Background: The term “men who have sex with men” (MSM) provokes the illusion of sexual risk homogeneity among male sexual minorities. The term overemphasizes a single aspect of sex between men (behavior) and overlooks nuanced factors (such as gender/sexual identity) that affect the spread of sexually transmitted infections (STIs). Beyond STIs, the expression of gender/sexual identity has observable traits that predispose non-normative sexual minorities to profiling, discrimination and human rights abuses. In India, three subgroups of male sexual minorities differ in gender/sexual identity. Kothis have effeminate gender expressions and often practice receptive anal sex. Panthis have gender expression that reflect more traditional masculine roles and they tend to practice insertive anal intercourse with other men. The gender expression of Double-Deckers is mixed and situational and they practice both insertive and receptive anal sex depending on the specific situation or sexual partner.
Methods: Respondent-Driven Sampling was used to recruit 12,022 men in 12 Indian cities from 9/2012 to 7/2013. In a questionnaire, participants were asked to select their gender/sexual identity from a list of locally recognized identities, including Panthis, Kothis, and Double Deckers. HIV and HSV-2 infection were ascertained using ELISA-based IgG assays. Syphilis was ascertained using standard Treponema (Treponema pallidum haemagglutination) and non-Treponema tests (Rapid Plasma Reagin) tests. Random-effects logistic regression was used for all aims. In aim 1, we estimated the associations between gender/sexual identity and serology-ascertained STIs (HIV, HSV-2, syphilis) as well as self-reported STIs (Hepatitis B, chlamydia, trichomonas, gonorrhea). We also estimated the association between gender/identity and concurrent infections (HIV and HSV-2, HSV-2 and syphilis, HIV and syphilis, HIV/HSV-2/syphilis concurrent infections). Associations were adjusted for age, intercourse type, sex work, number of partners, education, marital status, and circumcision. In aim 2, we estimated the association between gender/sexual identity and outcomes related to human/sexual rights (healthcare refusal, healthcare mistreatment, physical and sexual violence). In aim 3, we analyzed if 3 social stratifiers (age, family income and education) modified selected associations between gender/sexual identity and outcomes estimated in aim 1 and aim 2.
Results: The parent trial recruited a total of 12,022 men who self-reported sexual encounters with other men. This analysis was restricted to 9,542 (79.37%) men who self-reported the 3 gender/sexual identities of interest: Kothi, Panthi and Double-Deckers. The mean age was 28.45 years, 33.08% were married, and median age at first intercourse with a man was 18 years. Panthis represented the largest subgroup (32.7%), followed by Kothis (23.5%), and Double Deckers (23.3%). In terms of sexually transmitted infections (aim 1), after adjustment for behavioral and social factors, compared to Panthis, Kothis had higher odds of HIV (OR=2.20; 95% CI=1.60, 3.03), HSV-2 (2.55; 2.04, 3.20), syphilis (2.35; 1.42, 3.90), and coinfections with HIV/HSV2 (2.56; 1.74, 3.75), HIV/syphilis (2.93, 1.17, 7.34), HSV2/syphilis (2.97, 1.58, 5.59) and HIV/HSV-2/syphilis (3.84; 1.40, 10.56). In terms of relative differences in human/sexual rights (aim 2), compared to Panthis, Kothis had higher odds of reporting being frequently mistreated by hospital staff (4.59; 3.54, 5.94), of frequently being refused medical care or denied hospital services (5.08; 3.79, 6.80), of frequently being refused housing (5.49; 4.20, 7.16), history of serious physical violence growing up (6.69; 5.97, 7.49), and history of forced attempts at unwanted sexual activity by an intimate partner (4.11; 3.67, 4.61). In aim 3, the differences in the associations between gender identity and HIV showed modification across strata of age, education and income. Men with high family incomes, high education (or both) had lower odds of HIV but these protective effects were largely limited to younger (not older) Kothis and Panthis.
Conclusions: Men of different gender/sexual identities in India belong to heterogeneous subgroups. Kothis had elevated odds of HIV, HSV-2, and syphilis as well as higher odds of concurrent epidemics of these infections. Kothis were predisposed to human/sexual rights violations such as discrimination, physical and sexual violence. Education and income were associated with lower odds of HIV for younger but not older Kothis and Panthis. In contrast, sex work and the Kothi identity in India are associated with high risk of adverse sexual health outcomes independently of protective social variables. The role of education and income among younger men in their formative years warrants additional multi-disciplinary HIV research. Gender/sexual identity is an important biopsychosocial determinant of health that is associated with sexual behavior, epidemics of sexually transmitted infections, and the enjoyment of human rights
