Dennis Altman, Peter Aggleton, Michael Williams, Travis Kong, Vasu Reddy, et al. The Lancet. Volume 380, Issue 9839, July-August, 2012.
The first cases of AIDS were identified in gay men in the USA, and the disease was originally termed gay-related immune deficiency (GRID). Mobilisation of attention and resources was slow, partly because of the association between AIDS and male homosexuality and corresponding reluctance on the part of government officials to acknowledge the importance of the epidemic. 25 years later, the same reluctance is evident in many parts of the world, and again, scarcity in attention and resources is affecting responses to HIV transmission in homosexual men. The complex relation between homosexuality and HIV continues to mark the epidemic, even in countries where most infections are unrelated to homosexual contact. That most societies regard homosexuality with a mixture of disdain and disgust has therefore been, and remains, a major factor in the development of the epidemic.
Despite major changes over the past two decades, sex between men remains misunderstood, feared, and discriminated against in most parts of the world. In January, 2011, a prominent Ugandan gay activist, David Kato, was murdered shortly after winning a lawsuit against a local magazine, which had published his name and photograph identifying him as gay and called for his execution. At his funeral, the Christian preacher preached against gays and lesbians, before activists ran to the pulpit and grabbed the microphone from him, forcing him to retreat to Kato’s father’s house.
A few months earlier, in the USA, a series of suicides of adolescent boys occurred after constant taunts and bullying because of their sexuality. Few societies are without equivalent stories of persecution and bullying on the basis of sexual orientation or perceived deviance from accepted gender norms. An important difference exists within state sanctioned discrimination: many countries retain criminal sanctions against all forms of male (and sometimes female) same-sex behaviour, whereas other jurisdictions have legislated antidiscrimination protection on the grounds of sexuality and gender. But legal protections do not by themselves change dominant attitudes unless effective means are available to support people who experience dis crimination and persecution.
Because this Viewpoint concentrates on the links to HIV, we have put a strong emphasis on male homosexuals, but discrimination, oppression, and denial is equally experienced by women who are attracted to, or have sex with, other women. We recognise that dis crimination against homosexual women raises other issues that cannot be dealt with here, but have been overshadowed by the urgencies of HIV transmission through male-to-male sex.
The appendix contains additional references for readers who would like more information on certain subjects throughout the report.
Appropriate terminology
To call homophobia all examples of violence, persecution, and discrimination based on sexual and gender deviance might not be helpful. The term was coined by the psychologist George Weinberg to describe “the dread of being in close quarters with homosexuals and, in the case of homosexuals themselves, self-loathing.” Not all discrimination against people based on their sexuality necessarily results from this dread, and self-loathing is a term that is too easily deployed at anyone who might infringe communal norms (eg, not declaring one’s sexuality publicly is often termed self-loathing, but might result from other factors).
Moreover, an important distinction exists between homophobia, with its emphasis on individual pathology, and heteronormativity, which emphasises systematic discrimination or, as Tom Boellstorffputs it, “operates at the level of generalized belief and social sanction, rather than on an emotive plane”. Writing about Indonesia, Boellstorffargued that during the past decade, a particular form of political homophobia developed, consisting of a new violence directed against gay men (less often lesbians) who were seen as threatening a particularly masculinist nationalism. His analysis helps explain what is often seen as rising homophobia in many parts of the developing world, and links concerns about changing sexual and gender norms to larger sociopolitical factors. Homophobia might be explained as the expression of individual psychological needs, which leads to it being understood as an individual psychological flaw that should be corrected (ironically, a mirror image of the homophobe’s view of homosexuality), but it might also be used to explain state actions and scapegoating. More than 10 years ago, Barry Adam devised a taxonomy for analysing “the social opposition to same-sex desire and its embeddedness in contemporary societies” in ways that clarified the very different assumptions underlying different terminologies.
Although we accept that homophobia is the term most commonly used to cover discrimination, denial, and persecution of people based on their homosexuality, the term is less useful for analysis than is heteronormativity, which focuses on the structures and beliefs that assume that heterosexual relationships are normal whereas homosexuality is deviant. Another term that focuses on those beliefs is heterosexism, which comes from an extension of Adrienne Rich’s influential phrase “compulsory heterosexuality”. These terms all arise from the specific intellectual and political currents of the USA after the emergence of gay liberation at the end of the 1960s, and other notions might be more useful to describe hostility, denial, and persecution of homosexuality or homosexuals in other societies.
Like Boellstorff, David Plummer places substantial emphasis on physical violence as a manifestation of homophobia: “Studies on homophobic violence provide a useful foundation for investigating homophobia because violence is comparatively easy to define, is increasingly well documented, has major ramifications, and offenders’ statements often provide unequivocal evidence of homophobic motives.” Unfortunately, no robust cross-national data on homophobic violence exist, which would be useful for the reasons Plummer argues.
In many cases, homophobic prejudice is most strongly directed against those who infringe gender norms governing male and female behaviour. Many societies have allowed for same-sex relations when they were clearly linked to gender non-conformity, as in variants of the socalled third sex, such as Thai kathoey, Indian hijra, and Native American berdache. Fewer cases exist of specific roles for women who identify as masculine, but there are examples from Surinam (mati) and both east and west Africa. In many parts of the world, established transgender communities and roles exist, and reactions are strongest against people who seem to adopt western gay (or lesbian) styles. These reactions are evident in Iran, where gender reassignment is permissible, where as homosexual behaviour is brutally punished. Some Iranian women and men who in other societies would adopt homosexual identities undergo gender reassignment to meet these rules. Nevertheless, increasingly in many societies, the prejudice and discrimination experienced by visibly transgendered people is probably far greater than that encountered by the average lesbian or gay man, who often conforms to dominant gender stereotypes.
The contemporary world has seen the emergence of a range of distinct homosexual identities, unrelated to gender, which have become markers of modernity to be both sought after and feared. Globally, a sharp distinction seems to exist between the affluent liberal democratic world and much of the developing world, although these distinctions are often replicated within countries that themselves straddle different levels of affluence and political openness. Thus, in Mexico deep-seated homophobia, often sanctioned by the Catholic Church, coexists with the progressive policies of Mexico City, one of the first jurisdictions outside the rich world to accept same-sex unions. Equally, substantial violence directed at perceived homosexuals exists in South Africa, despite constitutional equality. The murders of several black lesbians (many who have been public about their identities) also confirm that attitudes change slowly despite legal protections. A study that tracked a representative cross-section of South African attitudes towards homosexuality since 2003 showed that across sex, age, religious affiliation, population group, and geography, South Africans remain far from comfortable with the rights and protections accorded to homosexuals in the Constitution.
Attitudes towards homosexuality have become markers of debates between tradition and modernity. The determination of human rights and gay groups to name sexuality, and declare it the basis for rights, reinforces the hostility to it from religious and political leaders, who see homosexuality as a mark of western decadence to be resisted. As Negar Azimi wrote of Egypt: “Politicians, the police, government officials, and much of the press are making homosexuality an ‘issue’: a way to displace nationalist bona fides in the face of an encroaching Western sensibility, to reject a creeping globalization… [and] to flash religious credentials and placate growing Islamist power.” Anxieties about changing family and socioeconomic structures make homosexuals, particularly those who seem to take on western identities of lesbians or gay men, particularly attractive as scapegoats. Such views are prevalent throughout parts of north Africa and the Middle East, even where there are long established patterns of sexual relationships between men. In such contexts, it is less same-sex affections, desires, and relationships that are the issue than is the danger of such becoming publicly known, thereby threatening the honour of family, kinship, and community.
Even in countries with antidiscrimination laws that include sexuality and, less often, changed gender status, substantial residual issues remain. Young people who feel they might be sexual or gender non-conformists experience great pressure, which is known to raise levels of anxiety, depression, and suicide rates. It is common to speak of internalised homophobia, but this term reproduces the emphasis on individual pathology, and is difficult to validate and measure.
Measuring political homophobia
Various methods have been developed by psychologists to measure homophobic attitudes within individuals, but measuring the origins and prevalence of anti-homosexual prejudices across different countries is more difficult.
One of the best-known indicators of institutional homophobia is the map from International Lesbian, Gay, Trans and Intersex Association (ILGA) on lesbian and gay rights in the world, and its accompanying report State- Sponsored Homophobia. The most recent ILGA report claims that five nations have the death penalty for homosexual conduct, and a further 76 nations have laws that criminalise same-sex conduct. Conversely, 54 countries extend some form of antidiscrimination protection to homosexuals in the workplace; ten countries have full rights to marriage; and 24 countries have laws providing recognition (such as civil unions) to gay and lesbian relationships. These laws can produce strange anomalies, so that for a period, Fiji’s Constitution (now annulled) provided protection against discrimination based on sexuality even while the colonial era’s antisodomy laws remained in place (these were abolished in 2010).
Although laws can be used to devastating effect to target and harass homosexuals, this type of mapping exercise places too much weight on formal regulation as a measure of homophobia. Informal laws and enforcement practices of police are far more important. Iraq seems to have no legal provisions against homosexual behaviour, but remains one of the most dangerous places in which to be perceived as homosexual. Russia does not criminalise homosexuality, but considerable persecution and state-sanctioned discrimination exist. The AIDS Accountability Project in South Africa has begun to work on issues of marginality of the lesbian, gay, bisexual, and transgender (LGBT) community, but so far, the only hard data provided apply to rates of testing of these populations, and not much can be concluded from their findings, especially in view of the determined use of identity categories that might often not be relevant. Various developing country organisations use the term LGBT and we use this term where it is the preferred term, while noting it does not encompass all expressions of homosexuality.
The Pew Research Centre, Washington, DC, USA, has sought to measure global perceptions of homosexuality. In its 2007 Global Attitudes report, the question of whether homosexuality should be accepted returned fairly predictable results: in those countries that are both more prosperous and largely secular (eg, Canada, UK, and Sweden), the majority supported acceptance. In African countries, majorities were strongly opposed (98% in Mali, and 97% in Nigeria and Ethiopia voted against acceptance). Similar negative results emerged in Middle Eastern nations such as Egypt (95%), Lebanon (79%), and Jordan (89%). In some countries, although not particularly religious, their populations opposed acceptance (China 69% and South Korea 77%). Citizens of the USA, and much of Latin America, were roughly equal in their views of acceptance, but attitudes were more positive in Argentina (72%) and Brazil (65%).
Aside from concerns about the methodology of surveys, generalisation about countries on the basis of such data provides an impoverished picture of how diverse homosexual communities actually exist within different regions. Brazil, for example, is commonly regarded as accepting of its gay and transgender citizen, but the images of flamboyance projected to the world during Carnival stand in contrast to the reports of the frequent killing of both gays and transgenders in the country. Malaysians polled low in their acceptance of homosexuality, but Kuala Lumpur has a thriving gay and lesbian community and an open gay and lesbian scene, which exist despite punitive laws or negative social attitudes.
The most recent Pew Center report on attitudes towards homosexuality in the USA suggests growing acceptance, particularly in young Americans. More women than men are accepting, with the greatest negativity coming from fundamentalist Protestants, whereas hispanic (64%) and white (58%) people are more supportive of acceptance than are African Americans (49%).
Different manifestations of homophobia
Prejudice and discrimination against homosexuals are often assumed to stem from religious teaching, and it is true that almost all institutionalised religions reject full acceptance of homosexuality. Certainly, the strongest opposition to acceptance is frequently voiced by religious leaders, and there is often a convergence between religious and nationalist ideology in defending particular expressions of sex and gender. This convergence is most obvious in Islamic states, but opposition to homosexuality is part of the official ideology of many states despite an antireligious tradition, including several in the former Soviet Union. Although the UK has abolished laws criminalising homosexuality and enacted anti-discriminatory legislation, most of its former colonies retain these laws, ironically largely the product of British colonialism.
38 countries in Africa criminalise same-sex relationships and punishment ranges from imprisonment to death, and increasingly, blackmail and extortion. Homosexuality is viewed as something to be contained, curtailed, regulated, and ultimately repressed, while serving as a metaphor for deep-seated political conflicts over identity, bodily integrity, and morality often publicly driven by African leaders. The prevailing view in much of the continent is that homosexuality is a Euro-American perversion that has contaminated African tradition, despite increasing evidence of the existence of homosexuality in precolonial Africa. The assumption that homosexuality is a sign of western decadence is underpinned by homogenising discourses that view tradition as static, unchanging, and fixed. Perceived as un-African, homosexuality still signifies sexual excess, even in societies that admire heterosexual promiscuity. The homosexual seems to infringe rigid gender norms prescribing preculturally defined roles for men and women.
Active hostility is pervasive, and political leaders have mobilised cultural and religious anti-gay sentiments in countries such as Zimbabwe, Kenya, Uganda, Malawi, and Namibia. In South Africa and Zimbabwe, women perceived to be lesbian are in danger of so-called corrective rape because they are viewed as masculinised women, and violence is justified to correct this. In much of Africa and the Middle East, homosexuality is primarily shaped by codes of silence, secrecy, and taboos that prevent public discussion and exposure because to speak about issues of sexuality is not socially acceptable. Equal taboos, and government-sponsored and church-sponsored hostility, is found in parts of eastern Europe, the Caribbean, and Asia, where the notion of Asian values was deployed by leaders such as Mohammed Mahathir against homosexuals, and specifically against his former protégé, Anwar Ibrahim. Right wing American politicians have also used fear and dislike of homosexuals to galvanise political support.
Examples of denial and persecution exist in many societies with rich homosexual traditions, as is true for China. Premodern legal, moral, and hierarchical obligations required men to fulfil social expectations, such as getting married and having children, and these obligations sought to contain excessive sexuality (eg, masturbation, prostitution, etc). Although homosexuality was always marginal, subordinated to Confucian beliefs in the patriarchal family that continue today, it was also widespread and acknowledged in classic literature. Similar observations could be made about Japan and Korea.
The major discourses of homosexuality in modern China are products of modernity. The medical discourse framing homosexuality as a mental illness stemmed from early translations of western theories of sexuality, notably Havelock Ellis, in Republican China. The Maoist period (1949-76) added the social deviance discourse, in which homosexuality was seen as a type of hooliganism–an umbrella term referring to a wide range of social misbehaviours. The Communist Party treated homosexuality as a social evil that should be handled by “ideological education, administrative disciplinary action, security punishment, and education through labor”. The mental patient and the hooligan have been two dominant images used to define the homosexual, and medical solutions (eg, aversion therapy) and social control have been used to regulate homosexuality.
China has undergone tremendous transformations since 1978, including the reconfiguration of the relation between the market economy and the state. Neoliberalism and the process of individualisation have nurtured a “desiring self”, keen to express him or herself in ways that include asserting sexual identities. More young gay men and lesbians have now come out to their families and seek to live openly homosexual lives. Thus, a new identity termed tongzhi (the catchall term for gay, lesbian, bisexual, and transgendered people) is emerging, a derivative of “global queer identity”-urban, middle-class, knowledgeable, civilised, cosmopolitan, and consumerist–to which many men do not have access.
The 1997 revised Criminal Law deleted hooliganism, the Chinese Psychiatric Association endorsed the removal of homosexuality from the list of mental illness in 2001, and men who have sex with men (MSM) have been included in AIDS policy since 2003. The state has lessened its regulation of private matters in the work unit, the family and popular culture, allowing for the rise of tongzhi communities and venues, mainly in major cities, as well as a male-to-male sex industry and several tongzhi websites. But frequent raids on venues used by homosexuals, the routine criminalisation of male prostitution, and censorship of websites remain. Moreover, “human rights”, “movement”, and “freedom of speech” are hypersensitive terms, which prohibit the development of a tongzhi political movement.
HIV and homophobia
Even though most global cases of HIV are not due to homosexual transmission, the connection between homosexual vulnerability to HIV and stigma has been a continuous issue in responses to the epidemic. Indeed, much of the stigma of AIDS is due to its association with marginalised groups and behaviours (homosexuality, sex work, injecting drug use). This association makes the development of effective programmes to reach those most affected more difficult.
By the late 1980s, the term MSM started being used to describe the reality that many men have sex with each other without any sense of homosexual identity, and this term is now widely used in discussions of HIV and AIDS. In 2011, the UN General Assembly High Level Meeting on AIDS spent much energy in debating whether to specifically mention MSM (along with sex workers and injecting drug users) in their declarations on HIV and AIDS. Opponents, led by Arab and African states and the Vatican, claimed that to name a group was to legitimise it.
Almost everywhere, rates of HIV infection are higher in men who have sex with men than in the rest of the population. This is partly because of inadequate information, denial of resources for prevention services of all sorts, and because heterosexism and homophobia marginalise people and make them less able to adopt preventive techniques, even if they are available. Although difficult to prove conclusively, good evidence shows that greater stigma and criminalisation helps increase vulnerability to infection. The best evidence comes from a comparative study in the Caribbean regions, in which infection rates in homosexual men were significantly higher in countries that criminalised same-sex behaviour (eg, Jamaica and Guyana) than in those that did not (eg, Dominican Republic and Surinam). However, the lowest rate of infection in this study was in Cuba, which until recently, has been deeply hostile to homosexuality. This finding reminds us that many variables can affect vulnerability to HIV, and even where strong correlations exist these might not be causal.
Homophobia both increases vulnerability and reduces access to services. Prevention programmes directed towards homosexual men are often harassed by police, and official silence means that some men mistakenly believe that homosexual intercourse is safe. In much of the former Union of Soviet Socialist Republics, Africa, and the Middle East, where any recognition of rights or citizenship is denied to homosexuals, programming of services to include MSM is difficult to achieve. Homophobia affects HIV in direct ways by driving discussion about MSM and homo sexuality underground, legitimising fear and prejudice, and compromising AIDS service organisations so that they cannot work publicly with LGBT and MSM communities. Ironically, a few African countries (despite legal proscriptions against same-sex conduct), have included MSM as a vulnerable population in their National Strategic Plans (eg, Kenya, Zimbabwe, Angola, and Senegal).
The AIDS epidemic has opened up space for research, discussion, and action around sexuality, which in some countries has brought about remarkable shifts in government policies. Various developed countries have implemented school programmes aimed at decreasing homophobia and winning greater acceptance for sexual and gender diversity. These programmes have been aided in recent years by a substantial emphasis on tackling homophobic prejudice made by some popular television programmes (eg, Glee or Modern Family). Homosexual characters are beginning to emerge in cinema elsewhere, such as in India with the film Dostana. Changes in attitudes within most western countries have been striking, with some observers claiming an important decrease in homophobic attitudes, despite evidence of continuing bullying and marginalisation.
Brazil has shown some of the most substantial developments, indicating the importance of joint action from social movements and government in opposing political homophobia. AIDS came to Brazil at the end of 20 years of military dictatorship (1964-85), and in the early 1990s, the National AIDS Programme pioneered dialogue between LGBT groups and the federal government. The most innovative outcome of this partnership was the conviction that strengthening the gay community and gay organisations needed to be a central focus in mobilising responses to the epidemic. During the 1990s, the National AIDS Program developed a nationwide campaign for HIV prevention in MSM and funded dozens of civil society organisations to develop community-based programmes for HIV prevention for MSM based on human rights principles. It created an Advisory Committee for HIV Prevention among MSM, and invested substantial resources in a capacity-building programme for leaders of the LGBT movement and in the creation of state and local political forums for promoting HIV prevention for MSM, making LGBT human rights a key part of its National AIDS Strategy. The National AIDS programme adopted “the promotion social and political visibility” of the Brazilian LGBT movement as a core strategy for combating the HIV epidemic. By the end of the 1990s, the programme was consistently providing financial support for events such as the Gay Pride Parade in São Paulo and film festivals and artistic exhibitions focusing on sexual diversity, and for a national network of HIV prevention work in the gay community.
The pioneering programmes developed by the Brazilian Ministry of Health in the 1990s have been extended over the course of the past decade53 through the creation of the Brazil without Homophobia programme, endorsed by the National Human Rights programme, which now places substantial stress on combating homophobic prejudice. Intended to fight homophobic violence and discrimination and promote LGBT citizenship, the programme includes 53 actions spread over ten ministries. The government has created the National LGBT Coordination Office, located within the Human Rights Secretariat of the President’s Office, and the National LGBT Council. In 2011, the Supreme Court ruled that same-sex partnership unions between so-called homoaffective couples must be recognised as equal to partnerships between unmarried heterosexual couples.
Some international organisations are beginning to integrate homosexual rights into their agendas. The Joint UN Programme on HIV and AIDS (UNAIDS) and the UNDP launched a joint programme to address the situation for MSM in 2009, and have been supportive of organising efforts, and the UN Educational, Scientific and Cultural Organization (UNESCO) organised a meeting of scholars, government education departments, UN agencies, and civil society organisations to examine homophobic bullying. The attendees endorsed the Rio Statement on Homophobic Bullying and Education for All. The statement calls on “governments to eliminate the unacceptable and devastating prevalence of lesbian, gay, bisexual, transgender and intersex (LGBTI) bullying in educational institutions and settings around the world”. The Global Fund to fight AIDS, Tuberculosis and Malaria launched the Strategy in Relation to Sexual Orientation and Gender Identity in May 2009, and developed a funding pool specifically dedicated to address most-at-risk populations. Since the launch of the Strategy and funding pool, the proportion of Global-Fund-funded proposals that include care and support activities for MSM has risen from 29% to 44%, while funded proposals including activities for MSM have risen from 10% to 53%. Questions remain, however, about the use of these supposedly ear-marked monies. The 2011 General Assembly meeting on AIDS, which mentioned MSM, did not include them in the list of groups targeted for prevention. In the meeting, resources were demanded to pay particular attention to “women and girls, young people, orphans and vulnerable children, migrants and people affected by humanitarian emergencies, prisoners, indigenous people and people with disabilities”. More importantly, the statement allowed any government to invoke its sovereignty to override any particular commitment to recognising rights it feels infringe national sovereignty or national laws.
A few European governments, and recently the USA, have started to include anti-homosexual discrimination as something to be addressed in their overseas assistance programmes. Last year, President Barack Obama and Secretary Hillary Clinton emphasised a commitment to homosexual rights in various pronouncements, and late in 2011, British Prime Minister David Cameron announced that: “Britain is now one of the premier aid givers in the world. We want to see countries that receive our aid adhering to proper human rights, and that includes how people treat gay and lesbian people”. Cameron’s statement followed a Commonwealth Heads of Government meeting, which refused to consider issues to do with decriminalisation of homosexuality, even when this refusal demonstrably made HIV prevention more difficult.
Both new ways of understanding homosexuality and strong reactions to homosexual assertion (often via religious fundamentalism) are being globalised. Too much pressure from western governments and movements that are seen as inspired and funded by foreigners can create a backlash that inflames political homophobia. Undoing heteronormativity and the effects of phobia and discrimination requires an engagement with religious and popular beliefs, as well as with legal frameworks and state actions. An effective response to HIV demands that the combination of pragmatism and respect for diversity that underlines the Brazilian programmes becomes universal. This change requires actions and research that go beyond an emphasis on individual behaviours and biomedical solutions to a broader understanding of social, political, and cultural contexts within which institutions and programmes operate. In periods of economic and political instability any marginalised group becomes increasingly vulnerable, and there will need to be constant vigilance to protect the recognition of sexual diversity as a fundamental basis for good public health efforts to address the spread of HIV.