Mixed Methods Research With Internally Displaced Colombian Gay and Bisexual Men and Transwomen

Abstract

We discuss the use of mixed methods research to further understanding of displaced Colombian gay and bisexual men and transwomen, a marginalized population at risk. Within the framework of communicative action, which calls for social change through egalitarian dialog, we describe how our multinational, interdisciplinary research team explored the subjective, objective, and social worlds of participants through life history interviews and surveys. We also describe the unique Colombian context, conscious efforts to establish egalitarian relationships among research team members, and efforts to disseminate and reflect on findings. Through discussion of our research process and results, we aim to demonstrate how mixed methods research can be utilized to facilitate noncoercive discourse and contribute to social change.

Mixed methods studies can contribute to a reduction in inequalities and provide solutions for pressing problems of society (Hesse-Biber, 2010; Mertens, 2011). In keeping with the aims of this Journal of Mixed Methods Research Special Issue, we discuss the use of mixed methods research to study groups at risk while promoting social change through egalitarian dialog. Mertens’s (2007) acknowledgment that social, political, and economic values influence whose realities are privileged by the research informed the following discussion of our research process.

This article presents a mixed methods approach utilized in an international study of HIV prevalence, sexual risk, and attitudes toward circumcision among Colombian gay and bisexual men and transwomen (GBT). The use of qualitative and quantitative methods was fundamental to achieving two aims of the study, which were (a) to examine structural, social, and individual factors relevant to HIV risk among Colombian men who have sex with men (MSM) and trans-women in Bogotá and (b) to integrate the information and draw conclusions that would guide the design of policies and interventions addressing HIV risk among MSM and transwomen in Colombia. Components of the original design included 19 key informant interviews, 11 focus groups, 42 life history interviews, 100 pilot surveys, and 1,000 audio-computer assisted surveys. Additional qualitative data collection (20 qualitative interviews and 13 key informant interviews) was conducted after preliminary results indicated low rates of HIV testing among participants.

In this article, we focus on a subset of the full sample, namely, gay and bisexual men and transwomen, who had experienced internal displacement due to violent conflict, social cleansing, and homonegativity (N = 113). This is a more vulnerable and marginalized subset of the Colombian GBT population, and displacement has engendered extreme poverty among many individuals in this group. By focusing on a group that has suffered the impact of violence and marginalization, this project demonstrates a way in which mixed methods can contribute to social change by giving voice and visibility to research participants who are often viewed as subjects of victimization and blame rather than as legitimate actors with valuable knowledge to share.

Theoretical Framework

Our research process is discussed within the framework of the Theory of Communicative Action (Habermas, 1984). Habermas argued that humans are rational beings and that language is the form in which rationality is expressed. Noncoercive dialog is seen as leading to greater mutual understanding, which encompasses subjective, objective, and social experience. Habermas further posited that communicative action is the product of this process of communication between equals and that such action can be the means through which societies become more egalitarian and inclusive.

We applied this theory to the process of mixed methods research in pursuit of increased knowledge about Colombian internally displaced GBT individuals. Although we hold noncoercive dialog as an ideal, we recognize that the interlocutors—be they research participants, U.S.-based researchers, or Colombian researchers—come to the research process with different perspectives, goals, and social and economic capital, and therefore it is necessary to institute conscious processes to overcome inequalities. Previous research has identified unequal power relations as an impediment to the establishment of effective interdisciplinary teams conducting mixed methods research (Lunde, Heggen, & Strand, 2013). Furthermore, the creation of a meaningful social group consisting of researchers who trust each other, deal effectively with conflicts arising from their differing backgrounds and perspectives, and share a social identity as a research team has been described as crucial to the success of interdisciplinary, mixed methods research (Curry et al., 2012; Hemmings, Beckett, Kennerly, & Yap, 2013).

In this article, we describe the procedures by which we tried to accomplish these goals within the research team and to achieve communicative action through egalitarian dialog among researchers and participants. We explain the ways in which we attempted to generate noncoercive discourse with both qualitative and quantitative methods, which then contributed to a deeper knowledge of the subjective, objective, and social perspectives and experiences of displaced GBT individuals. In the sections that follow, we discuss the context of Colombia, the composition of the bi-national research team, qualitative and quantitative data collection and analysis efforts, the richness of mixed methods findings, and avenues we pursued for political advocacy and social change.

Context for Internally Displaced GBT Individuals in Colombia

Colombia is a country that has endured 60 years of violence and intractable conflict, largely fueled by a struggle for control of resources and political power, with implications for social changes that maintain, exacerbate, or decrease social inequalities. Human rights abuses and poverty affect a large number of Colombians (U.S. Department of State, 2011). Few other countries have endured such protracted violence, which has permeated the media, personal communication, and other forms of human activity. As a result of the extensive internal conflict, much of the Colombian population has suffered internal displacement. A large percentage of the internally displaced population has migrated to Bogotá and lives under conditions of vulnerability and social exclusion (Hernández-Bello & Gutiérrez-Bonilla, 2008).

In addition to displacement as a result of conflict, GBT individuals have also been displaced by homonegativity and “social cleansing,” a phenomenon that aims to rid society of “undesirable” elements (Zea et al., 2013). Displaced GBT individuals constitute a population of great social relevance because the group carries the triple stigma of being internally displaced, homosexual or transgender, and economically disadvantaged. Moreover, this group remains largely invisible, in part because social programs that target displaced populations typically emphasize the plight of families, especially women and children.

The invisibility became evident in key informant interviews with individuals who were working with internally displaced people. Several acknowledged their own surprise when asked to reflect on GBT individuals within the displaced population and declared that they had never thought about that segment of the displaced population previously. Thus, the mere act of inquiring about the hidden population of internally displaced GBT called attention to their existence and changed the awareness among some individuals working in institutions providing services to internally displaced persons. Our team’s interactions with service providers sensitized the latter not only to the existence but also to the unique circumstances and needs of internally displaced gay and bisexual men and transwomen.

Although the GBT community has been greatly affected by the prevalent hegemonic and heteronormative discourse in Colombia, some public guidelines have been instituted to protect the rights of this group. The 1991 Colombian Constitution declared equal rights for the lesbian, gay, bisexual, and transgender (LGBT) community. Penalties are harsher when it can be proven that an act of violence against a GBT individual constituted a hate crime, that is, was motivated by the victim’s sexual orientation. At the local level, the office of the Mayor of Bogotá has promoted policies of inclusion and programs for LGBT citizens. Conflicting values are evident, however, in the recent backlash that occurred in response to the greater visibility of the LGBT community that resulted from these policies. An office dealing with LGBT affairs was defaced in 2013, and hate messages were inscribed on their walls. In addition, recent debates in congress on legalization of gay marriage in Colombia demonstrated little support from politicians and a staunch opposition from the Catholic Church.

Transdisciplinary and Transcultural Composition of the Research Team

In addition to the broad social context for GBT individuals in Colombia, we recognize that a research project creates its own social and cultural context that participants in a study encounter. We believe that researchers’ positionality exerts an important influence over every aspect of the research process (Curry et al., 2012; Lunde et al., 2013; Mertens, 2007). The group that wrote the grant application funding this study was based in the United States and was composed of four psychologists who have been working together for more than 15 years on HIV among gay and bisexual Latino men. Two are Latina immigrants, and two are U.S.-born White Americans. Although all four had been originally trained in positivistic approaches, the team has incorporated broader perspectives and has used qualitative methods to capture experiences of groups who have little voice in much of psychological research. The first author is an insider to the Colombian LGBT community but at the same time has the privilege of an academic position in the United States.

Important partners were two Colombian qualitative methods specialists (second and third authors of this article) who helped develop interview guides, conducted key informant and life history interviews, handled recruitment, administered quantitative surveys and HIV testing, and delivered HIV pre- and posttest counseling. Among their many contributions was their ability to provide the “native” perspective. One of these individuals is a self-identified gay man with a degree in social sciences, and the other is a woman with a degree in anthropology. Both were very connected with the LGBT community in Colombia; they knew the sociocultural context, as well as the geographic areas where MSM socialize in Bogotá. Their familiarity and local perspective facilitated the process of recruiting and gaining the trust of participants. The active participation of these two team members was essential for ensuring that the research reflected the concerns of the community. Additionally, the different world-views of the U.S.-based researchers and the Colombian participants were bridged by the Colombian team members who shared some of the perspectives and experiences of both groups.

Because team members came from diverse national, ethnic, theoretical, and disciplinary backgrounds, there were many opportunities to identify differences in assumptions, approaches, assets, and knowledge (Hemmings et al., 2013). Similar processes to those that take place in the global context can occur among team members of first- and third world societies. For example, the resources controlled by the U.S. researchers can result in a power differential, an attitude analogous to an imperialist stance, and a “use and discard” approach to third-world staff. Many hours of planning, developing mutual trust, establishing different means of communication across countries (e.g., face-to-face meetings, e-mails, Skype meetings), as well as honoring diverse styles of communication (e.g., more or less philosophical, analytic, political, direct) were needed to develop an egalitarian relationship among team members. We worked to avoid the assumption that the expertise came from U.S. universities or from existing, standardized surveys. The participation of the entire interdisciplinary team enabled the incorporation of the native perspective and the generation of ecologically valid, socially relevant knowledge.

Qualitative Component

As noted above, an important aspect of communicative action stems from noncoercive dialog, which can result in greater knowledge of a group by uncovering subjective, objective, and social perspectives and experiences. Although we believe that qualitative methods can illuminate all three, this approach is especially well suited to capturing the unique practices, understandings, and beliefs of individuals—hence, their subjective world. In this section, we describe a key qualitative component of the research study—the conduct and analysis of life history interviews.

We conducted 42 life history interviews in which participants’ provided narratives of internal displacement, risks, and survival. The interviews were semistructured, and interview guides included topics covering childhood, adolescence, family life, sexual orientation development, gender identity, experiences of discrimination and stigma, experiences of internal displacement and violence, sexual risk, sexually transmitted infections, HIV status, and knowledge and attitudes toward circumcision. Many of the topics addressed intimate and personal experiences, including interactions with perpetrators of violence. The Colombian researchers created a safe environment in which noncoercive dialog could take place. They were not judgmental, and they conveyed that participants had complete control over what and how much to disclose. They also assured, and carefully guarded, confidentiality.

Eligibility criteria for life history interviews were being between the ages of 18 and 49, having had sex with a man in the previous year, and having been displaced. Participants had to meet the criteria for internal displacement as defined by the United Nations Office of the High Commissioner for Human Rights, that is, having 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 generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized state border. (United Nations Commission on Human Rights, 1998, p. 5)

In keeping with this definition, we also considered as displaced those individuals who were forced to leave their home areas because of their sexual orientation, gender identity, or HIV status, because these factors stemmed from human rights violations (Zea et al., 2013).

Because this population is largely invisible and highly stigmatized, it took some time to recruit the first participants. Initial referrals were transwomen because they were most readily identified by referring Colombian service providers as gay, but eventually we recruited male-identified participants through other participants. Thus, partnerships and participant trust were critically important to reach the population of interest. Ages of those providing life history interviews ranged from 19 to 48; the mean age was 28.6. Fourteen of the 42 were transwomen, 1 identified as a heterosexual man, and the remaining 27 self-identified as gay or bisexual men.

The interviewers engaged in respectful communication with participants who had seldom had the opportunity to share their life experiences with outsiders in a safe environment. The resulting subjective narratives, told by the legitimate actors within them, revealed much about the lives of Colombians with intersecting identities as internally displaced, poor, gay, bisexual, or transgender. Asking individuals living in conditions of high vulnerability to share their life histories allowed for the generation of broad, human responses that illuminated pressing issues that were not limited to the domain of health and encouraged participants to view themselves as actively involved in decisions regarding their bodies and being. These dialogic interactions were in contrast to the participants’ frequent experiences of discrimination and stigmatization, including those encountered during displacement and in interactions with institutional powers.

Our attempts to maintain egalitarian dialog were also applied to the process of analyzing the qualitative data. Interviews were digitally recorded and transcribed in Spanish and entered into NVivo8 for coding and analytic purposes. Coding was constructivist and iterative: a conceptual framework and a preestablished set of codes guided the coding process, but open coding and memos (coders’ notes to themselves and to other coders) were used to allow for continued revision of the subcategories. Codes changed as a result of new and different insights stemming from analysis of discrepancies and were also augmented as new categories emerged. 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.

The qualitative data analytic group included the two Colombian experts and three researchers in the United States: a woman who was a native Spanish-speaker, a bilingual U.S.-born Latina graduate student, and a bilingual, bicultural researcher. Each life history interview was coded by four team members working in teams of two; the fifth researcher reviewed the coding done by the two teams of coders to identify discrepancies between groups, and the team met via Skype to resolve discrepancies (Zea et al., 2013).

The insight and understanding of the Colombian team members was critically important during the analytic phase. There were instances in which the U.S. coding team did not capture an accurate meaning of a narrative, not because of lack of Spanish language skills but due to local expressions and nuances that required the native team’s understanding and interpretation. A memorable example was one case in which a participant seemed to express that he had been gang raped, when in fact he was talking about being teased by a whole group. Moreover, the Colombian team members often wrote insightful memos that situated participants’ lived experiences within the historical, cultural, and political contexts. The U.S. team members acknowledged that without such memos, their depth of understanding of the participants’ narratives would have been more limited, and the knowledge generated would not have been adequately contextualized.

Quantitative Component

Similar to the situation with qualitative methods, we tried to institute procedures relative to our quantitative methods that would engender noncoercive communication. We believe that the resulting aggregated information is especially valuable for providing an objective description of the needs, experiences, and perspectives of the group, which can form the basis for the development of public policies. In this section we describe the development and administration of a quantitative survey.

The survey included questions concerning demographic background, sexual behavior, displacement, trauma, and discrimination. Another section concerned knowledge and attitudes toward circumcision. Preliminary findings have been reported elsewhere (Gonzales et al., 2012; Zea et al., 2013). Qualitative findings from the life history interviews described above, as well as key informant interviews and focus groups, were used to refine the quantitative survey and make content relevant to the lives of participants. The survey was programmed using audio-enhanced computer-assisted self-interviewing software and administered using touch screen laptops. In keeping with our approach of including community perspectives and knowledge in the design of the research, we sought participant input on the survey via two additional focus groups. These groups comprised GBT individuals of diverse ages, educational levels, and socioeconomic statuses. The egalitarian discourse in the groups provided feedback that enabled us to refine questions and to ensure relevance to Colombian reality. After some changes, the survey was administered to a pilot group of 100 participants and subsequently revised for administration to the final sample of 1,000.

Administration of the survey took place at LigaSIDA (Colombian League against AIDS). LigaSIDA is an organization widely recognized by MSM in Bogotá as a safe space for individuals of diverse sexual orientations, gender identities, and HIV status. The organization of the physical space allowed privacy and anonymity for participants. The space had been recently remodeled, and therefore, it was esthetically appealing and conveyed respect toward participants.

Participant recruitment took place using respondent driven sampling. In contrast with the life history interviews, being displaced was not a requirement for participation in the survey. Being born male, aged between 15 and 49 years, and having had sex with a man in the past 6 months were eligibility criteria. Bogotá has 19 localities, and all were represented in the final sample, reflecting great geographic diversity. Respondent driven sampling was a very efficient way to recruit the invisible population of displaced GBT individuals, as well as the more accessible but still somewhat hidden population of nondisplaced GBT individuals. For this article, we focus on the subset who self-reported having been displaced at some point in their life, that is, 113 out of 1,000 participants.

In the quantitative survey, participants could attribute their displacement to multiple causes. Only 7% of the 113 displaced GBT individuals reported being displaced as a result of politics. Forty-two percent reported displacement caused by violence, and 41% said that they had been threatened. Sexual orientation was selected as a reason for displacement by 38%. It is interesting to note that the most common reason cited for displacement was family rejection (43%). Thus, it is evident that homonegativity plays a role in contributing to internal displacement of GBT individuals.

Quantitative data also revealed differences in the life experiences of displaced and nondisplaced participants. Comparison of the two groups confirmed that displaced individuals had undergone higher levels of lifetime sexual and physical violence than nondisplaced individuals. For example, displaced participants reported more frequent experience of a variety of violent attacks, including having been threatened with a weapon, attacked with a knife, beaten, or tortured. With regard to HIV risk, displaced participants were significantly more likely to have been raped. In addition, displacement was associated with a greater likelihood of having engaged in exchange sex.

Because of the egalitarian atmosphere that we tried to create in the research setting, some participants gave us feedback about their reactions to and perceptions of the research process, including procedures around informed consent, instructions for the survey, the survey itself, and HIV counseling and testing. Their willingness to contribute in this way suggests that the participants felt validated and respected in the research setting. Several study participants noted the respectful and informative atmosphere and reported the sharp contrast with their experience in some health care settings. With each person, we would spend approximately 45 minutes providing pre- and posttest counseling, answering questions, and providing information about HIV/AIDS, STIs, condom use, and transmission myths. Every effort was made to refer newly diagnosed participants for medical care and to inform them about their right to receive health care according to Colombian laws regarding HIV/AIDS. As a result, some participants reported that they felt enabled to request medical attention. Thus, the noncoercive communication environment was beneficial, and even though it was not intended as a direct intervention, it led to greater empowerment.

Richness of Mixed Methods Findings

The use of mixed methods provided us with a plethora of findings and perspectives in a variety of domains. Analysis and writing of manuscripts from this project is still ongoing. Below are two examples of the ways in which mixed methods afforded a rich portrayal of the lived experience of participants.

Relative to sex work, quantitative data identified displacement as a driving force motivating many individuals to engage in sex work, whereas qualitative data provided a nuanced understanding of the experience of sex work. The latter revealed that in addition to the widespread financial need and greater sexual risk during the period immediately after displacement and arrival in Bogotá (Bianchi et al., 2014), there were some positive aspects of sex work. Some participants in qualitative interviews, particularly those who exerted control over their work circumstances, reported that sex work allowed for self-sufficiency and provided a sense of empowerment. Among transwomen, sex work also served as a context in which to enact femininity.

HIV testing was another domain in which the combination of quantitative and qualitative methods allowed us to gain greater insight. After quantitative findings indicated extremely low rates of HIV testing in a group with high HIV prevalence and vulnerability, it became urgent to understand reasons for such low rates of HIV testing in our sample. We conducted additional key informant and in-depth interviews to explore factors underlying these results. Quantitative and qualitative findings pointed to the combination of structural and personal characteristics as barriers to testing (Reisen et al., 2014). For instance, type of insurance coverage, varying bureaucratic procedures, perceived risk of HIV, and fears related to testing and disclosure affected individuals’ ability or motivation to obtain testing.

Dissemination as Political Advocacy and for Social Change

Another important aspect of this research project related to Communicative Action Theory stemmed from our belief in the importance of dissemination of findings among members of the target community, as well as among people in power to effect change at the policy level. We reported preliminary findings to former participants who had expressed an interest in the results of the study. Both the Colombian and the U.S. team members invited representatives from nongovernmental organizations, graduate students, former participants, and HIV/AIDS or LGBT activists to a meeting. In this context of egalitarian discourse, we listened to participants and community members and incorporated their reactions to and interpretations of the preliminary findings into the writing of this article and others. This type of process has been suggested to help produce socially valid knowledge (Puigvert, Christou, & Holford, 2012).

The interactions in the community meeting contributed to the process of triangulation, which involved not only the researchers’ integration of qualitative and quantitative results but also the community’s interpretations of findings. Moreover, in the noncoercive dialog and discussion of findings derived through qualitative and quantitative methods, the intersubjective or social world of the GBT participants was both demonstrated and further explicated. We believe that continuing to examine the data in this type of forum can deepen our understanding and foster communicative action and social change. Consistent with Communicative Action Theory, we have seen that individuals and groups often excluded from academic discussion or society “can make significant contributions to research, from the design to the analysis and dissemination of main findings” (Gómez, Puigvert, & Flecha, 2011, p. 237).

We also presented preliminary results on HIV prevalence to representatives from the Colombian government health sector, as well as from international organizations working on HIV/AIDS in Colombia. Preliminary findings and the body of knowledge generated by these public discussions have the potential to promote a more consensual and informed approach to establishing social and health priorities (Wuthnow, Hunter, Bergesen, & Kurzweil, 1984). The presentation and publication of findings can help bring the experiences of internally displaced GBT individuals to decision-makers and thereby provide greater representation of the needs of this marginalized community. The use of mixed methods was effective in this situation because qualitative findings offered nuanced details and compelling personal stories, and quantitative findings afforded a group portrait and an indication of the extent to which the personal experiences are generalized. The presentation of findings from mixed methods research encouraged dialog between different constituencies with various levels of power. Through the use of mixed methods, new socially valid knowledge that gives voice to marginalized populations can contribute to the promotion of social change.

Conclusions

Research projects that target understudied marginalized populations such as displaced Colombian GBT individuals entail complex processes. As stated by Mertens (2007), “The reason we need good mixed methods research is that there are real lives at stake that are being determined by those in power” (p. 214). We attempted to generate an egalitarian dialog among all partners and participants, and we believe that in doing so, we were better able to explore the subjective, objective, and social worlds of Colombian displaced GBT individuals. We believe that more egalitarian and inclusive policies could result from listening to the voices of participants and the community, and the amplification of those voices to the sometimes deaf ears of government and state may be necessary to accomplish social transformation. Dialog with participants and among researchers, as well as with decision makers and others, is a step toward generating knowledge that includes stakeholder input and informs social change. We hope that our efforts to engage in useful, respectful, and meaningful research will be of interest to other scholars seeking to involve marginalized populations in social action research. The products of this research study are the fruits of engaging in communicative action.