Armed conflict, homonegativity, and forced internal displacement: Implications for HIV among Colombian gay, bisexual, and transgender individuals

Abstract

Colombia has endured six decades of civil unrest, population displacement, and violence. We examined the relationships of contextual conditions, displacement, and HIV among gay, bisexual, and transgender individuals in Bogotá, Colombia. Nineteen key informants provided information about internal displacement of sexual minorities. Life history interviews were conducted with 42 participants aged 18 to 48 years, and included questions about displacement experiences, sexual behaviour, life prior to displacement, and participants’ economic and social situation in Bogotá. The interplay of a variety of factors—including internal conflict and violence, homonegativity and “social cleansing,” gender and sexual identity, and poverty—strongly shaped the varied experiences of displacement. Migration, sexual violence, exchange sex, and low rates of HIV testing were risk factors that increased vulnerability for HIV in this displaced sample. Although displacement and HIV in Colombia are major problems, both are understudied.

Introduction

Internal displacement is a major problem worldwide, affecting over 27 million people in 2010 (Internal Displacement Monitoring Centre (IDMC) 2011). According to the United Nations Office of the High Commissioner for Human Rights, internally displaced people are those “who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalised violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognised state border” (UNCHR 1998, p.5). This paper describes the experiences of internal displacement and subsequent life circumstances of a sample of Colombian gay, bisexual, and transgender individuals, as well as heterosexually identified men who have sex with men, and explores possible links between displacement and HIV in this context.

Situation in Colombia

Colombia has the largest internally displaced population in the world, estimated at 3.6 to 5.3 million (IDMC 2012) and more than 5 million exiled in other countries (Magil 2008). Between 8.6% and 11.2% of the entire Colombian population is displaced, with the majority under 25 years of age (IDMC 2012). Moreover, displacement is underreported due to bureaucratic, practical, and social barriers to becoming certified as an internally displaced person (e.g., lack of property deeds, limited access to registration sites, stigma, denial of displaced status by the government). In addition, fear of retaliation from illegal armed groups can be an obstacle to registration (US Department of State 2011).

Colombia’s long history of internal conflict, human rights abuses, and poverty continues to affect large segments of the civilian population (US Department of State 2011). The United Nations estimates that approximately 57,200 civilians have forcibly disappeared in Colombia in the last three decades (ICRC 2011), many more than those who disappeared during the military regimes in Chile and Argentina together. Moreover, multiple massacres have been recorded (Giraldo 1996; Grupo de Memoria Histórica 2009) and rampant violations of human rights have occurred, including the killing, injuring, and torturing of civilians (Gill 2009; Rodríguez Garavito et al. 2009). These factors have created a climate of fear and terror that has contributed to internal displacement. Although the situation in Colombia has improved, the country’s poor performance relative to human rights is still evident in data from a variety of monitoring agencies and indices (US Department of State 2011; Cingranelli and Richards 2010; Hicks and Spagat 2008; Wood and Gibney 2010).

Displacement and HIV

In addition to continuing violence, civil unrest, and localised human rights abuses, HIV is a major problem in Colombia. Colombia ranks second in HIV prevalence in Latin America. It is estimated that between 0.7% to 1.1% of Colombian adults are living with HIV (UNAIDS 2010). The epidemic is mostly concentrated among men who have sex with men and other vulnerable groups. A study using a venue-based convenience sample of men who have sex with men in Bogotá found HIV prevalence of 20% (Montano et al. 2005). Despite these high rates, the epidemic remains understudied in this part of the world (Cáceres 2002; Cohen 2006; Frasca 2009).

There is disagreement among researchers concerning the relationship between displacement and HIV. Internal conflict and displacement of populations sometimes create conditions that fuel the HIV epidemic (e.g., Couldrey and Herson 2010; Hankins et al. 2002; Iqbal and Zorn 2010), such as when rape is used as a weapon against local populations (Spiegel 2004). Other circumstances can actually serve a protective function, such as when communities are isolated in remote locations away from urban areas with high HIV prevalence. Internally displaced people have been found to be less knowledgeable about the health care system and to face greater barriers accessing care than other poor and vulnerable groups in Colombia (Hernández and Gutiérrez 2008).

There is scant research examining the link between internal conflict, displacement, and the HIV epidemic in Latin America, and investigations specifically among gay, bisexual, and transgender individuals are even more limited. People who are gay, bisexual or transgender constitute a vulnerable population in the contexts of armed conflict, targeted killings, displacement, and the HIV epidemic. Homonegativity, which is defined as negative social attitudes and stigma concerning homosexuals (Hudson and Ricketts 1980), often results in discrimination and mistreatment of sexual minorities. Despite this vulnerability, there are no clear records indicating the number of displaced gay, bisexual and transgender people in Colombia, and we were unable to find any studies on the impact of armed conflict and forced displacement on HIV risk or care among displaced gay, bisexual and transgender individuals.

Conceptual Framework

The current study is grounded in a conceptual framework shaped by a social epidemiological model of HIV/AIDS population incidence (Poundstone et al. 2004). This model posits that the interplay of conditions at multiple levels influence HIV incidence. At the structural level, such conditions include societal factors such as the legal system, civil war, and migration patterns. At the social level are characteristics of social groups, such as prevailing attitudes and norms, stigma, social network composition, and family structures. The individual level reflects attributes of the person, such as physical, behavioural, and socioeconomic characteristics. Conditions at the different levels are conceived as directly influencing and shaping each other, and events such as civil wars and political transitions are seen as having epidemiological consequences experienced by individuals (Friedman and Reid 2002).

In this study, we explored the life trajectories of displaced gay, bisexual and transgender individuals living in Bogotá in order to understand more fully how conditions surrounding forced internal displacement in Colombia affect HIV risk for these individuals as well as the shape of the epidemic in the country.

Methods

This paper is part of an on-going 5-year NIH-funded study of HIV prevalence, sexual risk, and attitudes toward circumcision among Colombian gay, bisexual and transgender individuals and men who have sex with men. The data reported here come from the qualitative component, which included interviews with key informants and life history interviews of internally displaced gay, bisexual, and transgender individuals in Bogotá.

Participants

Key informants

Key informants were selected based on their knowledge about structural and social conditions that affect internally displaced populations, as well as gay, bisexual and transgender individuals, in Colombia. A total of 19 key informants were interviewed. Some key informants worked with individuals who were displaced, some with gay, bisexual, and transgender populations, but none worked with individuals who were both displaced and gay, bisexual or transgender.

Life History Interviews

We interviewed 42 participants, listed in Table 1 with pseudonyms. We used female names when participants identified as such. Inclusion criteria were to have had sex with a man in the last 12 months; be born as a man; be living in Bogotá, and be between 18 to 49 years of age. In addition, participants had to meet the criteria for internal displacement, as defined by the UNCHR (1998), which would encompass displacement due to human rights violations related to sexual orientation, gender identity, or HIV status.

Table 1.

Self – reported demographic characteristics of participants in life history interviews.

Pseudonym	Age	Current Source of Income	Strata	Years of Education	Sexual Orientation / Gender Identity	HIV Status
Linda	28	Military pension	NR	5	Transgender	Negative
Rocío	30	Sex work	NR	7	Transgender	Negative
Carmen	46	Sex work	1 or 2	5	Transgender	Negative
Reinaldo	28	Government worker	5	16	Bisexual	Negative
Jesús	22	Video sex chat	4	14	Homosexual	Negative
Romúlo	41	Acting	4	13	Homosexual	Negative†
Rogelio	48	Recycling	NR	14	Homosexual	Negative*
Javier	20	Call centre, beauty salon	3	11	Homosexual	Negative
Celia	24	Beauty salon	3	9	Transgender	Negative
Guillermo	23	Construction work	3	10	Homosexual	Negative
Pablo	21	Call centre	4	13	Gay	Negative*
Hector	33	Freelance	4	13	Bisexual	Negative†
Daniel	23	Parents	1	14	Homosexual	Positive
Julio	37	Help from others	NR	10	Gay	Positive
Armando	32	Unemployed nurse	2	13	Gay	Negative
Andrés	19	None	4	13	Gay	Negative†
Emilio	33	Sex work	1	9	Heterosexual	Negative†
Mario**	23	Mother	3	14	Homosexual	Not Tested
Hernán	26	Sex work	1	12	Heterosexual	Negative†
Alejandro	18	Parents	1	11	Gay	Untested
Pedro	29	Hustling/sex work	1	8	Bisexual	Untested
José	26	Restaurant employee	3	8	Gay	Negative*
Misael	24	None	2	11	Bisexual	Untested
Roberto	24	Server/bar promoter	2	11	Gay	Negative
Alvaro	26	Hustling	1	7	Bisexual	Untested
Carlos	23	Hustling	2	6	Homosexual	Unknown result
Gustavo	23	Hustling	1	9	Gay	Negative*
John	33	Hustling, sex work	1	11	NR	Untested
Jorge	27	Hustling, construction	1	11	NR	Untested
Gabriel**	38	Handing out flyers	2	11	Gay	Untested
Juan	34	Hustling, sex work	1	6	Homosexual	Untested
Rodrigo	21	Hustling, sex work	NR	10	Bisexual	Untested
Alexandra	36	Hairdresser	2	8	Homosexual, Transgender	Positive
Monica	22	Hustling	2	7	Transgender	Negative†
Paola	32	Non-profit organisation	NR	11	Transgender	Negative†
Mariela	26	Sex work	NR	11	Homosexual, Transgender	Negative†
Marisol	32	Non-profit organisation, sex work	NR	11	Transgender	Negative†
Janet	23	Non-profit organisation	1 or 2	9	Transgender	Negative*
Cristina	23	Non-profit organisation, sex work	1	9	Transgender	Untested
Melody	32	Sex work	1 or 2	8	Transgender	Untested
Mariana	35	Hairdresser, sex work	1 or 2	4	Transgender	Negative*
Luisa	29	Activist	4	16	Transgender	Positive

Note 1: Names of small towns are omitted to protect participants’ identities. In the case of small towns, state names are reported.

Note 2: Housing in Colombia is classified by estratos (strata) according to physical characteristics of homes and neighbourhoods. Strata classifications range from 1 (the poorest) to 6 (the wealthiest) (Gonzales et al., 2012). Strata are highly correlated with socioeconomic status.

NR = Not reported

^†Time since last HIV test unknown

^*Last HIV Test was more than a year ago

^**Participant may not be an internally displaced person; his transcripts were excluded from analysis for this paper.

Participants’ ages ranged from 18 to 48 (mean = 28.4). Despite the moderate educational level of the sample (see Table 2), over half the participants were living in neighbourhoods from the two lowest estratos (government-defined socioeconomic strata). Very few participants in life history interviews reported having regular employment.

Table 2.

Summary of Self-reported Demographics of Participants in Life History Interviews (N = 42)

	n	%
Strata
Low (1 and 2)	22	52
Medium (3 and 4)	11	26
High (5 and 6)	1	2
Not reported	8	19
HIV Status
Positive	4	10
Negative	25	60
Tested > 1 year ago	6
Time since testing unknown	9
Never tested	12	29
Tested but did not get result	1	2
Level of Education
Elementary school or less	3	7
Middle school (6–8 grade)	9	21
Some high school (9–10 grade)	8	19
Finished high school (11 grade)	10	24
Some college	10	24
Finished college	2	5
Arrival Year in Bogotá
1979–1984	1	2
1985–1990	0	0
1991–1995	2	5
1996–2000	3	7
2001–2005	12	29
2006–2009	21	50
Not applicable	3	7

Procedures

Two experienced Colombian interviewers, who were knowledgeable about gay, bisexual and transgender life in Bogotá, carried out the majority of key informant and life history interviews. Approval was obtained from the university internal review board and from Profamilia’s ethics committee. Training sessions concerning the central research questions of the study were conducted in Bogotá and in Washington, DC.

Key informant interviews

Key informants interview guides included questions about various topics and their relationship to HIV risk: structural and social conditions in the city; experiences of violence; migration issues; homonegativity and anti-gay violence; HIV/AIDS awareness and attitudes; patterns of sexual risk behaviour; and availability of STI/HIV prevention and treatment programmes.

Life History Interviews

Recruitment strategies included using referrals from key informants and other participants. Interviewers provided information about the study, read the consent form, and obtained consent as well as permission to digitally record the interviews. Life-history interviews then explored the contexts of participants’ lives. Interviews took place during 2008 and 2009.

Interview guides included questions about participants’ life experiences, with a focus on internal displacement and associated personal experiences (e.g., situations with paramilitary or guerrilla groups; circumstances around displacement; migration to the city, life after arriving in Bogotá). We were interested in gaining an understanding of participants’ personal experiences within the broader social and structural context and of connections to HIV risk. Open-ended questions also addressed current sexual behaviour, sexual risk, early sexual experiences, and HIV testing. Participants received 85,000 Colombian pesos for their time (approximately $50 US dollars).

Data Analysis

All life history interviews were transcribed in Spanish. Data were entered into NVivo 8 software and were coded by four researchers, in teams of two from each country. The US coding team was comprised of one native Spanish speaker and one bicultural, bilingual US-born woman of Latino descent. The Colombian coding team included the two local qualitative researchers who had conducted the life history interviews. A fifth bilingual, bicultural researcher reviewed the coding of each interview done by the two teams of coders to identify discrepancies. The content areas covered by the coding scheme were broad and included the following subcategories relevant to this paper: displacement (e.g., stigma, causes, violence); gay, bisexual and transgender issues (e.g., stigma, anti-gay violence, rights); life experiences (e.g., education, family); identity and social network (e.g., gender identity, community); sexual practices (e.g., condoms, sex work), and HIV and STI history.

Discrepancies in coding were discussed in bi-weekly meetings using Skype until consensus was reached by both teams. Coding was constructivist and iterative: a conceptual framework and a pre-established set of codes guided the coding process, but open coding and memos were used to allow for continued revision of the subcategories (Richards 2005). Memos were mainly used to record observations about the data, which could be helpful during interpretation of findings, and to indicate changes to coding definitions and creation of new codes.

Results

First, we will present general themes related to primary reasons for displacement reported by many participants. These factors included armed conflict, poverty, and discrimination and social cleansing. Because the life trajectories of participants reflected the complex interplay of such factors, we will then present detailed portrayals of the experiences of different participants.

Factors causing displacement

Armed conflict

Experiences of displacement among participants were often the result of widespread violence due to political and economic conflict between armed groups. In Colombia, for decades, leftist guerrillas have been fighting both the military and right-wing paramilitaries, who aim to protect large landowners’ and multinational companies’ interests (Romero and Torres 2011). Young men were forcibly recruited by both the guerrilla and the paramilitary. Several participants were directly threatened by armed groups. Others left their hometowns after family members were killed, fearing they would be next.

A consequence of the lack of civilian government control is that the guerrilla and paramilitaries engage in disputes to control certain areas, exacerbating poverty and violence. Conflict is also related to attempts to obtain large extensions of land for multinational agro-industrial businesses and for drug trafficking routes (Romero and Torres 2011). Some areas were entirely controlled by one of the groups, which then “taxed” crops to raise funds, resulting in further poverty for people in the area. Participants described how armed groups exerted social control, set curfews, accused campesinos of being informants of other groups (e.g., the guerrilla), and killed local people.

Poverty

Lack of political stability and poverty caused food insecurity and homelessness in many participants’ places of origin. Several participants reported that they had not had stable housing in their home towns. Some had moved to relatives’ homes prior to moving to Bogotá. In addition, governmental policies sometimes contributed to poverty, leading to displacement. For example, coca fumigation performed as part of drug policies destroyed crops and animals, and ultimately resulted in displacement.

Social cleansing and discrimination

Several participants described experiences in their places of origin related to the “social cleansing” of “undesirable” elements, which included drug users, destitute people, and gay, transgender, or HIV-positive individuals. A key informant corroborated the widespread practice of social cleansing, and noted that in zones of intense conflict, health providers refer HIV-positive clients to Bogotá, because if local armed groups learned of someone’s infection, “it would be like a death sentence.” Although much less common, social cleansing also occurred in Bogotá. A key informant reported an instance in which a transsexual woman and her family received threats from members of the paramilitary because of her HIV-positive status and had to leave the area. In addition to social cleansing carried out by armed groups, some participants described situations in which homonegativity among relatives or other members of the community forced them into displacement. In addition, stigma associated with HIV was a cause of discrimination, and at times, displacement. Discrimination was expressed in varied ways, including name-calling, assault, and sexual violence.

Personal life trajectories

In participants’ descriptions of their own lives, we saw the complex ways in which contextual factors, as well as personal attributes and situations, combined to shape experiences of displacement and attendant vulnerabilities. In this section, we present in greater detail several participants’ reports of events in their own lives. In addition, we examine the various risks, including HIV, associated with the different scenarios.

Julio

At the time of the interview, Julio was 37 years old. He self-identified as a gay man, and he was HIV-positive. He currently survived by receiving financial help from others. Julio had been displaced multiple times. As a child, he was displaced from a rural area with his family due to an eruption of a volcano that buried the region. Subsequently they all moved to another rural part of the country, which was the scene of intense armed conflict. Julio reported that his mother worried about the possibility of his forced recruitment by a paramilitary or guerrilla group in the area, so he made himself scarce. He left at age 20 to go to Bogotá. He and his brother were targeted because his brother was a community leader and Julio was suspected of being gay.

I came in ’92 from Arauca because there the guerrillas and the paramilitaries were looking for single people. I had to run from one place to another, so that my mom would not worry. That was when I came here for the first time…I had a problem with the paramilitaries, with the Aguilas Negras (a paramilitary group). … Some men arrived at my brother’s. They said “You have to decide, one of you has to go.”…I had to leave that night.

Julio had his first experience with anal intercourse in Bogotá, although he had known since he was a teenager that he was gay. Upon arriving in Bogotá, he had no money and engaged in sex work in order to pay for his basic needs. He learned that he was infected with HIV in 2004. His situation illustrates the increased risk in a large urban centre, where there is greater access to partners, high HIV prevalence among men who have sex with men, and at times, financial pressure to perform sex work.

When he became very ill, Julio returned to his family’s home. His parents were disturbed by his state and insisted on separate silverware. In contrast, his brother and sister-in-law took him in and cared for him. Members of the paramilitary eventually forced him to leave again because he was identified as a gay, HIV-positive man. He returned to Bogotá, where again he lived in poverty. The impact on his health was evident in his report:

The doctor told me I had to take that pill with food; so in a day in which I can’t eat, I can’t take my medicine… If I have 1,000 pesos [less than 50 US cents] and use 500 in the morning and 500 in the afternoon, that’s all I have for the day. Black coffee and bread in the morning, lunch at three wherever I can, until the next day.

In Julio’s story, we see the confluence of different forces. Julio was displaced three times: first by a natural disaster, and then twice in response to paramilitary groups. His family ties played an important role in his story. He left Arauca for his brother’s sake and returned when ill to be cared for by family members. Although in Bogotá he could live as a gay man without facing the discrimination that was present in Arauca, in the city he had little money or social support. His poverty initially increased his risk of HIV due to his engaging in exchange sex, and then later decreased his adherence to HIV medications.

Alejandro

Alejandro was 18 years old at the time of the interview and living with his parents, who financially supported him. He was born in Bogotá, but when he was very young, his family moved to a variety of places in search of a way to make a living. Ultimately, they settled in the region near Armenia, but they had to leave their land due to a major earthquake. They moved to the state of Meta when he was a teenager, and Alejandro became active in a charismatic church in an attempt to eliminate his sexual attraction to men, which he considered sinful. After several years, he left the church and accepted his sexual orientation.

Alejandro described the prevalence of social cleansing in this area, with the mayor and businessmen paying the paramilitary group to rid the town of drug addicts, robbers, and other people considered undesirable. He reported witnessing the killing of two teenagers he had passed on the street:

I had to act as if I hadn’t seen anything. Mainly it was because of that that I came to Bogotá… The truth is I lived constantly in fear because one would see that four, five, six people were dying per day, acquaintances, friends. I kept [my homosexuality] very quiet but they knew my life, because they investigate everyone’s life. They knew what places I would frequent, what I did, who I was with. They knew everything.

Alejandro and his family left and went to Bogotá. Because Alejandro’s identity card reflected the fact that he was born in Bogotá, he was unable to obtain the government document indicating that he had been displaced. Thus, he has been unable to receive any government benefits available for displaced people.

Although Alejandro is able to live a gay life in Bogota without the threat of anti-gay violence perpetrated by paramilitary groups, he noted that there are occasional instances of social cleansing, particularly aimed at transgendered individuals in the city. He has benefitted from HIV prevention messages in the gay community. He reported always using condoms, except in a four-month relationship with a partner who had tested negative for HIV. Public health campaigns, however, were not sufficient to induce Alejandro to get tested for HIV or to seek medical care for a penile wart, which he had at the time of the interview.

José

José was a 26 year-old man who identified as gay. He migrated to Bogotá in 2008 and worked in a restaurant. He was HIV-negative, but has had other STIs. His mother abandoned him and his siblings when José was three, and he was adopted by a friend of his aunt and grew up in a small town. In contrast to Alejandro, whose displacements occurred due to a natural disaster and to social cleansing by a paramilitary group, José’s displacement stemmed from severe victimisation by civilians in his community. He was assaulted and raped on multiple occasions by men in his town. He explained:

Why did I come to Bogotá? Because in my town everyone discriminated against me. I would go into a store, and it was like they were seeing the devil, seeing Satan in person. People looked at me in a way that made me feel really bad. I felt worse than garbage. People at least pick up garbage, pick up garbage and lift it up, tie it, pick it up, and take it out. No, to me, they didn’t even do that… I had to run away and run, run, for my own protection… Men threw rocks at me and then raped me. On one occasion they cracked my head open. Someone threw a big stone at me and yelled, “Fag, son of a bitch.” I arrived in town all bloody, with my back full of blood.

José noted that life in Bogotá, a city of 8 million people, contrasted sharply with life in a small town. Although he escaped mistreatment for being gay, the autonomy and anonymity of the city also brought a loss of social support.

Here today, I am filled with a lot of energy. There are a lot of gays here; there is less discrimination here. Here everyone minds his own business. And what one learns from that is that one has to learn to live one’s own life. Nobody cares about you. In a town everyone cares about their neighbour; …while here, no. Everyone is on his own.

Carmen

Carmen was a 46-year old, male-to-female transgender woman. At the time of the interview, she worked as a sex worker and was HIV-negative. Her father had died when she was about six years old. Her mother then went to search for a job and left Carmen and her sister with a paternal grandmother in a rural area. She first came to Bogotá at age 16 to live with her uncle and aunt and to go to school.

Prior to her transition to being a woman, Carmen completed her military service, which is compulsory. She reported being coerced into sex by a sergeant who said that there were rumours that Carmen liked other men. Carmen explained that despite denying those rumours,

…he started touching my legs, and I said “No, sergeant, I am not what you think,” and he said, “Do you want me to refresh your memory? So-and-so [another soldier] told me.”… Then he started kissing me by force, forcing me, and I was trembling, and I kept thinking this can’t be happening to me. And he said “Lie down. I am going to be good to you.”

After that, she had consensual relationships with men in the army, including the sergeant, a lieutenant, and a corporal. The sergeant gave her money, and he wanted her to be monogamous with him, because he was worried about acquiring a sexually transmitted infection and transmitting it to his wife.

Upon leaving the military, Carmen moved to work with her uncle who had a farm in a very isolated eastern area. Soon thereafter she became a hairdresser and developed a successful salon business, due to the region’s economic prosperity stemming from the booming coca trade. It was during this period that Carmen started to take on a more feminine appearance, with longer hair and women’s clothing.

Carmen reported that after Uribe became president in 2002, widespread fumigation of coca fields was instituted. She described the devastation that occurred:

Plantain, yucca, animals, everything, even the water, gets contaminated. The fish die. It [fumigation] kills everything. People who get some of that poison on their head become bald.

The area became economically depressed, and she lost her business and her house. She then moved to Bogotá where she moved in with her sister and helped take care of her sister’s children. Although she wanted to continue working as a hairdresser, she was unable to get a job because she lacked the formal credentials required to work in a salon in Bogotá. Therefore, she began to sell sex in order to support herself. She obtained a sex worker identification card, which allowed her to work legally. Although she has been unable to take the U.N.-funded HIV prevention class due to lack of time and money for transportation, she reported always using condoms with her clients and getting tested for HIV regularly.

In Carmen’s story, we again see multiple instances of migration. Her first move was due to poverty, with the goal of obtaining education and greater opportunity. After a stint in the military, where her femininity brought about sexual coercion but also some financial benefit, she moved to a rural area to work with a family member. Government policy concerning coca fumigation was then the cause of her displacement. It is interesting to note that despite her feminine presentation, Carmen was not the target of social cleansing and was accepted by her mother and siblings. Once in Bogota, she joined the ranks of the urban poor, due in part to her lack of formal training. However, she benefited from government policies legalising sex work and providing HIV education.

Reinaldo

In contrast to most of the participants, Reinaldo was educated and came from a higher social status. Several members of his family had been involved with the paramilitary movement, and therefore they were threatened by the guerrillas. Reinaldo went abroad for several years under a joint US-Colombian government programme that paid his tuition and a stipend. He returned to Barranquilla with an U.S. male partner, who received numerous threats because he was a gay gringo. He was killed in a car accident when someone deliberately cut off their car.

At a later time, Reinaldo lodged a formal judicial complaint against a guard who harassed a gay man in a public restroom. A consequence of this action was that two men came to Reinaldo’s home, kicked down the door, and frightened his mother and sister. Reinaldo was not present, but after this event, his family encouraged him to flee to Bogotá for his own safety. Although he had a brief difficult period upon arriving in Bogotá, he obtained a government job after a few weeks.

Reinaldo identified as bisexual from the time he was a teenager and reported living in the bisexual “double closet,” in which he hid his bisexuality from both his gay and female romantic partners. He frequented gay neighbourhoods with his male partners and friends, but with women he would favour non-gay neighbourhoods. Over time, he was able to be open about his bisexuality, and he has become a public voice for bisexuals within the gay, bisexual and transgender community.

Reinaldo’s life history is in sharp contrast with those of less privileged men. After his displacement, he was able not only to obtain a good job due to his education (and perhaps social capital), but also to find much greater acceptance of his sexual minority status among his educated peers. Nonetheless, he suffered a tragic loss of his partner, as well as removal from his family, due to his sexual orientation.

Discussion

This study investigated experiences of internal displacement among Colombian gay and bisexual men and male-to-female transgender individuals. The life histories illustrated the complex interplay of forces that shaped participants’ trajectories and pathways to HIV risk and other vulnerabilities. There were varied causes of displacement, and we heard many stories that included multiple displacements. Poverty was an overarching theme, either as a motivating force for migration or as a result of migration. In contrast, the life history of Reinaldo illustrated how higher socioeconomic status and educational level can insulate a person from some of the common negative outcomes of displacement.

Colombia has an advanced legal framework protecting human rights and a constitution insuring freedom of sexual expression. Despite this fact, many people suffer severe human rights violations, including gay, transgender and HIV-positive individuals, as was evident in this study. The discrepancy stems in part from the different worlds operating in more sophisticated and tolerant urban centres versus isolated rural areas, characterised by guerrilla or paramilitary rule, limited health and educational infrastructure, and negligible state presence. However, the presence of the state does not guarantee protection of human rights, because the state itself, including the army, is sometimes a perpetrator of violations. The long history of armed conflict in Colombia has permeated many aspects of society, and findings showed that the lack of civilian rule and the supremacy of guerrilla or paramilitary groups in certain areas have resulted in violence that infects social interactions.

Moreover, in rural areas social norms and values are generally more traditional and restrictive, and greater acceptance of sexual minorities has not been achieved. The hate crimes perpetrated against José illustrated not only human rights violations, but also a context in which reporting such violations would be dangerous and futile. It is interesting to note that, in contrast, Reinaldo felt empowered to launch a judicial complaint about anti-gay bullying. As a result, he found himself a victim of vigilante justice, which led to his displacement. Thus, even when citizens feel protected by the law, in reality they may not be.

People who are gay, bisexual or transgender are at particular risk due to social stigma, and our participants were often the targets of sexual violence. It is well established that gay, bisexual, and transgender individuals constitute a group highly affected by the HIV epidemic; this paper illustrates how a context characterised by armed conflict, poverty, and internal displacement can magnify exposure to HIV or impede treatment.

Some patterns found in this study are similar to those occurring in the general population of internally displaced Colombians. Precursors of displacement included several structural factors: armed conflict, lack of political stability, and poverty. Coca fumigation, which damaged crops and threatened livelihoods dependent upon agriculture, forced migration. Displacement in turn led to increased poverty, which has been linked to HIV in countries with high inequality (Fox 2012). Poverty, food insecurity, and homelessness were expelling factors, but were also conditions encountered during migration and after resettlement. These factors placed individuals at high risk for HIV directly through exchange sex and often decreased ability to access medical care. Moreover, they created additional difficulties in adherence to a medication regimen for those living with HIV, as reported by Julio.

Displacement was often associated with multiple losses: of place, loved ones, and social support. The potential for mental health consequences of the trauma associated with armed conflict and displacement was great. The disruption of social networks and exposure to new cultural conditions (e.g., gay community culture) resulted in both positive and negative changes in expectations and behaviours.

Some factors affecting the link between displacement and HIV were specific to sexual minorities. For example, structural conditions, such as armed conflict and poverty, interacted with social stigma concerning homosexuality, gender non-conformity, and HIV to create particular situations promoting internal displacement among gay, bisexual and transgender individuals. Social cleansing, which was often a motivating force behind migration, is an example of this type of interaction.

Sexual violence arising from the mixture of armed conflict and negative attitudes toward sexual minorities also increased the likelihood of spreading HIV. Rape has been widely inflicted on Colombian women during this conflict (US Department of State 2011), and we saw some evidence that it was also used against gay and transgender individuals. Sexual coercion and sexual violence sometimes motivated displacement and potentially magnified risk of HIV among gay, bisexual and transgender individuals, as well as the perpetrators of the violence.

Migratory patterns and increased mobility took individuals through different geographic areas with varying HIV prevalence, including in the original, intermediate, and final destinations. Population movement can result in decreased or increased HIV risk, as shaped by the community viral load in different locations. Furthermore, HIV stigma that caused those living with HIV to migrate from one area to another potentially contributed to the spread of infections across localities. Rural-to-urban migration constituted a source of possible risk to migrants because of the higher rates of HIV in the city. Moreover, the combination of high prevalence in the partner pool with the vibrant gay social life and access to sexual partners further increased risk. The easing of social restrictions sometimes resulted in greater risk behaviour, particularly shortly after arrival in an urban area, a finding that has also been reported in other settings (Bianchi et al. 2007).

Public health programmes serving displaced individuals should include specific components aimed at sexual minorities who are often overlooked due to institutional hetero-normativity. Training service providers to be more aware of sexual minorities among the displaced population would be a first step to decrease invisibility and to increase HIV prevention efforts. Given the risks in some areas of the country associated with being identified as gay, bisexual, and transgender or HIV-positive, special procedures to protect confidentiality would be important.

In addition, reception sites for migrants, not only in urban areas but also in smaller towns, should be increased, and health education and services—including those for sexual minorities—should be offered. Moreover, special attempts to identify migrants soon after their arrival should be instituted to increase access to services and health care. Programmes open to all migrants should include information relevant to sexual minorities, who would then have access without having to identify themselves as such. This approach would also enable greater participation of heterosexually identified men who have sex with men. Furthermore, HIV and STI testing should be widely administered so as to avoid situations such as that reported by Alejandro, who had never tested for HIV and had not sought care for his penile wart.

The practice described by a key informant of referring HIV-positive clients to larger urban areas in order to protect them from social cleansing was clearly done with good intentions. However, participants noted that lack of financial assistance to cover transportation, room, and board while in Bogotá made this arrangement untenable. Moreover, the bureaucracy sometimes resulted in a two-week wait to receive medication. Therefore, public health policies should facilitate this type of arrangement through financial support and the guarantee of immediate care.

Human rights violations are common in the general population of Colombia, and they were evident in our findings. Education about human rights in the school system and in media campaigns would raise awareness, as well as decrease the attribution that human rights protection is solely a leftist cause. Attempts to negotiate peace with the guerrillas and to demobilise the paramilitary groups, if successful, will contribute to an atmosphere with improved human rights. In addition, other policies should include training members of the military and police forces about human rights and prosecuting those who violate the law.

This study has some limitations. It is possible that participants declined to reveal some important information. Only four participants reported that they were living with HIV. It is possible that some participants preferred not to disclose positive HIV status. Moreover, we probably missed participants for whom the retelling of their life histories would have been very stressful.

Despite these limitations, our inquiry allowed us to gain insight into ways in which armed conflict and violence contribute to internal displacement of gay, bisexual and transgender people. Our findings illustrated ways that the structural and social environment destabilised participants’ lives and potentially led to the spread of HIV. Despite the importance of specific cultural context, many patterns found are applicable in other parts of the world experiencing internal conflict. The victimisation of members of sexual minority groups and the invisibility of that victimisation in official statistics occur in many countries. Moreover, as was seen in this study, the displacement of sexual minorities within a setting characterised by civil unrest and violence, can affect pathways to HIV exposure. Awareness of these patterns could be relevant for other areas of conflict.