Sexual practices, identities and health among women who have sex with women in Lesotho - a mixed-methods study

"Empowerment for Us by Us (E4UBU)": Developing a Model of Empowerment Using Feminist Participatory Methods with LBQT+ Persons Assigned Female at Birth in Western Kenya

Lesbian, bisexual, queer, trans and other gender diverse persons assigned female at birth (heretofore referred to as "LBQT+ persons") in Western Kenya experience intersectional oppression and stigma. This stigma can manifest in acts of sexual and gender-based violence (SGBV) and sexual and gender minority (SGM)-based violence, as well as various forms of discrimination-all of which have been linked to disproportionately higher levels of negative health outcomes for this group. Despite these challenges, many LBQT+ persons have been able to gain personal and collective power and thrive in this oppressive environment. The Empowerment for Us by Us (E4UBU) project is a mixed methods feminist participatory research study focused on exploring how LBQT+ persons conceptualize and define empowerment for themselves, and to understand their perspectives on how feelings of power and powerlessness influence their physical and mental health. This paper focuses on data from the first phase of the study, in which qualitative in-depth interviews were conducted with 40 LBQT+ persons (ages 19 to 50) from Kisumu and Homa Bay in Western Kenya. A participatory interpretive phenomenological analysis was conducted to understand the lived experiences of LBQT+ persons as they navigate intersectional oppression and its influence on their experiences of empowerment and subsequent health outcomes. Findings from this analysis were presented to two different focus groups composed of participants who had participated in the in-depth interviews to gather their insights on the interpretations of the interviews as a form of member checking. Findings revealed that "empowerment" was not experienced and viewed by LBQT+ persons as a monolithic construct, but rather a process through which LBQT+ persons are able to transform negative forces of intersectional oppression and powerlessness into experiences of power and subsequent individual and collective action and impact-all leading to improved mental health and well-being. This process is facilitated at several junctures by participatory seeking and attainment of community-appropriate resources at multiple socio-ecological levels that, when accessed with sufficient intensity, frequency, and duration, enhance one's journey through the process of empowerment. These facilitation junctures are viewed as likely points of focus for public health intervention. Analysis also revealed that the process of empowerment is dependent on the context within which the process is occurring, the specific issues being faced, and the population of focus. Recommendations for how this model can be used for future research and practice to improve the lives of LBQT+ persons in Kenya are discussed.

Sexual rights and sexual pleasure: Sustainable Development Goals and the omitted dimensions of the leave no one behind sexual health agenda

This commentary explores the missing discourse of sexual rights and sexual pleasure in the Sustainable Development Goals (SDG) that purport to leave no one behind. The SDG propose a welcome focus on sexual health and human rights for all, expanding beyond the Millennium Development Goals. While promising in many ways for advancing global sexual and reproductive health, and reproductive rights, the omission of sexual rights is troubling. So too is the erasure of lesbian, gay, bisexual, transgender and queer (LGBTQ) persons, and sex workers, from the SDG discussions of social inequities. Illustrative examples are provided to demonstrate how a sexual rights focus could advance SDG 3 focused on healthy lives and well-being for all. First, sexual rights are presented as integral to realizing Target 3.3's focus on ending the HIV pandemic among LGBTQ persons and sex workers (and LGBTQ sex workers). Second, sexual pleasure is introduced as an integral component of sexual health and sexual rights that could facilitate the realization of Target 3.7's aim to provide universal access to sexual and reproductive health information and education. To truly leave no one behind and realize sexual health for all, the SDG need to begin from a foundation of sexual rights.

Conceptualizing LGBT Stigma and Associated HIV Vulnerabilities Among LGBT Persons in Lesotho

Social marginalization harms lesbian, gay, bisexual, and transgender (LGBT) persons’ wellbeing in Lesotho. Socio-cultural mechanisms linking LGBT stigma, depression, substance use, and HIV among LGBT persons in Lesotho are understudied. We explore associations between LGBT stigma, mental health stressors, and HIV vulnerabilities among LGBT persons in Lesotho. We conducted in-depth, semi-structured interviews with 46 LGBT persons and six key informants (e.g. healthcare providers). Participants described depression, substance use, and HIV as mutually reinforcing and situated in larger social contexts of stigma. Alcohol use was a stigma coping strategy and a way to build LGBT connections. At the same time, alcohol use elevated HIV vulnerabilities by lowering condom use uptake. Pervasive stigma reinforced barriers to healthcare engagement. Community-led support and services were leveraged to navigate stigma, reduce HIV vulnerabilities, and ultimately improve health. Findings emphasize the key role contexts play in shaping sexual and mental health among LGBT persons in Lesotho.

Southern African Lesbian and Bisexual Women Responses to Symptoms of Sexually Transmitted Infections

Sexually transmitted infection (STI) in lesbian and bisexual women is a relatively unexplored topic, particularly for women from low- and middle-income countries. Despite perceptions that women who have sex with women (WSW) are at negligible risk of contracting STI, existing research demonstrates that WSW do become infected with STI. Given the opposition between assumptions of invulnerability and the observed risks, we explored how WSW would respond to symptoms of STI (i.e., wait until symptoms passed, see a medical doctor, and inform sexual partners). We used data collected as part of a collaboration between academic researchers and community-based LGBTQ organizations in Botswana, Namibia, South Africa, and Zimbabwe. Chi-squared tests were used to test whether participants' responses to hypothetical STI symptoms varied in relation to several intrapersonal, interpersonal, and structural factors. Multivariable logistic regression (backward) was used to assess whether these variables were independently associated with women's responses. Most women would be proactive in response to potential STI symptoms and would see a medical doctor. However, most women would not inform their sexual partner of symptoms of STI. Findings demonstrate several intrapersonal, interpersonal, and structural factors that influence WSW's health agency, and show a clustering of high-risk factors among women who would not be proactive about their health. Our findings suggest the need for improved health and health care of WSW in Southern Africa.

The discursive construction of low-risk to sexually transmitted diseases between women who are sexually active with women

This paper uses a discursive analytical method to explore dominant discourses concerning the sexual health of women who have sex with women. In-depth interviews were conducted with a cross-cultural sample of women from England and Brazil. Sex between women was discursively constructed as 'safe', and women who have sex with women were seen as being at low to negligible risk of contracting/transmitting sexually transmitted infections. Analysis identified two discourses underlying these constructions: a binaries discourse which focused on dichotomies of gender, sexuality and risk; and a sexual double-standard discourse, which focused on the positioning of sex between women as safe and the use of barrier methods of protection as indicative of not engaging in or fully enjoying the sexual act.

Experiences and perceptions of social constraints and social change among lesbian, gay, bisexual and transgender persons in Lesotho

Lesbian, gay, bisexual, transgender and other sexually and gender diverse persons negotiate for their identities, create communities and advocate for their rights throughout the world. However, there are limited data about the perceptions of social change among sexually and gender diverse persons in contexts where same-sex sexual practices have been recently decriminalised, such as in 2010 in Lesotho. We conducted semi-structured in-depth interviews with sexually and gender diverse persons (n = 46) and six key informants. Findings were analysed using Social Worlds Theory. Participants discussed social constraints and marginalisation across structural (legal systems, employment, education), community (beliefs that sexual and gender diversity are incongruent with Basotho culture; stigma), and familial (tensions with religion and cultural gendered economic traditions) dimensions. The narratives also revealed perceived change across structural (changing norms in legal, employment and education spheres), community (larger community and LGBT community change), familial (negotiating acceptance), and internal (active resistance) domains. The findings reported here can inform multi-faceted programmes to challenge stigma, violence and gender inequity; build social capital; and address the health and human rights priorities of sexually and gender diverse persons in Lesotho.

Marginalization and social change processes among lesbian, gay, bisexual and transgender persons in Swaziland: implications for HIV prevention

Swaziland has among the highest national adult HIV prevalence globally. There is limited knowledge of HIV vulnerabilities and prevention engagement among lesbian, gay, bisexual and transgender (LGBT) persons in the context of Swaziland's criminalization of consensual same-sex practices. This study explored social processes of marginalization to assess how they could potentiate HIV vulnerabilities and limit engagement in HIV prevention services. Additionally, we assessed positive change to better understand existing strategies employed by LGBT persons to challenge these HIV prevention barriers. Guided by community-based research methodology and conducted in Mbabane and Manzini, Swaziland, data were collected by LGBT peer-research assistants (PRA) in collaboration with an LGBT community organization in Manzini. Semi-structured interviews were conducted by trained PRAs and explored HIV prevention, including experiences of stigma and coping. Audio files were transcribed verbatim, translated to English, and analyzed using thematic techniques. Among participants (n = 51; mean age: 26.47, SD: 4.68), 40 self-identifed as gay or lesbian (78.4%), 11 bisexual (22.6%), and 12 (23.5%) identified as transgender. Findings highlighted three primary processes of marginalization and positive change in structural, community, and internal domains. First, structural marginalization, which included criminalization, healthcare discrimination, and a scarcity of LGBT tailored HIV prevention resources was challenged by grassroots networks created to access and share specific HIV resources with LGBT persons and the Ministry of Health. Second, community marginalization included stigma and multi-dimensional forms of violence, however, this was met with LGBT persons providing mutual peer support, including for accessing HIV testing services. Thirdly, internal marginalization comprised of self-stigma and associated sexual risk practices was contrasted with coping strategies focused on self-acceptance, stemming from social support and leading to healthcare utilization. Jointly, these findings can inform the implementation of community-based and rights affirming HIV prevention and care cascade strategies that improve coverage of services with LGBT persons in Swaziland.

Criterion and Divergent Validity of the Sexual Minority Adolescent Stress Inventory

Sexual minority adolescents (SMA) consistently report health disparities compared to their heterosexual counterparts, yet the underlying mechanisms of these negative health outcomes remain unclear. The predominant explanatory model is the minority stress theory; however, this model was developed largely with adults, and no valid and comprehensive measure of minority stress has been developed for adolescents. The present study validated a newly developed instrument to measure minority stress among racially and ethnically diverse SMA. A sample of 346 SMA aged 14-17 was recruited and surveyed between February 2015 and July 2016. The focal measure of interest was the 64-item, 11-factor Sexual Minority Adolescent Stress Inventory (SMASI) developed in the initial phase of this study. Criterion validation measures included measures of depressive symptoms, suicidality and self-harm, youth problem behaviors, and substance use; the general Adolescent Stress Questionnaire (ASQ) was included as a measure of divergent validity. Analyses included Pearson and tetrachoric correlations to establish criterion and divergent validity and structural equation modeling to assess the explanatory utility of the SMASI relative to the ASQ. SMASI scores were significantly associated with all outcomes but only moderately associated with the ASQ (r = -0.13 to 0.51). Analyses revealed significant associations of a latent minority stress variable with both proximal and distal health outcomes beyond the variation explained by general stress. Results show that the SMASI is the first instrument to validly measure minority stress among SMA.

A developmentally informed adaptation of minority stress for sexual minority adolescents

Sexual minority adolescents (lesbian, gay, bisexual) experience disparities in behavioral health outcomes compared to their heterosexual peers, generally attributed to minority stress. Although evidence of the applicability of the minority stress model among adolescents exists, it is based on a primarily adult literature. Developmental and generational differences demand further examination of minority stress to confirm its applicability. Forty-eight life history interviews with sexual minority adolescents in California (age 14-19; M = 19.27 SD = 1.38; 39.6% cismale, 35.4% cisfemale, 25% other gender) were completed, recorded, transcribed, and analyzed using thematic analysis in QSR NVivo. Following a consensus model, all transcripts were double coded. Results suggest that minority stress is appropriate for use with adolescents; however, further emphasis should be placed on social context, coping resources, and developmental processes regarding identity development. A conceptual model is provided, as are implications for research and practice.

Sexual rights but not the right to health? Lesbian and bisexual women in South Africa's National Strategic Plans on HIV and STIs

Synergies between securing sexual rights and the right to health have been pursued where there are clear public health gains to be made, such as lowering incidence of HIV and other sexually transmitted infections (STI). South Africa's 1996 Constitution outlawed discrimination on the basis of sexual orientation and promoted the right to health. This qualitative health policy analysis sought to understand why and how interventions to improve sexual health of lesbian and bisexual women and address sexual violence were initially proposed in the HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 and why and how these concerns were deprioritised in the National Strategic Plan (NSP) on HIV, STIs and TB 2012-2016. A conceptual framework considered several determinants of political priority for the inclusion in NSP development in 2007 and 2011 around sexual health concerns of women who have sex with women. This article presents findings from 25 in-depth key informant interviews and document review and highlights results of application of categories for a framework on determinants of political priority for lesbian and bisexual women's issues to be included in South Africa's NSP including: actor power, ideas, political context and issue characteristics. The article demonstrates how the epidemiological and structural drivers of lesbian and bisexual women's vulnerability to HIV and STIs, including sexual violence and other violations of their sexual rights, have been expressed in policy forums and whether this has made an impact on lesbian and bisexual women's ability to claim the right to health.

Making the invisible visible: a systematic review of sexual minority women's health in Southern Africa

BACKGROUND

Over the past two decades research on sexual and gender minority (lesbian, gay, bisexual and transgender; LGBT) health has highlighted substantial health disparities based on sexual orientation and gender identity in many parts of the world. We systematically reviewed the literature on sexual minority women's (SMW) health in Southern Africa, with the objective of identifying existing evidence and pointing out knowledge gaps around the health of this vulnerable group in this region.

METHODS

A systematic review of publications in English, French, Portuguese or German, indexed in PubMed or MEDLINE between the years 2000 and 2015, following PRISMA guidelines. Additional studies were identified by searching bibliographies of identified studies. Search terms included (Lesbian OR bisexual OR "women who have sex with women"), (HIV OR depression OR "substance use" OR "substance abuse" OR "mental health" OR suicide OR anxiety OR cancer), and geographical specification. All empirical studies that used quantitative or qualitative methods, which contributed to evidence for SMW's health in one, a few or all of the countries, were included. Theoretical and review articles were excluded. Data were extracted independently by 2 researchers using predefined data fields, which included a risk of bias/quality assessment.

RESULTS

Of 315 hits, 9 articles were selected for review and a further 6 were identified through bibliography searches. Most studies were conducted with small sample sizes in South Africa and focused on sexual health. SMW included in the studies were racially and socio-economically heterogeneous. Studies focused predominately on young populations, and highlighted substance use and violence as key health issues for SMW in Southern Africa.

CONCLUSIONS

Although there are large gaps in the literature, the review highlighted substantial sexual-orientation-related health disparities among women in Southern Africa. The findings have important implications for public health policy and research, highlighting the lack of population-level evidence on the one hand, and the impact of criminalizing laws around homosexuality on the other hand.

Strategies employed by sexual minority adolescents to cope with minority stress

Sexual minority adolescents (SMA) experience disparities in health and behavioral health outcomes, including high rates of depression, anxiety, self-harm, substance use, HIV risk behavior, suicidal ideation, and suicide attempts. These outcomes are commonly attributed to minority stress. Stress experiences are different for SMA than their adult counterparts. For example, disclosing their sexual orientation may be more likely to result in homelessness because these youth more often live with parents or other family members. Although stress in this population has been explored in previous research, very little is known about how SMA cope. Relying upon an adolescent coping model, this study examined the coping strategies, responses, and resources of SMA related to stress. Forty-eight racially and ethnically diverse SMA (age 14-19) were recruited for 90-minute tape-recorded interviews. The semi-structured interviews were guided by a life history calendar. Recordings were transcribed verbatim and entered into QSR NVivo. All transcripts were coded by two members of the research team and went through a consensus process. Forty-three unique coping statements emerged that fit with the Compas model of adolescent coping. SMA cope with minority stress in similar ways to heterosexual youth coping with general stress, but findings suggest that SMA may also use different kinds of coping resources. Although further research is needed, the present study identified a variety of ways SMA cope with stress and can inform future research on the development interventions.

Women Who Have Sex with Women Living in Low- and Middle-Income Countries: A Systematic Review of Sexual Health and Risk Behaviors

Women who have sex with women (WSW) have long been considered at low risk of acquiring and transmitting HIV and other sexually transmitted infections (STIs). However, limited research has been conducted on WSW, especially those living in low-and middle-income countries (LMICs). We reviewed available research on sexual health and risk behaviors of WSW in LMICs. We searched CINAHL, Embase, and PubMed for studies of WSW in LMICs published between January 1, 1980, and December 31, 2013. Studies of any design and subject area that had at least two WSW participants were included. Data extraction was performed to report quantifiable WSW-specific results related to sexual health and risk behaviors, and key findings of all other studies on WSW in LMICs. Of 652 identified studies, 56 studies from 22 countries met inclusion criteria. Reported HIV prevalence among WSW ranged from 0% in East Asia and Pacific and 0%-2.9% in Latin America and the Caribbean to 7.7%-9.6% in Sub-Saharan Africa. Other regions did not report WSW HIV prevalence. Overall, many WSW reported risky sexual behaviors, including sex with men, men who have sex with men (MSM), and HIV-infected partners; transactional sex; and substance abuse. WSW are at risk for contracting HIV and STIs. While the number of research studies on WSW in LMICs continues to increase, data to address WSW sexual health needs remain limited.