HIV Vulnerability and the Erasure of Sexual and Gender Diversity in Abidjan, Côte d'Ivoire

Abstract

In the fight against concentrated HIV epidemics, men who have sex with men (MSM) are often framed as a homogeneous population, with little attention paid to sexual and gender diversity and its impact on HIV vulnerability. This article draws on ethnographic research conducted in Abidjan, Côte d'Ivoire among les branchés – a local term encompassing several categories of same-sex desire and practice. In the context of increased HIV prevention programming targeting Ivoirian sexual and gender minorities, such diversity is effectively erased. This obfuscation of difference has particularly negative impacts for travestis, who may be at higher risk for HIV infection, though research and prevention efforts in which they are grouped with “MSM” render them underrepresented and make their vulnerability difficult to quantify. Branchés whose class and/or ethnic backgrounds compound their stigmatized status as sexual and gender minorities also bear the burden of this exclusion. Furthermore, some branchés deploy “MSM” as a form of self-identification, further complicating who such categories represent. By highlighting the ways in which constructions of gender and sexuality within HIV/AIDS programming obscure complex social realities, I aim to reorient thinking around the development of purposeful HIV programming that engages the complexity of sexual and gender minority experience.

Introduction

In this article, I offer an ethnographic examination of the ways in which constructions of gender and sexuality within HIV/AIDS programming obscure the complex social realities of sexual and gender minorities in Abidjan, Côte d'Ivoire. Drawing on research conducted in Abidjan among les branchés – a local term encompassing several categories of same-sex desire and practice including travestis and transgenres, woubis, yossis, and increasingly “MSM” – I explore the erasure of difference and the creation of new boundaries of belonging and exclusion in the context of increased HIV prevention programming targeting Ivoirian sexual and gender minorities. Throughout this article, I focus on the category of “men who have sex with men” (MSM), a term often assumed to be apolitical and “outside” of culture because of its relationship with evidence-based interventions and an unyielding focus on identifying risk practices and behaviors. I argue that such uncritical use of language in HIV/AIDS programming and research overlooks the diversity of sexual and gender minority experience and fails to address the ways in which complex, intersecting and overlapping social realities may shape HIV vulnerability. In fact, this language effectively erases certain populations from the category of MSM, thus excluding them from HIV care and prevention. In Abidjan, this exclusion is perhaps most felt among travestis and transgender persons, whose vulnerability to HIV is shaped by both the state-sponsored violence and victimization that they experience as gender trangressive sex workers, as well as their exclusion from branché spaces and broader society (Thomann 2014; Thomann & Corey-Boulet 2015). Other branchés whose class and ethnic backgrounds are stigmatized within broader cosmologies of belonging in Côte d'Ivoire (Akindès 2001; Akindès 2004; Cutolo 2010; Konate 2006; Marshall-Fratani 2007; McGovern 2011; Newell 2006, Newell 2012) also feel this exclusion. Thus, certain branches find themselves excluded from the institutional spaces and programs, and thus the resources and “community”, intended to serve them.

Many branchés further identify themselves and others according to “local” categories such as woubi, yossi, and travesti. These seemingly local identifications are complicated by and run parallel to the term MSM, which is claimed and deployed by some sexual minority men in Abidjan, particularly those with ties to local non-governmental organizations (NGOs). These branchés deploy “MSM not only as a bio-behavioral risk category in their community-based HIV prevention work, but also as an emic identity category with a set of symbolic meanings of its own. This political and strategic negotiation of the MSM category by some is not to suggest that all branchés deploy this identification when referring to their same sex practice, desire, or identities, nor that other terms are not available and in wide circulation in Abidjan (indeed this article will discuss many of them). However, I argue that the deployment of the MSM category by branchés in Abidjan destabilizes the assumed coherence of epidemiological and evidence-based perspectives that imagine sexual and gender minorities as a universally comparable subpopulation and argue that enumerative regimes articulate with local identity politics to create new and unexpected forms of sociality.

Following recent anthropological scholarship, (Boellstorff 2011; Lorway & Khan 2014; Parker & Aggleton 2015), I do not advocate for purging the acronym MSM or any of its derivatives from our vocabulary. For all of the label's shortcomings, this article will not outline a plan for eschewing the MSM category in favor of one or a few other emic categories. Such a substitution would not guarantee more inclusive depictions of gender and sexual subjectivities and may enable the reification of cultural categories, as they are “fed back into HIV and AIDS research as seemingly culturally inherent forms of sexuality…” (Boyce, 2007, p. 176). In Abidjan, a turn to emic categories in HIV prevention and programming would entail its own set of erasures because not all branchés have the same operational definitions for and lived experiences of local identifications. Furthermore, these identifications overlap with other social realities, including class and ethnicity, in meaningful ways.

Thus, this article tackles the following questions: How are the specific cultural categories used in HIV prevention programming locally interpreted and embodied? How should public health practioners and researchers understand travestis, who may or may not identify as transgender and whose risk factors overlap with but are distinct from most gender normative men? Who does “MSM” represent as a culturally “neutral” risk category if it has been transformed into a culturally loaded form of identification? What are the ideological aims of MSM “body counts” (Nguyen, 2010, p. 178-180) and how are they shaping the landscape of HIV/AIDS prevention? What new forms of sociality are produced by evidenced-based interventions and global health research targeting gender and sexual minorities?

Methods

Between 2010 and 2012, I conducted eight months of ethnographic fieldwork in Abidjan, primarily in two community-based NGOs – Alternative-Côte d'Ivoire (Alternative) and Arc-en-Ciel + (Arc-en-Ciel) – as well as a clinic with which the HIV peer educators and activists in both NGOs collaborated. Other than Claver, who, as the Executive Director of Alternative, is a highly visible public figure and who insisted that I use his real name, I have assigned research participants pseudonyms to ensure their anonymity. At the request of leadership at Alternative and Arc-en-Ciel, which have been highly publicized in both the local and foreign press (Corey-Boulet 2012, 2013, 2014; Fioriti 2014; Kouassi 2011;), I have retained the real names of both organizations.

Research Participants

The findings presented in this article are not representative of all sexual and gender minorities in Abidjan. As Patrick, the former Head of Monitoring and Evaluation for Arc-en-Ciel, explained to me in 2012 – the branché milieu touched by HIV prevention programming is only the “tip of the iceberg.” This is perhaps most evident in the relative absence of women in leadership positions within the local nonprofit industrial complex (Rodriguez 2007; Smith 2007; Spade 2011), which marginalizes and overlooks the particular vulnerabilities of sexual minority women through its focus on counting and enrolling MSM into research and interventions.

Though on the periphery of the homosocial milieu, the lives of my branché research participants were deeply tied to a diverse set of individuals identified as female from birth. Some had developed close friendships with lesbian-identified women and joked about marrying such women to please their families, while maintaining romantic connections with other branchés. Other branché research participants had or previously had intimate, sexual relationships with women and a few had married and/or had children with women. Most of these men identified as bisexual but also as branché. As the branchés that I came to know explained to me, bisexual practice and desire did not preclude inclusion in the branché milieu.

Interviews

I conducted interviews with HIV peer educators, activists, and branchés who frequented these milieus. Interviews were conducted in French and touched on a variety of themes about the experiences of gender and sexual minorities in Abidjan. Perhaps most pertinent for the purposes of this article, I asked branché research participants questions about their subjective experiences of sexual and gendered identifications and how they are or are not related to the HIV/AIDS programming in which they participate to varying degrees. I also asked research participants to discuss their experiences with violence, broadly defined, and the divisions that exist within the community and within NGO spaces in particular. In total, I conducted, audiotaped, and transcribed interviews with 45 members of Arc-en-Ciel and Alternative, as well as branchés who used their services or regularly hung out in their headquarters. Of these interviews, 24 were conducted with peer educators and activists employed by Alternative and/or Arc-en-Ciel, 10 identified as travestis or transgender (one of whom was also a peer educator at Arc-en-Ciel), and 12 were members or “clients” of Alternative and/or Arc-en-Ciel.

Participant Observation

My participant observation at the headquarters of Alternative and Arc-en-Ciel were filled with the quotidian activities of the organizations. I recorded field notes, observed, and asked questions as staff prepared for last-minute audits conducted by foreign donors and intermediary NGOs, sat in on organizational meetings, translated reports and budgets, and participated in support groups and weekly discussions activities. I also spent several hours per week socializing with branchés outside of the NGOs. My daily participant observation in NGOs and other “safe spaces” (mostly bars, restaurants, and branchés' apartments) was also guided by questions concerning the relationship between how branchés understood and organized themselves in relation to the ideas, norms and values promoted by HIV prevention programming and by Ivoirian society more generally. I supplemented participant observation with a mapping project (Thomann 2015) and archival research, including analysis of US President's Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans, organizational documents and budgets, and national and international media coverage pertaining to issues of homosexuality.

“MSM”, foreign interventions and sexual and gender minority organizing in Abidjan

A basic, university library search will turn up nearly 50,000 results when queried for “men who have sex with men.” The ubiquity of the MSM category in public health is tied to epidemiological and evidence based logics and the imperative to generate data that can be analyzed statistically, with the aim of uncovering some “truth” about a population. This logic situates qualitative work as anecdotal and unscientific. Like the randomized controlled trials (RCTs) described by anthropologist Vincanne Adams, the MSM category “eliminates the need for data collection about complex social realities” (Adams, 2013, p. 71), and supplants qualitative evidence on sexual identity rather than being used alongside it (Young & Meyer, 2005, p. 1144). In an effort to scale up testing among “most at risk populations” the MSM category is used to identify and group a population and to document their coverage in interventions, the results of which may then be quantified (Nguyen, 2010, p. 180). However, as I will show, some gender and sexual minorities “do not count” as MSM. And though the MSM category has been internalized and reappropriated by some sexual and gender minorities in Abidjan, it remains a deeply normative category and a means by which branchés establish boundaries for group membership (Lorway & Khan, 2014, p. 52).

From an epidemiological perspective, the push towards a category of practice that is culturally universal and therefore measurable and quantifiable is understandable. Globally, men who have sex with men shoulder a much greater HIV-burden than the general population. In sub-Saharan Africa, approximately 5% of the general population is living with HIV, compared to nearly 18% of men who have sex with men (Beyrer et al., 2012). This distribution is strikingly similar in Abidjan, where 5.1% of the general population is HIV+ (PEPFAR, 2013), while 18% of men who have sex with men in Abidjan are living with HIV (Aho et al., 2014, Hakim et al., 2015; Vuylsteke et al., 2012). However, this universalizing category of practice, which eschews identity in favor of behavior, erases a significant amount of heterogeneity. Furthermore, the enumerative rationality of epidemiology and evidence-based interventions is more complex than the desire to save lives. Sexual and gender minorities have become part of an industry wherein continued financial support is contingent upon counting and enrolling them into international programming.

When I first arrived in Abidjan in the summer of 2010, Alternative and Arc-en-Ciel ran their programs on small budgets funded by French NGOs and had few paid staff. Arc-en-Ciel was housed in a bare, one-room office and the newly-formed Alternative had no official headquarters and held its meetings in private homes. A PEPFAR-implementing partner had begun working with Arc-en-Ciel activists in 2007, employing them as peer educators to provide counseling in the clinic. Despite this progress, controversy over governance and leadership and rumors of financial misconduct had begun to divide the staff members at Arc-en-Ciel. Feeling that the organization's reputation had taken a major hit and after repeated disagreements over leadership, Claver and a few other key members of Arc-en-Ciel left to create Alternative in 2010, shortly before I arrived.

By the time I returned to Abidjan in 2012, PEPFAR was financing a $1.7 million project aimed at improving access to HIV prevention and care for men who have sex with men and female sex workers. And there was a new player in town. Heartland Alliance International (Heartland), the global arm of a nearly $82 million Chicago-based NGO, had responded to PEPFAR's 2010 call for a new “primary partner” to work with “highly vulnerable populations” (PEPFAR, 2010). Their project provides technical and financial support to 12 clinics across Côte d'Ivoire and to three community-based NGOs in Abidjan, including Alternative and Arc-en-Ciel. Both organizations acquired large headquarters, well equipped with computers, office furniture, LCD projectors, and Wi-Fi capabilities and employed government-certified HIV peer educators with different titles, responsibilities, and pay scales. This outsourcing of HIV prevention programming and testing is part of broader trends in the commodification of testing (Fan, 2014, p. 86) and came with the expectation that these “community members” would recruit an ever increasing number of MSM into intervention programming, data which they can then use to prove a “return” on donor investments.

When Heartland arrived in Abidjan in 2010, they entered a complex network of advocacy and organizing around issues faced by branchés. In 1994, militant travesti activists, who later formed an organization called Association de Travestis de Côte d'Ivoire [Travesti Association of Côte d'Ivoire], stormed the headquarters of an Ivoirian newspaper that had published an inflammatory report about the community, assaulting journalists and breaking windows (Nguyen, 2010, p. 165). A few years later, a French-documentary entitled Woubi Cheri (Brooks & Bochaut, 1998) chronicled their work and was aired in Abidjan on Canal +. After its leader, an outspoken travesti named Barbara, emigrated to France, the organization lost momentum. Despite this setback, a homosocial milieu has flourished in Abidjan for over four decades (Broqua 2012; Nguyen 2010; Vidal & Le Pape 1984) and the milieu have long used a coded language, known as woubi-can, in order to identify one another in social and intimate settings and to remain discreet. Understanding this language, its limitations, and the politics of its use is imperative to ensuring fuller representation of sexual and gender minorities in Abidjan in current research and programming.

Branchés in focus: The language and politics of “MSM health” in Abidjan

In Abidjan, sexual and gender minorities identify themselves and one another as les branchés, a euphemism long used in place of words such as homosexual and gay (Nguyen, 2010, p. 163). The literal English translation of the French verb brancher is “to connect” or “to plug in,” as in an electrical cord. Though likely seen as dated in the contemporary French context, the adjective branché can be used as slang to identify an individual as “hip” or “trendy,” and thus “plugged in” or “connected” to popular culture. In Abidjan, sexual minority men and travestis employ this identification in public settings, without passersby comprehending its hidden meaning^†. However, whom exactly the branché identification constitutes is hardly agreed upon. When I asked HIV peer educator Alain about the identifications he used to describe himself, he first stated that he used the French homo to connote his sexuality identity. When I asked him if he also employed the word branché, he admitted to using it, adding,

It means more, though [than les homos]. I would say that a branché is someone who is homo and someone who knows a lot more. There are people who are homo but who aren't branché. That means they don't go out. They don't go to the branché bars. They are at home. They stay camouflaged in their corner.

Within the localized category of practice of branché, there exists a diverse set of identifications. This form of in-group identification forms part of a “flexible language” (Leap 2004), whereby branchés sometimes self-identified using North Atlantic terms such as the English “gay” and the French homo while other times employing woubi-can, which allowed them to have discreet discussions about broad sexual preferences, specific sexual acts, penis size, and preferred sexual position. During one meeting, Jean, an HIV peer educator and proud woubi explained:

We use woubi only between branchés. All the branches know what woubi and yossi are. You know what it means to gnazri [to fuck]. You know what gbali [dick] means. You know what tchapa [rectum] means. It's our language. If you are branché you should know all of that. If you don't know what they mean, you are not branché. We call it woubi-can.

I first learned of woubi-can in 2009 while watching Woubi Cheri, the 1998 documentary that followed Barbara the leader of Association de Travestis de Côte d'Ivoire. In one of the opening scenes, Barbara discussed the coded language with a woman whom she identified as heterosexual:

We have our own dictionary, our own way of talking. So, for example, when we say woubi, woubis are boys who play the role of the woman, who aren't necessarily travesti, who remain boys and who love men. Me, I am a travesti, it's special. Well, they call me woubi too because despite everything, I am a boy but I behave like a woman. And then there are the yossis. They are boys who sleep with women, travestis, and homosexuals. They are boys who keep their role. They play the role of the boy. They are the ones who behave like boys. They are the husbands of the woubis.

As Barbara highlighted, and as was confirmed by nearly every branché with whom I spoke, woubis played the role of les femmes [women] and yossis of les hommes [men]. As Barbara pointed out, travestis deserve special consideration. Branchés use the category of travesti to refer to individuals born anatomically male who live their lives as women on a full or part time basis. Some travestis undergo hormonal therapy to produce secondary sex characteristics associated with women, such as breast growth, fat redistribution and the thinning of body hair (Thomann & Corey-Boulet 2015). Still, travestis should not be uniformly considered to be transgender women. Like the Brazilian travestis described by anthropologists Don Kulick, many travestis “did not conform to standard northern Euro-American sexologies” (Kulick 1998, p. 12) and most of those I came to know were only marginally aware of “transgender” as a social and political category. In Côte d'Ivoire, the definition of a travesti varies widely, even among travestis themselves. Points of contention include how often one must dress and present as a woman to qualify as a travesti as well as whether sex work is an essential component of travesti identity. Julie, a young branché peer educator who had recently began taking hormones and living as a woman after leaving her parents home, explained this diversity:

There are transgender women (transgenres) who live strictly as women as often as possible. Like me, like Sarah [another travesti]. There are also travestis who are professional sex workers, some of whom change just at night to do sex work. During the day they are dressed as men. There are also transgender women who are sex workers, like Sarah, who live strictly as women and who are sex workers. And there are occasional transgender women who do it maybe just two times each year.

Thus, while Barbara suggested that she is “despite everything, a boy,” in contemporary Abidjan, branché definitions of who constitutes a travesti vary widely (Thomann & Corey-Boulet, 2015).

Despite the ubiquity of terms like woubi, yossi and travesti, they are not recognized as salient categories by major donor institutions and the international NGOs that act as intermediaries between these donors and Arc-en-Ciel and Alternative. In their recent summary of their cross-sectional, bio-behavioral surveillance study on MSM, Aho et al. (2013) do not explore the woubi/yossi distinction or how it may shape vulnerability to HIV. Though they did ask survey respondents whether or not they identified as travestis, only 2% of the sample identified as such, providing little evidence about how their experience might differ from that of gender normative branchés. Descriptive statistics of these categories were only presented in the original report (Semde-Abla 2012) but were ignored entirely in subsequent publications (Vuylsteke et al. 2012; Aho et al. 2013; Hakim et al. 2015). Furthermore, questions posed about the gender of respondents' sex partners did not include travestis or transgender persons as an option, providing minimal information about the extent to which gender-normative men who have sex with men engage sexually with travesti and transgender partners. These and other questions assume that respondents understand travestis as “men who have sex with men,” though perhaps more effeminate versions of themselves, an assumption that does hold true for some branchés (Thomann & Corey-Boulet 2015) but also miss an opportunity to engage the complexity of sexual and gendered identifications and the reality of their practice.

It is worth considering, though, what the wholesale adoption of terms like woubi, yossi and travesti would add to current HIV prevention efforts in Abidjan. Cultural competence advocates might argue that adopting the woubi/yossi dichotomy into HIV prevention programming makes sense. If researchers had clear and culturally specific roles then they would be able to envision two discreet risk groups, while having the added benefit of resonating with the local population. Like those gendered homosexualities in rural South Africa discussed by anthropologist Graeme Reid, the categories of “woubi” and “yossi” reveal a “sharp distinction between masculine and feminine, with a marked hierarchical aspect that resonates with a heterosexual model” (Reid, 2012, p. 59). However, my branché research participants described these as idealized categories, suggesting that they offer little insight into the lived experience of sexual and gender minorities. Many of the branchés that I came to know during my research suggested that there is more fluidity in branché relationships than the dichotomous terms woubi and yossi imply.

Thus, integrating emic categories into current prevention efforts runs the risk of the same kind of reification and oversimplifications that the MSM category is guilty of, when in fact, those who practice these identifications recognize them as anything but. Merely integrating woubi-can terms into HIV prevention language without a critical understanding of the ways in which other social realities complicate lived experience would lead to the same kind of homogenization as the category of MSM. In the following section, I turn to the ways in which issues of gender normativity, class, ethnicity, and even religion shape lived experiences of these categories.

NGOs as sites of social ordering

When Alternative and Arc-en-Ciel were chosen as subcontractors on the PEPFAR-funded project in 2011, their new headquarters became spaces in which increasingly large numbers of branchés gathered to celebrate national holidays, hold dance parties, and attend HIV prevention and identity workshops. Because of the deeply heteronormative context in which they live, branchés came together in these spaces to socialize, to learn, and to build relationships. But while NGO spaces seemingly disrupted Abidjan's heteronormativity, they were also sites for the reproduction of various forms of social exclusion. HIV peer educators and activists asserted moral orders that reflected their assumptions about what kinds of branchés belong – and where. In this section, I show that inclusion in community-based, HIV prevention programming for branchés is circumscribed by other social realities which create “zones of exclusions” (Lorway & Khan 2015, p. 60) and raise questions about the extent to which branchés are covered by current HIV research and prevention programming.

Branchés who come from the northern regions of Côte d'Ivoire, who are Muslim or were raised in Muslim families, and/or who have a sub-standard level of education found it difficult to fit into the new milieus that have emerged around NGOs like Claver's Alternative. Stigma within the community has resulted in low participation from branchés living in Abidjan's northern neighborhoods and a rift between branchés in communities like the northern Ivoirian and Muslim-dominated neighborhood of Abobo and those residing in neighborhoods that NGO activists and peer educators deemed “gay friendly,” creating a moral geography of belonging to Abidjan's branché milieu (Thomann in press). On numerous occasions, I witnessed HIV peer educators and activists single out branchés from Abobo for being too loud, too flamboyant, and too aggressive. They claimed that branchés from Abobo were less versed in proper social decorum and etiquette and unconcerned with their visibility in neighborhoods that were not their own. Even branchés who did not work as peer educators or activists confirmed the existence of such stigma and its links to cosmologies of modernity and belonging in broader Ivoirian society. Ibrahim, himself un gen du nord [a person from the north], but born in Abidjan, provided his own explanation of such stereotypes:

It's sad but there is truth to the stereotypes about branchés from Abobo, like that they like fights and that they are poorly raised and all of that. In my opinion, it's because people from Abobo are mostly from the north of Côte d'Ivoire, where I am also from. And we, the people from the north, we are said to be hot-blooded…So they don't know how to behave well in society.

These branchés were often ridiculed for their ethnic, linguistic, or cultural backgrounds in the same spaces they sought tolerance on the basis of their sexual orientation and/or gender identity. HIV peer educators, activists and members of the organizations saw branchés residing in northern districts as drawing unwanted attention with their uncouth behavior, as victims of a culture of poverty that made them prone to aggression, and as unable or unwilling to become “modern” Ivoirian branches (Thomann, in press).

Travestis also confronted stigma from gender normative branchés, compounding their vulnerability to state-sponsored violence in the wake of Côte d'Ivoire's brief, but all too familiar, political conflict. A month after the Ivoirian government recognized Alternative as a legal NGO, Ivoirians went to the polls to elect a new president, only the third election in Ivoirian history. When incumbent President Laurent Gbagbo refused to cede power to the internationally recognized victor Alassane Ouattara, the country erupted into bloody violence. Following the 2010-2011 post-election crisis and regime change, a new military presence rendered branchés, and travesti sex workers in particular, more vulnerable. The Forces Républicaines de Côte d'Ivoire (FRCI) are former-rebel members of the Ivoirian armed forces with a reputation for being violent, hostile and extortive. During my research in 2012, the FRCI attacks on travesti sex workers had been the subject of much discussion at Alternative and Arc-en-Ciel. And yet, travestis rarely frequented, nor were they particularly welcomed at, the community-based NGOs. Indeed, throughout my research, travestis' presence at Alternative and Arc-en-Ciel was a subject of much controversy. There were numerous occasions on which gender normative HIV peer educators and activists discouraged travesti participation in events sponsored by the NGOs. For example, when planning for one of their “mass HIV sensitization” events, Kouadio, a 23-year-old peer educator, organized a small faction of the staff to instill an unofficial policy of not giving out invites to travestis and to telling those lucky enough to receive one not to bring anyone “who would dress like a queen.” Furthermore, at weekly “identity workshops,” HIV peer educators and activists relayed messages concerning a variety of gender non-normative behaviors that could attract unwanted attention to the individual and to the milieu more broadly, highlighting the behavior of travestis as particularly problematic. Even the Executive Director of Alternative, Claver, told me unabashedly when asked,

If you have to dress as a travesti, that's going to cost you your family. It's not worth doing it. I call those things that aren't necessary… I can't keep people who feel like they are women from doing it [living as a travesti]. But if you think that you can wear a dress and walk in front of a mosque and they are not going to stone you, go right ahead. Because you know that's going to cost you your life.

Increased vulnerability for travestis extends beyond their vulnerability to state-sponsored violence and exclusion from NGO programming – there are also important and underexplored differences in their sexual behavior. While exceptions exist, all but a few of the travestis I've interviewed since 2012 currently support themselves primarily through sex work or have engaged in sex work at some point in their lives. When I asked Jocelyn, a travesti sex worker, if most of the travestis she knew engaged in sex work, she stated simply, “Yes, they are travestis!” Jean, one of the few HIV peer educators who was friendly with many travestis, suggested that sex work is an essential part of their lived experience. He explained, “I think that travestis are very different from gays, the other gays. A travesti doesn't have the spirit of someone who is not travesti. You see? They have their separate thing. That is the trottoir [stroll]. The travesti is the stroll. They don't have time to insert themselves in activities that don't bring them anything.”

Thus, travestis and branchés from the northern districts of Abidjan were not only vulnerable to violence and discrimination because of their sexual and gendered identifications, but also because they faced discrimination and exclusion from the same organizations meant to improve their conditions. Furthermore, there are important differences in behavior to consider. Travesti's involvement in sex work rendered them more vulnerable to HIV and violence. Excluded from the very spaces meant to provide inclusion based on sexual orientation and gender identity, northern branchés and travestis were effectively cut off from the interventions, resources, and “community” intended to serve Abidjan's sexual and gender minorities. These networks offer political inclusion and new opportunities for self-fashioning to only certain members of Abidjan's branché milieu, while further entrenching existing forms of exclusion. In the following section, I examine the deployment of the identification “MSM” and consider the new social boundaries enabled by MSM interventions.

“We're an industry”: The Making of MSM

Anthropologist Tom Boellstorff has suggested that the term MSM “may be on its way to becoming a globally dominant identity category” (Boellstorff, 2011, p. 288) that is altogether different from what public professionals had in mind when they began employing the acronym to connote sexual behavior instead of identity. In this section, I argue that interventions targeting men who have sex with men do more than describe sexual and gendered subjectivities, “rather they are one of the discourses available through which people might conceive what they understand their sexuality to be” (Boyce, 2007, p. 184). Institutions like Alternative and Arc-en-Ciel become those in which gender and sexual minorities come to understand, identify and organize themselves and one another, producing new social relations and entrenching existing ones. I argue that the deployment of MSM as an identity category by local HIV peer educators and activists challenges the widely accepted notion that the category is purely behavioral and demonstrates that MSM interventions are part of a broader industry which shapes new forms of sociality among sexual and gender minorities.

The first time I heard someone say “Je suis MSM,” [I am MSM] was in 2010. I was seated in the offices of Arc-en-Ciel, taking field notes and participating in a staff meeting, when Marius, a young HIV peer educator explained, “We're all MSM, right?” Later, I asked him why he had said “MSM” and not branché, or any of the other linguistic choices sexual minority men held in their repertoire. Marius rolled his eyes, laughed, and said, “MSM, branché, it's all the same.” In Abidjan, many HIV peer educators and activists – and to a lesser extent the branchés served by local NGOs – self-identified as MSM both to me and to one another. During a conversation with Felix, a 28-year-old peer educator and certified HIV tester, he explained its use in local NGO networks: “It's [the use of MSM] in the NGO milieu. It's a language that those who hang out in the NGOs understand. If I say MSM to you and you are not in a MSM NGO, you'll say ‘MSM, what's that?’ If you were in the NGO you would know what that means.

It's a technical term. If you are on the inside.” Branchés also used the term MSM to be discreet in public settings, which woubi-can could also have accomplished. For example, Antoine, the Head of Communications at Alternative described it as follows: “It's a word that you can say everywhere without looking to see if someone is watching. If you say, “I am gay,” everyone is going to look at you. While in the middle of the street you can say ‘I am MSM’ and no one knows what that means.” Not all of the branchés whom I met in Abidjan identified as MSM, indeed most of them did not, but many of the peer educators and activists discussed in this article drew on the MSM category as a form of self-fashioning, whereby they discreetly indexed their same-sex desire, as well as their position within local NGOs.

This dynamic use of the MSM category is tied to shifts in the industry of global public health. Men who have sex with men are one of several marginalized populations (in addition to sex workers and intravenous drug users) on which the global health community has increasingly focused, as its strategy has shifted towards addressing concentrated HIV epidemics. This recently acquired exceptionality is perhaps most evident in the growing industry of donor institutions and NGOs from the global North targeting the HIV epidemic among sexual and gender minorities throughout the global South. As sub-contractors in this system, HIV peer educators and activists are charged with doing the “on the ground” work of reaching men who have sex with men, while staff at Heartland engage in monitoring and program evaluation and conduct financial audits that carry with them the threat of funding cuts. In our discussions about their relationships with foreign donors and intermediary NGOs, peer educators and activists at Alternative and Arc-en-Ciel complained of a relentless focus on numbers-based results. Taped to the wall of Claver's office were poster-board sized Post-Its with “new MSM” targets to be reached that year. These numbers were a constant source of anxiety and frustration for the staff at Alternative. In 2011, Heartland set the target at 1,570 MSM reached. In 2012, the target jumped to 2,153 new MSM. The staff often joked about the enormity of these targets, noting that if targets continued to rise this way in 2013 they would have to start “making MSM.”

In October of 2012, Heartland proposed a performance-based pay system for HIV peer educators working at Alternative and Arc-en-Ciel, which would pay them 500 CFA (approximately 1 USD) per “new MSM reached.” This performance based pay model draws on business models of development that creates competition (between organizations and between staff within the same organization), while turning branchés and other sexual and gender minorities into (single) dollar signs. The proposed program would have effectively removed long-term social support for HIV positive branchés from the organization's formal objectives. Heartland's strategy would also have defunded transportation and activity costs for the HIV support groups and compromised other long-term relationships that peer educators and activists had worked to cultivate with some of the most vulnerable members of the community. Many peer educators and activists voiced these concerns during internal meetings that Claver held to discuss the suggested plan and they coordinated a coalition-based response with other community-based organizations to reject it. Speaking to me hours before that meeting, Claver explained:

With Heartland, if you are a new person, that's great. But if you already came and we already wrote your name down, that means that you are not eligible to take any more condoms. If that's the case, then you can't come back for more. Because they put [in the action plan] that you have to reach 2,000 new people. But just because someone is not a new person doesn't mean that you are going to leave him. With Heartland, it's not like that. Because it's only numbers that interest them.

This enumeration-based programming assumes that data can be generated and analyzed statistically to measure the impact of prevention programming. But who is actually counted among these thousands of MSM? This terminology, intended to lump people together, distracts from other complex social realities and lived experiences, including those of ethnicity, gender performance and class. Furthermore, it threatened to erode social support for HIV positive individuals and reimbursements that HIV peer educators needed in order to continue service provision. Thus, an increasing number of “new MSM” enrolled in interventions did not ensure that the most vulnerable were reached.

As Claver suggested, financial interests are served by this audit culture (Strathern 2000). Heartland, via its PEPFAR grant, puts pressure on HIV peer educators and activists to reach the largest sample of MSM possible. However, this drive for an adequate statistical power belies other forms of diversity that shape HIV vulnerability in the Ivoirian context. In their conversations and actions, activists and peer educators regularly challenged the fundamentally unequal donor/recipient relationship that existed between them and Heartland, between them and PEPFAR, and ultimately between the Ivoirian and U.S. governments. Eric, a 23-year-old peer educator at Alternative said:

In Africa, we [branchés] have become a bit like AIDS. We're an industry. Meaning that most people are taking more care of what is going back in their pockets than the lives of branchés. Organizations care about branchés insofar as they can fill their pockets. They don't care about the health of branchés.

Conclusion

In this article, I have argued that the diversity of sexual and gender minority experience is obscured by the uncritical and reductive language used in HIV research and interventions, resulting in their failure to address the complex and intersecting social realities that shape HIV vulnerability. In Abidjan, this has resulted in questionable coverage of branchés in current research and programming, as the assumption of a homogeneous population of men who have sex with men entrenches the invisibility and exclusion of travestis and Ivoirians of stigmatized ethnic and/or class backgrounds. While I have argued that recent research and prevention ignore the salience of emic identity categories in their work, I have also suggested that the mere integration of local identifications, such as woubi and yossi, would be inadequate to ensure greater inclusion and representation. Researchers and practioners concerned with the health and well being of sexual and gender minorities should not take local identifications to be self-evident. Rather, they must acknowledge the diversity of lived experience within terminologies, and investigate, in local contexts, other social realities that may shape HIV vulnerability.

I have also argued that these shallow conceptualizations of sexual and gender minority experience are linked to the culture (and business) of public health itself, which prioritizes quantitative evidence and considers qualitative knowledge to be anecdotal at best. In order for HIV prevention programming to reach those most in need, it is paramount that researchers begin to think about the development of programming that engages the complexity of sexual and gender minority experience. This includes thinking about the ways in which interventions shape identity. Importantly, as Fan points out in her work on the outsourcing of HIV testing among men who have sex with men in China (Fan 2014), much of the current international HIV funding for key populations requires that NGOs continually redefine themselves in order to exist. Heartland needs HIV peer educators at Alternative and Arc-en-Ciel to produce these numbers in order stay relevant. It is essential to question normative identifications in public health, whether they are imposed by outside forces or developed from within, and to interrogate the goal of using, promoting, and accepting them.

Increased research on the intersections of critical public health and sexuality studies will allow researchers to engage with novel and fluid sexual and gender subjectivities and their impact on HIV vulnerability. Ethnographic research provides a powerful tool for studying both the complexity of the lived experience of sexual and gender minorities and the impact of interventions in shaping new form of social reality and may lead to greater insight into the “broader politics that enmesh and shape global health priorities” (Fan, 2014, p. 95). Ethnographic data that engages both the complexity of lived experience and the impacts of interventions that almost always overlook those complexities could serve as a starting point for rethinking the assumptions inherent in the culture of public health itself. An engagement with this kind of complexity requires a movement away from the logic that devalues qualitative research, prioritizes generalizability and eschews individual experience, as well as a deeper reflection on the ways in which public health culture itself may be contributing to and further entrenching vulnerabilities.