Sexual identity stigma and social support among men who have sex with men in Lesotho: a qualitative analysis

Abstract

Men who have sex with men (MSM) face sexual identity stigma in many settings, which can increase risk for HIV by limiting access to care. This paper examines the roles of social support, sexual identity stigma, and sexual identity disclosure among MSM in Lesotho, a lower-middle income country within South Africa. Qualitative data were collected from 23 in-depth interview and six focus group participants and content analysis was performed to extract themes. Four primary themes emerged: 1) Verbal abuse from the broader community is a major challenge faced by MSM in Lesotho, 2) participants who were open about their sexual identity experienced greater stigma but were more self-sufficient and had higher self-confidence, 3) relationships between MSM tend to be conducted in secrecy, which can be associated with unhealthy relationships between male couples and higher risk sexual practices, and 4) MSM community organisations provide significant social and emotional support. Friends and family members from outside the MSM community also offer social support, but this support cannot be utilised by MSM until the risk of disclosing their sexual identity is reduced. Greater acceptance of same-sex practices would likely result in more open, healthy relationships and greater access to social support for MSM.

Résumé

Les hommes qui ont des relations sexuelles avec des hommes sont souvent en butte à la stigmatisation pour leur identité sexuelle, ce qui peut accroître le risque de VIH en limitant l’accès aux soins. Cet article examine les rôles du soutien social, de la stigmatisation due à l’identité sexuelle et de la révélation de l’identité sexuelle chez les hommes qui ont des relations sexuelles avec des hommes au Lesotho, un pays à revenu faible-intermédiaire enclavé dans l’Afrique du Sud. Des données qualitatives ont été recueillies lors de 23 entretiens approfondis et une analyse de contenu et de participants de six groupes d’intérêt a été menée. Quatre thèmes principaux sont apparus: 1) les insultes verbales de la communauté élargie est un défi majeur rencontré par cette population au Lesotho, 2) les participants qui étaient ouverts sur leur identité sexuelle connaissaient une stigmatisation accrue, mais étaient plus autosuffisants et jouissaient d’une confiance en eux plus élevée, 3) les relations entre les hommes qui ont des rapports sexuels avec des hommes tendent à être conduites dans le secret, ce qui peut être associé à des relations malsaines entre couples masculins et des pratiques sexuelles à plus haut risque, et 4) les organisations communautaires de ces hommes fournissent un soutien social et psychologique important. Les amis et les membres de la famille hors de la communauté des hommes qui ont des rapports sexuels avec d’autres hommes prodiguent aussi un soutien social, mais ce soutien ne peut pas être utilisé par les intéressés tant que le risque de révélation de leur identité sexuelle ne sera pas réduit. Une plus grande acceptation des pratiques homosexuelles résulterait probablement en des relations plus saines et ouvertes et élargirait l’accès au soutien social pour les hommes qui ont des relations sexuelles avec les hommes.

Resumen

Los hombres que tienen sexo con hombres (HSH) enfrentan estigma relacionado con su identidad sexual en muchos entornos, lo cual puede incrementar el riesgo de contraer VIH al limitar el acceso a los servicios de salud. Este artículo examina los roles del apoyo social, el estigma relacionado con la identidad sexual y la revelación de la identidad sexual entre HSH en Lesoto, un país de ingresos bajos y medianos en Sudáfrica. Se recolectaron datos cualitativos por medio de 23 entrevistas a profundidad y seis participantes en grupos focales, y se analizó el contenido para extraer temáticas. Surgieron cuatro temáticas principales: 1) el abuso verbal de la comunidad es un gran reto que enfrentan los HSH en Lesoto, 2) los participantes que hablaron abiertamente sobre su identidad sexual sufrieron mayor estigma pero eran más autosuficientes y tenían más confianza en sí mismos, 3) las relaciones entre HSH tienden a ser llevadas a cabo en secreto, lo cual puede estar asociado con relaciones no saludables entre parejas de sexo masculino y prácticas sexuales de mayor riesgo y 4) las organizaciones comunitarias de HSH brindan considerable apoyo social y emocional. Amistades y familiares fuera de la comunidad de HSH también ofrecen apoyo social, pero este apoyo no puede ser utilizado por HSH hasta que se reduzca el riesgo de revelar su identidad sexual. Mayor aceptación de las prácticas entre personas del mismo sexo probablemente produciría relaciones saludables más abiertas y mayor acceso al apoyo social para HSH.

Key words:

• Lesotho
• male homosexuality
• stigma
• sexual behavior
• social support

Introduction

Men who have sex with men (MSM) are among those at highest risk for HIV infection worldwide.¹ Even in the context of the broadly generalised HIV epidemics of Southern Sub-Saharan Africa, MSM have been found to carry a higher burden of HIV compared to other age-matched reproductive age men.^2,3 In a recent study of more than 500 MSM in Lesotho recruited via respondent-driven sampling across two urban centers, prevalence was 31.1% in the capital of Maseru and 35.4% in Maputsoe.⁴ Prevalence data such as these have been previously described across Sub-Saharan Africa, with MSM estimated to have nearly four times the odds of living with HIV compared to other reproductive aged adults.⁵ In addition, MSM in these regions face high levels of stigma secondary to sexual practices and sexual identities including verbal, physical, and sexual harassment from friends, family members, or broader community members; and discrimination within healthcare settings.^{6 -10} While zero HIV-related stigma has been described as an international goal, a recent report shows that very few of the studies that characterise the burden of HIV or associated determinants of prevalent HIV infections had measured any form of stigma.¹¹ Studies have consistently demonstrated that punitive laws criminalising same-sex practices combined with high levels of stigma and discrimination affecting MSM exacerbate the epidemic by limiting the provision and uptake of HIV prevention, treatment, and care services.^2,12,13

Lesotho is a lower-middle income country in southern Africa with one of the highest burdens of HIV in the world, estimated to be 23.4% among adults aged 15-49.¹⁴ In Lesotho, same-sex acts were decriminalised in 2012 but remain highly stigmatised.¹³ To our knowledge, there are only two studies assessing HIV risks in relation to stigma among MSM in Lesotho, both conducted by the authors.^10,15 Baral et al noted a high prevalence of stigma among these men, with 76% reporting at least one event including rape (10%), blackmail (21%), fear of seeking healthcare (22%), or verbal or physical harassment (60%).¹⁵ Further, Stahlman et al found a strong positive association between stigma experienced from broader community members and depression, as well as an inverse association between social capital and depression.¹⁰ These studies indicated a need for in-depth qualitative studies to characterize a nuanced understanding of the relationships between stigma and social support among MSM in Lesotho.

In such stigmatising social environments, MSM and lesbian, gay, bisexual, and transgender (LGBT) community groups are often the only groups willing to and competent in providing HIV-related services to MSM.¹⁶ These programs also provide social support to communities of MSM in the form of social capital,¹⁷ in that they can strengthen bonds between group members, increase the availability of resources through social networks, improve perceptions of the trustworthiness of others and the ability to work together to solve problems. Improved social capital can result in increased uptake of HIV services and also in greater feelings of connection and self-esteem among MSM.^16,18 In various settings, perceived social support has been associated with increased levels of mental well-being as well as increased preventive health behaviours and lower risk for HIV infection.^10,19-21

Seeking support and resources from peers can be a successful strategy among MSM for coping with sexual identity stigma in highly stigmatised settings.^18,22 In particular, recent research suggests that openness about one’s stigmatised identity can improve the impact of social support on positive health outcomes.²³ However, MSM who have disclosed and are open about their sexual identity often experience greater stigma from members of the broader community, potentially because they are more easily identified as targets for discrimination or harassment.^22,24 Among MSM in sub-Saharan Africa, factors associated with disclosing one’s sexual identity include self-confidence, financial security, and educational attainment.^22,25 MSM also tend to disclose their sexual identity to different individuals based on their anticipated reactions, such as being less inclined to tell a family member who would likely have a negative reaction.²⁶

Overall, a better understanding of sexual identity stigma, social support, and openness about sexual identity could facilitate improved HIV prevention and treatment services, as well as improved mental well-being and self-efficacy of MSM community members. Subsequently, these analyses seek to describe the adverse health and social consequences of sexual identity stigma, the positive influences of social capital (i.e., social support), and the role of sexual identity disclosure in the lives of MSM in Lesotho, ranging from the broader community to the smaller MSM community.

Methods

In-depth interviews were conducted with 23 MSM in Maseru and Maputsoe, Lesotho, in April and May of 2014. A single focus group was conducted with six MSM in Maseru who were not part of the in-depth interviews. MSM at both sites were eligible to participate if they were aged 18 years or older, assigned male sex at birth, and reported having receptive or insertive anal intercourse with another man in the past 12 months. In addition, participants were required to have lived in Lesotho for the past three months, to be capable of providing informed consent, and to understand either English or Sesotho. All eligible participants provided informed oral consent prior to completing the face-to-face interview or focus group with a trained interviewer who was either an MSM or an LGBT ally. This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board and the Lesotho National Health Research Ethics Committee.

Interviews and focus group included a discussion of family and livelihood including relationships with the community, sexual identity, sexual behaviours, the general situation of MSM in Lesotho including main social concerns and challenges, social experiences, HIV prevention, testing, and treatment, and concluding with ideas for programs/services/support services for MSM and any advice that the participant would offer to other MSM. For the purpose of these analyses, we focused on social relationships between MSM and the larger community and also within MSM groups. All interviews took 60-90 minutes to complete and were audio- and digitally-recorded. The focus group lasted approximately 90 minutes. Each participant was reimbursed approximately 2 USD for participation and 2.60 USD for transportation.

Interviews and the focus group were conducted in Sesotho, translated into English, and transcribed for the analysis. The response text was searched, labelled, extracted, and categorised for each topic of interest using content analysis. The themes were then analysed for content pertaining to our research objectives, following Crabtree and Miller’s “interpretive process” of describing, connecting, and representing what has been learned from the text in an iterative process.²⁷ Data were triangulated through in-depth interviews with two key informants who work closely with the MSM community; the results of which are not presented here. The interviews were independently coded by two study investigators and discrepancies compared to standardise code definitions. All data were analysed using ATLAS.ti 7 (ATLAS.ti GmbH, Berlin, Germany).

Results

Stigma and social support in the broader community

The majority of participants cited verbal abuse as being the primary challenge faced by MSM in the broader community, such as being insulted or told that it is better to have sex with an animal than with another man. When questioned about the abusive things that were said to MSM in Lesotho, one participant explained,

“Such things make us lose hope about our future because we are forced to hide our true identity.”

Although fewer men cited experiences of physical abuse, many recalled an account of physical violence that was experienced by them or someone they knew. For example, one man mentioned that when MSM are in the streets at night they sometimes have stones thrown at them or dogs set on them and they have to run away to avoid being physically harmed. Others spoke of being victims of sexual assault or knew someone who had been sexually assaulted by a member of the broader community.

Even in the absence of verbal or physical abuse, participants described the difficulty in being accepted by the larger community. One participant described that although nothing was said to him directly, he could tell by the reactions and whispering of people in his village that they did not accept his sexual identity. He went on to say:

“It is not a good feeling because you end up feeling insecure all the time and wondering what people are saying about you even when they are not discussing you.”

However, many participants did report feeling accepted by the community. One participant indicated that the general level of acceptance was increasing with increasing visibility of MSM. He stated:

“I think society is becoming more understanding, I think if I am open about my sexual orientation people will understand that I am a man who has sex with other men and that I will not change.”

Numerous participants reported hearing discussions about same-sex relationships on the radio. Listeners would call in and describe their views, which were sometimes hostile and sometimes supportive. Focus group participants suggested that increased depiction of MSM in the media would help to reduce stigma. Indeed, some participants mentioned examples of MSM portrayed in the media in a supportive way, including a friendly radio interview of finalists of a “Miss Gay” pageant as well as a South African TV soap opera that featured a gay couple in an honest manner. A focus group participant described,

“There are South African TV soap operas that we watch here in Lesotho that features gay couples and this is a true reflection of what happens in our everyday lives. The lives of gay people should be depicted in every situation because they are part of the community and they exist at all levels of society. This will help reduce discrimination against gay people and also reduce homophobia. This will also help reduce the negative and unsupportive attitude of the police towards gays who are harassed and assaulted because of their sexual orientation.”

However, others described homophobic messaging by certain radio stations and newspapers, which perpetuated discrimination by discussing the sinfulness of homosexuality and suggested that MSM should be punished for their behaviours.

Almost all participants attended church. Although several men reported harassment from Christian church members, such as church members who read the Bible to them in order to illustrate that homosexuality is a sin, some reported actively feeling accepted at church. One man even pronounced that his church accepted MSM and that MSM attend the church in large numbers.

Multiple men spoke of the lack of HIV services specifically for MSM, and that MSM often faced discrimination at the government healthcare facilities. As a result, many hid their sexual identity from healthcare workers to avoid unnecessary attention or discomfort, such as by claiming that they needed to be tested for HIV because they had unprotected sex with a woman. Participants also feared the “double” stigma of testing positive for HIV and worried about others finding out about both their sexual identity and their HIV status. This led some participants to avoid HIV testing altogether. HIV stigma (from both MSM and non-MSM) was also a concern for those receiving HIV treatment services, as indicated by a focus group participant,

“There are occasions when gay people do not collect their medication at the health centres because of fear that their status will become a subject of gossip in the gay community.”

Sexual identity disclosure to the broader community

Experience of stigma appeared to be influenced by whether community members knew the participant’s sexual identity, with those who were not open about their sexual identity reporting fewer instances of stigma. In contrast, those who were more easily identifiable as gay, such as by expressing feminine walk or gestures in public, were subject to more frequent or extreme verbal harassment. Despite this increased stigma, some participants noted the benefit of being open about their sexual identity. One participant commented that he was always happy when he came across people who knew about his sexual identity, suggesting that it allows him to be himself and to act comfortably. In response to being asked why he disclosed his sexual identity to his friends, another participant described,

“Life will be easier for me because I won’t have to be lying about myself and my partners.”

Participants who were able to support themselves financially were more likely to disclose their sexual identity to a community member outside of the MSM community, although reasons for men wanting to hide their sexual identity varied. Some mentioned hiding out of fear of being harassed or verbally abused, and others out of respect for the cultural norms of the community. Another participant attributed the desire to live in secrecy to his age, implying that he would not be ready for the socio-cultural changes that might occur if gay marriage were to be legalised in Lesotho. He believed that MSM should live in secrecy, and stated that he did not like to be associated with MSM who dressed or acted like women and would avoid them in public; however, he later admitted that he believed the reason for this was because he had not fully accepted and disclosed his own sexual identity.

Regardless of the reasons for living in secrecy, many men commented on the negative effects of living a secret life. For example, participants noted that many MSM marry women in order to hide their sexuality or because their parents pressure them into doing it. As a result, several participants argued that it was difficult to maintain healthy and supportive relationships because of the secrecy and the fact that their male partners were keeping their relationships hidden out of feelings of shame to be having sex with men. In addition, they noted that having sex with men who are married to women can cause instabilities and conflict within families because the wife in the heterosexual relationship may feel neglected or suspicious. Another participant noted the enhanced risk for acquiring sexually transmitted infections as a result of living in secrecy. He commented:

“The problem is that our relationships are secret and when relationships are conducted in secrecy the tendency is to be promiscuous and there is a high risk of sexually transmitted infections.”

Sexual identity disclosure to family and friends

Several participants had not yet disclosed their sexual identity to their family. A few mentioned that parents were the most difficult with whom to be open about their same-sex practices, often because they were the least accepting. Some participants had disclosed and were still accepted and supported by their families. However, a few men reported being rejected by at least one family member after disclosing. One man emphasised the importance of managing family relationships, especially if an individual is not self-sufficient. He advised:

“My advice to MSMs who are not being accepted by their families is that they should manage their family relations in a manner that will ensure they are not thrown out of their homes by their parents.”

For those who reported having heterosexual friends, there was a mix of responses regarding trust and disclosure of sexual identity to these individuals. For example, one participant reported receiving verbal encouragement from his heterosexual female friends after he disclosed his sexual identity to them. In contrast, another man mentioned that some of his friends (who did not know he had sex with men) disliked gay people. He was afraid to upset these friends and chose not to disclose his sexual identity to them because he did not want to be rejected.

Stigma and social support in the MSM community

Most participants interviewed were members of a local gay organisation such as Matrix or the multilateral NGO known as Population Services International (PSI), which provides services to MSM. Participants believed the objectives of these organisations were to assist members in accepting themselves, deal with personal life challenges, provide advice for safer sex, and to advocate for the LGBT community on legal issues. Most of these men reported receiving various types of support from these organisations as well as from other MSM, including emotional, social, moral, and sometimes financial support. One man referred to the gay organisation of which he was a member as a “beautiful family” and claimed that he was happiest when socialising with other group members. In addition, another participant noted the benefit of being around other MSM (not necessarily in the context of a gay organisation) was simply in being free to express oneself. He described:

“It is not always necessary to hide our sexual orientation, when I join a group of gays we affectionately call each other ‘babe’.”

However, a few participants commented on harassment experienced from other MSM, such as men who were hiding their same-sex practices and were offended by MSM who are explicit about their sexuality. This was reinforced by the participant who believed that MSM should live in secrecy and avoided other MSM in public. One man commented,

“I have noticed that most of the time the abuse comes from men who are hiding their homosexuality and are offended by people like me who are explicit about their sexuality.”

Another participant noted that high levels of promiscuity caused discordance among MSM in social support networks. He explained:

“One of the challenges within the gay community is that there is a culture of unfaithfulness amongst friends and this creates a lot of problems in our relationships.”

This idea was reinforced by focus group participants, several of whom expressed a belief that most MSM are promiscuous and that their relationships are short-term. This led many to lose hope in seeking a safe and healthy relationship with another man because they felt there was no future with their male partners. One participant clarified his belief for why this was, stating that:

“The relationships do not last because at the end of the day, the relationship is not going anywhere. There is no point in the relationship because it will not end in marriage. I think that is why the relations are short; MSMs in Lesotho cannot get married.”

Discussion

These data contribute contextual evidence to the growing knowledge of the importance of stigma and social support as determinants of health and well-being among gay men and other MSM in Lesotho and across Sub-Saharan Africa.^10,12,15 Four key themes emerged from the analysis: 1) Verbal abuse was a major challenge identified by MSM in Lesotho; 2) participants who were more open about their sexuality experienced more frequent or extreme stigma but were also able to live and feel more comfortable with themselves; 3) relationships between MSM tended to be conducted in secrecy, which can promote sexual risk behaviour and unsupportive relationships between MSM; and 4) local LGBT organisations provided valuable social and emotional support to MSM that extended beyond HIV prevention education.

Previous studies have indicated a high level of verbal, physical, and sexual abuse among MSM in Sub-Saharan Africa.^{8 -10,15,29} Concurrent with previous data, our study shows that participants who had either disclosed being gay or MSM, or reported other members of the community being aware of their same sex practice, reported higher levels of stigma.^24,25 In societies with greater acceptance of LGBT populations, there is less reported stress associated with being a sexual minority, especially at the time of disclosing one’s sexual orientation. Moreover, if people feel comfortable to disclose to health care workers, they are more likely to receive more targeted care that better addresses their specific needs. However, there is an inherent paradox whereby disclosure is associated with greater experiences of stigma, even if in the long term it can result in greater awareness and acceptance of LGBT populations. Even within the MSM community in our study, data highlighted incongruences between the relative benefits of being open about sexual identity and those who preferred to remain hidden. Indeed, the data presented here highlighted that some MSM who preferred to be hidden were the perpetrators of abuse towards MSM who were open about their sexual identity. These actions would limit the visibility of gay men and other MSM in these urban centers of Lesotho and may be caused by internalised homophobia and heteronormativity.^30,31 Alternatively, these men could be publicly engaging in attacks against MSM in order to affirm their heterosexuality to the broader community in order to avoid stigma.³¹

In this study, the majority of the social capital supporting these men appeared to be derived from within the MSM community. Some men reported having no heterosexual friends and other participants noted the intense fear related to rejection of disclosing their sexual identity and practices to heterosexual friends and family. Encouragingly, there were some participants who had disclosed to their families and were not rejected. This disconnect between perceived or anticipated stigma and experienced stigma has been observed in other settings, where for example fear of seeking care generally is far more prevalent than rejection in health care settings. Thus, interventions that focus only on decreasing the chance of experiencing stigma will only indirectly affect those with significant perceived stigma, highlighting the need for multi-faceted approaches that will also address perceptions of stigma. However, underpinning these strategies aimed at mitigating stigma should be the recognition that in many settings, there remains a real risk of disclosing sexual identity to friends and family, including being thrown out of homes or rejected from existing social networks.^22,24

One potential method for changing social attitudes towards LGBT populations is better engagement of the media to discourage homophobia and homo-prejudice, portray MSM in a non-discriminatory manner, and sensitise the community to gay/diverse sexual identity-related issues. Such media campaigns have been undertaken in several South American countries in the 2000s and included posters and TV/radio advertisements.³² And although there have been some challenges with this approach, there have also been documented successes.³² In South Africa and Lesotho, a popular television dramatic series called “Generations” introduced gay characters in 2013.^* Participants in this study mentioned this show, demonstrating the potential benefit of media normalising these relationships and introducing homosexuality in a non-discriminatory manner. This is not dissimilar from what has been observed with changing attitudes related to popular shows in the United States such as “Ellen”, “Will and Grace”, and “Modern Family” which have all prominently introduced LGBT characters.

Nearly all of our participants reported attending church. More than 90% of Lesotho is Christian with religion playing a significant role in the life of the Basotho people.^† There have been religious leaders who have taken progressive stances relating to LGBT people, including a famous quote by Archbishop Desmond Tutu indicating that “he would not worship a homophobic God."^‡ However, there have been many religious leaders who have taken regressive perspectives on LGBT issues that potentiate sexual identity-related stigma, highlighting the need for further engagement to try and mitigate a promoter of both social and internalised homo-negativity.

Stigma appeared in these data to play a role in facilitating risks for the acquisition and transmission of HIV and other sexually transmitted infections. Similar to previous studies, MSM here reported layered intersectional stigma pertaining to their sexual identity and HIV status.^26,33 Here, consistent with earlier data, the intersectionality of these stigmas appeared to result in avoidance of HIV testing, non-disclosure of sexual practices to healthcare workers, and reduced HIV treatment uptake. There are several health issues associated with non-disclosure, including the aforementioned potential for suboptimal clinical management and associated risk for poor health outcomes.³⁴ Moreover, dating in secrecy is a theme that has been identified by other qualitative studies of MSM in numerous settings.^25,31,35,36 Compared with relationships that are conducted in the open, secretive relationships can lead to larger and non-dense sexual networks where people are less likely to know the HIV status of their sexual partners, ultimately resulting in increased risks of HIV.²⁶

Lastly, participants who reported being able to support themselves financially were more likely to have disclosed their sexual identity to at least one community member outside of the MSM community, consistent with findings from South Africa and Uganda.^22,25 Financial self-sufficiency is likely linked with self-confidence and self-acceptance, allowing MSM to better cope with the stress of being a sexual minority in a highly stigmatised setting.²²

This study is not without limitations. Because of the sensitive nature of the topics discussed there is a potential social desirability bias inherent in participants’ responses. In particular, sexual risk behaviours may be underreported. Those who are the victims or perpetrators of abuse may also underreport these occurrences. However, interviews were conducted by trained male interviewers who identified either as gay, bisexual, or as an LGBT ally, which hopefully served to minimise this potential bias. In addition, because focus group and in-depth interview participants were sampled from NGOs, it is likely that the views of more hidden MSM are underrepresented. As with most qualitative research, the sample size was small and is not intended to generalise to broader populations of MSM in Lesotho or Sub-Saharan Africa.

Overall, this study provides a more nuanced and detailed understanding of the role of stigma, social support, and sexual identity disclosure among MSM living in Lesotho. Even in a country that does not overtly criminalise same-sex practices, MSM face high levels of stigma and abuse, and this often leads to relationships being conducted in secrecy. MSM community organisations are valuable in mitigating stigma, providing social and emotional support, and promoting health behaviours. However, friends and family members from outside the MSM community also offer social resources that cannot be utilised by MSM until the risk of disclosing their sexual identity is substantially reduced. Media campaigns against homophobia and partnerships with MSM-friendly religious organisations may encourage broader acceptance of LGBT issues. Regardless of the method, greater acceptance of same-sex practices and a shift in cultural norms are needed to remove barriers to social support and ultimately improve health outcomes for all gay men and other MSM in Lesotho.

Acknowledgements

We would like to acknowledge and thank the Lesotho LGBT community for their participation and effective mobilisation to disseminate messages about this study. We also wish to thank the study staff and interviewers who worked on this project at personal risk, including disclosure of sexual orientation to their families or communities. The Lesotho Ministry of Health was instrumental in the oversight, direction, and supervision of the study, and we are grateful for the considerable government engagement and ownership of this work. This study was funded by the U.S. Agency for International Development (USAID, AID-674-A-00-00001), and implemented by Population Services International/Lesotho (PSI).

Notes

* http://www.channel24.co.za/TV/News/Generations-The-gays-stay-20130712.

† http://www.state.gov/j/drl/rls/irf/2007/90104.htm.

‡ http://www.bbc.com/news/world-africa-23464694.