Sexual Health Among Minorities in the Middle East: Cultural Pressures as a Barrier
Art by @fearlesscollective
Written by Ismaël Maatouk, Moubadda Assi, and Rusi Jaspal.
Both sexual minorities and sexual health are taboos in Middle Eastern societies. For religious, social, and cultural reasons, sexual minorities feel pressured to hide their sexual orientation from their families and friends. Moreover, they are often expected to have a heterosexual marriage and to produce children. This can put them at higher risk of suffering poor mental health outcomes such as depression and anxiety. The stigma and invisibility of sexual minorities in the Middle East is apparent at so many levels: decreasing willingness to come out, no gay clubs, no Pride parade, very limited and exceptional gay social or scientific events, family rejection, bullying toward gay public figures, discrimination and even violence in some cases. Sexual minorities have no legal protection and expect to be rejected from their surrounding circles. It is common to hear of a gay person kicked out by their parents, or being attacked by a sibling or extended family member, or facing blackmail by significant others because of their sexual orientation. For most in the West, this may seem incredible. For sexual minorities in the Middle East, these stories reflect their lived reality.
Yet, these experiences vary based on geography and on the sub-communities of sexual minorities. For instance, Lebanon is more ‘tolerant’ toward gays when compared to most other countries in the Middle East. In Lebanese society specifically, religious diversity and the large diaspora importing “Western” concepts have played a major role in challenging homophobia in Lebanese society. On the other hand, not all sexual minority groups experience the same level of stigma and discrimination. For instance, gay men tend to be more out compared with gay women or, especially, bisexuals. The latter is the least likely to come out possibly because of the bi-phobia from both gay/lesbian people and the general population. Transgender communities are highly stigmatized and rejected, and many become involved in sex work (for financial reasons) or seek asylum to live in better conditions.
In these settings, sexual health becomes a hard topic to discuss. Finding stigma-free testing centers offering the most pertinent and updated information, diagnosis, and treatment is difficult. Moreover, it is difficult to disseminate key messages, such as HIV testing, pre-and post-HIV prophylaxis (drugs used to prevent infections), condom use, etc. On the rare occasions that these topics are discussed, they are often focused exclusively on the heterosexual population, ignoring the health needs of sexual minorities who, incidentally, face greater health inequalities. Messages about homosexual relationships and sexual health services or information are considered extremely sensitive. One of us still remembers, during his very first TV interviews, the clear discomfort experienced by the interviewer when ‘sexual minorities’ were mentioned. On top of these matters, the new coronavirus pandemic, and the consequent restrictions have negatively affected access to sexual health services. It was shown that, due to curfews and other restrictions, sexual minorities in Lebanon decreased their HIV and sexually transmitted infections testing, but were also found to increase risky behavior such as condomless anal sex.
It is easy to see how stigma, marginalization, and prejudice can adversely impact both the mental and sexual health of sexual minorities. Testing is avoided, prophylaxis (whether pre or post) is unknown, condom use is rejected, unavailable, or not demanded (people are shy to ask). Moreover, sexual minorities may not even disclose their identity to the screener. Thus, if they do test positive for HIV, they would be counted as heterosexual, which adds bias to the already weak HIV/sexual health reporting system in the Middle East.
To cope with stigma, sexual minorities may engage in various risky or maladaptive behaviors, including sex in the context of drugs (chemsex), alcohol, condomless intercourse, and avoidance. It is easy to see how these behaviors can in turn lead to higher rates of HIV, sexually transmitted infections, and negative mental health outcomes.
Globally, it is expected that, by 2030, 90 percent of people living with HIV will know their status; 90 percent of those who know their status will be taking antiretrovirals (HIV treatment), and 90 percent of those who take antiretrovirals will be virally suppressed (undetectable). Unfortunately, the countries of the Middle East are still far from reaching these global targets and, in 2019, were among those furthest away from these targets.
To achieve the global targets, the Middle East will need serious and bold strategies to improve testing and treatment, mainly targeting the populations at highest risk, i.e. sexual minorities. Any strategy failing to specifically target sexual minorities will almost definitely result in failure to improve HIV detection and treatment in the region.
2030 may seem far away. While we are busy fighting another pandemic – that of COVID-19 – we must never lose sight of the work needed to achieve our target to end HIV transmissions in the world. This is certainly achievable. To do so, we must first reduce the insidious stigma that undermines our HIV prevention efforts.