World AIDS Day 2011 - our pledges

All TB patients will be empowered to utilize HIV C & T

All HIV infected TB patients will be provided CPT and put immediately on ART

All HIV high risk groups will have free access to TB services

PLHIV groups have the capacity to screen themselves for TB and equally empowered to utilize the TB services

INH prophylaxis for the the people living with HIV

Sex workers (female & male) will be empowered to use condoms correctly and consistently with all their clients,

Early detection and treatment of all STIs

Complete decriminalization and destigmatization

STI cases will be empowered to utilize HIV C & T services

Strengthening of routine case reporting of STIs

Women are empowered to say 'no' to unprotected sex

Sexual abuse and violence must receive timely justice from the court of law

Youth groups should have complete information on SRH, STI and HIV/AIDS

Hideout

While crossing the river someone in the boat asked me, 'Your face looks familiar. Where are you going?'  It is quite natural to be a known face to the localities now because I became a regular visitor of Mangalpur village for Rinky. 'I am going to Dr Jalil's house to see his small daughter' 'Oh, the poor girl who caught polio' I received prompt reply from the fellow, 'The Government is spending so much money  for giving polio drops to the kids, still they are hit by polio. What a bloody wastage' he turned his face away from me. I turned into the villain in the boat.

By that time, I came to know the directions of Rinky’s house like the palm of my hand. Get down at Mangalpur Ghat, walk half a mile right along the river bank, then turn left to fall into the narrow strip of meadow leading straight to her place. The fifth house of the village belongs to Dr Jalil, Rinky’s father. He has set up his clinic in one of the rooms of his house but I could never see any patients there while visited his house earlier.

Rinky was sitting beside her mother on a shabby cot at their courtyard. Her flaccid, polio-stricken left limb was hanging like dead branch of the tree. Her mother covered her face the moment she saw me entering the courtyard. Rinky gave me one of her finest smiles. She was confident that I am not going to give her injection like her father did to her. When I was examining her first time she was crying like hell. She was carrying the dreaded experience of her father grasping her small waist tightly on the ground and pushing hard the thick needle into her buttock to get rid of her sudden paralysis. The rural doctors believe to treat and cure diseases by injections. They don’t even spare the kids.

I could not see Dr Jalil this time. His clinic was locked from inside and the clinic signboard was also missing. This is unusual because I was always greeted by Dr Jalil every time I visited his house before and his clinic used to remain open with the glowing signboard on its top.

Her mother rushed inside the house to bring me a chair. Children playing in the courtyard assembled around us. Rinky couldn’t play with them anymore so they play in her place to keep their paralyzed non-playing friend happy. I often saw this before – solidarity among the kids.

This was a follow up visit. I did the routine check up of Rinky’s paralyzed limb. Rinky got her due chocolate bar. My communication with her was so far silent except exchange of smiles. She only understands the local ‘Suryapuri’ language, which is spoken in many parts of the North-East Bihar bordering with Bangladesh. I know there are a number of Bengali words in Suryapuri but I always remain a pathetic learner of the new languages.

‘Where is Dr Jalil?’ I asked her mother. I had to give him some physiotherapy references for Rinky. ‘He is caught by the police two weeks back and in jail now.’ I got a shocking reply.

‘But why’

‘Why not?’ came forward a middle aged Hindi-speaking villager. ‘There are so many charges against Dr Jalil – murder, extortion, robbery, rape. Police was tracking him for years.’

‘But he is a doctor’ I couldn’t help expressing my utter surprise.

‘That was a total eye-wash. He used this place as his perfect hideout.’

‘But he was treating you people for your illnesses, wasn’t he?’

‘So what, there are so many quacks treating us in our places because doctors like you never come to the villages to look after us’ replied the villager with sheer frustration.

Rinky’s mother already broke into tears. Some other women were trying to pacify her but the poor lady was inconsolable.

‘She has five children. Rinky was the second youngest. Who will look after these children now? Who will feed this family? How can this woman get Rinky married? Who will marry this disabled, debilitated girl? We are poor farmers. We can’t meet our both ends meat, how can we help this ill-fated family to meet their basic needs?’

I didn’t have their answers. I was looking at Rinky’s friends. They were back to their games. Rinky was so happy to see them play again. She was laughing loudly, clapping constantly and shouting at them incessantly as if she was very much a part of the playing team.

I was actually looking for a place in her playing team to make my own hideout.

Sugata M

(From Eradicator's Diary)

The fate of single mothers in ibo land

Uchenna Anozie, Nigeria

 

Ibo tribe is found in the eastern region of the country Nigeria, they are rich in culture and are very enterprising, they are known in the world as people who are always pushing hard to stand economically.

Culturally and religiously in Ibo land young girls that fall victim to pre marital pregnancy are stigmatized, they are withdrawn from schools and relegated at home to bear the pregnancy in shame, often times, the young lady is not given the opportunity to go out and interact with people or appear in public functions because it is believed that the girl is a disgrace to her family.

Most times less attention is paid on the responsible person for her pregnancy and often times the male partner involved denies responsibility. Some families just pay off the family of the pregnant lady in question.

I was on my way to my office as usual, Monday mornings. The streets were busy and congested in a town called Awka in Anambra state, children going to school, civil servants trooping to work, hawkers selling on the streets, travellers waiting for buses and taxis. I stopped to pick my routine phone recharge cards. I formed it as a habit to be buying recharge phone cards for the office and my personal phone being the beginning of the week, the phones are always busy. Luck befall one particular young nice looking girl, fair in complexion, blue eyed with long hair, she is the type that every young man would like to say hi to, she sells various recharge cards and I patronized her because of her astonishing beauty, in fact it became a tradition that I bought bulk cards from her and her polite character always motivated me to come back again. This particular morning something in particular struck me. I asked myself so many questions, why is it that Jane is selling recharge cards instead of continuing her studies?  Why is she always polite irrespective of the harsh conditions in street trading? Why is Jane selling on the street at her age?

After having a busy day in the office and my usual field work involving visiting female sex workers at Onitsha, I decided to visit Jane at the spot she sold cards, luckily for me she was at her spot with her usual smile and welcoming attitude but this time around I opened up to her that I was not here for buying of cards, I told her I was here to talk with her and be her company, she looked straight into my eyes and smiled without uttering a word. I bought some soft drinks and we shared together, I wanted her to see me as a friend and someone she could confine to. I asked her where she was from and she replied ‘’ Awka”. We spoke at length on street activities of the day; I introduced myself as uchenna, as a health worker and an advocate for abused females and female sex workers. We exchanged ideas on factors pushing ladies in our society into prostitution before 2 little girls rushed to her and greeted her “good evening aunty”, and she replied them “how is school today? Hope you have eaten at home? Is mama at home?”

With the few observations I made, I noticed Jane was staying with mama at home with the kids and an aunty, I could not place whom the children belonged to, whether they were hers or her aunt’s daughters, but wait a minute I told myself, these kids greeted her “good evening aunty.”

I did not want to ask her questions concerning her family background on our first meeting so after a few more minutes I left for my home but before I left she told me “thank you uchenna for your  company, you cannot really know how I feel when someone shows me concern”.

I thought of her words and I felt Jane had more pressing conditions and things she needed to discuss with someone ready to listen to her. I began to pay her regular visits after work to make her get used to me and tell me more about herself.

3 months after being friendly to Jane, I was chatting with her and one old friend of mine Ejike, who was always high in spirit due to regular smoking of marijuana and taking of alcohol from the same Awka town saw me and called me, he then laughed loudly and said”stop wasting your time on that lady with 2 kids, there are so many other young sexy ladies littered on the streets, why go for Jane? For god’s sake she is a mother of two and no husband”. I gently replied him that she is my friend nothing attached to our friendship and I knew she was a mother of 2 kids, “it’s no news my dear friend”. Though I was shocked inwardly because all these days Jane never told me anything about her past and the kids just that she mentioned they were her aunt’s kids but I did what I did to protect Jane’s image and to show my solidarity support to her. Ejike left in his usual lousy manner, I turned and saw Jane crying and packing up her sales implements and I asked her why she was crying and packing, then she told me that the embarrassment she faced from her immediate community was becoming too much for her to bear and contain, I left her to cry and after that she said to me, “now that you have also known that am a mother of two without a husband please live my life alone and abandon me too”. I told her its people like her that I like being with and I try to work with. I then took her for a long walk and we ended up in bar, I bought some bottles of beer and roasted meat and we started talking.

I told her that I knew how she felt and I understand what she was passing through but children are gifts from God and are never meant to bring sadness rather joy, she smiled unconvincingly and said thank you sir but her kids have ended up bringing shame and much suffering for her. She then started narrating the long awaited story, she cried and I told her that the pain is ours and not for hers alone, so she should better stop crying and talk to me like a brother. I congratulated her for bearing the kids and being alive to watch them grow, I told her that her daughters will bring much joy to her in future and she should love them with all her heart, kids worth our love, support and protection no matter the circumstances surrounding us. I let her understand that those kids are her family and will make her proud someday. I encouraged her for not aborting the kids just like many women in our society do after considering what they will pass through if eventually they keep their pregnancies, I told her am an advocate preaching for the right of ladies and children, that am against abortion and maltreatment of unwanted children.

It was her turn to tell me the long awaited story that she has been keeping away from me:

She told me she felt left alone with her daughters on earth, she told me that she never knew his father as she was told that her father had died the same year she was born and she had no brother nor sister, the father’s family accused her mother of poisoning her late father. This is a usual problem faced by widows in Nigeria when young married men die; widows are often subjected to so many horrible treatment and rejection. Subsequent to her father’s death her mother got married to another man and abandoned her with her grandmother. She then stated that it was in her junior secondary school when she was in junior secondary III, that one young boy also in secondary school from a wealthy home befriended her and sexually exploited her and unfortunately got her impregnated. Her immediate family then asked her after who was responsible; being a young girl of 15years she never wanted to open up because the boy had already threatened to deny his involvement, meanwhile she never wanted to end up with the boy because of his arrogance and attitude.

She insisted on keeping to herself and her aunties decided to confront her physically and torture her to confess who was responsible for her pregnancy but she insisted on not opening up. After the abuse she had serious cuts on her body and haemorrhage (she showed me eminent and pronounced healed wounds on her body), it was then that one young lady that served as a sales girl for one of her aunts out of compassion decided to take her to hospital, she consequently harboured her in her place at Amawbia till after 5 months she delivered a baby girl without complications.

7 months after delivery her grandmother came looking for her, she took her home and reaccepted her at home, she felt happy again and relieved but then had stopped her education. After another 6 months she was forcefully handed to another elderly woman whom had no husband to take her as a wife and for her to make babies for her. (Culturally when a lady is without a husband and children and she needs to raise a family, she is allowed to marry a fellow woman who will fuck with men and beget children for her and make her own family, it’s a tradition in most Ibo towns and this is generally accepted). Young Jane whom had stopped school, lost a lot of affection in her life was now betrothed to an elderly woman to start having sex with different men and make babies for the elderly woman; the elderly woman operates a highway restaurant in Ore, a road linking the east of Nigeria and west Nigeria (city of Lagos). She was meant to serve people in the restaurant and to be sexually exploited and abused by fat tummied heavy duty drivers that are ready to pay the owners of the road side restaurants to have their maidens fucked. Jane’s case was special because she was to serve in a restaurant, trade her body for sex and moreover make babies for her lady. She had no option than to fit fast into the system and she began to discharge her new functions without hesitations, already she was frustrated and was feed up with life especially with the burden of her young daughter, this time around, Jane was turned to a sex slave at the age of 17years.

She later gave birth to another daughter without proper care and normal abuses that she has been passing through. one day Jane got very sick and was not given attention by her madam so after some weeks of continuous sickness and suffering she decided to escape with her two daughters back home to Awka and this time around she was ready for whatever but luckily one of her aunts came back from the city and heard all she has passed through then offered to take her along to the city leaving the two daughters with her grandmother at Awka.

She then finished her secondary school education and was given some money to go back to Awka and take care of her daughters and look up for something doing to sustain herself. Jane broke into full tears again and stopped then tuned to me and said “now I feel better that I have told you about myself and my ugly background and past”. After that, she told me that she felt she was unfortunate on earth that God has rejected her and her sufferings, she told me that till date most members of her family neglected her and call her a prostitute and they saw her as a demon stricken girl, she said that the height of stigmatization and marginalization she witnessed in her family was alarming but she could cope with that considering what she passed through in the past she is now living better and believes that someday she will be a great woman.

I was silent for a long while and I ordered for more beer, I asked her if she loved her daughters and she said “yes, very dearly”. I asked her if she has gone for HIV test ever since then, she said yes and she was negative, I asked her if she would love to be screened again she said yes without hesitation, I convinced her that children are blessings and what she has done remains the best thing to do in such a situation, leaving her sex salve job for home, finished her secondary school education and taking the decision to sell on the street to sustain her daughters and pushing on in life believing seriously in a better future. Really it takes guts and great courage for a young lady at her age.

The following day I invited her to my office where I counselled her on STI/HIV/AIDS and I took her to the clinic where she underwent a free HIV screening and she was HIV negative. I encouraged her to carry on with life and practice safe sex to avoid getting into more challenges; she was full of tears and said nobody has ever given her such attention in her entire life but I made her understand that I was just doing my job and nothing more, we are trying to touch lives and bring people to the safe side and make everyone feel safe from the scourge of STI/HIV, sexual abuse and stigmatization. Though I cannot assess many people in the same conditions I believe in doing my best with anyone I come across that needs assistance, these girls are people that spread the good work and try and affect other peoples’ lives, I believe that when we rehabilitate people properly they also rehabilitate other people positively and positive changes are spread across the society.

Today Jane has a shop of her own where she earns her living, she lives in her own apartment to avoid family intimidation and stigmatization and her daughters are doing well in a private primary school and are growing up fast. Jane believes strongly that someday she will enrol into the university to study marketing or public administration.

Clinical experience: association of sexually transmitted infections with sexual dysfunctions

Sexual dysfunctions in the form of Erectile Dysfunction (ED), Premature Ejaculation (PD), Nocturnal Emission (NE), Dhat Syndrome (DS) are not uncommon in clinical practice. These disorders predominantly affect the male community of different age groups. Many  times sexual dysfunctions arise from excessive stress, sustained depression, sexual boredom though physical reasons like long standing diabetes, hypertension, excessive smoking, chronic alcoholism, trauma, neurological disorders should be always screened among the cases of sexual dysfunctions through detailed history, proper clinical examination and appropriate investigations.

Sexually Transmitted Infections in males are most of the time symptomatic (unlike females). I have had the opportunity to treat around 3000 cases of sexually transmitted infections (both males and females) during my tenure in Sonagachi Sexual Health Project (1999 – 2002) as a clinical healthcare provider of the STI & HIV clinics of the project. The project also gave me ample scope to treat a number of male cases with sexual dysfunctions; many of them finally landed into the project clinics after seeking treatment at a number of places including road side quacks, pharmacists and qualified sexologists (though the number of qualified sexologists are very few in the city like Kolkata).

Approximately 10% cases of sexual dysfunctions was detected with sexually transmitted lesions during clinical examination, either in the form of genital ulcer or urethral discharge, which were never revealed by the patients during the history taking. The key need of all those patients was primarily to regain their sexual potency, not to get the co-existing sexually transmitted infections treated and cured.

I am still not able to find scientific studies that match with my own clinical experience.

Sexually Transmitted Infections generate considerable concern and stress in the patients which may easily lead to temporary loss of sexual  activities. But as a general phenomenon, STI cases are seen to remain sexually active during the course of the disease and that’s what makes it an absolute necessity for them to practise safe sex with their partners/spouses correctly and consistently.

But my experiences with the sexual dysfunction cases explored the other side of the coin.

When they lost their sexual desire and potency (partially or completely) they left no stone unturned to regain their vigour which ranged from witchcraft treatment to visiting a sex worker.

Once, a boy around 17-18 years came to my clinic complaining of discharge of semen on the slightest sexual excitement and frequent nocturnal emission. He was often teased by his friends and also intimidated that he can never satisfy his wife after marriage because these are the symptoms of losing one’s sexual potency. The poor boy, who had been working in a local factory was looking severely tense and going through lot of mental agony and distress.

When examining the boy, I found he was running temperature. I examined his genitalia and found discharge of thick purulent pus on gentle urethral milking. After further interrogation he admitted associated symptoms like urinary burning and fever which started after he had visited a local brothel with one of his friends. The friend advised him to have sex with a sex worker to know correctly if he had actually lost his sexual potency or not.  The poor boy would like to prove to himself that he is sexually healthy but he just didn’t bother to use a condom.

All my patients suffering from sexual dysfunction strongly opined that condoms further kill their desire and performance, so they did not use them during sex with a stranger or a sex worker.

Another of my patient, a man in his early forty, who complained of lack of sexual desire after reaching his fifteenth year of married life, was found to nest an incompletely healed genital ulcer which, after a detailed history, was found to be acquired from unprotected sexual contacts again with sex workers. The man didn’t bother about the painless lesion which was healing gradually, because his mind was completely pre-occupied with the growing concern over his decreasing sexual desire and potency.

I do feel these are important observation. A man primarily with sexual dysfunction lands finally into STIs while experimenting on his own sexual performance and potency but without caring about safe sex knowingly or unknowingly.

I didn’t have the records of their syphilis or HIV screening tests and results. But they were all treated for bacterial STIs, cured and given thorough education on STIs, HIV/AIDS and correct & consistent condom use. They were also counselled for the dysfunction part with varied outcome. Some of them were referred to the psychiatrists and lost to follow up.

But the experiences were invaluable to me because they taught me to screen all cases of sexual dysfunction for the presence of STI lesions through detailed history taking and meticulous physical examination and promptly treating the STIs with adequate and appropriate health education.

 Sugata M

UNIVERSAL Health

TI-TB collaboration - why it is not happening?

I would like to draw your kind attention to the important topic of TI-TB collaboration (TI: Targeted Intervention for high risk groups like sex workers, MSM/Transgender, Injecting Drug Users, Migrants and Truckers).

In 2005-06, when I was working with CARE India as the Technical Head of the HIV/AIDS program in 22 cities of 5 highly vulnerable states of the country, during one of my field visits in UP I observed there was a strong need of TB services for the sex workers and due to no knowledge of RNTCP they used to visit private practitioners for TB treatment by spending huge amount of their hard-earned money.

Later on, Avahan project (supported by BMGF and technical support provided by Family Health International/FHI) made similar observation in their project areas (emerging TB treatment needs of the HIV high risk groups) and developed operational linkages between their on-going TI projects with RNTCP. By keeping Avahan’s TI-TB collaboration experiences in mind, Central TB Division (CTD), while developing the schemes for NGO/PPs also came up with the opportunity of the TB/HIV NGO-PP scheme.

The uptake of the TB/HIV NGO-PP schemes remain sub-optimal. Among them the situation of TI-TB collaboration through such scheme is even poorer (only 03 TI projects of the whole country have been linked to RNTCP through the TB/HIV NGO-PP schemes).

NACP III has been currently implementing  454 TI projects of the sex workers (coverage: 7.09 lakhs), 155 TI projects of the MSM (coverage: 2.74 lakhs), 261 TI projects of the IDUs (coverage: 1.42 lakhs), 212 TI projects of the migrants (coverage: 37 lakhs) and 76 TI projects for truckers (coverage: 11 lakhs).

I do believe, the potential of TI-TB collaboration is still largely untapped and we are missing TB cases in the HIV high risk groups (especially IDUs, migrants and female sex workers). This is critical in the perspective of CTD’s decision to achieve targets of universal access in the next phase of the program.

Sugata M

Female Genital Mutilation in Africa

Uchenna Anozie, Nigeria

Female Genital Mutilation is a cultural practice that started in Africa approximately 2000 years ago. It is primarily a cultural practice, not a religious practice. This practice is so well inculcated into these cultures.

What is Female Genital Mutilation?

Female Genital Mutilation is the term used for removal of all or just part of the external parts of the female genitalia. There are three varieties to this procedure.

Types of Female Genital Mutilation

• Sunna Circumcision - consists of the removal of the prepuce(retractable fold of skin, or hood) and /or the tip of the clitoris. Sunna in Arabic means "tradition".
• Clitoridectomy - consists of the removal of the entire clitoris (prepuce and glands) and the removal of the adjacent labia.

·         Infibulation (pharonic circumcision) consists of performing a clitoridectomy (removal of all or part of the labia minora, the labia majora). This is then stitched up allowing a small hole to remain open to allow for urine and menstrual blood to flow through.

Most times this procedure is done without the care of medically trained people, due to poverty and lack of medical facilities. The use of anesthesia is rare. The girl is held down by older women to prevent the girl from moving around. The instruments used by the mid-wife will vary and could include any of the following items; broken glass, a tin lid, razor blades, knives, scissors or any other sharp object. These items usually are not sterilized before or after usage.

Side Effects of Female Genital Mutilation

This procedure can cause various side effects on the girls which can include death. Some of the results of this procedure are serious infections, HIV, abscesses and small benign tumours, haemorrhages, shock, clitoral cysts. The long term effects may also include kidney stones, sterility, sexual dysfunction, depression, various urinary tract infections, gynaecological and obstetric problems.

In Africa

In most societies in Africa a girl cannot be considered to be an adult until she has undergone this procedure. As well as in most cultures a woman cannot marry without female genital mutilation.

It is obvious in cultures that carry out this procedure as an initiation into womanhood. Most FGM societies feel that unless a girl has this procedure done she is not a woman as well as removal of these practices would lead to the demise of their culture.

Belief and reasons this procedure should be done and these are as follows:

·         This procedure will reduce a women's desire for sex and in doing so will reduce the chance of sex outside the marriage.

·         Some view the clitoris and the labia as male parts on a female body, thus removal of these parts enhances the femininity of the girl

·         Intact clitoris will generate sexual arousal and in women if repressed can cause nervousness

·         Removal of clitoris makes a women's face more beautiful

·         Clitoris can lead to clitoris can lead to masturbation or lesbianism.

Legislation and policies on Female Genital Mutilation

Amnesty International now has taken up the fight to do away with this practice that mutilates millions of girls each year. Today FGM is seen as a human rights issue and is recognized at an international level. FGM was in the universal framework for protection of human rights that was tabled in the 1958 united Nation agenda. It was during the UN Decade for Women (1975-1985) that a UN Working Group on Traditional Practices Affecting the Health of Women and Children was created. This group helped to develop and aided to the development of the 1994 Plan of Action for the Elimination of Harmful Traditional Practices Affecting the Health of women and Children. the World Health Organization, the United Nations Children's' Fund and the United Nations Population Fund, unveiled a plan in April 1997 that would bring about a major decline in FGM within 10 years and the complete eradication of the practice within three generations.

Personal experiences and Confessions

In Sierra Leone, the women say and sing in their native language:” today the ripe mango will be plucked” this means it’s time to remove the clitoris. They are initiated into the women hood, they believe this makes the women to be unpromiscuous and reduces sexual urge.

The girls range between 6 to 12 years. The cost of the procedure and ceremony is also high and are often delayed so that the parents can get enough money for the ceremony. They believe they are maintaining tradition.

They also believe that excessive bleeding or death during this procedure is caused if the girl is possessed by a demon.

Talking with a Isha from Guinea, she stated that her mother had her younger sister’s daughter undergo excision twice. First when she was 8 years old and after that her grandmother felt the clitoris was not properly removed, the grandmother forced her to undergo the second circumcision at the age of 18. She said the girl’s experience was indescribable but it is still a mark of a strong woman and she strongly believes that what her grandmother did was the best thing she could do for her.

Some Key Information

• Current status: Excision and circumcision are reportedly practised in Guinea-Bissau. According to information available to the WHO, average prevalence could be 50% and affect 100% of Muslim women. It is reportedly 70 to 80% for the Fula and Mandigue women. In urban areas, it is estimated that 20 to 30% of girls and women have been mutilated. However, there is no first-hand official
• Legislation: In 1995, a bill was reportedly rejected by Parliament. Nevertheless, the Assembly has reportedly approved a proposal calling for criminal liability for female excision practitioners in the event of death brought on by female genital mutilation.
• Other information: A nation-wide awareness-building programme was launched by the Government in January 1997 with the support of NGOs.
• Current status: Excision and circumcision are reportedly practised in Guinea. According to official estimates in 1999, 98% of women between 15 and 50 have undergone FGM. However, awareness-building campaigns conducted since 1998 have brought this percentage down to 20%, and 450 female excision practitioners have abandoned their trade. Nevertheless, the IPU has no first-hand official statistics or other details on this subject.
• Legislation: 
  - Article 6 of the Constitution prohibits cruel, inhuman or degrading treatment. 
  - Article 265 of the Penal Code (1994) prohibits female genital mutilation and provides for the death penalty in this respect; however, the Parliament has not yet forwarded the references and text of the law to the IPU.

• Other information: The Government launched with WHO a 20-year programme (1996-2015) for the elimination of female genital mutilation and works together with NGOs. The programme includes films, TV shows, workshops, etc.

Regrets, reality and the untold truth.

Talking with some nurses, mid wives and doctors in Burkina Faso, Senegal, Nigeria and Guinea. I personally found out that despite these efforts made by the government, United Nations, Amnesty international, these health workers still carry out these surgeries which violates the law and collect money from clients. I personally found out that some health workers do not do this for money but believe that irrespective of orthodox medicine, culture should be maintained and sustained.

Trying to go deeper into the matter, I found out that even the members of the legislative arm of government perpetuated these practices and still publicly announce that FGM is prohibited.

In fact irrespective of these laws put in place against FGM nobody has been apprehended nor arrested by government on female genital mutilation, they just put up a front that FGM is prohibited to distract the international concern against FGM.

FGM is women right violation and should be seriously condemned due to numerous reasons: the practice is cruelly conducted in most places, the women are denied sexual pleasure during sexual intercourse, numerous infections and diseases can emanate from this practice.

The most concerning aspect of this practice is that since a circumcised woman has limited sexual pleasure during sexual intercourse, the mucous secretion is limited and can lead to wares and tires of the virginal walls due to friction in sexual intercourse, this leads to serious exposure to STI and HIV transmission.

More awareness and serious legal emphasis should be put in place to condemn female genital mutilation. Also for public health workers, global health professionals, policy makers, social and developmental workers should see this area of study as an explorable avenue of study and analysis.

 

Basics of homosexuality - key definitions (From the Desk of Universal Health)

Sexuality: Sexuality is a combination of following six components:

•         Biological sex – physical and genetic sex (That is, born with which genitalia?)

•         Sexual orientation – Sexually attracted whom (male, female or both)

•         Sexual behavior – Sexual act with whom (male, female or both)

•         Sexual identity – Self identity of the sexual orientation

•         Gender identity – psychological sense of being male or female

            (That is whether considers oneself as man or woman?)

•         Gender expression – adherence to the cultural expectations for feminine or masculine behavior

Sexual orientation: One’s erotic, romantic, and affectional attraction to people of the same sex, to the opposite sex, or to both sexes.

Heterosexuality: Erotic, romantic, and affectional attraction to people of opposite sex.

Bisexuality: Erotic, romantic, and affectional attraction to people of both sexes.

Homosexuality: Erotic, romantic, and affectional attraction to people of the same sex.

Similarly, Sexual behavior and identity can be divided into heterosexual, bisexual and homosexual.

A person with same sex behaviour will feature the following attributes:

1) Homosexual or Bisexual orientation

2) Homosexual identity is sometimes not identified by the person himself. In that case it is known as label but not an identity

3) Sexual behaviour varies from heterosexual, bisexual to homosexual (a person with homosexual orientation may have heterosexual behaviour)

4) A person who is born with normal male genitalia may think himself as a woman, so the orientation of the person becomes heterosexual. (He likes to have sex with the male partner like a female).

Some important definitions:

Eunuchs: A castrated male. It is not used any more because it is considered to be a derogatory term.

MSM: Men demonstrating sexual behaviour between each other irrespective of their sexual orientations. (A man can have sex with another man with heterosexual/bisexual/homosexual orientation)

Gays and Bisexuals: MSM may hail from upper, middle and low socio-economic strata. MSM with homosexual and bisexual identity and belonging to upper and middle classes are known as Gay and Bisexual respectively. A Gay can not be always a MSM and vice versa.

Kothis: Similarly MSM with homosexual identity and belonging to lower socio-economic class is known as Kothis. Kothis call their partners as Panthis if they only penetrate them during sexual act and Double Decker/Do Paratha if they penetrate and get penetrated by the kothis during sexual act. Both these terms Panthis and Double Decker are not identities but labels given by the Kothis to their sexual partners.

Few more important aspects on Kothis:

A Kothi is a man with feminine features with homosexual orientation. But the Kothis may demonstrate heterosexual behaviour as well. A number of kothis in India are married and even have children. All kothis do not have anal sex.

Kothis/Gays show varying degree of homosexual orientation like

• A combination of homo and heterosexual orientation making the person bisexual who may demonstrate bisexual behaviour as well (sex with both male and female partner)
• Homosexual orientation without homosexual behaviour
• Homosexual orientation with gender identity as a man
• Homosexual orientation with gender identity as a man but dislikes some of features of the male body

When gender identity of a male person becomes a female the sexual orientation becomes heterosexual. To satisfy the desire of becoming a female the person adopts a number of techniques like: Dress like the females (Cross dressing), development of breasts, undergoes castration operation (removal of male genitalia) and emasculation (removal of both male genitalia and penis) Sometimes the desire is so strong that he likes to undergo sex change operation to have a female body.

Persons who transgress societal gender norms are known as Transgender. Transgender have variant range of gender identity starting from gender dysphoria (dissatisfaction with one’s own gender identity) to extreme condition of transsexualism where the person strongly believe that he is a female ‘entrapped in a male body’. Female-to-male transsexuals are sometimes referred to as "FTMs" or "transsexual men," and male-to-female transsexuals as "MTFs" or "transsexual women." Transsexualism is a neurodevelopment condition in the hypothalamus of human brain which is considered to be normal in present days though Gender Identity Disorder (GID) if affecting the day to day activities of life is considered to be a psychiatric condition. GID may be childhood or adult onset.

Hijras are basically biological males but transsexuals with the Kothi identity. Feminine MSM is also having Kothi identity. Incidentally the word Kothi comes from Hijra community.

Intersex is the term used to describe persons who carry both male and female genitalia (mostly non functioning) due to developmental anomalies (such condition occurs in one out of one lac new borns). They should not be confused with the Hijras because a Hijra is a normal biological male only. Hermaphrodite is an obsolete term for Intersex.

Differences between Hijra and Kothi (though there are overlapping between the two groups):

HIJRA	KOTHI
Gender identity is female	Gender identity is mostly male
Mostly Transsexuals	Rarely transsexuals
Often cross dress	Rarely cross dress
Generally heterosexual orientation	Generally homosexual, sometimes bisexual orientation
Sexual behaviour may rarely be heterosexual with female partners	Sexual behaviour may sometimes be heterosexual with female partners
Tendency to breast development, castration common	Not common
Develops separated community with ‘guru’ system	Stay with partner or alone. Rarely form a group though networking among the kothis is very strong
Sometimes penetrates male partner	Rarely penetrates male partner
Commercial sex work common	Commercial sex work is not that common
Thigh sex common	Thigh sex not common

 

In South India Hijras are known as Aravani. Ali is a derogatory term of Hijra. Some common terms related to Hijras:

Ackwa Kothi: Hijra with intact genitalia. They are also known as pre operative male to female transsexual (MTFT).

Nirvana kothi: Castrated Hijra. They are also known as post operative male to female transsexual.

Non operative Transexxual: Some Hijras do not like to go through castration operation.

Castration is sometimes done by unqualified doctors leading to urethral stricture and urinary retention. This procedure is also carried out by the elder member of the hijra community known as "Dai-Mai".

Some important steps of Sex Reassignment Surgery/SRS:

• Creation of new vagina
• Application of female hormone
• Development of artificial breasts from abdominal muscle
• Silicon prosthesis for breast development
• Laser surgery for vocal cord
• Electrolysis/laser treatment to remove hair

Lesbian: A lesbian is a woman whose primary sexual and romantic attractions are to other women. She may have sex with women currently or may have had sex with women in the past. A smaller number of lesbians may never have had sex with another woman for a whole host of reasons (age, societal pressures, lack of opportunity, fear of discrimination), but nonetheless realize that their sexual attraction is mainly to other women. Some lesbians have sex with men and some don't. It is important to note that some women who have sex with other women, sometimes exclusively, may not call themselves lesbians.

Homophobia: It is the irrational hatred and fear of lesbian and gay people that is produced by institutionalized biases in a society or culture. Heterosexism: the assumption that only heterosexuality is normal and other sexualities are abnormal and immoral. Coutsey: Humsafar Trust and Dr V. Chakrapani