Homophobia, stigma and HIV in Jamaican prisons

Abstract

Success in addressing HIV and AIDS among men who have sex with men, a key population in the global epidemic, is impeded by homophobia. Homophobia as a barrier to HIV prevention and AIDS treatment is a particularly acute problem in the prison setting. In this qualitative study, we explore HIV and AIDS, stigma, and homosexuality in the largest all male prison in Jamaica by conducting iterative in-depth interviews with 25 inmates. Participant narratives unveil a purposeful manipulation of beliefs related to homosexuality that impedes an effective response to HIV and AIDS both in prison and wider society. Findings indicate that homophobia is both a social construction and a tangible tool used to leverage power and a sense of solidarity in a larger political and economic landscape. This use of homophobia may not be unique to Jamaica, and is an important issue to address in other low and middle income post-colonialist societies.

Introduction

On August 21st, 1997 the headline of Jamaica’s most prominent newspaper described a “Brawl at General Penitentiary” resulting from statements by the Commissioner of Corrections that condoms be distributed to inmates and warders to prevent HIV transmission (Gleaner 1997). This statement incensed inmates and warders who feared they would be condemned as homosexuals by the wider community. It was also used as a strategic political tool against the Commissioner, considered by some as too liberal in his rehabilitation programs. The result was a strike by prison warders and rioting in the two largest correctional institutions during which an estimated 16 inmates were killed (Ministry of National Security (MNS) 1998). The Commissioner resigned soon after and a separate section was created to house inmates labelled as homosexual. HIV and its association with male homosexuality became the scapegoat for the prison riot, and a culture of fear paralysed HIV prevention efforts in the correctional system.

More than a decade later, the XVII International AIDS Conference called for a renewed focus on men who have sex with men (MSM) in low and middle-income countries like Jamaica for both epidemiological and human rights reasons (Flynn and Kort 2009). Until recently, discourse and action related to HIV stigma and discrimination has followed an illness-focused framework (but see, Maluwa, Aggleton, and Parker 2002; Parker and Aggleton 2003; Norman, Carr, and Jimenez 2005) with stigma related to same sex activities seen as contributing to the symbolic meaning attached to the disease (Herek 1999). In countries with primarily heterosexual transmission, efforts to reduce HIV-related stigma have focused on “normalizing” the epidemic by distancing the perception of persons infected with HIV from behaviours and members of socially marginalised groups. Few interventions focus principally on reducing stigma related to transmission behaviours and vulnerable groups at the root of the symbolic element of HIV-related stigma, with the exception of several programmes to reduce stigma related to sex work (Herek 1999; Berkman et al. 2005).

While it is important to foster a realistic perception of risk among the wider population in a generalised epidemic, it is also true that in the Caribbean and globally MSM as a group are disproportionately affected by infection and overlap with the heterosexual population (Cáceres 2002; Baral et al. 2007; amFAR 2008). In Jamaica, the national HIV prevalence is 1.6% while the prevalence estimated among MSM is between 25-31%, and sexual ‘bridging’ is suspected between MSM and heterosexual networks (Figueroa, Duncan et al. 2008a). It is clear that achieving success in disease control efforts at the national level requires the ability to effectively reach and reduce transmission of HIV among the MSM population in Jamaica and in countries with similar transmission patterns, although there is a lack of consensus and political will regarding how this should be done.

Based on this understanding, and newly armed with funding for antiretroviral treatment, the Jamaican Ministry of Health strengthened their relationship with the Department of Corrections (DCS) in 2005. A cautious and clinical approach was taken that focused on testing and treatment, and purposely avoided the issue of intra-prison transmission. The programme was couched as part of a larger initiative in Jamaica to increase HIV testing. An HIV prevalence of 3.3% was determined for all participating incarcerated men, but prevalence was significantly higher among MSM, estimated at 25% and resembling rates for this population outside prison (Figueroa et al 2008a Andrinopoulos et al. 2010). During the programme, the mention of the need for condoms in prison in a public forum resulted in riot threats and programme closure for a three week period. Resumption was possible only with assurances from the Commissioner of Corrections that condoms would not be made available, and that the focus was on clinical services for all inmates. This distancing technique allowed the programme to continue and provide needed medical support for inmates living with HIV, although the ability to effectively reduce transmission was greatly hampered. The implication of the lack of prevention reaches beyond prison walls, as approximately half of the inmate population is released to the community each year (MNS 2006). Moreover, inmates labelled as ‘homosexual’ continue to face stigma and discrimination and suffer a disproportionate burden of infection without access to effective methods of HIV prevention.

Unfortunately, the challenges faced in Jamaica are present in many correctional systems globally. Few correctional systems in low and middle income countries provide even the basic HIV testing and treatment services now available in Jamaica (Dolan, Kite and Black 2007), and condom distribution in prisons is a contested issue world-wide (Júrgens 2005; Okie 2007). In the USA, the country with the highest incarceration rate in the world, condoms are available in less than 1% of prisons and jails (McLemore 2008). The tension surrounding this issue is less related to beliefs about sexual restrictions during incarceration (as few arguments have been presented about conjugal visits), and more a recognition that condom distribution in same sex facilities would raise the issue of the legality of same sex sexual relations in the wider community. In this respect prisons are unique social institutions with the capacity to influence larger structural level change.

Prior to the HIV testing programme, qualitative in-depth interviews were conducted with inmates to identify barriers to programme implementation. Given the sensitive nature of homosexuality this issue was not initially intended for explicit exploration. However, the pervasive influence of stigma related to homosexuality in reported daily experiences and interactions in prison, and the open-ended nature of the research methods, led to the natural evolution of discussions centred on this topic. The present manuscript describes the findings from this qualitative study related to stigma, homophobia and HIV in the Jamaican prison context. The narratives presented represent these constructs in a particular cultural context, however, the relationship among these social forces and HIV is transferable to other settings and may contributes to the discourse on addressing HIV in prisons and among MSM globally.

Methods

In-depth interviews were conducted in the largest correctional centre in Jamaica. This prison is an all-male adult maximum security facility housing approximately 1,600 inmates, and representing 43% of the total inmate population. The majority of inmates in this institution are convicted felons serving time or life sentences, with a smaller portion awaiting trial and sentencing. Twenty-five (25) inmates were interviewed on two separate occasions, within a two week period. Participants were selected in a strategic manner to gain insight from a variety of inmate perspectives. Recruitment began with the two head inmate medical orderlies, who by the nature of their position were trusted confidants of the majority of the inmate population. We explained the purpose of the study to these participants, and utilised their expertise in selecting additional inmate participants. Recruitment continued until we reached a point of redundancy and saliency in the themes and concepts (Bernard 2006).

Participants were interviewed in private consultation rooms in the medical unit of the prison. Oral consent was obtained prior to each interview. Both interviews were conducted by the same interviewer trained in qualitative research methods to build rapport. A donation of $300 Jamaican dollars (US$5.00) for each interview was made to the prison to purchase sports equipments and educational resources for inmates. The study was approved by the Institutional Review Board of the Johns Hopkins School of Medicine and the Ministry of Health Committee on Medical and Ethical Affairs in Jamaica.

Interviews were semi-structured and included open-ended questions. During the first interview, participants were asked to describe a typical day, their experience being incarcerated, different social groups in the institution, and how these groups interact. Participants were also asked to discuss their knowledge of HIV and AIDS, their experience with HIV testing, and personal experience with persons infected with HIV. During the second interview, participants were asked to describe potential challenges to implementation of an HIV testing programme, HIV-related stigma, and how being infected with HIV might influence their life. After the second interview, a 15-minute educational session on HIV/AIDS was conducted. Because of their sensitivity, questions related specifically to the 1997 prison riots and to homosexuality were not included as items on the original guides. However, all participants discussed homosexuality when asked to describe the different sections of the institution, being that the prison began a policy of separating persons labelled as homosexuals on a specific section after the 1997 prison riot. Most participants also discussed homosexuality when asked to describe potential barriers to implementation of an HIV testing programme. Several participants also discussed the 1997 prison riot during this part of the interview. When raised by participants, these topics were probed. Interviews were conducted using Standard English, although some participants responded in Jamaican Patois. Interviews were audio recorded, translated, and transcribed by a transcriptionist familiar with both languages.

Interviews were analysed through the process of content analysis. First, each interview was read through in its entirety and important concepts and themes were identified. Transcript texts were broken down into the equivalent of nominal variables by identifying segments representing an important concept and labelling this text with a code. These codes were used to extract segments from complete interviews, facilitating the review and synthesis of coded concepts in the form of short memos to converge on larger themes in relation to the research goals (Hseih and Shannon 2005). The ethnographic software, ATLAS.ti version 4.2 (© Scientific Software Development, Berlin) assisted in this process. Example codes include “sources of HIV stigma,” “perceptions of homosexuality,” and “HIV and homosexual double stigma.” In addition to formal interviews, the first author of this study worked in the correctional institution daily for 12 months, observing the functioning of various programmes, the medical unit, and assisting with the peer education and HIV counselling and testing. This author also engaged in numerous meetings with the head office of the DCS, representatives from local HIV non-governmental organisations, and the Ministry of Health.

Study Sample Characteristics

A purposive sample of inmates including medical orderlies (n=2), school teachers (n=2), work orderlies (n=5), and 16 additional inmates from each section of the institution, including two from the “special” section, participated in the study. The median age of participants was 29 years (range, 20-55 years). The median time served was 4 years and 3 months (range, 7 months – 20 years). Seven participants (28%) were serving life sentences. Of the 18 participants serving time sentences, the median remaining sentence was 3 years and 6 months (range, 2 months -30 years). Seven (7) participants were recidivist. The median number of lifetime incarcerations for recidivists was 2 (range, 2-3 incarcerations). The highest level of education attained was primary school for two participants (8%), some secondary or high school for 11 participants (44%), completed secondary school for 9 participants (36%), and tertiary training for three participants (12%). Two participants were homeless prior to incarceration. The median annual income prior to incarceration (for both legal and illegal activities) was $84,000 Jamaican dollars. This was slightly higher than the poverty line for an individual (JA $58,508), but significantly lower than the poverty line for a family of 5 (JA $221,130) in 2004 (National Poverty Eradication Programme 2004). Seventy-two percent (72%) of participants had children. The median number of children was 1 (range, 0-7). Prior to the study and programme, HIV testing was available through physician referral or through a two week medical mission of overseas doctors the previous year. Fourteen participants (56%) had previously tested for HIV, and nine of those tested (64%) did so during their current incarceration. Four persons who tested never received their results, and two were HIV-positive.

Results

HIV-related Stigma

All participants reported stigma as an important issue influencing the lives of people they knew personally who were living with HIV. The source of the stigma in these stories was framed as instrumental stigma (Herek 1999), meaning that the negative association and behaviour was due to fear of contracting the disease and subsequent physical consequences. Examples of stigma included the transfer of an inmate medical orderly because he was HIV-positive, and denial of service to HIV-positive inmates who shared their status at the barbershop. Most suggested that people would interact with an HIV-positive inmate, but in a limited way. The two participants living with HIV described a variety of responses, with examples of some persons showing great empathy and support while others shunned or “scorned” them. The most extreme example of this scorn was described by an HIV-positive inmate, who reported an ongoing conflict with the warders on his section, and that warders used his HIV status to harass him. This influenced his ability to cope with HIV and led to his contemplation of suicide. He described this as follows:

“It reached a point that I said that if this was the way that they are dealing with it [HIV status], I am going to finish my life right there…Because people knew that I was sick, they abused me. There is a grill in the cell and he [a warder] would come to it and say, ‘you will soon be dead.’”

-Norris¹ 26 years old, 2 years incarcerated

Many also suggested that fear of HIV-related stigma would weigh heavily on an inmate’s decision to test for HIV. Participants repeatedly expressed that knowing they had HIV would make them “fret” or worry which, compounded with social isolation, would hasten the physical progression of HIV. HIV was described as an additional burden that would be difficult to bear during the already stressful experience of incarceration. One inmate noted this as follows:

“Knowing only makes you die faster. It sounds silly… I am not a doctor so I am not sure if I have HIV. But I am a prisoner and I am sure that this HIV thing on my brain won’t work…I have bigger things on my mind.”

Tyson, 28 years old, 8 years incarcerated

Few participants were aware of the availability of HIV medication, and those that were felt they would have limited access to treatment during incarceration and would not be able to afford it on their own. Given involvement in criminal activity and the daily dangers faced during incarceration, the threat of death due to infection was less feared than the perceived physical and social deterioration suffered by people with the infection. As one inmate stated:

“Everybody has to die, but with AIDS I have a fear of suffering. If I had my choice to die, I would want a gunshot to the head - a quick death. But to see your body deteriorating and having all those rashes would be depressing. Give me a sudden death anytime. I am used to violence. I am not used to AIDS.”

-Harrison, 33 years old, 6 years incarcerated

HIV-related and homosexual double stigma

Symbolic stigma, defined as a stigma due to beliefs attached to behaviours that transmit the disease (Herek 1999), was not apparent in reflections of acquaintances with HIV nor in participants’ description of how others would react to them personally if they were infected. However, the link between homosexual stigma and HIV was a central theme in discussions of what people might think of other inmates who test for or are infected with HIV. This dissonance was based on participants’ self proclaimed reputation as overtly masculine heterosexual men, who would not be victim to the same perceptions related to homosexuality and HIV. To some degree this may also have been an effort to display to interviewers that they were in no way homosexual, nor could ever be perceived as such, as continuously demonstrating heterosexuality was key to survival in the institution. However, participants did suggest that in addition to fear of contagion as a motive for stigma, perceptions of homosexuality were also important. As one inmate stated:

“[stigma] is because they are afraid of catching it. They are afraid of the disease itself not, the person. How judgment comes in is with the homos. We in our Jamaican culture, we don’t allow ourselves to deal with a homosexual.”

Carlton, 29 years old, 1 year incarcerated

Some participants also suggested that an inmate who tests for or is HIV-positive might be perceived as having had sex with another man. As one participant stated:

“When a man has HIV, many people believe that he is a homosexual, and they don’t want to be a part of it. It is even worse in [this prison]. As long as you are a homosexual inside this institution, you are nobody and you don’t really exist.”

-Adrian, 43 years old, 18 years incarcerated

Not all participants were of the view that HIV infection would automatically be linked to participation in homosexual behaviour. Many stated that people in Jamaica are aware of the different modes of transmission resulting from widespread education. Participants understood that multiple partnerships increased risk, and that many inmates had multiple girlfriends prior to detention. Participants suggested that the perception of HIV as a homosexual disease had changed over time with education and as more people have come to know someone living with the infection. As one HIV-positive participant stated:

“When I first learned about HIV, people were not too educated on it. They would say that it comes from homosexuality. …Today, people find out that he, she and the old lady has it…You have ‘shottas’ [bad men] gunmen and girls men, who catch it. So, the public has more understanding of it and it is not as discriminatory as it once was.”

-Norris, 26 years old, 2 years incarcerated

Homophobia and “branding”

While there was variation in participants’ reports of the overlap of HIV-related and homosexual stigma, there was a clear consensus among participants, including two who reported sex with men, that homosexuality was an “abominable” act deserving of social rejection. When asked about different types of inmates and how they interact, most participants immediately described a division based on sexual behaviour, with “big men” identified as respectable heterosexual men contrasted with “boys” who were homosexuals relegated to the caste of inmates segregated on the “homosexual” or “special” section. Upon entrance to the institution, participants quickly learned the significance of this division, and would restrict their social interactions accordingly so as not to be “branded” as a homosexual. Aligning with other big men in the institution promoted a sense of safety and solidarity. Being labelled as a homosexual was based on the inmates’ criminal charge, or by their behaviour and interaction with labelled homosexuals. Participant’s discussion of homosexuality focused on the rules of interaction that should be followed lest one be labelled as homosexual, rather than their beliefs about homosexuality. Several participants described these rules as follows:

If a man comes in and is charged with sexually abusing a boy or for raping a man, they will go there [special]. Or, you may have a man who has groundsed out [lowered] himself in the prison and he will have to be put there too. If you just came in the prison and made a wrong walk over by ‘special’ don’t think that you can come back and mix with the normal men. They will beat you up.

-Jonas, 43 years old, 20 years incarcerated

When we have our football competition and those things, they [homosexuals] are not involved in it. People won’t even shuffle dominoes with them. Those inmates play their own games.

-William, 33 years old, 2 years 3 months incarcerated

The only work available for inmates on “special” is to remove refuse or clean toilets. This type of work was described as another way inmates on the special section lower themselves and become “groundsed” or socially untouchable. Interaction with an inmate from “special” means risking contamination with the label of homosexual, and becoming “groundsed” oneself.

Many participants reported that not all inmates located on the special section were homosexual. Rather, there was an acknowledgment that a number of inmates had false allegations of homosexuality put on them by inmates with whom they had a conflict. These ranged from minor arguments to more significant “wars” carried over from the outside community. One participant described how conflicts led to false allegations as follows:

For example, if someone asks you for money but you don’t give him, if he later sees you giving money to another inmate who is a friend, he will say that you are a chi-chi man [homosexual]. So he is putting a false allegation on you. A lot of corrupt people are in here. …they will tell lies on you.

-Horace, 22 years old, 2 years 4 months incarcerated

Many participants reported that inmates sometimes ended up on “special” for protection from “big men” in prison who threatened to kill them. They were placed there by a warder or moved there themselves, knowing that it was the only safe place in the prison. Once located on “special”, however, inmates were branded as homosexuals for life both in the prison and their communities on the outside. Fear of being labelled a homosexual, and the chronic nature of this social mark, was emphasised more than fear of HIV and related stigma. One HIV-infected participant not located on “special” lamented the plight of a friend from the outside labelled as homosexual:

When I took sick at the police station because of HIV, there was a man in there that I knew from the road. I didn’t know that he was gay. We were friends in the same way in the outside world and in jail. …He is in prison now and is over by the ‘special’ section. Now, I can’t socialise with him like I did when we were on the road.

-Norris, 26 years old, 2 years incarcerated

Another participant located on “special” described how being labelled as a homosexual would influence him, even after his release:

I tell myself that when I go back on the road, I will have two guns. I am in prison now and when I go out in the wider society, I will see all my friends. They won’t trust me because I came to prison and ‘bow’. So they will want to kill me. I am published [known homosexual]. So they will say, ‘— can’t come back on the road and spar [socialise] with me because you went to prison and bow’.”

-Malcolm, 30 years old, 7 years incarcerated

Masturbation and oral sex

In addition to “buggery” or anal sex as an offence that would condemn an inmate to the realm of homosexuals, other forms of sexual expression including masturbation and oral sex were also noted as abhorrent behaviours by several participants. These behaviours were described as “nasty stuff” outside of a normal sexual repertoire for a heterosexual man. One participant described the consequences of oral sex as follows:

It is not only for homosexual behaviour that you are sent over ‘special’ for. They will run you over there if you mention oral sex as well. It is because of the stigma attached to things. If a man is new and comes on a section and he mentions that he has oral sex, the men will run him over to Boystown. If he does not go there, his life will be at risk.

-Rayan, 32 years old, 7 years incarcerated

Sentiments towards masturbation and oral sex mirror the stigma associated with these behaviours in wider Jamaican sexual culture (LaFont 2001). However, the stigma against masturbation and how inmates negotiate the meaning attached to this behaviour is particularly interesting given the lack of access to women and that sexual virility in Jamaica is a defining characteristic of masculinity (Chevannes 2001; Figueroa 2009). Coping with sexual repression was a difficult task for inmates. The participant identified as William, 33 years old, described “duppy” stories about female ghosts in the institution used to explain away sexual dreams experienced while confined in cells crowded by other men. Indulgence in masturbation was strictly prohibited. Other inmates located in the cell would either physically harm the inmate or bring the allegations to warders as a means of self preservation from also being labelled as a homosexual. One participant described an incident where an inmate was accused of masturbation as follows:

The fight was because one man said that the other man was masturbating. The other guy denied and the way that he stood up to it left doubt in people’s minds as to whether he was doing it…You have some people who are mature enough to say that they have wet dreams and I masturbate, but the majority of the population frowns at it…Outside it would be your business. You would just get a girl outside. In [prison], it is different. If you do that you are ‘groundz’ or the inmates feel that you are gay.

-Harrison, 33 years old, 6 years incarcerated

Another participant described the penalty for masturbation and its association with homosexuality as follows:

It can’t go on at the straight inmate’s section. For example, if three ‘big men’ are located together and one of them is caught ‘jerking off’ [masturbating] in the cell, before it is time for fly up, that inmate would be dead. They will stab him and kick him down. Masturbation is not allowed on the straight man’s section.

-Norris, 26 years old, 2 years incarcerated

Riots and those at risk

The few participants incarcerated during the 1997 prison riots, and several who heard about these events reflected on the use of culturally sanctioned norms against homosexuality as a tool to leverage power within the correctional administration and by inmates in the institution. These participants described warders’ dislike of the Commissioner, and disagreements between the Commissioner and warder labour unions that preceded comments about condom distribution. One participant described this underlying motive as follows:

The inmates were for Mr. Prescod [the Commissioner] and the officers [warders] thought that Mr. Prescod was against them… It was the officers who did not like him…It was like politics. If he did something that you did not like, you would be against him. The warders went on strike and the inmates blew things out of proportion and it got violent.

-Adrian, 43 years old, 18 years incarcerated

Other participants described the warders’ strike and subsequent rioting in the institution as obligatory to prevent the shame of association with homosexuality, regardless of feelings towards the Commissioner. One participant stated this as follows:

Because the distribution of condoms was a well publicised act, many warders and inmates felt that he was shaming and disgracing them. They felt that he wanted to bring them down and even bring shame to their families and friends, and this prompted them to be violent.

-Tyson, 28 years old, 8 years incarcerated

Once the warders went on strike, inmates in the institution were able to attack enemies. Some suggested that inmate orderlies were targeted and killed because of their direct working relationship with warders. Others suggested that apart from being orderlies, these inmates were homosexual, which made their persecution acceptable during the riots. All participants who discussed the riot suggested that inmates who were not homosexual were killed during the event, although the rationale for the violence was sanctioned as a reaction against homosexual shaming. The use of homosexual stigma to enable an “us” versus “them” division and justify acts of violence or rebellion in this context and others was described by one participant in the following way:

When you want to burn a fire we say homosexuality because it is an abominable act. Devon, 26 years old, 5 years incarcerated

In response to the riot, the correctional administration began the separation of inmates perceived to be homosexual. Several participants described this separation as a “scapegoat” that would hide acts of homosexuality in the wider population. Current segregation was explained as a necessary condition to maintain safety in the institution, both by administrative personnel and by inmates. All participants, including those residing on “special” endorsed the separation of homosexual inmates. No participants, including the two on “special” thought that condoms should be distributed, and cited the violence that resulted from the riot as a reason against this measure. At the same time participants acknowledged sexual activity of others, and the one HIV-positive participant located on “special” reported ongoing unprotected sex. While recognizing that availability of condoms would aid in reducing HIV transmission, several participants stated that pushing the issue would put the lives of inmates on “special” at risk. As one participant stated:

If a riot occurs in the prison, they will be the first set of people who will die. [They would be killed] because they are gay and people say that they do nasty stuff.

–Colin, 25 years old, 2 years 9 months incarcerated

Discussion

The findings of this investigation provide a descriptive analysis of the relationship between stigma, homosexuality and HIV useful for understanding local challenges and potential responses, and in contextualizing the global issue of HIV in prisons and among MSM. It is evident that HIV-related stigma, as a consequence of fear of contagion, and as a result of beliefs about transmission behaviours, continues to negatively affect people living with HIV. A lack of knowledge about treatment was also expressed and may decrease inmates’ perception of ability to cope with illness. At the same time, it is clear from this study and other national surveys that knowledge about HIV has increased over time (Hope Enterprises 2004; Figueroa et al. 2005), and according to participants, led to a decrease in HIV-related stigma.

Reduction of stigma and discrimination has been a priority area for the National AIDS Programme with recent mass social marketing campaigns promoting greater acceptance of people living with HIV, including radio announcements accessible to persons in detention (National AIDS Programme 2010). These efforts to reduce HIV-related stigma and discrimination should continue and be expanded. Case management and social support of HIV-infected inmates is also necessary to mediate instances of discrimination such as the ones described by participants. With increased knowledge, the double stigma of HIV and homosexuality also seems to have decreased over time. However stigma related to homosexuality, as a root cause of symbolic HIV stigma remains a significant challenge. Further advances in the prison and in the wider society regarding HIV require a focus on reducing stigma and discrimination related to homosexuality.

In Jamaica, there exists a significant body of work that characterises sexual culture from a gendered perspective, using a symbolic interactionist framework to explore the meaning and reproduction of norms of masculinity (Sobo 1993; Chevannes 2001; UNIFEM 2006). Attempts to understand homophobia have also employed an interactionist lens, and explain fierce rejection of same sex relationships as a result of deviance from accepted gender norms (UNESCO 1999; White 2005). In this study, the meaning of homosexuality as it relates to masculinity was not the focal point of participants’ discussions. Rather, participants’ descriptions of homosexual stigma were related to its uses, and align more clearly with a Durkheimian functionalist understanding. From this perspective, stigma begins as a social fact used to foster solidarity among “normals,” and define appropriate behaviour when dealing with “outgroup” members (Lukes 1989). In theory, the purpose of stigma is to quarantine and eliminate behaviour detrimental to the functioning of a social system. In practice, as exemplified in this study, stigma can also be used as a tool to manipulate balances of power. Used in this way stigma becomes a scapegoat for what might otherwise be considered deviant behaviour. This use of homophobia was evident in participants’ description of underlying political motives for the 1997 warder strike that led to the prison riot, and inmates’ targeting of orderlies as homosexuals during this event. Further, participants’ description of the use of “false allegations” of homosexuality as a weapon during conflicts demonstrates the practical application of homophobia in maintaining prison social order.

The grouping of oral sex and masturbation as part of sexually deviant behaviour associated with homosexuality also support the notion of homophobia as a tool when considered in historical context. An analysis of Jamaican sexual morés has also noted that among Afro-Jamaican slaves oral sex and masturbation were practices considered “nastiness” outside of respectable behaviour (Lafont 2001). According to LaFont (2001), rejecting the immoral sexual behaviours of the elite plantocracy allowed slaves to “…assert their own moral superiority. They could not exert economic or political superiority –indeed it was one of the only ways to assert dignity and pride (p. 16).” In the same way that moral superiority was gained through the practice of “respectable” sexual behaviours in colonialist Jamaica, rejection of outside neo-imperialist ideas about homosexuality and human rights in the current global political and economic landscape may serve as a source of nationalist solidarity and pride. The potential for homophobia in part as a reaction to “foreign nastiness” to function in this way exists in other post-colonial low and middle income countries as well (Aarmo 1999), and this may serve as a significant detriment to HIV and AIDS efforts, largely funded by foreign donor agencies. The case of Uganda, where legislation has been proposed to punish homosexuality by death, serves as a devastating example of the potential for human rights for homosexuals to deteriorate rather than improve, while multinational HIV and AIDS agencies push for greater acceptance of sexual minorities (UNAIDS 2008; International AIDS Society 2009). It is important for outside organizations to recognise this tension as they continue to advocate for a human rights approach to public health. Engaging regional and local health and human rights organisations in this process is critical, both in Jamaica and in other countries with similar colonialist histories and present day challenges.

If homophobia is used as a tool, how might social change happen in Jamaica so that the situation for those who engage in same sex behaviours is improved and an enabling environment for HIV/AIDS prevention and treatment achieved? Structural level approaches alone that target laws and policies may not accomplish the desired outcome, and moreover, may not be possible without micro and meso- level social movements. To this end, some ground has been gained through the work of civil society organizations including the Jamaican Forum for Lesbians, All-Sexuals and Gays, and Jamaica AIDS Support for Life (Williams 2000), as well as the Ministry of Health. Further progress requires the support of government agencies outside the health sector. Religion in the form of fundamentalist Judaeo-Christian doctrine in both colonialist and present day Jamaica, as well as the more recent Rastafarian movement, plays a large role in shaping negative beliefs about homosexuality. Thus, religious organisations that serve as the fulcrum of Jamaican society must also in some way be included in this movement.

Perhaps the most challenging but necessary component for social change is a sense of collective identity and agency among MSM. A recent study that engaged MSM stakeholders in the research process was successful in obtaining a sample of MSM that showed variation in social vulnerability associated with HIV infection (Figueroa, Weir, et al 2008b). It may be possible to obtain additional descriptive data that would contribute to our understanding of persons who engage in same sex relationships, within group similarities and differences, social and health needs, and how to foster a sense of individual and collective agency using a similar strategy. Following homosexual inmates upon their release from prison and engaging their social and sexual networks provides an additional opportunity to gain insight into MSM in Jamaica, albeit skewed towards economically marginalised men.

Circumstances in Jamaican prisons currently prohibit promotion of condom distribution. However, this should remain a long term goal to be implemented when it would not pose risk to homosexual inmates. Just as knowledge and sentiments towards persons with HIV have changed over time, sentiments towards condom distribution may also change in the prison context as the clinical diagnosis and treatment of HIV-infected inmates continues, and more inmates and warders come to know someone with HIV. Documenting the prevalence of HIV and experiences of HIV-infected inmates is at least an initial first step towards being able to advocate for future policy and programmatic change.

Approaches to condom distribution that have been successful in the USA, where sex among inmates remains illegal include condom distribution during private counselling sessions with health professionals and condom dispensing machines (Grinstead, Klein and Sylla 2008). The counselling approach may be more acceptable among inmates already labelled as homosexuals, as all participants in this study acknowledged that sex between men occurs in the “special” section. In the case that sex does occur outside of the “special” section as suggested by a few participants, condom dispensing machines would allow these inmates to access condoms but still conceal their sexual behaviour. However, these types of interventions will only be possible with the full support of the correctional administration and staff warders in the institution to ensure the safety of inmates labelled as homosexuals. This is currently not the case.

Acts of discrimination endured by homosexual inmates and their legality should be challenged. Further exploring same sex relationships during incarceration would increase our understanding of factors influencing abstinence in prison. In addition to providing physical pleasure, sexual relationships cultivate social bonds that satisfy emotive and financial needs. The harsh and isolating environment described for inmates labelled as homosexuals suggests a deficit in social and financial resources that these inmates may seek to fill through sexual relationships. Effective promotion of abstinence requires that contextual level variables that influence individual sexual behaviour be better understood and addressed. This is important in Jamaica, and other countries that restrict access to condoms in prisons, expecting abstinence to function as the only method of HIV prevention. Another important area for investigation is the potential role dependency of stigma related to insertive versus receptive anal intercourse. In this study participants did not differentiate between types of homosexual acts in assigning stigma, as has been the case in other Latin American countries (Carillo 2003).

The use of qualitative research methods facilitated a rich contextualised understanding of important socio-cultural factors influencing HIV services in Jamaican prisons and among MSM. While the narratives are unique to this context and therefore not generalisable, what we have learned is transferable both to other prison settings, and more widely to other countries where stigma against same sex relationships increases vulnerability and serves as a barrier to prevention and treatment. Chief among these lessons are that public health interventions, even those as basic as condom distribution for HIV prevention, must be sensitive to the sexual culture and context. Sensitivity should not result in inaction, but rather caution and long term commitment to addressing social issues relevant to HIV. It is also important that we broaden our focus on stigma so that we address stigma related not only to illness, but to the groups most vulnerable to infection. Finally, in addressing stigma related to HIV and to homosexuality, it is necessary to understand both the production and the function of this social construct.