number of highly competitive grants including The Spencer Foundation, The American Foundation for AIDS Research (amfAR), the Australian Research Council (ARC) and the Australian Federation of AIDS Organsitions (AFAO). The amfAR project supported online peer outreach and prevention (OPOP) and popular opinion leader (POL) programmes for gay men, other MSM and transgenders in Chiang Mai Thailand with a focus on access to justice and legal rights. The AFAO project supported the production of 4 animations for use in peer face-to-face and online HIV education and prevention programmes for marginalised communities disproportionately at risk of HIV. Currently, he works on English in Action (EIA) a large-scale project delivering in-service teacher professional development to 80,000 teachers using mobile phones in Bangladesh and is Senior Research Analyst and Policy Advisor for the Bridges Across Borders South East Asia Community Legal Education Initiative (BABSEA CLE).

Email: c.s.walsh@open.ac.uk

Endnotes


[i] To read more about the work BABSEA CLE does with LGBT and other MSM see this article: Walsh, C.S., Lasky, B., and Morrish, W. (2011). Building Local Capacity to Protect Public Health and Promote Social Justice Through Online Peer Education. IADIS e-Democracy, Equity and Social Justice Conference 2011. Rome, Italy. Available at: http://open.academia.edu/ChristopherWalsh/Papers/803084/BUILDING_LOCAL_CAPACITY_TO_PROTECT_PUBLIC_HEALTH_AND_PROMOTE_SOCIAL_JUSTICE_THROUGH_ONLINE_PEER_EDUCATION

[ii] To view in English http://babseacle.org/sites/default/files/Sexual,%20Human%20and%20Legal%20Rights%20for%20Chiang%20Mai%27s%20MSM,%20MSW%20and%20TG%20(English).pdf

[iii] Information comes from research conducted by the US-CDC-TUC (2005) and the Thailand Ministry of Public BoE (2007).


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