Empowering Men Who Have Sex with Men to Live Healthy Lives in Colombia

Gender, Men Who Have Sex with Men, and HIV in Colombia

Entrance to the LGBT Community Center.

Although Colombia's national HIV prevalence is low (roughly 0.6 percent; Joint U.N. Programme on HIV/AIDS [UNAIDS] 2006), the number of people living with HIV (PLHIV) in Colombia is one of the highest in Latin America—estimated at 170,000 to 200,000 (UNAIDS 2006). MSM (along with sex workers) are among populations most-at-risk for HIV infection. Although data on HIV indicators among MSM are scarce, small-scale studies indicate the prevalence of HIV among MSM to be anywhere from 10 to 18 percent (Liga Colombiana de Lucha Contra el SIDA 2000). Yet there is little public investment in HIV prevention.

Unlike other countries in the region, Colombia has no nationally-funded HIV program, though there is a National Plan to Respond to HIV and AIDS 2008–2011. Comprehensive operational guidelines for the plan include a programming framework for MSM, national campaigns, educational projects on HIV and other sexually transmitted infections (STIs) targeted at MSM and providers, and informational projects on rights and access to services. However, implementation of the plan is very limited. The national HIV plan is coordinated and monitored by the Ministry of Social Protection but is not centrally funded. Under Colombia's decentralized public health system, provincial ministries can decide whether or not to invest funds to execute the activities recommended in the national plan. As a result, levels of effort to address HIV vary throughout the country. In Bogotá, one of the more progressive districts, there is a nascent initiative to develop a public policy on HIV by the Secretary of Health, but in other sectors, a response to HIV is practically non-existent.

A number of local and national laws assert equal rights for same-sex couples and prohibit discrimination and mistreatment based on sexual orientation, but these protections often fail. There is a strong fear and aversion among politicians to be seen as investing in MSM and prostitutes, though they are the groups that are most vulnerable to HIV infection.

Indeed, the MSM population in Colombia is highly stigmatized and discriminated against for their sexual orientation and gender identity. This leads to increased HIV risk in various ways. Violence against MSM is said to be common, and many have been murdered, under the guise of "social cleansing," by paramilitary groups and death squads (Human Rights Watch 1994). As a result, MSM deny their identity and likewise, their HIV risk (Saewyc et al. 2006 in Spratt 2010). In addition, MSM may also hide their sexuality, which, as studies have shown, can prevent them from receiving information about HIV transmission and prevention or adequate health services (Morrison 2006). Staff and users of the LGBT CC said that health care providers had denied them services based on either HIV status or perceived sexual orientation or gender identity.

Over the last decade, however, rights organizations for LGBT individuals have sought to combat stigma and discrimination through advocacy for legal rights and protection. As a result of many years of advocacy, in particular by the nongovernmental organization (NGO) Colombia Diversa (Diverse Colombia), landmark legal reform has taken place, making Colombia one of the world's most progressive countries with respect to rights for LGBT. Perhaps most notably, individuals in same-sex partnerships now have the right to access health and social security benefits of their partners.

Luis Eduardo Garzón, mayor of Bogotá from 2004 to 2007, passed a decree that defines the principles, objectives, strategic processes, and components of public policy for LGBT in Bogotá. The resulting policy framework created and designated the Subsecretariat for Women, Gender and Sexual Diversity within the Planning Secretariat to formulate, monitor, and evaluate activities under the LGBT policy framework. The decree also established an LGBT Advisory Council, which is made up of delegates from the LGBT community, to provide input into the work of the Office of Sexual Diversity within the Subsecretariat. The most visible work is currently being done by the District Institute for Community Participation and Action (IDPAC), which strengthens LGBT organizations to meet its objectives of increased citizen participation of these groups. IDPAC also oversees and funds the work of the LGBT CC and has managed the community center since 2009.

However, these advances in LGBT inclusion occurred in isolation from the work being done to address HIV and required much advocacy by champions of the sexual diversity agenda within the government. Moreover, the MSM community has not been active in advocating for increased attention to the problem of HIV. Pervasive attitudes—including a public perception that all MSM are infected with HIV and a strong taboo, even among MSM, to discuss HIV openly—render such advocacy very difficult, make PLHIV unwilling to come forward, and constitute a major lost opportunity to mitigate the HIV crisis. As a result, efforts to create a group representing the interests of PLHIV have been unsuccessful.

Program Objectives

The LGBT CC was established in 2006 with the overall goal of increasing citizen participation and advancing the rights of the LGBT population of Bogotá. The community center seeks to empower LGBT individuals and groups to reach their fullest potential—including acceptance with individual sexual orientation, helping families and communities to understand the rights of LGBT individuals to choose a gender identity and have loving relationships, and support collective action by LGBT groups and organizations to defend and demand their rights at the local and national levels. LGBT individuals can meet at the community center to organize political actions, conduct advocacy, provide emotional support to one another, participate in cultural and educational activities, and receive legal or psychological services for personal problems resulting from stigma and discrimination based on their sexual orientation and gender identity. Although it is open to all of the LGBT community and their friends and families, the majority of users—some 43 percent—identify themselves as MSM (Centro Comunitario LGBT 2009).

The concept for the LGBT CC was born in 2005, under the leadership and direction of civil society with the support of Mayor Luis Eduardo Garzón. The leader of the Chapinero neighborhood consulted with LGBT groups to identify what they considered to be priority issues and needs in the community. LGBT groups, led by Colombia Diversa, proposed the idea of the LGBT CC. Subsequently, Colombia Diversa called upon PROFAMILIA because they are the strongest Colombian NGO working on sexual and reproductive health, a major NGO health service provider, and a leading proponent of HIV prevention, as well as for its expertise in project execution and service provision (see Box 1 on the next page). Fundación Arcoiris (Rainbow Foundation), the philanthropic arm of Theatrón, Bogotá's largest LGBT club, was enlisted to help with fundraising. The mayor's office would support the idea as a pilot project initially, which in effect meant only partial funding.

Collectively, Colombia Diversa, PROFAMILIA, and Fundación Arcoiris—referred to as the Temporary Union—designed and managed a pilot project lasting from October 2006 to January 2009. During the first phase of the project, the mayor's office provided 60 percent of the costs to run the LGBT CC; the Temporary Union had to raise the rest of the funds through events and in-kind donations, including volunteer human resources. The Temporary Union worked closely with the municipal government to conceptualize and design the LGBT CC, but even in the pilot phase the NGOs had to justify the center's value by regularly presenting service statistics and audits to members of the municipal government who questioned the need for and integrity of the program.

Lesbian, Gay, Bisexual, and Transgender Community Center Services

The original vision of the LGBT CC did not include service provision; those provisions were added during the pilot to meet demands from users. PROFAMILIA designed the health and psychological service components and ensured quality of services, while Colombia Diversa designed legal components.

Sexual and reproductive health and HIV: HIV was not the main focus of the LGBT CC during its formation. However, the involvement and experience of PROFAMILIA, combined with the many requests from users, led the center management to incorporate a sexual and reproductive health component, including HIV, within the pilot project. Activities such as game nights, movie nights, and eight "Sexual and Reproductive Health Days" were initiated by activists and volunteers and supported by the director of PROFAMILIA's gender and sexual diversity program. All of these activities incorporated discussions about sexuality, sexual and reproductive health, STIs, condom use and negotiation, and safer sex. During some chats, La Red Colombiana de Personas Viviendo con VIH (The Colombian Network of People Living with HIV) and Liga Colombiana de Lucha Contra el SIDA (Colombian network responding to AIDS) provided their expertise on HIV prevention, care, and support. Center staff distributed condoms, supplied by PROFAMILIA, during various events, and referred users to PROFAMILIA for special sexual and reproductive health needs such as voluntary counseling and HIV testing services. During World AIDS Day 2008, the LGBT CC also conducted a public campaign to raise awareness about HIV.

Services to increase legal rights and protection: Legal services that have been provided at the LBGT CC address same-sex partner rights to health and pension benefits, workplace discrimination, harassment based on sexual orientation, and violence against LGBT. For transgender people, legal interventions have included development of processes to change their names and sex on official documentation. The community center has helped a number of PLHIV in the community to file discrimination suits against health services that have refused to attend to them, or employers who have dismissed them, because of their HIV status.

Psychological services: The psychological services that have been provided at the LGBT CC, and are in very high demand, are for LGBT individuals who have experienced discrimination, violence, and rejection based on their sexual orientation by families or friends (see Box 2). The psychologist works with families and friends of LGBT individuals, or the individuals themselves, to help them accept the idea of sexual choices outside the social norms; the psychologist also addresses a few cases of MSM living with HIV who experience discrimination in the health care setting or in the workplace.

Social work: Social work that has been provided consists of helping organize specific political interest and support groups promoting a range of issues of interest to LGBT individuals. These groups and their activities are the foundation and center point for the theory of personal and collective empowerment behind the LGBT CC. All of these groups seek a "safe" space—MSM, for example, want to socialize and interact in non-sexual ways, and parents' groups seek to better understand and accept the sexual orientation and gender identity of their children.

Currently, a multi-sectoral team, made up of a lawyer, two psychologists, a social worker, a coordinator, and administrative staff, work to provide the services described previously. In addition, the community center relies on various volunteers and interns, particularly for the counseling work provided by the psychologists, which is in high demand. The LGBT CC also provides cultural and entertainment activities; training for health center staff, schools, government entities, and police; and referrals to other organizations and services.

High demand for services and high attendance—in 2009 alone, the center served over 14,000 people through its activities or services—demonstrated that the pilot program had been a success. Based on these results, starting in 2009, the mayor's office agreed to completely fund the community center as part of the district's development plan. After the end of the pilot phase, a new mayor, Samuel Moreno, took leadership of Bogotá's government and supported the policy framework put into place by Garzón. Although Moreno is not seen as a strong supporter of LGBT rights, the policy framework already put in place by Garzón committed the government to continuing to address LGBT issues; the high visibility and demand for services of the LGBT CC would make it politically risky not to continue funding it. Moreover, support for the community center continued in the Office of Sexual Diversity and other government offices. The center continues to operate as a government entity managed by IDPAC.

What Worked Well

The LGBT CC has not been formally evaluated. However, LGBT CC staff collect and monitor service statistics routinely, which are then reported to IDPAC. Also, the coordinator of the LGBT CC pilot project developed a summary of the lessons learned during the pilot. Based on those data and interviews with key informants and focus groups with users, the following are lessons learned and successes of the project.

Users of the LGBT CC get ready to march in Bogotá's LGBT pride march.

Filling a service gap for LGBT individuals in Bogotá: Since its inception, LGBT CC staff noted a very strong, sometimes overwhelming, demand for services. In focus group discussions, users of the community center noted that they appreciate having access to a place where they know they will be understood and accepted by staff, as opposed to legal and psychological services for the general public where LGBT individuals must explain their gender identity. Both staff and users of the community center emphasized the value that the psychological services alone provide to community center users; MSM said that the center has helped them to accept their sexual orientation and gender identity, and to understand and defend their rights as MSM. The community center added more space in response. As a result of the first LGBT CC's successful establishment, there is the possibility of opening similar community centers in other cities such as Medellín. This would be an important achievement given the very conservative political environment at the national level.

HIV prevention through social and political action: HIV experts and researchers argue that by encouraging at-risk groups to seek support for the internal and external stigma they face, either because of their identity as sex workers or MSM, or their HIV status, individuals may be more likely to engage in protective behavior, such as condom use and seeking life-saving support, including HIV services (see, for example, International Center for Research on Women 2009; Martinez 2004; Pronyk et al. 2008). Participants and program staff felt that the main benefit of the LGBT CC was the space it provided to socialize and network with others of the same gender identity outside a bar or sauna setting, where casual sexual encounters are common. The activities and environment provided at the LGBT CC are much safer in terms of HIV risk. The value of the space and support that the community center offers for reflection, organizing, and empowerment cannot be overestimated in terms of its contribution to HIV prevention and mitigation.

Challenges

After the pilot phase, LGBT CC was converted into a government-run and -funded institution that is supported by IDPAC, which focuses mainly on citizen participation. A number of challenges and lessons emerged through this process.

Loss of expertise with new management: The transfer of management from the Temporary Union (PROFAMILIA, Fundación Arcoiris, and Colombia Diversa) led to a significant loss in expertise and lessons learned. For example, while the LGBT CC developed a directory of referral services during the pilot years, the current staff stated that they were developing their own referral system and seemed unaware of the referral directory by the previous LGBT CC staff. Moreover, the role of the LGBT CC in training and sensitizing other institutions and service providers on LGBT rights has been transferred to the Office of Sexual Diversity. This approach loses the special perspective of the LGBT CC, which works more directly with the community and has a stronger understanding of LGBT concerns.

Lack of integration of sexual and reproductive health issues: Likewise, because the community center's main goals currently fall under objectives related to increasing citizen participation in Bogotá's development plan, and because PROFAMILIA is no longer involved, HIV and health issues do not play a role in the community center's current activities and services. The new team does not seek to link PLHIV with HIV service organizations, even though several users have sought help of this kind. There are ad hoc efforts to address HIV, such as discussions about the myths related to HIV, and there is a move to organize a PLHIV support group. However, these efforts are still in the initial stages of planning.

Other key barriers to incorporating HIV prevention and care into the LGBT CC include the following:

• Weak external partnerships and networks with well-established and experienced HIV organizations, and lack of expertise in health and HIV among the center's present management and staff—even to orient and refer users who come to the center with specific health issues is a key challenge.
• The continuing widespread belief that all MSM have HIV may increase the stigma directed at community center staff and users by those within and outside the LGBT community.
• Overall weak leadership on the issue of HIV on the part of the government. As discussed previously, both at the national and municipal levels, HIV has not been prioritized.

Barriers in government: Under its new leadership, the community center conducts less outreach than it did previously on the rights of LGBT, despite the desires of center staff and users, who would like further public promotion of LGBT rights, including a curriculum on LGBT rights within professional and academic training programs. However, government bureaucracy can potentially decelerate the progress of campaigns to counter discrimination. For example, under the present arrangement, all messages released by the LGBT CC must be reviewed and approved by the municipal government's Secretary of Communication, which can delay or derail advocacy efforts. Moreover, since staff are government employees, there may be more reticence to confront government on gaps in laws and policies. To be sure, users of the LGBT CC currently do conduct advocacy activities. However, the users go to the community center largely to socialize and seek support from peers, for psychosocial services, and to a lesser extent, for legal services. These services are still important strategies for reducing HIV risk.

Recommendations

Draw on the strengths of various sectors to develop integrated services: The development of the LGBT CC was a completely new effort for any one group in Colombia. Thus, Colombia Diversa, when initially approached by the mayor's office, was wise to bring in the expertise of other organizations. Colombia Diversa brought its expertise in human rights, advocacy, and legal services; PROFAMILIA brought its expertise as a sexual and reproductive health service provider; and Fundación Arcoiris brought its experience in fundraising. PROFAMILIA's experience and reputation also reassured the government and public that the funds were being managed and invested in worthwhile activities, and counteracted the apprehension that public funds were being spent on "gay" activities. Finally, the municipal government's leadership in financing, coordinating, and politically supporting the creation and existence of the LGBT CC was essential to its sustainability.

The importance of this multi-sectoral approach is underscored in the current status of the LGBT CC. Despite the government's important role in sustaining the work of the LGBT CC, they lack the specific expertise in legal, health, and general service provision, as well as experience in working through networks. Thus, while the current LGBT CC is relatively stronger as a space for political and social activity for LGBT, it is less able to meet this community's continuing demand for health, legal, and psychological services. Similar efforts to establish a center that provides multi-sectoral services may require either a longer transition period from civil society to government, wherein both co-manage the program to allow for transfer of knowledge and resources. Alternatively, the program should be administered and coordinated by a unit in the higher reaches of government, such as the mayor's office, which can coordinate various government agencies involved, such as health, social services, and the department of justice.

Assess community needs in advance of designing programs: Although this may seem like an obvious point, it should still be underscored. During the pilot phase, the staff of the LGBT CC were initially unprepared for the deluge of clients for services, especially psychological services. Even after they hired the relevant staff, they were often understaffed and unable to meet demand. Moreover, while current political objectives by municipal leadership dictate the LGBT CC focus on citizen participation, there is clearly a need for comprehensive services. Understanding and prioritizing those needs is essential to improve the well-being of the LGBT community.

Secure internal expertise and leadership to maintain the focus on HIV: Because the LGBT CC's current funding stream is tied to line items related to citizen participation in Bogota's development plan, and because PROFAMILIA is no longer involved, HIV and health issues no longer play a role in the center's activities and services. However, program statistics and focus group discussions with program participants demonstrate strong uptake of and interest in support groups and services related to HIV. PROFAMILIA's experience shows that there must be a champion to lead the effort of integrating such a specialized topic into a broader program.

Combat HIV-related stigma as well as stigma based on gender identity: In settings with highly concentrated epidemics, HIV is extremely stigmatized and information about HIV is extremely distorted. In Colombia, this stigma has steered the LGBT movement away from involvement with the HIV movement. Clearly, much work needs to be done to tackle the stigma, which undermines the potential for a more comprehensive approach to HIV prevention.

Involve appropriate and representative groups to represent LGBT populations: Overall, the LGBT CC can be replicated in settings with a strong health and legal framework in place. In Colombia, for example, years of effort by Colombia Diversa, PROFAMILIA, and other advocacy and service groups, combined with a relatively favorable policy environment, enabled the creation and success of the LGBT CC, first as a service provider and later as a center for political and community participation. In other settings—for example, where the LGBT community is persecuted for even identifying as outside the social norm—establishing an LGBT center could endanger those attending or prevent their attendance entirely.

Where the political environment is favorable enough, the government may in fact be a key collaborator. However, groups that adequately represent LGBT interests and concerns must always be part of the process to maximize the benefit of their experience. As initial lessons from this experience in Colombia have shown, this may require a longer process for civil society experts to work alongside government.

Rigorous monitoring and evaluation is essential: The effects of the LGBT CC on HIV prevention were not evaluated following the pilot phase. Still, the literature indicates that a rights-based approach to HIV prevention that addresses issues of discrimination and violence, as the LGBT CC's services do, can be more effective than strictly focusing on sexual risk behavior of MSM. It is not clear, with its current structure, whether the LGBT CC would benefit its users by adding HIV services or whether this would diminish the quality of existing services by stretching limited resources. Given that there are already other organizations that can provide expertise in HIV, it may be better for the center to take advantage of these existing services and its wide accessibility to MSM to raise awareness about HIV risk or refer MSM to HIV services at other organizations.

Future Directions

Under the city's development plan, the program "Bogotá Respects Diversity" includes plans to open three more community centers in the city, one of which is a mobile center that is already functioning. This mobile center does not provide services; instead, it refers individuals to services as needed. The main focus of the mobile center, as with the first LGBT CC, is to promote political and community participation by LGBT to advance the objectives of increased equity and recognition of sexual diversity. The others have yet to open. According to representatives of the mayor's office, the main barrier is a lack of funding because the centers were not well budgeted for when they were initially proposed.

In addition, the health sector is developing protocols to attend to LGBT in the health care setting, an effort being led by the Hospital of Chapinero. There are also efforts to reduce discrimination in schools, as well as cultural activities in the community to raise awareness about LGBT rights. To that end, the Office of Sexual Diversity will be carrying out trainings for teachers, health providers, and other government service providers on LGBT rights.

References

Centro Comunitario LGBT. 2009. Un Lugar de Encuentro y Convivencia con la Diversidad: Informe Final de Gestión (A Meeting Place and Living with Diversity: Final Management Report). Colombia: PROFAMILIA).

Human Rights Watch. 1994. Generation Under Fire: Children and Violence in Colombia.

International Center for Research on Women (ICRW). 2009. Sex, Rights and the Law in a World with AIDS: Meeting Report and Recommendations. Washington, DC: ICRW.

Joint U.N. Programme on HIV/AIDS. 2006. Prevalencia de Infección por VIH en HSH de Bogotá. Informe final (Preventing HIV Infection in MSM in Bogota: Final Report). Colombia: UNAIDS.

Liga Colombiana de Lucha contra el SIDA (LCLS). 2000. Estudio de Prevalencia al VIH con HSH en Bogotá (HIV Prevention Study with MSM in Bogotá). Colombia: LCLS, SDS (Secretaria Distrital de Salud de Bogotá), and UNAIDS.

Martinez, A. 2004. "Social Capital: Convergences and Divergences Between Sociology and Public Health Research." Paper presented at the annual meeting of the American Sociological Association, San Francisco, August 14.

Morrison, K. 2006. Breaking the Cycle: Stigma, Discrimination, Internal Stigma and HIV. Washington, DC: U.S. Agency for International Development Policy Project.

Pronyk, P. M., T. Harpham, L. A. Morison, et al. 2008. Is Social Capital Associated with HIV Risk in Rural South Africa? Social Science & Medicine 66(9):1999–2010.

Saewyc, E., C. Skay, K. Richens, et al. 2006. Sexual Orientation, Sexual Abuse, and HIV-Risk Behaviors Among Adolescents in the Pacific Northwest. American Journal of Public Health 96(6):1104–10.

Spratt, Kai. 2010. Technical Brief: Integrating Gender into Programs with Most-at-Risk Populations. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.

Acknowledgements

The author greatly appreciates the former and current staff and users of the LGBT CC, as well as representatives of civil society and government who took the time to discuss the LGBT CC, the LGBT movement, and HIV in Colombia. Special thanks goes to Elizabeth Castillo Vargas of PROFAMILIA for the time and effort she took to accompany the author throughout the case study data collection visit and provide useful insights into the establishment of the LGBT CC. The author thanks Maritza Ochoa for helping to document focus group discussions with LGBT CC participants. Thanks also to the PEPFAR Gender Technical Working Group for their support and careful review of this case study.

Recommended Citation

Betron, Myra. 2011. Empowering Men Who Have Sex with Men to Live Healthy Lives: Integrated Services at Bogotá's Lesbian, Gay, Bisexual, and Transgender Community Center. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.