Monday, October 17, 2011

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

Saturday, October 8, 2011

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.

 

Wednesday, October 5, 2011

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

Human Sexual Behavior & its effect on Reproductive Health

Sugata M

Sexual activity is one of the most crucial psychophysical activities in the lives of humans. It leads to pleasure and satisfaction which is critical for a fruitful and meaningful living. At the same time the sexual act remains as the most critical expression of the human sexual behavior and is also positioned as the central theme of the reproductive health.

Outcomes of sexual activity: Other than psychosomatic recreation sexual activity may have the following outcomes under various contexts affecting the reproductive health: 1) Pregnancy/Conception, 2) Infection and 3) Injury

Pregnancy: Sexual activity between heterosexual couple during a particular period of time (ovulatory phase of menstrual cycle) results in pregnancy provided both the couple is physically competent to procreate. Pregnancy may be wanted, unwanted as per the objective of the mating couple. Pregnancy is a normal physiological phenomenon but it definitely puts the women under certain degree of risks (like abortion related problems, pregnancy associated or induced health problems, post partum hemorrhage, complications in puerperium, complications of teenage, repeated and late pregnancies, implications on the newborns including Mother To Child Transmission/MTCT of HIV) 

Infection: There are plenty of evidences globally that unprotected penetrative (rarely non penetrative) sexual acts are responsible for genital tract infection (genital tract means sexual and reproductive organs), anal tract infection, oro-pharyngeal infection, body infection (scabies, lice infestation) and other infections (hepatitis, enteric fever etc). The most talked about sexually transmitted infection in today’s world is HIV/AIDS. All the STIs have their epidemiological pattern, pathogenesis and treatment measures. But there is a uniform understanding (based on scientific evidences) throughout the world that protected sex can prevent 90-95% of STIs. Modification of the sexual behavior is unanimously accepted globally as the most critical strategy to ensure safe sex practice among vulnerable as well as general community to control STI/HIV.

Injury: Violent sexual act damages the sex organs (mostly the recipient partners). Rape, molestation, sexual harassment, sexual aberrations (sadism, masochism), some accepted social norms (sodomy, alcoholism, drugs) are common features, which ultimately push the passive partners into the risks of sex organs’ injuries including psychological trauma. 

Behaviors in the form of non penetrative non touching sexual practices (like masturbation, exhibitionism, voyeurism, fetishism etc) also exist in the human society, which have different psycho-social implications and reflect a different dimension of human reproductive health.

So it is evident that the reproductive health is strongly influenced by the sexual behavior which is actually a critical psycho-physical human expression of a number of complex emotions driven by religious/spiritual beliefs, economic condition, cultural background, gender issues, educational status, legal implications and societal norms.

What is sexual behavior
Sexual behavior is a unique combination of knowledge, attitude and practice of sexual activity guided by one’s sexuality and a number of important environmental factors.

Reversing adverse outcome of sexual behaviour through modification of sexual behaviour is very challenging.

Inviting comments.