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WHO: People most at risk of HIV not getting health services they need

WHO released “Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations”, in the lead-up to the International AIDS Conference in Melbourne, Australia, starting on 20 July. The guidelines outline steps for countries to reduce new HIV infections and increase access to HIV testing, treatment and care for these five ‘key populations’.

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WHO

Failure to provide adequate HIV services for key groups – men who have sex with men, people in prison, people who inject drugs, sex workers and transgender people – threatens global progress on the HIV response, warns WHO.

These people are most at risk of HIV infection yet are least likely to have access to HIV prevention, testing and treatment services. In many countries they are left out of national HIV plans, and discriminatory laws and policies are major barriers to access.

WHO released “Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations“, in the lead-up to the International AIDS Conference in Melbourne, Australia, starting on 20 July.

The guidelines outline steps for countries to reduce new HIV infections and increase access to HIV testing, treatment and care for these five ‘key populations’*. They include a comprehensive range of clinical recommendations but, for these to be effective, WHO also recommends countries need to remove the legal and social barriers that prevent many people from accessing services.

For the first time, WHO strongly recommends men who have sex with men consider taking antiretroviral medicines as an additional method of preventing HIV infection (pre-exposure prophylaxis)** alongside the use of condoms. Rates of HIV infection among men who have sex with men remain high almost everywhere and new prevention options are urgently needed.

Modelling estimates that, globally, 20-25% reductions in HIV incidence among men who have sex with men could be achieved through pre-exposure prophylaxis, averting up to one million new infections among this group over 10 years. Studies indicate that women sex workers are 14 times more likely to have HIV than other women, men who have sex with men are 19 times more likely to have HIV than the general population, and transgender women are almost 50 times more likely to have HIV than other adults. For people who inject drugs, studies show the risks of HIV infection can be also 50 times higher than the general population.

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“None of these people live in isolation,” says Dr. Gottfried Hirnschall, director of the HIV Department at WHO. “Sex workers and their clients have husbands, wives and partners. Some inject drugs. Many have children. Failure to provide services to the people who are at greatest risk of HIV jeopardizes further progress against the global epidemic and threatens the health and wellbeing of individuals, their families and the broader community.”

The guidelines are published as new figures underline the need for continued global progress on HIV. By the end of 2013, around 13 million people were taking antiretroviral therapy (ART), with 11.7 million of these people living in low- and middle-income countries. This has led to a 20% drop in HIV-related deaths between 2009 and 2012.

But while the number of people dying of AIDS is falling sharply, preventive efforts are still lagging too far behind, particularly among key populations.

There are still significant gaps in addressing their needs in national HIV plans. Globally, just 70% of countries surveyed explicitly address the needs of men who have sex with men and sex workers, while the figure for injecting drug users was 40%. Transgender people are rarely mentioned in HIV plans. And even where policies exist on paper, it is hard for people to access services that can help them.

Key populations are less likely to have equal access to HIV treatment. For example, in some settings in Eastern Europe, people who inject drugs make up more than half of all people living with HIV, but only one third of people living with HIV have access to lifesaving ART.

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In many countries, discrimination is reinforced by laws that criminalize sexual behaviours, drug use, gender expression or perceived sexual orientation. However where laws and policies support access to HIV services for these key populations, illness and death due to HIV among these groups has declined and new HIV infection rates remain low or have fallen, especially among sex workers and for people who inject drugs.

“Bold policies can deliver bold results,” says Dr. Rachel Baggaley, from WHO’s HIV Department. “Thailand was one of the first pioneers of programmes to recognise the need to keep sex workers healthy and reduce new HIV infection. Malaysia, Spain and the United Republic of Tanzania have made major advances in providing opioid substitution therapy and needles and syringe programmes for people who inject drugs. Data show that where a combination of effective HIV prevention and treatment services for people who inject drugs are available, HIV transmission among people who inject drugs is minimal.”

These new guidelines outline ‘comprehensive HIV packages’ for prevention, diagnosis, treatment and care for the five key populations and address specific issues and needs of adolescents from these groups. These include measures to better manage sexual and reproductive health, mental health and co-infections such as tuberculosis and hepatitis. They highlight the need for needle and syringe and opioid substitution therapy programs and include recommendations for treatment of overdose in the community.

At the International AIDS Conference 2014 in Melbourne, WHO will call on governments to re-energize and strengthen HIV programs so that all key populations benefit from the ongoing advances in HIV treatment and program scale-up.

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*Key populations are defined groups who, due to specific high risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and social issues related to their behaviours that increase their vulnerability to HIV. These guidelines focus on five key populations.

** Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV, but who are at risk of getting it, to prevent them getting HIV by taking a single pill (usually a combination of two antiretrovirals) every day. PrEP, when taken consistently, has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently.

NEWSMAKERS

Boys who are bullied online may have more risky sex

Adolescent boys who are cyber bullied pursue risky sexual behaviors more frequently than girls who are cyber bullied. Results may reflect a culture of toxic masculinity and highlight the need to pay special attention to male victims, who may be reluctant to self-identify, and therefore, at greater risk of negative health outcomes.

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Peer victimization is associated with adverse psychological and behavioral problems, including depression and risky health behaviors such as substance use and unprotected sex with multiple partners. This is according to a A collaboration of researchers at Louisiana State University, University of Missouri, and University of Tennessee in the US.

The study, “Peer victimization, depression and sexual risk behaviors among high school youth in the United States: a gender-based approach“, by Youn Kyoung Kim, Mansoo Yu, Courtney Cronley and Miyoun Yang has been published in the International Journal of Adolescent Medicine and Health. The authors examined gender differences in the relationships between four types of peer victimization (school bullying, cyber bullying, physical dating violence, and sexual dating violence), depression, and risky sexual behaviors among US high school students.

In 2015, approximately one-third of high school students in the US alone reported having sex recently. Of these, 43% had not used a condom, 21% had drunk alcohol or used drugs before sexual intercourse, and 14% had not used any contraception.

Recent research suggests that adolescent boys who are cyber bullied pursue risky sexual behaviors more frequently than girls who are cyber bullied. Results may reflect a culture of toxic masculinity and highlight the need to pay special attention to male victims, who may be reluctant to self-identify, and therefore, at greater risk of negative health outcomes.

For this newer study, the researchers analyzed the 2015 Youth Risk Behavior System Survey, a nationally representative survey of US high school students containing data from 5,288 individuals who reported having engaged in sexual intercourse. The results show that all types of peer victimization are related to symptoms of depression for both females and males, and physical and sexual dating violence are associated with increased risky sexual behaviors. However, school bullying does not predict risky sexual behaviors. Among males, cyber bullying predicts increased risky sexual behaviors and the relationship is greater when a boy is depressed.

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Bullying is, of course, a big issue for members of the LGBTQIA community.

In April 2018, for instance, a study that investigated gender expression and victimization of youth aged 13-18 found that the most gender nonconforming students reported higher levels of being bullied, were more likely to report missing school because they feel unsafe, and are most likely to report being victimized with a weapon on school property.

The effects of bullying are also long-term. In November 2018, another study found that 35.2% of gay/bisexual men who had experienced frequent school-age bullying experience frequent workplace bullying. Among lesbian women, the figure was 29%.

“It is critical to create safe and private spaces for boys to share their experiences, and we hope that this research will encourage schools to consider efforts to destigmatize victimization through peer mentorship and open communication,” said Youn Kyoung Kim.

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Progressive gender beliefs in teen boys may be protective against violence

Adolescents with more equitable gender attitudes – those who felt boys and girls deserve equal opportunities and respect – had lower odds of reporting violent behaviors.

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Teenage boys who witness their peers abusing women and girls are much more likely to bully and fight with others, as well as behave abusively toward their dates, compared to teenage boys who don’t witness such behaviors, according to an analysis led by the University of Pittsburgh School of Medicine and UPMC Children’s Hospital of Pittsburgh.

Conversely, the study found that adolescents with more equitable gender attitudes – those who felt boys and girls deserve equal opportunities and respect – had lower odds of reporting violent behaviors. The results are published today in the American Journal of Preventive Medicine.

“The #MeToo movement brought to light how pervasive sexual violence and derogatory behavior toward women is in our society,” said lead author Elizabeth Miller, M.D., Ph.D., professor of pediatrics, public health and clinical and translational science at Pitt. “Our findings highlight the wide-ranging impact that witnessing sexual harassment and dating violence has on our teenage boys, and present an opportunity to teach adolescents to challenge negative gender and social norms, and interrupt their peer’s disrespectful and harmful behaviors.”

This study is the first to gather information from U.S. male adolescents in community-based settings, rather than schools or clinics, about multiple types of violence, including bullying and sexual harassment, and the role of gender norms and peer behaviors.

Miller and her team surveyed 866 13- to 19-year-old boys at after-school programs, libraries, churches and other youth-serving organizations in 20 lower-resource Pittsburgh neighborhoods. The teens completed the surveys anonymously between August 2015 and June 2017 as part of a larger study evaluating the effect of a prevention program to reduce sexual violence. Seventy percent of the teens identified as African American and 21% as Hispanic, multiracial or ‘other.’

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Of the 619 boys who had ever dated, 1 in 3 reported using abusive behavior toward someone they were dating in the previous 9 months. Sexual harassment, whether dating or not, was also common, with 485, or 56%, saying they’d engaged in such behavior. And 587, or 68% of the respondents, said they’d been in physical fights, or threatened or injured someone with a weapon.

Boys who said they’d witnessed their peers engaging in two or more of nine different harmful verbal, physical or sexual behaviors toward women and girls – such as making rude or disrespectful comments about a girl’s body – had 2 to 5 times higher odds of engaging in a variety of violent behaviors, some having nothing to do with women or dating.

“This reinforces that pressure to conform to stereotypes about masculinity that perpetuate harmful behaviors toward women and girls is also associated with getting in a fight with another guy,” said Miller, who is also director of the Division of Adolescent and Young Adult Medicine at UPMC Children’s. “These behaviors aren’t happening in silos – if we’re going to stop one, we need to also be addressing the other.”

Interestingly, the research team did not find that teens who reported having more gender equitable attitudes were any less likely to engage in homophobic teasing, something three-quarters of the survey respondents endorsed.

“It’s a puzzling and troubling finding. We believe it may be because these teens have normalized homophobic teasing – it is so commonplace, they may see it as a form of acceptable, possibly even pro-social, interaction with their peers,” said Alison Culyba, M.D., Ph.D., M.P.H., assistant professor of pediatrics in the Division of Adolescent and Young Adult Medicine at UPMC Children’s. “This study illustrates the need for cross-cutting prevention strategies that address multiple aspects of youth violence.”

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As part of their study, this team of researchers are evaluating a sexual violence prevention program called Manhood 2.0. Miller has also conducted research on a program called Coaching Boys into Men that guides middle and high school coaches in talking with their male athletes about stopping violence against women and girls. Both Manhood 2.0 and Coaching Boys into Men involve reinforcing more equitable gender attitudes and increasing the number of youth who intervene when witnessing peers’ disrespectful behavior.

Kelley A. Jones, Ph.D., of UPMC Children’s and Pitt, is senior author of this research. Additional authors are Alison J. Culyba, M.D., Ph.D., M.P.H., Taylor Paglisotti, B.A., Michael Massof, M.P.A., and Qi Gao, M.P.H., all of UPMC Children’s and Pitt; Katie A. Ports, Ph.D., of the Centers for Disease Control and Prevention (CDC); Jane Kato-Wallace, M.P.H., of Promundo-US in Washington, DC; Julie Pulerwitz, Sc.D., of the Population Council in Washington, DC; Dorothy L. Espelage, Ph.D., of the University of North Carolina at Chapel Hill; and Kaleab Z. Abebe, Ph.D., of Pitt.

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From as young as 4, children see males as more powerful than females

When the children had to consider their power relation with a person of the same gender as themselves, the girls and boys both largely identified with the dominant character.

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As early as 4 years old, children associate power and masculinity, even in countries considered to be more egalitarian like Norway. This is what scientists at the Institut des Sciences Cognitives Marc Jeannerod (CNRS/Université Claude Bernard Lyon 1) report, in collaboration with the Universities of Oslo (Norway), Lausanne and Neuchâtel (Switzerland), in a study published in Sex Roles. They also show that in some situations the power-masculinity association does not manifest in girls.

Little is known about how representations of power interact with gender in early childhood. Researchers at the Institut des Sciences Cognitives Marc Jeannerod (CNRS/Université Claude Bernard Lyon 1), in collaboration with the Universities of Oslo (Norway), Lausanne and Neuchâtel (Switzerland) wanted to know whether children aged 3 to 6 years old in France, Lebanon, and Norway attribute more power to masculine figures than feminine figures.

In a first experiment, they showed the children a picture with two non-gendered individuals. One of them adopted a dominant physical posture and the other a subordinate posture. First the children had to guess which of these two individuals was exerting power over the other. Next they had to assign a gender to each individual (Who is the girl? Who is the boy?). The results reveal that from 4 years old, a large majority of children consider the dominant individual to be a boy. The power-masculinity association was observed in both boys and girls, and just as much in Lebanon as in France and Norway. However it was not significant in 3-year old children.

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In a second experiment, this time in children aged 4 and 5 years old all in school in France, had to imagine themselves in the picture and imagine the other person as a boy or a girl. When the children had to consider their power relation with a person of the same gender as themselves, the girls and boys both largely identified with the dominant character. But when they had to consider their power relation with a person of the opposite gender, boys identified more often with the dominant character whereas girls did not significantly identify more with one or other of the characters.

Finally, in a third experiment, children aged 4 and 5 years old in Lebanon and France watched a series of exchanges between two puppets, one representing a girl and the other a boy, behind a board (1). In one case, the puppets were getting ready to play a game together and the child heard one impose their choices on the other. In the other case, one puppet had more money than the other to buy ice cream. In France and Lebanon, most of the boys thought that the puppet that imposed their choices or that had more money was the male puppet. However, the girls in both countries did not attribute the dominant position preferably to one or other gender.

These results show that children have early sensitivity to a gender hierarchy, though in some situations girls do not associate power and masculinity. The scientists now hope to find out what power forms they attribute to feminine figures and whether they legitimize the expression of gendered power.

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1 The puppets, which were shown to the children before being hidden behind the board, were manipulated by the same speaker and “spoke” with the same voice, working as in a cartoon. So, behind the board, it was not to possible to differentiate them by their voice.

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LIVING HISTORY

Supreme Court junks with finality petition for same-sex marriage

But in its earlier ruling on the matter, the SC said the Constitution does not restrict marriage on the basis of sex. It stated that the 1987 Constitution, from its “plain text,” “does not define, or restrict, marriage on the basis of sex, gender, sexual orientation, or gender identity or expression.”

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The Supreme Court (SC) of the Philippines has junked – with finality – the petition that sought to legalize same-sex marriage in the country.

In a two-page notice issued by the SC last December 10, 2019 (but only made available on January 6, 2020), the SC denied “with finality the said motion for reconsideration as no substantial arguments were presented to warrant the reversal of the questioned decision.”

In October 2015, Atty. Jesus Nicardo Falcis III filed the petition that sought to strike down the prohibitions against same-sex marriage under the Family Code. But the SC dismissed Falcis’ petition “on account of his lack of standing, violating the principle of hierarchy of courts, and failing to raise an actual, justiciable controversy,” SC’s spokesperson Brian Keith Hosaka said in a news conference on September 3, 2019.

But in its earlier ruling on the matter, the SC said the Constitution does not restrict marriage on the basis of sex. It stated that the 1987 Constitution, from its “plain text,” “does not define, or restrict, marriage on the basis of sex, gender, sexual orientation, or gender identity or expression.”

The High Court, nonetheless, had to deny the petition based on Falcis’ lack of standing, violation of the principle of hierarchy of courts, and failure to raise an actual, justiciable controversy.

This time around, the SC stated that “no further pleadings or motions will be entertained,” said SC Clerk of Court Edgar Aricheta.

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For the SC, through Associate Justice Marvic Leonen who penned the decision, “same-sex couples may morally claim that they have a right against discrimination for their choice of relationships and that official recognition of their partnerships may, for now, be a matter that should be addressed to Congress.”

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NEWSMAKERS

Gender norms affect attitudes towards gay men and lesbian women globally

Negative attitudes are guided by the perception that gays and lesbians violate traditional gender norms.

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Gay men and lesbian women have often been the targets of prejudice and even violence in society. To better understand what shapes these attitudes and prejudices, Maria Laura Bettinsoli, Alexandra Suppes, and Jamie Napier (all New York University – Abu Dhabi) tested how beliefs about gender norms (expectations of society for how men and women act and look) and people’s attitudes towards gay men and women relate across the globe.

They found that globally, gay men are disliked more than lesbian women across 23 countries. Their results also suggest negative attitudes are guided by the perception that gays and lesbians violate traditional gender norms. But in three countries, China, India, and South Korea, the correlation between beliefs in gender norms and attitudes towards gays and lesbians was absent or even reversed.

The research appears in Social Psychological and Personality Science.

The team assessed attitudes towards gay men and lesbian women separately, noting that most research focuses on homosexuality as a broad category and doesn’t separate attitudes by gender.

Bettinsoli and colleagues were surprised at how consistently gay men were rated more negatively than lesbian women in a vast majority of their samples.

They were also surprised “at the consistency of the relationship between gender norm endorsement and sexual prejudice,” says Bettinsoli. “Even though there were some non-Western countries that did not conform to the pattern, the majority of countries did.”

These findings were true for western countries including Argentina, Australia, Belgium, Brazil, Canada, France, Germany, Great Britain, Hungary, Italy, Mexico, Peru, Poland, Spain, Sweden, and the US. The same was true for Russia, South Africa, and Turkey too.

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“We also found that, in line with previous research, the endorsement of gender norms was associated with anti-gay attitudes–toward both gay men and lesbian women–in every Western country in our sample,” says Bettinsoli.

In South Korea, the researchers saw that endorsement of gender norms was unrelated to attitudes toward gays and lesbians, and in Japan, there was a small association between gender norm endorsement and attitudes toward gay men, but not towards lesbian women.

“In China and India, the reverse pattern emerged. Those who were highest on endorsement of traditional gender roles were the most positive toward gay men and lesbian women,” says Bettinsoli.

While some of the countries show friendlier attitudes towards gays and lesbians, Bettinsoli notes that even in the more tolerant places discriminatory attitudes still exist.

The study is one of several appearing in a future special issue of Social Psychological and Personality Science focused on underrepresented populations.

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NEWSMAKERS

Having to defend one’s sexuality increases fear of childbirth

Fear of childbirth is the same, regardless of sexuality. The difference is that in addition to this fear, lesbian and bisexual women and transsexual people are afraid of being questioned or offended because of their identity.

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In order to help people with fear of childbirth, there must be trust between the patient and the healthcare staff. But for many lesbian and bisexual women and transgender people, this trust never develops. These are the results of a study in the journal Midwifery from researchers at Linköping University.

Fear of childbirth (FOC) in heterosexual people is a well-researched field, but we know little about how lesbian and bisexual women and transsexual people experience pregnancy, childbirth and reproductive healthcare. Anna Malmquist and Katri Nieminen, researchers at Linköping University, have investigated the topic in depth. The study has been published in the journal Midwifery.

“This study shows that fear of childbirth is the same, regardless of sexuality. The difference is that in addition to this fear, lesbian and bisexual women and transsexual people are afraid of being questioned or offended because of their identity. That is, their fear has an added dimension,” says Malmquist.

The study includes interviews with 17 people who identify as either lesbian, bisexual or transgender. Many of the interviewees state that they have numerous positive experiences of maternal care and obstetrics, but also negative experiences. The additional layer of fear and stress felt by this group in its encounter with health care is called minority stress. This is the stress experienced by people who challenge norms when they must repeatedly explain their relationship or are forced to deal with comments, misunderstanding or incomprehension.

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The study’s conclusion is that lesbian and bisexual women and transsexual people with FOC are particularly vulnerable in healthcare. In order to help people with FOC, there must be trust between the healthcare staff and the patient. If instead the staff stress the patient more, for instance by assuming the patient is heterosexual, this trust will never develop to a level where the FOC can be addressed.

Malmquist explains that improving the situation for lesbian and bisexual women and transsexual people with FOC requires training. Healthcare staff must be familiar with the various groups they can encounter at work, keep in mind that not everyone is heterosexual, and understand what minority stress is.

“It’s not enough that healthcare staff feel they are ‘open-minded’ in their interaction with this group. They need knowledge. These patients are already having a lot of difficulty with their fear of childbirth. They shouldn’t have to train their midwife as well,” says Malmquist.

Looking forward, Malmquist and Katri Nieminen will study whether FOC is more common in lesbian and bisexual women and transsexual people than in heterosexual people.

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