The term, MSM, is an English language term used by public health professionals to define a group by their common risk behaviour.. The term was introduced to Vietnam in the early 1990s alo[r]
(1)Male sexuality in Vietnam: the case of male-to-male sex
Bao Ngoc VuA,F, Philippe GiraultB, Binh Van DoC, Donn ColbyD and Lien Thi Bich TranE AFamily Health International, Vietnam Office, Hoan Kiem District, Hanoi, Vietnam.
BFamily Health International, Asia-Pacific Regional Office, Lumpini, Phatumwan, Bangkok 10330, Thailand. CCentre for Social Work and Community Development Research and Consultancy (SDRC), Binh Thanh District,
Ho Chi Minh City, Vietnam
DVietnam–CDC – Harvard Medical School AIDS Partnership, Tropical Disease Hospital, Ho Chi Minh City, Vietnam
ESocial Sciences and Humanities School, Ho Chi Minh City National University, Ho Chi Minh City, Vietnam. FCorresponding author Email: bao@fhi.org.vn
Abstract. Background: To implement effective behaviour change interventions for men who have sex with men, qualitative information was collected about the contexts and meanings of sex and relationships between men in Ho Chi Minh City.Methods:Individual interviews and focus groups were conducted with 74 men aged 18 years or older who had had sex with another man in the previous 12 months.Results:Findings reveal that sex between men exists and is associated with two common descriptors in Vietnam:bong lofor those who are feminised in public andbong kinfor those who are not, and are often married In sexual relationships, for both groups of men, there is a trade off between sexual pleasure and risk Condoms may not be used, particularly when having sex with a partner who was considered to be good looking or perceived as ‘clean’.Conclusions:The study highlights the need for HIV prevention programs which address issues of sexual meaning in male-to-male sexual relationships
Additional keywords: HIV prevention, men who have sex with men Introduction
Despite rising prevalence rates, Vietnam is still in the early stages of an HIV epidemic that is concentrated primarily in most at-risk populations such as injecting drug users, female sex workers, clients of sex workers and men who have sex with men (MSM).1 Men make up most of the detected infections
(85%), associated with injecting drug use and unprotected sexual practices, including male-to-male sex Against this background the specific prevention needs of MSM in Vietnam are largely unmet
As in most countries of Asia, same-sex sexual relations in Vietnam are highly stigmatised and usually hidden Use of sexual health services among men in general is low,2 and due to stigmatisation and discrimination against men who have sex with other men, the use of health services by this population is assumed to be even lower Indeed, MSM have little access to appropriate services and information, and their social environment does not encourage them to adopt safer sex behaviours
What is known about male-to-male sex in Vietnam is limited, but several published3−5 and non-published reports6−9 are
available These studies have focussed primarily on knowledge and risk behaviours related to HIV infection The authors of these reports conclude that an elevated level of sexual risk behaviour exists among MSM due to high numbers of sexual partners and low rates of consistent condom use Colby et al.5commented there is a lack of more broadly based social
research, particularly studies led by Vietnamese researchers that might inform behaviour change interventions to reduce HIV transmission among MSM
Initial HIV prevention efforts for MSM in Vietnam were undertaken by Save the Children/UK in 1997 The program achieved some success in terms of increasing HIV/AIDS knowledge and risk-perceptions but the level of behaviour change was not obvious.7 The importance of cultural systems
in shaping sexual practices and vulnerability to HIV infection, as well as successful HIV prevention has increasingly been emphasised since the late 1980s.10Boyceet al.11concluded that inadequate conceptualisation of human sexuality in HIV and AIDS work is among the reasons why HIV sexual transmission prevention has had limited success Within this perspective we argue that a limited understanding of male-to-male sex and sexuality continues to be the major barrier to effective HIV prevention for MSM
The findings on which this paper is based were gathered from qualitative research in Ho Chi Minh City (HCMC), funded by United States Agency for International Development through the President Emergency Plan for AIDS Relief, and conducted by Family Health International (FHI) and the HCMC AIDS Committee in April and May 2004 The research helped to inform the design of FHI-supported HIV prevention programs for MSM, first implemented in HCMC and then expanded to four Vietnamese provinces (Hanoi, Can Tho, Khanh Hoa and Da Nang)
(2)Methods
To facilitate fruitful, friendly and non-threatening discussions with interviewees, non-directive interviews were undertaken Topic guides for these were developed focusing on social characteristics, sexual identity and behaviours, type of sexual partners, HIV knowledge, and perceptions of risk for HIV and sexually transmissible infections (STI) In addition, focus group discussions were held to focus on the identification and description of locations where MSM gather in HCMC, risk factors for HIV and STI infection, stigma and discrimination towards same-sex relations and HIV-positive people, and the identification of interventions or activities that could help participants improve their sexual health
The research team, which included trained social scientist interviewers and peer educators, recruited men who were at least 18 years old and who had had sex with another man at least once in the previous 12 months Interviewees were contacted through a peer network, and a total of 40 in-depth interviews were conducted An additional 34 men participated in focus group discussions The age range of the enrolled participants varied from 19 to 45 years old Their educational level varied from primary school to university level, and their occupational status varied from unemployed or self-employed (e.g hairdresser, amateur singer, businessman) to white collar workers Peer educators were in charge of recruiting potential respondents, building relationships with them and administrating the verbal informed consent Respondents were purposely selected in relation to several social and demographic criteria such as sexual identity, age and socioeconomic status
Before the fieldwork, the research team participated in a 5-day training session which covered crucial topics such as sexuality, local terminology related to sexuality used by MSM, knowledge of HIV transmission and prevention, interview techniques, ethical issues and research protocol and procedures
As part of the assessment, the team also conducted key informant interviews with 16 people representing organisations that either provided services to the general public or served as entertainment establishments for MSM
Since the purpose of this study was to design a public health program targeting MSM in HCMC, it was considered as public health assessment and was exempted from the review by FHI’s Protection of Human Subjects Committee Assessment protocol and procedures were also reviewed and approved by the HCMC AIDS Committee before the implementation Potential participants were approached and fully informed about the study If they were willing to participate in it, witnessed oral informed consent was obtained No personal identifiers were recorded and consenting participants were then interviewed or invited to take part in the focus group discussion Interviews were conducted in private locations with only the interviewer and participant present All interviews and focus group discussions were tape-recorded and transcribed fully into Vietnamese Tapes were destroyed after transcription Directly after the interviews, respondents received free samples of condoms and lubricants, HIV prevention information and a small stipend of 50 000VND (US $3.20) to cover travel costs
Data were analysed descriptively and thematically Before beginning data analysis, the research team developed a codebook
covering all anticipated themes and sub-themes However, during the analysis new themes such as perceived norms among MSM, sexual preferences, and expression of sexuality and marriage dilemmas, emerged and were also included in the codebook Three independent coders then coded the complete dataset (i.e the transcribed texts) One principal investigator incorporated the data into a full report The findings and recommendations were discussed with the members of the research team and MSM representatives Their comments were integrated into the study findings after validation by the research team
Conceptualisation of male-to-male sex
Terms used
The term, MSM, is an English language term used by public health professionals to define a group by their common risk behaviour The term was introduced to Vietnam in the early 1990s along with the HIV epidemic It is difficult to find an equivalent term in Vietnamese and thus the phrase is translated word by word, into ‘nam quan he tinh duc voi nam’ However, this term is not commonly used in Vietnamese In a review of studies on sexuality in Vietnam, Hong8revealed that most people were aware of male homosexuality and believed that any men who were engaged in male–male sexual behaviour were ‘dong co’ Dong cofirst referred to men who wore women’s clothes for religious ceremonies to communicate with people in another world, and later the term was expanded to refer to transgender and finally to any other same-sex attracted men Dong cois the most commonly used term in northern Vietnam, whilebong [shortened frombong cai] is the most commonly used term in southern Vietnam These terms translate literally into English as ‘the same as women’ or ‘female shadow,’ respectively
In Vietnam, male-to-male sex is not illegal but the behaviour has been hidden and under-reported because it transgresses social norms and values As outlined by Kelly,12homosexuality
is ‘mocked in Vietnam, but not outlawed’ In Vietnam, as in many other Asian countries13−15 there exists dynamic and
broad spectrum of sexual identities and labels used by same-sex attracted men The rapid industrialisation and development of Vietnam, with increasing migration to the cities and a liberalisation of social change, has also furthered the emergence of a more visible gay culture in the urban centres of Hanoi and HCMC
(3)identified themselves as ‘trai’ [straight men] Another term used for straight men is ‘cong’ [plus]
Beyond the preferred terms, there are labels considered as discriminatory and demeaning by MSM For example, the term ‘pˆe- ˆe’ [adopted from the French term: ‘p´ed´e’, itself a contraction of ‘p´ed´eraste’ (pederast)] carries derogatory connotations; and the term ‘lady boy’ [English/Thai adopted term] is used to refer to men who look like women Other terms such as ‘xang pha nhot’ [gasoline with lubricant] or ‘hai thi’ [two strokes, derived from the two-stroke motor] are used to refer to men who are not ‘real’ [straight] men; and ‘hi-fi’ or ‘da he’ [multi-system, derived from the high fidelity stereo player] is a term used to refer to men who have sex with both male and female partners Male sex workers, who may be eitherbong kin,bong lo or heterosexual, are often referred to by the discriminatory term ‘di duc’ [male prostitute]
In close relationships both bong kin and bong lo may address one another using feminine pronoun such as ‘chi em’ [older/younger sister] Sex between bong lo or sex betweenbong kinandbong loin the same group was commonly considered unethical due to a perceived familial link
In the same group we call each other ‘sisters’. And ‘eating meat’ [having sex] of the same animal [family] is not permissible People in the same group have close relationships – understood as family relationships – so they should not have sex with each other.[Bong lo identified respondent, 24]
For fear of revealing their same-sex attraction, bong kin usually did not want to be associated in public with bong lo. Because of stigma and discrimination,bong kinfind it difficult to express their sexual preference, orientation and identity with their families The difficulty is two-fold: they may be stigmatised and discriminated by their families, and their families may be stigmatised and discriminated by society Therefore, somebong kinchose to live alone or with their partner to socialise freely with their peers and partners
I live alone in a separate house thereby bothering no one in my family I can freely invite my friends there on the weekend Living so, I feel more comfortable than before when I lived with my family.[Bong kinidentified respondent, 30] Somebong kinmarry and have children to satisfy family and community responsibilities, although they preferred sex with men over sex with women
Sometimes one bong kin has a wife and children. Although married, he stills solicits male sexual partners to have sex, in addition to having sex with his wife.[Bong kinidentified respondent, 22]
Experiencing sexual life
Sexual preference
The choice of sex partners differed forbong kinandbong lo. Bong kinpreferred having sex with otherbong kin Occasionally
bong kin would have sex with straight men or with bong lo However, sincebong loconsider themselves women, they preferred to have sex with straight men, but sometimes had sex withbong kin.
Bong kin and bong lo consider themselves friends and rarely have sex with one another. Only bong kin have sex with other bong kin. When bong kin like each other, they go to a private place to have sex Bong lo may have sex with bong kin For example, I, [bong lo]may have sex with one bong kin who is a male sex worker.[Bong loidentified respondent, 36]
Bong kinchose sex partners of any age, whereas manybong lowere more likely to choose sex partners who were younger
I prefer to have sex with partners who are younger than me I don’t like those who are older than me at all In the past I loved a boy .I asked him to go to my house to watch TV I kissed him and fell in love with him I tried to have sex with him once afterward.[Bong loidentified respondent, 30]
Bong kintended to choose sex partners who were strong and muscular, whereasbong lowere attracted to gentle, smart, lovely and educated sex partners
I like a polite man who does not ask for sex right away He invites me to a karaoke bar or the cinema or a restaurant first, and later on has sex with me When talking with him I not feel hurt He is a smart and educated person I like such men.[Bong loidentified respondent, 36]
Multiple sex partners
This study indicated that multiple sex partners were common for bong kinandbong lo The majority ofbong kinandbong lodid not stay with one long-term partner They might have a boyfriend for a while, but then would separate from them, often due to jealousy
(4)In general,bong kinreported that it was easy to find male sex partners, whereas it took time or money for heterosexual men to find female partners Having sex between men did not require building a long-term relationship Changing sex partners was like ‘changing food’ to avoid being bored
As the same gender, it is easy for me to make acquaintances with men It takes me about five minutes to get to know a man, and right after that I can have sex with him In contrast, it takes a lot of time for a man to find a woman, to get to know her, before she agrees to have sex.[Bong kinidentified respondent, 24, who was not a sex worker]
Marriage dilemmas
Families in Vietnam usually expect their sons to marry Pressure to get married may come in the form of reminding, pleading, blaming or forcing
My brother forced me to get married to a girl in the countryside He forbid me from going out with my[bong kin]friend I told my mother that I had the blood of ‘bong’; getting married would only make someone else suffer My brother lives abroad When he came back last year, he again blamed me[for my problem].He said to me that if I was not ‘pˆe- ˆe’, he would sponsor me to go abroad, but if I were pˆe- ˆe, he would disown me. He dislikes me so much I am already pˆe- ˆe How can I change? [Bong kinidentified respondent, 28]
Somebong kinwere married, however, and lived with wives and children but secretly found time to meet their male sexual partners If the wife were to discover this, the family could be broken
My partner has a family and I am married too; therefore finding the time to meet is quite difficult His wife knows he’s worked there[in a brothel] in the past I feel embarrassed to let his wife know we go out together If we have a good reason to go out, we will take the chance to meet each other Each time is about 1–2 hours Since he’s been married, we only meet each other once a month, sometimes once every 3–4 months.[Bong kinidentified respondent, 39, with a wife and two children]
Sexual partnerships and condom use
Casual and commercial sex partners
Bong kin and bong lo solicited casual male sex partners from the places where they socialised during their spare time For example,bong kinsolicited sex partners in discotheques, cinemas, saunas, swimming pools and bars, and also bought sex from street-based male sex workers
Before I started going bald, I went to discotheques, cinemas, sauna parlours,
swimming pools or road-side bars to make friends and find potential sex partners who face the same dilemma as me[soliciting a partner] After I started going bald, it seemed that I was no longer attractive to others Now I sometimes have to buy sex I go to dark streets where both male and female sex workers work I drive my motorbike around to solicit a partner, and have sex in a rented room.[Bong kinidentified respondent, 31]
Bong losolicited casual male sex partners in road-side bars, karaoke bars and cafes
When I meet someone who is the ‘right’ man for me, I invite him to a karaoke or road-side bar. Then he and I go to my house or his house to have sex together.[Bong loidentified respondent, 30] Bong kinandbong loin HCMC who earned higher income were drawn to other provinces in Vietnam and to countries part of the Association of Southeast Asian Nations for tourism or business In these places they solicited new casual and commercial sex partners
I often go to other provinces on the weekend. My friends have asked me to go to Vung Tau next week We take a tour The tour will cost one million (US$65) each In these places we solicit new sex partners After drinking, we invite them to the hotel, and then have sex with them I have been to Thailand, Singapore and Malaysia I feel very comfortable searching for a sex partner there, because I am not afraid of being arrested by the police – like in Vietnam In Thailand, there are safe places for gays to solicit sex partners In Singapore, male sex workers are issued health certification cards so there you don’t worry about the disease[AIDS] [Bong kin identified businessman respondent, 30]
Male sex workers
This study revealed that both somebong kinandbong loengaged in sex work Male sex workers (MSW) averaged two to three clients per night – both Vietnamese and foreigners Earnings per sex act depended upon the meeting place and the type of client.Bong lowere likely to charge cheaper prices thanbong kin because they solicited clients on the street and therefore more commonly accessed lower class Vietnamese men In contrast, bong kinwere more likely to work in discotheques or brothels and have access to higher-class men, including foreigners.Bong kinsex workers had clients who were eitherbong kinor straight men
(5)[Bong kin identified street-based sex worker respondent, 36]
Anotherbong kinsex worker, 24, entered the sex trade at the age of 18 and worked in a sex shop in Cambodia before returning to HCMC Once back, he worked in a brothel before soliciting clients on the street, finally becoming a pimp for onebong lo. He explained:
Working in Cambodia, on the average I had two clients per night The cost of one sex act was US$50 out of which the owner got US$10. During the elections, the shop was closed, so I returned to HCMC My clients in Cambodia were either Taiwanese or Westerners When returning to HCMC, I first worked in a brothel. Somebong loreported pretending that they were ‘female sex workers’ (FSW), working in the street to solicit heterosexual male clients They dressed like women and frequented the same places as FSW, leading male clients to assume that they had picked up a woman rather than abong lo To prevent the client from knowing that they are really men, bong losex workers mainly had oral sex or thigh sex with their client If the client found out that they were men, they would first deny, then negotiate, and finally give money back to the client
At night I hang on in the street where sex workers work For example, women[FSW]are in the up-street, and we are in the down-street I mainly had oral sex with clients Many men [clients] were so excited with sex so they didn’t pay attention to who I am because I already had breast surgery I had thigh sex with the clients who get drunk by holding their penis between my legs and using lubricant[Vaseline].Some clients found out that I was ‘pˆe- ˆe’, they asked me to give them money back otherwise they would beat me In such cases I first denied If they still firmed so, I would turn my voice down to negotiate with them If I was not successful, I would have to pay them back.[Bong loidentified street-based sex worker respondent, 36]
Condom use
Although condoms are available, accessible and affordable in the market, mostbong kinandbong lodid not use condoms or used them inconsistently for both anal and oral sex Decisions regarding condom use were based on judgments about individual sex partners Sex with loved partners, favourite partners, ‘clean’ partners, young partners and ‘regular’ partners was commonly not associated with condom use For example, when having sex with men whom they cared for, respondents spoke of expressing their emotions by not using a condom Such partners were often strong and good-looking
When having sex with a partner I like, I will not use a condom Because I like him, I want him I would like to give him emotional pleasure The highest emotional pleasure is having sex without a condom.[Bong kinidentified respondent, 23]
When having sex with favourite partners, the emotional excitement sometimes outweighed the fear of disease
When I meet a man who is strong and healthy, I won’t use a condom when having sex with him. Sometimes I feel scared of AIDS, but my sexual desire is so strong that I dare to that[having sex without a condom] [Bong loidentified sex worker respondent, 36]
Bong loandbong kinbelieved that using a condom was not necessary when having sex with ‘clean’ partners
If a sex partner looks ‘clean’ and his penis looks ‘normal’, I won’t use a condom When I am sexually excited, I think it is not necessary to use a condom with a man who looks ‘clean’.[Bong loidentified respondent, 27]
Somebong kinbelieved that having sex with boys aged 20 or younger carried no risk or very low risk because the boys may not have had sex with an FSW yet Having sex with these boys, particularly swallowing their semen, was also thought to be ‘good’ for their health On the contrary, having sex with older men [over 20] was thought risky because they may have already had sex with an FSW
Bothbong kinandbong loconsidered having sex with regular partners as safe Having sex with these regular partners did not require condom use because they were ‘honest persons’ This belief often persisted, even after experiencing infidelity from such regular partners
Conclusion
This paper presents empirical data to support a growing understanding of sexuality in HIV prevention Most MSM in Vietnam identify themselves either as masculinebong kinor feminine bong lo Both groups commonly reported having multiple sex partners and found it difficult to practice monogamy Bong kin and bong lo solicited casual and commercial sex partners in variety of public locations such as streets, parks, swimming pools, and entertainment establishments MSW solicited male clients on the street or in discotheques or brothels HIV prevention programs targeting MSM can focus their outreach services in these locations where MSM regularly meet to socialise and look for sex partners
One particularly worrying finding was the highly inconsistent use of condoms Sexual pleasure was weighed over the risk of not using a condom in some circumstances, particularly sex with favourite, clean, young or regular partners Emotional and sexual excitement at times also precluded making rational decisions about safe sex Health promotion messages need to include information on how to practice safe sex and sustain sexual pleasure at the same time
(6)provinces, these findings and recommendations were discussed and validated with MSM and key people in each location to account for regional cultural differences within Vietnam and to modify the program to meet local needs
What is known about male sexuality in Vietnam is still relatively modest in scope and this paper suggests some preliminary parameters for a research agenda that can help to develop sexual health programs for MSM in Vietnam Such an agenda ought to include, but not be limited to, exploration of sexuality and culture among men who have sex with both men and women and evaluation of male sexual health intervention models in Vietnam and elsewhere in the region
Acknowledgements
The research described in this paper was partly supported by United States Agency for International Development (USAID) through the President’s Emergency Plan for AIDS Relief, and was implemented by Family Health International, Cooperative Agreement No 486-A-00-06-00009-00 The views expressed are those of the authors alone and not necessarily reflect the views of USAID or the United States Government We would like to thank the HCMC AIDS Committee, especially Dr Le Truong Giang, Dr Tran Thinh and Mr Le Cao Dung, and the Binh Thanh District Health Center, especially Dr Pham Bao Lam and staff at the Blue Sky Men’s Health Club, for their support to the implementation of the project We also thank the peer outreach workers, the interviewers and the respondents who participated in the study We would like to acknowledge the critical comments and suggestions provided by Ms Donna Flanagan, Dr Stephen J Mills, Dr Philippe Guest, Ms Tenley Mogk and Ms Jennifer Nugent The authors are grateful to Dr Paul Boyce and Professor Peter Aggleton for their comments on earlier drafts of the paper
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