This article was written in September 2017. Since then, thanks to the work of NGOs including our member HERA, Macedonia’s incoming socialist government has committed to providing long-term funding for all HIV programmes for marginalised people.
Being young and gay in Macedonia is to live in fear of your safety. Like many Balkan countries, Macedonia is notoriously patriarchal and conservative, and homophobia is systemic.
“In the Balkans we’re still under this patriarchal system,” says Laki, a 22-year-old bartender. “Masculinity means being muscled, beating your wife, and being the boss.”
In this staunchly traditional society, where homophobia is rampant, most LGBTI people live closeted lives. Stigma towards homosexuality frequently erupts into harassment and abuse. Many young LGBTI people speak of being bullied at school, and facing verbal and physical harassment throughout their lives.
“When I go out to a disco they might hit me with a bottle or something,” says 21-year-old Eli (not her real name), a transgender sex worker working in Skopje. “I was attacked, I was mugged, money was taken away from me.”
Grigor, a young gay man living in Skopje, says his school provided no information about sexual health and that everyone keeps silent about sexual issues. Attempts to talk to his friends about his sexuality ended in disaster. “They started saying to me, “you’re sick, you have to see a doctor, you’re not normal, you’re abnormal.” He has still not come out to his family.
The effect of stigma and harassment, as well as self-stigma, serves to keep many people in the closet. Research shows just 13.6 per cent of LGBT people are open about their sexuality.
The knock-on effect is that many young gay men avoid having long-term relationships, Grigor says. “If they were in a long-term relationship, they would have to disclose all sorts of information about partners and everything to their close ones, so they prefer having ‘sex dates’ in order to keep quiet.”
These one-off liaisons tend to go hand-in-hand with risky behaviour, making people more vulnerable to contracting HIV.
Zoran Jordanov, Director of EGAL, an HIV prevention organisation for LGBTI people and men who have sex with men, says condom use also remains low because people see them as a barrier against pregnancy rather than disease: “When there are two men, they [feel] they don't need to use condoms.”
Research data showed that in 2013, just 47 per cent of men interviewed used a condom when they last had sex.
Severe anti-LGBTI discrimination also means many men lead double lives. “Most of them have families: they're acting as straight people but at the same time they’re having sex with guys,” says Vojo Ivanov from IPPF member HERA, a sexual health NGO. This, in turn, potentially exposes women to HIV. Rumena Gjerdovska, a social worker at the Clinic for Infectious Diseases at the University Hospital, says most of the HIV positive women they treat have contracted the virus this way.
Stigma and hostility towards LGBTI people keep many away from state services. “The GP would be the last resort because the doctor would say that my sexuality was the cause of my health issues,” says Grigor.
“I’ve had people laugh in my face when I’ve asked for help at the state hospital,” says Eli. “The level of discrimination at the state hospital is really high.”
Often GPs refuse to register HIV positive patients and surgeons refuse to operate on them: according to HERA, one quarter of people living with HIV have been refused medical services. Fear of exposure and distrust in the judiciary discourages patients from prosecuting, meaning medical staff get away with it and the practice continues.
Sex workers are another group who live precarious lives, exposed daily to police harassment and client violence. They are also highly susceptible to HIV and other sexually transmitted infections. Around a third of sex workers use drugs, and some of them have incomplete primary education; some have not attended school at all.
There is increasing HIV prevalence, particularly amongst male sex workers. This recent trend warrants urgent action. Among sex workers from the Roma community, the use of contraceptives other than condoms is very low, at just 5.7 per cent.
There are 3000-4000 sex workers in Macedonia, working either on the street, behind closed doors or in massage parlours. Like other marginalised groups, many are fearful of using state services due to stigma and discrimination, instead using NGO HIV testing services.
People Who Inject Drugs
Drug users are often harassed or discriminated against because they are so easy to spot.
Risky behaviour like having unprotected sex with long-term partners or sharing needles is widespread among drug users. Despite this, the number of people who inject drugs who contracted HIV through contaminated equipment is low, accounting for just one of the 42 new cases in 2014. But in large part this is due to the huge sums of money pumped into harm reduction programmes and needle exchange by the Global Fund since 2004.
“Everyone uses clean needles,” says Genghis, a young Roma man and methadone user. “We get them from HOPS” – Healthy Options Project Skopje (HOPS), an NGO supporting people who inject drugs and sex workers.
Silvana Naumova, HOPS programme manager, says things aren’t quite so straightforward. Studies show risky behaviour like sharing needles continues, she says. One study reported that only 70 per cent of drug users used sterile equipment the last time they injected, while only 50 per cent said they used condoms when they last had sex.
The Roma Community
For more than eight years, around 8000 women of reproductive age in the largest Roma municipality in Europe, Šuto Orizari (Šutka), a tightknit neighbourhood of around 50,000 people in northern Skopje, did not have a primary healthcare gynaecologist. As of three months ago, the new government have began supplying gynaecological care in the neighbourhood.
In Šutka, unemployment and poverty are widespread, and education levels are poor. Against this backdrop of scarce services, the sexual and reproductive health clinic I Want To Know, run by our member HERA, currently provides crucial free support.
Although cases of HIV are few and far between here, experts fear that cultural and sexual practices could make Roma people vulnerable to HIV, were the infection to penetrate Šutka. The high prevalence of other sexually transmitted infections (STIs) like chlamydia, gonorrhoea, HPV and Hepatitis C have set alarm bells ringing.
“I’m very afraid that if somehow HIV entered into this community, it would spread very quickly,” says EGAL director Zoran Jordanov.
Many Roma people begin having sex young, at around 13 or 14. Strict laws about marriage and girls’ virginity mean that many young people have anal sex. Around 70-80 per cent of Roma men have sex with another man at some point before marriage, Jordanov says. Condoms tend to be perceived as protection against pregnancy rather than disease and so are rarely used, making people highly vulnerable to infection.
The Roma also face barriers to public healthcare. “Very frequently the institutions’ conduct towards the Roma population is inappropriate – they discriminate against them,” says Nicolina Nikolovska, a social worker at I Want To Know in Šutka. Many Roma people are turned away from clinics on spurious grounds. Others have a poor grasp of Macedonian or are illiterate, making navigating the health system almost impossible, or might lack the identification documents they need to get health insurance. Additionally, many people have no idea how to exercise their rights to health care and social welfare.
Thousands of young people in Skopje are side lined and stigmatised because they don’t adhere to the “social norms” ascribed by society. In Macedonia, a country of just over 2 million people, patriarchy is a pervasive force, influencing family life, education, the media and government. If socially excluded groups are to every have equal access to care in Macedonia, the government must fight to eliminate the factors that allow dangerous taboos, stigma and misinformation to flourish. Improving state health care and introducing sexuality education into the school curriculum is crucial if the country is to progress.
Photos: John Spaull/ IPPF EN