Introduction

In the Philippines, a significant number of young people are infected with HIV. UNAIDS (2002) data reveal that an estimated 2,500 young men and women aged 15 to 24 are living with HIV/AIDS. Of the HIV positive cases registered in the country by April 2005, almost one third (32%) were aged 10 to 29 (FETP, 2005).

Unfortunately, few programs or policies specifically target the youth. These limited attempts fail to recognize the diversity of the young population, excluding many young people who are especially vulnerable to HIV infection particularly, the homosexual youth.

Sighted for being young and stigmatized for being sexually different, the young homosexuals are at greater risk of contracting HIV. The efficiency of HIV transmission through sexual intercourse makes this population particularly vulnerable to the infection, with the marginalization of this population further increasing its vulnerability.

Despite the critical importance of this issue, there are only a handful of empirical studies that address the sexual behaviors of young homosexuals. Tan (1994) noted that there is a lack of data on the situation and needs of this sub-population.

To address this need, a study was conducted employing a two-stage research design, which made use of survey and in-depth interviews, to explore the sexual risk behaviors and safer sex practices of young homosexual males aged 15 to 24 in three urban poor communities in the Philippines. In addition, more than ten research reports were reviewed to establish the current state of knowledge about the social and behavioral aspects related to HIV and homosexuality in the Philippines.

What sexual behaviors predispose the young homosexual males to HIV infection?

Early sexual initiation

The young homosexuals in the study initiated sex very early in life. All of the respondents were sexually experienced even before reaching the age of 20, averaging 14 years of age at first sexual intercourse. This proportion is twice of that of the general population in the country (Tiglao, 1990), which only registered 54 percent of the population being sexually experienced by the age of 20. Compared to the larger young male population (Ramos-Jimenez and Lee, 2001), the proportion is twice as much.

On the other hand, this pattern is consistent among MSM population. In a survey among participants of The Library Foundation’s (TLF) workshop for MSM, 90 percent of the respondents had their first same-sex experience before they reached the age of 20 (TLF, 1992; Tan, 1994). In a similar survey (TLF, unpublished) conducted from September to December 2000, almost all (94%) of the respondents reported having sex before reaching the age of 20, with more than half (54%) being sexually experienced even before reaching the age of 15. This result runs parallel with the study conducted by Iwag Dabaw (1999) among gay men in Davao City, where most of the respondents reported initiating sex at puberty with some as early as seven.

Early initiation of sexual activity lengthens the period for sexual experimentation, increasing the likelihood for an individual to engage in HIV-related risk behaviors. It was also noted that once young people initiate sexual activity with partners, a return to abstinence is very unlikely (Sonenstein, Pleck & Ku, 1991), ensuring continued risk. At the same time, initiating sex early increases the proclivity of individuals to have multiple partners, advancing chances of acquiring sexually transmitted infections (STIs), including HIV.

Elevated number of sexual partners

Generally, the young homosexuals in the study had many sexual partners, reporting a lifetime mean of 19 same-sex partners. Meanwhile, an average of four sexual partners was reported among the respondents who declared sexual activity for the past three months prior to the survey. Over half of the entire sample disclosed having multiple (two or more) sexual partners in the recent months.

This proportion is way above the norm of the general Filipino male population as indicated by the data of recent population-based surveys (Ramos-Jimenez & Lee, 2001; DOH-USAID-WHO, 2000; Tiglao, et al., 1996). The aforementioned studies reported that a large majority of Filipino men only had one recent sexual partner. Only a little over a fifth or even less disclosed having multiple sexual partners in the recent months. However, it was noted that recent sexual partners in these studies included those the respondents had sex with six to 12 months prior to the surveys, while this study only included sexual partners for the past three months. If the inclusion had covered sexual partners from the previous six to 12 months, the average number partners may considerably increase.

Still and all, this trend is not uncommon among MSM. In fact, various studies on this population revealed higher mean of recent sexual partners. The study of PLOMS Consultancies (1999) found an average of four same-sex partners a week among their homosexually active male respondents. A similar pattern was also observed in studies conducted among MSM in Davao City (Iwag Dabaw, 1999) and Metro Manila (TLF, unpublished). However, it is noted that the samples of homosexually active men from the foregoing studies were relatively older and purposively selected.

These findings are particularly daunting since empirical evidences show that the risk for HIV exposure and transmission is elevated with a relative increase in sexual partners (Schiltz, 1993; Rosario, et al., 1999).

Sexual practices that facilitate transmission of HIV

Over two-third of the homosexual respondents disclosed practicing receptive anal sex with their recent sexual partners. This proportion is way above the norm among MSM population as reported in various studies. In TLF’s HIV workshops for MSM, pre-workshop surveys showed that only about 22 percent of the respondents had anal sex six months before the survey (Tan, 1993). In more recent similar survey (TLF, unpublished), the rate is 36 percent. Still another survey (Iwag Dabaw, 1999) conducted among homosexual men in Davao City, revealed 37 percent rate of receptive anal sex among its respondents, which is less than a third of the proportion in the study.

This sexual practice carries great risk as studies among homosexual men (Rietmeijer, et al., 1989; Winkelstein, et al., 1997; Koopman, et al., 1992; Mastro & de Vicenzi, 1996; Caceres & van Griensven, 1994) found this to be highly efficient in transmitting HIV. More so, the risk of infection is particularly high among receptive partners.

More practiced among the young homosexuals in the study is receptive oral sex, echoing the findings from other studies among homosexually active men in the country (Lee & Sison, 1990; Tan, 1993; Iwag Dabaw, 1999; TLF, unpublished).

Although not as effective as anal sex in transmitting HIV, unprotected oral sex carries a risk as well (Samuel et al, 1992; Adib et al., 1991), remaining a highly risky practice for other STIs.

Low and inconsistent condom use

The rate of condom use remains very low among the young homosexuals in this study. More than two-third of them never used condoms, while less than a third reported inconsistent use.

This pattern is akin to the findings of population-based studies among Filipino men, in general (Ramos-Jimenez & Lee, 2001; DOH-USAID-WHO, 2000; Tiglao, et al., 1996), and young Filipino men, in particular (Balk, et al., 1999).

The same pattern holds true among homosexually active men. The DOH-FETP’s (2000) Behavioral Sentinel Surveillance results for 1997-2000 showed that consistent condom use among MSM was only 12 percent. Similarly, a survey by TLF (unpublished) among homosexually active men in Metro Manila yielded nine percent rate of consistent condom use. In a related study in Davao City (Iwag Dabaw, 1999), more than half (51%) of homosexual men surveyed had never used condoms. However, no breakdown was made on the consistency of use.

In recent local studies (ASEP, 2000; TLF, unpublished) variations in condom use based on sexual activities was noted. The findings of these studies suggested that MSM were more inclined to use condom during anal sex than oral sex.

The outcome of this study showed a similar trend. Less than a tenth of the young homosexuals who had anal sex with their five recent sexual partners claimed condom use. Yet, no respondent had ever claimed condom practice with oral sex.

This is attributed to the fact that oral sex is seen as relatively safer compared to anal sex as established by anecdotal accounts from some of the respondents. This is also corroborated by findings of other studies among MSM (Patino, 1996; Valbuena, 2001; TLF, unpublished).

All the same, the rate of unprotected sexual intercourse either anal or oral among the young homosexuals in the study is outrageously high. Majority (90%) of the respondents who disclosed receptive anal sex reported an average of three episodes of unprotected anal intercourse with their five recent sexual partners. The average episode for unprotected oral sex with five recent partners is even greater, registering a mean of four episodes for the respondents disclosing oral sex practice.

The rate of unprotected sex found among the respondents is exorbitantly high even in comparison to the proportions reported in studies among MSM. In a pre-workshop survey conducted by TLF (unpublished) among MSM in Metro Manila, about 30 percent of the respondents engaging in receptive anal sex reported condom use, while four percent disclosed condom practice in receptive oral sex.

What influenced the safer sex practices of the young homosexuals?

Knowledge on HIV/AIDS

Generally, the level of knowledge on HIV/AIDS of the young homosexuals in the study remained low. This outcome is in contrast with the findings of other studies (Tan, 1994; Patino, 1996; TLF, unpublished), which found fairly high level of knowledge on HIV/AIDS among MSM. However, it is noted that the samples of homosexually active men from the foregoing studies were limited to Metro Manila and were highly educated, therefore probably more exposed to HIV information.

Nonetheless, this only provides a weak argument for the risk-taking behavior of the young homosexual respondents considering that they manifested adequate knowledge on HIV prevention. The respondents mostly attested the facts that HIV can be transmitted through unprotected sexual intercourse and that consistent and correct condom use provides protection against this infection. This outcome distinctly shows an apparent gap between knowledge on HIV prevention and condom practice among the homosexual youth in the study.

Perceptions on HIV/AIDS and personal vulnerability

The young homosexual respondents generally believed that AIDS is a dreadful disease and should be feared. In which case, they had no doubt that it is something they need to worry about. These findings conform to the outcomes of previous studies conducted among MSM (TLF, unpublished) and college students (Tan et al., 1992).

However, it is difficult to ascertain if these beliefs personally hold true among the homosexual youth in the study. Despite the recognition of personal risk to HIV/AIDS, the respondents believed that the likelihood for them to actually contract the infection is improbable.

Inspite of the fact that condom usage was close to nil, anecdotal evidences showed that the respondents may have employed other precautions to protect themselves against HIV infection, affording them a sense of security. Screening of sexual partners was found to be a common practice employed by the young informants to assuage their risk from contracting the infection. Age and degree of familiarity were found to determine the selection of their sexual partners, as well as their decision to forego condom use. Younger sexual partners were perceived to be free from infections. Similarly, regular partners were generally believed to be safe. This parallels the findings of other studies among MSM (Patino, 1996; Valbuena, 2001; TLF, unpublished).

Majority of the young homosexuals in the study had someone who are close to them or at least someone they are familiar with, mostly a friend, acquaintances or a boyfriend, as their recent sex partners. Nonetheless, this does not lessen their risk for HIV transmission because they admitted to have no assurance of their partners’ sexual history. Therefore, this false belief could not actually guarantee them safety, even perpetuating the erroneous belief that HIV infection is readily apparent upon visual inspection.

The respondents’ low perception of personal susceptibility may also be ascribed to the seeming invisibility of HIV infection within their immediate community, as demonstrated by the narrative accounts of some of the informants in the study. Consequently, this may have induced the sexual risk taking of most of the young homosexual respondents.

Attitude towards condom use

Despite low condom usage, the homosexual youth in the study recognized the importance of condoms. They generally deemed it necessary for protection against STIs including HIV, validating the notion that it helps save lives. These positive outcomes run parallel to the findings of studies among Filipino men (Ramos-Jimenez & Lee, 2001; DOH-USAID-WHO, 2000; Tiglao et al., 1996). Similar findings were also observed in studies among MSM (Tan, 1994; Iwag Dabaw, 1999; PLOMS Consultancies, 1999; ASEP, 2000; Valbuena, 2001).

The low level of usage can be partly explained by the respondents’ negative views on condoms. A significant number of young homosexuals in the study believed that condom reduce sexual pleasure. This finding is consonant with the results of the studies among Filipino men in general (Ramos-Jimenez & Lee, 2001; DOH-USAID-WHO, 2000; Tiglao et al., 1996) and MSM in particular (Tan, 1994; Iwag Dabaw, 1999; PLOMS Consultancies, 1999; ASEP, 2000; Valbuena, 2001; TLF, unpublished).

It was noted that the negative consequences of condom use were generally given more credence against its positive outcomes as established by the anecdotal accounts of the respondents exhibiting high-risk sexual behaviors. Despite of the recognition that condom use can protect them from sexually transmitted infections, most shunned its use in favor of a more gratifying sexual experience. Evidently, personal protection from HIV infection wasn’t given much regard.

Subjective norms surrounding condom use

The respondents generally held that their sexual partners approve of condom use. Yet, this may be contested since majority of them reported opposing practice. Besides, anecdotal accounts maintained otherwise.

The informants disclosed that condom use is not popular among their sexual partners, in fact, others demand not using condoms. In which case, at least for the informants who exhibited high-risk sexual behaviors, the demand of their sex partners to forego condom use takes precedence over safer sex consideration, or for that matter, personal protection.

This finding is consistent with the results of other studies among homosexual men (ASEP, 2000). The outcomes of this and the foregoing studies suggest that support of partner for preventive act is an important determinant for condom use.

In the same token, the homosexual youth in the study commonly asserted that their friends encouraged condom use. However, they also contented that condom practice has not been the norm among their peers. Although some informants expressed different views, they all attested that majority of their friends do not subscribe to the practice. It has also been noted that their friends have indirectly, if not outwardly, discouraged some of the informants to use condoms.

While the informants with low-risk sexual behaviors attested that they do not necessarily accede to this negative persuasion, those exhibiting high-risk sexual practice expressed their intention to comply with condom use if their friends support and endorse the practice.

This finding is consistent with the results of other studies among MSM (ASEP, 2000), which established relationship between friends’ support for condom use and protected sex.

Perceived behavioral control over using condom

The respondents generally expressed capability to exercise condom use. At the same time, they commonly believed that the decision to use condom is mostly up to them, asserting their power over making the choice. However, as an informant attested, knowledge on condom use does not always translate in actual practice, as manifested as well by the respondents’ opposing condom practices. This echoes the results of other studies among Filipino men (Balk et al., 1999; ASEP, 2000; Valbuena, 2001; Ramos-Jimenez & Lee, 2001).

Despite being generally recognized as a function of will, it was noted that condom use is also controlled by external factors. As stated earlier, sexual partner’s cooperation and support for condom use determines safer sex practice. An informant of the study disclosed that for fear of being denied of sex, he complies with his partner’s demand to forego condom use. A significant number of respondents attested the difficulty of negotiating condom use with their sex partners.

The availability of condom was also identified by the informants as another factor for safer sex consideration. Although generally believed to be readily accessible, it is not always available during sexual encounters. In such cases, sexual urge takes precedence over consideration for protective sex. This finding parallels the results of other studies conducted among MSM (ASEP, 2000; TLF, unpublished).

In addition, the informants have identified information on HIV/AIDS and other sexually transmitted infections to facilitate condom use. This suggested that low condom practice among the young homosexuals in the study is partially attributed to their low knowledge on this subject. This deficiency was further confounded by the illusive nature of HIV infection. As one informant observed, the apparent invisibility of HIV infection in their locality rendered the young homosexuals to be complacent and reckless with their sexual practices.

The informants also reiterated the importance of friends’ support for protective sex in facilitating condom use practice. However, they attested that this support was currently lacking, if not totally absent.

All in all, the findings suggest that the lowly incidence of condom practice was subject to the weak perceived control over condom use, as demonstrated by the data among respondents and informants exhibiting discordant practices.

Conclusion

The foregoing data, particularly those that directly pertain to unsafe sex practices, clearly indicate that the young homosexual males in the study are highly susceptible from acquiring and transmitting HIV.

With the imminent danger posed by HIV/AIDS on the young population, it is imperative to heed this reality. Despite the assertion of a low and slow transmission of HIV in the country, the current patterns in sexual behavior among young homosexuals pose potential for further spread of the disease in the future.

Unprotected receptive anal intercourse, unequivocally the most risky homosexual activity, was the norm among the young homosexuals in the study, engaged by two-third of the sample. This dispels the earlier contention that anal sex among homosexually active men is unpopular.

This finding is particularly alarming considering that patterns in sexual behavior among homosexual youth showed a trend towards early sexual initiation, which lengthens the period for sexual experimentation and exposure to HIV.

Compounding this problem is the unpopularity of condom use among the population, as well as among the population of men they have sex with. Various factors can be attributed for this problem, mostly pointing to the inadequacy among government and non-government entities in reaching the population.

The low level of knowledge on HIV/AIDS demonstrated by the young homosexual respondents is indicative of this insufficiency. This is further evidenced by persistent misconceptions prevailing among the respondents inspite of claims of continued education initiatives. Evidently, this goes to show that current efforts on HIV/AIDS are limited and do not extend to the population who needed it most.

However, the fact that knowledge is not always congruent with safer sex practice suggests that efforts should not be limited to provision of knowledge and information on HIV/AIDS. This also indicates that current interventions are inadequate in providing essential skills that would help translate knowledge into practice.

Some intervention programs in the country have been noted to provide information and skills acquisition workshops to MSM, but these initiatives were limited mostly to major cities in the Philippines. These interventions are not available among the vulnerable population in outlying cities in the country.

These shortcomings indicate that the sexual health needs of the homosexual youth remain largely unheeded.

Recommendations

The findings of the study emphasized the risk of the young homosexual to HIV/AIDS. It highlighted gaps in current interventions that contributed to the increased vulnerability of the population. In this regard, the study recommends the following initiatives to government and non-government institutions in bridging this serious gap.

Increase and strengthen existing HIV intervention efforts especially among vulnerable population. Education programs should be extended particularly among young homosexuals from low-income background who lack access to HIV/AIDS information. Specific attention should also be given to dispel persistent myths and erroneous perceptions on HIV prevention, particularly the use of antibiotics and withdrawal as preventive measures.

Intervention strategies should move beyond provision of information, and should afford essential life skills that would help facilitate conversion of knowledge into actual practice. Among the crucial skills that homosexual youth must learn are: (1) negotiating for safer sex, (2) strengthening self-esteem or self-worth, and (3) learning self-control.

Advocacy for safer sex practice, particularly condom use, should not only emphasize young people’s vulnerability to HIV infection, the severity of infection, and condom effectiveness, but should also be more effective to include social acceptability of condom practice in future interventions.

Peer-facilitated initiatives are still recommended for a more effective information dissemination and safer sex promotion. This is in recognition of the instrumental role of peers in facilitating safer sex practice. This also builds a system of social support that could help initiate and sustain behavioral change among young homosexuals.

While targeted approach is necessary in addressing specific needs of the homosexual youths, focus should not only be limited to the population. Program support should also be extended to their sexual networks. Particularly, it should also take heed of the sexual health needs of the partners of the young homosexuals. This initiative could further promote an enabling environment for safer sex practice.

Give face to HIV/AIDS. Despite the growing number of HIV infections among MSM, there is still strong denial among the young homosexuals mainly because many still do not know or have not met someone with HIV. Therefore, the study urges HIV-positive MSM to come out and help in the education work among the young homosexual population to make them aware of the real threat of HIV.

* Study from www.hain.org (Health Action Information Network)
* Paper Presented at the 7th International Conference on AIDS in Asia and the Pacific, Kobe, Japan