In Asia’s bleak HIV landscape, Thailand has long stood out as a prevention miracle. So why are Thai men who have sex with men on the verge of an AIDS catastrophe?
Evidently, the Beach doesn’t want to be found. This
“men’s sauna” sits on a dim, unmarked residential street miles from
Silom Road, the center of Bangkok’s roiling sexual economy. For 99 baht
($2.50), I’m given a locker and towel, then granted entrance to a
thoroughly un-Thai cement-and-stucco house. Two giggly friends
monopolize the karaoke machine in the pleather-and-fish-tank
first-floor lounge. Out back is an illuminated pool bordered by palms
and a comically small sauna. The place seems eerily empty—until I
notice men in towels crowding onto a spiral staircase.
On the second floor, Thai men line a dark hallway with
private booths on each side. Most of them stare as I walk past; of
Bangkok’s 21 gay saunas, the Beach is one of a handful catering
exclusively to Thai men (the others serve farang, foreigners,
like me). The Beach lacks a single visible HIV-prevention poster or
other paraphernalia, but peering into the only empty booth, I see an
unused condom still neatly tucked into its ripped package. At the end
of the hall, men cluster at a swinging booth door. They watch as the
two naked bodies inside wrestle passionately and the sound of their sex
reaches a punishing crescendo.
Thailand is Asia’s much-touted HIV success story.
While neighbors India and China face skyrocketing new infections (Burma
and Cambodia have just begun to keep such statistics), Thailand has
radically reduced its transmission rates through more than a decade of
progressive prevention measures: routine testing of female sex workers
and military recruits, a police-enforced “100 percent condom use” rule
in brothels, massive education campaigns that reduced the number of
Thai men who pay for sex. Such measures pushed new infections into
freefall, from peaks of 140,000 in 1991 to 20,000 in 2002. Thailand has
big treatment plans, too: Since 2001, the Government Pharmaceutical
Organization has produced generic HIV meds, providing them to one-fifth
of the 100,000 Thais who have opportunistic infections or CD4 counts
below 200. By the end of the year, the GPO hopes to reach half.
Thailand has earned well-deserved plaudits for its prevention
efforts, and on July 11, the massive XV International AIDS Conference
comes to Bangkok; conference organizers have praised the country’s
“effective interventions in the prevention of HIV.” Forgotten among the
government initiatives, sterling statistics and international praise,
however, are Thai men who have sex with men (MSMs), like those who
frequent the Beach. Forgotten, that is, until a recent groundbreaking
study showed an alarmingly high HIV prevalence among Thai MSMs.
Cofunded by the Thailand Ministry of Public Health and the U.S. Centers
for Disease Control and Prevention, the study found that 17.5 percent
of 22- to 28-year-old MSMs and 20.8 percent of those 29 and older were
HIV positive, startling numbers, especially when compared to Thailand’s
national adult prevalence (1.8 percent) or New York City’s MSM
population (12.1 percent, the highest in the U.S.).
After years of a heterosexual transmission pattern like
Africa’s, Thailand now looks disturbingly familiar to Western
researchers, explains Chris Beyrer, MD, an epidemiologist at Johns
Hopkins University who has worked in Thailand since the early ’90s and
wrote War in the Blood: Sex, Politics and AIDS in Southeast Asia.
“You’ve got a country where HIV predominates among MSMs,
intravenous-drug users and very high-risk heterosexuals,” says Beyrer.
“Just like America.” Dutch epidemiologist Frits van Griensven, PhD, the
MSM study’s lead researcher, puts it more bluntly: “Thailand’s in an
emerging epidemic for MSM. It will get worse before it gets better.”
Along Silom Road, the heart of Bangkok’s Patpong
district, vendors hawk bootleg CDs and teak ashtrays with nude girls
affixed to the rim. But by nightfall, most tourists are looking for a
different kind of souvenir. Any introduction to Thailand’s sexual
culture starts in the sois (alleys) off Silom, where gay and straight
massage parlors, strip clubs and go-go shows are stacked on top of one
another. Though prostitution is technically illegal in Thailand, Silom
lures customers with masturbation races, vaginal stagecraft and “fuck
shows” that serve as the gateway to money-for-sex encounters.
Despite Bangkok’s international reputation for straight- and
gay-sex tourism, discretion dominates Thai culture. Open references to
homosexuality, sex work and “minor wives” (mistresses) would mean
“losing face,” writes Beyrer in War in the Blood, “and to force
a Thai to lose face is to make a fast and enduring enemy.” So MSMs in
Bangkok cruise Silom’s sois and the city’s Lumpini Park or visit one of
its gay bathhouses, although such visits carry risks. Gay bathhouses,
as well as gay clubs, theaters and brothels, have been raided by police
as part of a recent “social order” campaign—a ruthless, largely
antidrug initiative that has resulted in the deaths of more than 2,000
people supposedly involved in drug trafficking. (The Beach was raided
the week before I visited.) Police often force suspects to give urine
samples and in some cases take them to the police station where they
are photographed. “A night like that could close you down for a year,”
said one bathhouse owner, who requested anonymity for fear of further
harassment. When asked whether his family knew of his work and
orientation, he answered, “Are you kidding? My father would spin in his
grave.”
Since HIV in Thailand has been seen as a heterosexual
epidemic, the disease never forced gay life—or unsafe gay
sex—aboveground as it did in the U.S. and Europe. Thai MSMs have few
out public figures to admire, limited political presence and a sparse
gay press. “We have no ‘gay’ identity as you do in the West,” says
Rapeepun “Ohm” Jommaroeng, a researcher for the Red Cross and secretary
of Rainbow Sky, Thailand’s most visible gay, lesbian, bisexual and
transgender group. “We have one word, katoey—a man who dresses
like a woman and wants to be a woman.” While katoey—akin to
transsexuals—are a recognized part of Thai life, there is no word for
“gay” in Thai.
The collective silence around MSMs in general has meant that
at-risk men neither get the prevention info they need to stay negative
nor the HIV tests they need to survive. In the spring of 2003, Van
Griensven and outreach workers intercepted 1,121 men at the Beach and
16 other gay venues across Bangkok to calculate, he says, “a baseline”
of HIV’s prevalence among Thai MSMs. The team interviewed subjects
about sex behavior, administering an oral HIV test the results of which
could be given anonymously. “Not that many followed up” to find out
their status, says Van Griensven. “Until recently, there hasn’t been
any treatment, so there hasn’t really been any reward for knowing.
Except a lot of shame.”
Van Griensven discovered sexual patterns among Thai MSMs
reminiscent of black and Latino men in the U.S. who keep their
homosexuality “on the down low” in part because of homophobia in their
communities: 44 percent of study participants reported having had
unsafe sex with other men in the preceding six months, and 36 percent
said they’d had sexual intercourse with a woman. Twenty-two percent of
the latter group said they’d had sex with a woman in the past six
months.
Concerned, Van Griensven met with gay-bar and -bathhouse owners
last fall to discuss his study’s findings before he was ready to
publish them. An undercover reporter for a Thai newspaper leaked the
results, provoking a minor controversy. The government dismissed the
study as U.S.-funded muckraking; the Thai newspaper The Nation
quoted a health official as saying Van Griensven’s sample was too
“specific” to represent all Thai gays. But fellow epidemiologists
rallied. “Van Griensven’s findings don’t surprise me,” says Beyrer. In
terms of prevention and research, “virtually nothing’s being done,”
says Hakan Bjorkman, the deputy resident representative of the United
Nations Development Programme in Thailand, who calls MSMs in Thailand
“the blindspot.” For his part, Van Griensven argues that “the Thai
government got complacent. They thought HIV was under control. Well,
it’s not.”
With his boy-band insouciance and coiffed flat top, Tom
Apasit, 35, looks about 17. That was his age back in 1987, when he came
to Bangkok from rural, northern Thailand to become a singer. The amulet
he wears around his neck for luck testifies to years spent coping with
HIV. “In 1989, my boyfriend told me he was positive and died five
months later,” Apasit says. “I got infected from him. And from then on,
I hid deep within myself.”
Apasit told nobody, avoiding all medical care. There was no
point. “The information we had was that if you got HIV, you’re dead,”
he says. Apasit didn’t visit a hospital until 1997, when a rash of dry
skin erupted on his arm. “I told myself that if I survived on my own
for eight years—the point at which I should have died—then I would get
help,” he says.
A part-time makeup artist, Apasit volunteers at the Wednesday
Friend’s Club, Bangkok’s leading support group for HIVers, where most
clients are MSMs. The Club operates out of two stacked shipping
containers behind Bangkok’s HIV-NAT Center, a research collaboration
among the Netherlands, Australia and Thailand that runs the city’s
pioneer anonymous-testing clinic. Inside the humble digs, the club’s
men (and the occasional woman and child) do peer counseling, watch
television and swap stories about treatment. Many are “too healthy” to
qualify for generics from the government’s new treatment initiative,
which requires a CD4 count below 200 or an opportunistic infection.
Apasit’s count is 400.
Instead, Apasit and other Thais scramble to enroll in
“projects” (drug trials), which give free meds, albeit irregularly.
Apasit has been on and off HAART therapy for three years. He’s taking
AZT, 3TC and saquinavir (boosted with ritonavir), but eight months ago,
he was taking three different drugs through a trial. “I’m dependent on
the projects to get the medicine,” he says. “I’ll start one, and
they’ll ask me to quit taking drugs for a while [to clear his system],
so I do, and then I start up again.” With every combo change, Apasit
risks drug resistance and a dangerous narrowing of his already limited
treatment options.
Other positive Thais run a similar risk when they buy drugs
from hospitals and “take them just three times a week because that’s
all they can afford,” says Ood, a tall and gracious 39-year-old man who
was diagnosed 12 years ago. A month’s treatment costs 15,000 baht, or
$375; Bangkok minimum wage is 170 baht a day, or $4.25. Ood used to be
in a treatment no-man’s-land—his CD4s were too high for government
help, but too low for some drug trials. “I used to cry every day
because there was no hope for us,” he says.
Ood eventually qualified for a trial prescribing a HAART cocktail
and self-injections of the experimental immune booster IL-2, which
lifted his count to 1,364. But he suffered dry skin, “fat face” and a
relentless fever. Six months ago, the trial stopped. He now gets the
HAART regimen for free (one of the trial’s perks), and his CD4 count
has fallen to 250. “I’ll be on it for the rest of my life,” he says.
When Chris Beyrer began interviewing Thai soldiers about
their sexuality, only 3.7 percent acknowledged that they had had sex
with men—until a Thai researcher suggested his questions were wrong.
“We were asking, ‘Have you ever had sex with another man?’” he writes
in War in the Blood. “Why should that be confusing? Because
‘man’ does not include ‘katoey.’” Thai culture has three genders in its
origin myth—man, woman and katoey. When Beyrer added katoey, the
acknowledgment rate more than doubled. Some recruits had sex only with
katoey because they will perform oral and anal sex, which Thai women
consider off-limits.
The fluidity of Thai male sexuality poses significant challenges
to HIV researchers like Beyrer and Van Griensven. When I meet cherubic
Chaiya “Kai” Sunanthawilat, he’s wearing a Red Cross ID card around his
neck that shows him dressed differently—as a woman with burgundy hair
and ruby lipstick. He’s known he was a katoey for as long as he can
remember and once considered a sex change. “But I’m afraid of it,” Kai
says. “I’m not sure how my positive status would affect the healing of
my wounds.” Diagnosed in 1998, he has been on various drugs for the
past four years provided by Doctors Without Borders, but struggles with
side effects. His CD4 count is 119, not his lowest (11), but hardly his
best (300). “Before I knew I was positive, I dressed up like a woman
all the time,” he says, grasping his ID. “Now, I don’t always feel like
it.”
The sexual identity of Thailand’s male prostitutes—many of whom
are poor men enticed by the lure of good money—also defies easy
classification. A recent U.N. report found that 75 percent of male sex
workers said they were heterosexual, even if they worked predominantly
with men. (Nearly one-third were or had been married.) Consider Jupiter
2002, a popular go-go club in Bangkok’s Silom area. Farm-boy types
dance in Lycra shorts with a number pinned to the hip. To meet one, you
pay for his drink (200 baht, or $5). To take him elsewhere, you pay the
bar 300 baht ($7.50), then negotiate with your intended.
I talk to “Pet” because he looks nervous and bewildered. He’s
shy, 19 and on his third day on the job—his third day in Bangkok since
leaving the rural Northeast. He’s never had sex with a man and isn’t
sure what he’s gotten into. Pet may not be gay, but he’s definitely at
risk.
Men like Kai and Pet complicate MSM treatment and prevention, and
provincial doctors, who care for 80 percent of the population, are
underinformed and overworked. “In a hospital I know, there’s one doctor
with 20 beds who sees 200 patients a day,” says Paul Cawthorne, a nurse
who works for Doctors Without Borders in Thailand. “So if somebody
starts [HIV] treatment, the doctor doesn’t know anything about HIV,
plus he has about two minutes to deal with him.” There’s little chance
such a doctor could take the time to determine where his MSM patient
fits in a spectrum of sexual risk—even if he knew what to look for.
“When doctors hear ‘MSM,’” says Ohm, “most service providers assume
that’s a katoey.”
The impending International AIDS conference will shine
a spotlight on HIV in Thailand, and even Thai MSMs will get some
attention. An “Empowering Visit” will give participants a chance to
meet Thai MSMs, and Van Griensven, who is organizing a satellite
meeting dedicated to MSMs, will present his MSM-study findings.
Nonetheless, there are signs that the political climate in Thailand has
cooled to AIDS. The prime minister is traditionally the head of the
country’s AIDS committee, but the current PM, Thaksin Shinawatra, sends
a deputy instead. Shinawatra’s “social order” campaign has driven
IV-drug users underground, and prevention efforts, despite all the
kudos, have been more than halved: In 1996, the Thai government
invested more than $85 million—$1.30 per person—in HIV programs,
according to Swarap Sarkar of the Joint United Nations Programme on
AIDS in Thailand. That’s fallen to 60 cents. And the “explicit appeals
to sex-worker visitors in the mass media,” says Sarkar, “have gone
away.”
It’s unclear how destructive such a climate will be for Thai
MSMs. A gay-friendly HIV clinic is slated to open this summer near
Silom Road. In 2005, Van Griensven hopes to conduct a follow-up study
on Thai MSM infection rates. And a modest network of MSM organizations
seems to be taking root. Three-year-old Rainbow Sky already canvasses
Bangkok parks, giving condoms to MSMs who wouldn’t go near the Beach.
“Since we didn’t have an office, Rainbow Sky used to meet at
McDonald’s, and it shocked people,” says Ohm. “Twenty gay men talking
about HIV and condoms? People thought, ‘Did they just have an orgy or
something?’” The group now has a home near the HIV-NAT clinic.
Rainbow Sky’s challenges are basic. For example, since
water-based lubricant is expensive in Thailand, men smart enough to use
condoms choose Vaseline and Nivea hand cream, says Beyrer, which
destroy the integrity of the condom. I asked Thawatchai “Guide” Pachun,
32, who runs the group’s condom-distribution program, why he himself
has never been tested for HIV. “I don’t know,” he answered. “There are
good reasons to get tested—you can get early treatment. But there are
bad reasons, too. Knowing could affect your disposition.” If an openly
gay man like Guide, who is deeply involved in HIV prevention, fears
getting tested, educating and treating Thailand’s MSMs seems a
formidable hurdle. My last night in Thailand, I joined my translator,
Willi, and his boyfriend for dinner. When the subject of HIV testing
came up, his boyfriend shook his head. He has never been tested. “I
don’t see the need to,” he said. “It’s your issue, not mine.”
Velvet Gloves
Thailand’s katoey pioneer was once a beautiful boxer
Thai MSMs may have few role models, but at least one katoey
(a Thai man who dresses as and wants to be a woman) has struck a blow
for the LGBT cause. Nong Toom, a 23-year-old actress and model, used to
be a champion kickboxer—and a man. Like many young Thais, she started
kickboxing, at 12, to earn money for her family. “And,” says the shy,
soft-spoken Toom, “to get the strength so no one would beat me up.”
Muay Thai, as Thai kickboxing is known, is a macho, often
bloody sport, but as a teen, Toom never hid her determination to have
sex-reassignment surgery, which she did in 1999. Even before her
transition, Toom’s story won the hearts of Thais nationwide and landed
her in ads and on soap operas. This year, The Beautiful Boxer,
a movie based on her life—“she fights like a man, so she can become a
woman,” the tagline promises—was released internationally (for more
info, go to www.beautifulboxer.com).
“I’m worried about HIV,” says Toom, who says that despite her star
status, “katoey are not accepted by everyone” and that “it’s common for
families not to accept a daughter or son who is lesbian or gay.
Historically, it hasn’t been OK, and it’s not getting better.” She has
fought back by supporting gay organizations, receiving a 2003 Utopia
Award for contributions to the Asian gay community and speaking at
Bangkok’s Gay Festival. If they’re lucky, young Thai MSMs will find
their way to Toom. “I teach kids kickboxing,” she says, “and then I
become a kid again.”
