The Marginalisation of LGBT
The marginalization and discrimination that sexually diverse people experience in most countries around the world are in many ways mirrored in the AIDS response. In many research projects sexual orientation and gender identity have been pushed aside or lost under the ambit of gender and/or most at risk populations (MARPs) and combined with injecting drug users (IDUs), and sex workers (SW). Irrespective of the level of exposure to HIV, LGBT people across the world face stigma and discrimination that deny them universal access.
The AAI LGBT Scorecard will make it very clear that most of these groups are ‘invisible’ to national and global M&E efforts. This means that we have little systematic data with which to assess the burden they carry in terms of HIV prevalence or what level of access they have to treatment and other essential services. For the same reason we will fail to implement targeted interventions that would reduce HIV incidence in concentrated epidemics that are likely to lead to HIV infections also in the general heterosexual population. In this context, MSM represent the exception. Many countries monitor HIV and AIDS among MSM effectively and, in some countries, the necessary services appear to be provided at scale. A central argument that underpins this scorecard analysis is that the political struggle that won these victories for MSM in some countries needs to be broadened to include sexually diverse groups in general in all countries.
There are, in other words, epidemiological reasons for focusing a scorecard analysis on government performance in relation to sexually diverse populations. If these groups remain invisible to the AIDS response, many people will become infected, fall ill and die unnecessarily.
The second rationale is even more simple and direct. Beyond the science of epidemiology, and beyond the notion of group or identity, remain diverse ways of showing love and sharing the joys of sex. As these are essential to what it means to be human, they are essential human rights. The AIDS Accountability LGBT Scorecard is therefore also an argument for making sure that sexually diverse populations have full part in advocacy for securing human rights in general and rights to health in particular. If sexually diverse populations are invisible also in the discourse on human rights we undermine the very principle of Universal Human Rights, an omission from which all stand to lose.
The following sections will sketch out how this general reasoning applies to different sexually diverse people:
Women who have sex with women, bisexual and lesbian women
All women are vulnerable due to gender inequalities resulting in reduced employment opportunities (and the related financial constraints), freedom of movement, and exposure to domestic and other violence, among various other societal factors. This situation is exacerbated for lesbian and transgender women, as stigma and discrimination worsen barriers to accessing quality health care.
The belief that sex between women carries a low possibility of HIV transmission has led to the almost universal exclusion of WSW in HIV prevention efforts and research. The lack of indicators and focus on these women reflects the current state of mainstream knowledge about HIV epidemiology which does not see these groups of sexually diverse women as being affected to a degree that warrants inclusion in a global M&E framework.
Contrary to this mainstream argument, data and analyses are increasingly coming to the fore that shows the extra vulnerability of WSW. For example, a study found that the majority (85%) of British women, who had had sex with other women, had also had sex with men. However, “compared with women who reported sex exclusively with men, women who reported sex with women and men reported significantly greater male partner numbers, unsafe sex, […] and sexually transmitted infection diagnoses.” There is an urgent need for additional attention to be paid to this group of highly marginalized individuals globally.
These findings are important not only as the basis for new and better M&E indicators, but also to affect policy development and programming. Further, it is important also to inform WSW themselves of their increased vulnerability to HIV infection and thus affect behavior change. Moreover, these women and transgender men are at heightened risk of homophobic rape and other forms of physical violence that put them at increased risk of HIV infection. Discrimination and violence represent violations of human rights that must stop.
Homophobic, or more correctly lesphobic rape, often leads to genital trauma, lesions on the body, unprotected sex and increased risk of HIV infection.
The apparent “rationale” for raping lesbian women is that the perpetrator can “cure” the women of their sexual orientation and it has become an epidemic of its own in South Africa. So much so in fact, that research indicates that 86 per cent of black lesbian women in the Western Cape Province live in fear of sexual assault.
Indeed, human rights groups estimate that no less than 30 lesbian women have been murdered in South Africa in recent years. Triangle, a gay rights organization, based in Cape Town, says it works with as many as ten new cases of ‘corrective’ rape every week. This places lesbian women at a substantially high risk of contracting HIV, yet still no acknowledgement of the need for inclusion in HIV M&E statistics exists.
Transgender men and women
Transgender refers to the gender identity of an individual and their self-identification as either a woman, man, both or neither one of these. Transgender people consider that their gender identity does not match their sex assigned at birth. For some people they may identify themselves as transgender, bi-gender, as having no gender or even as moving effortlessly along a gender continuum, traditional or not. Transsexual people usually have had some medical or surgical assistance in achieving their ideal gender identity.
Transgender gender identity has no connection to sexual orientation as transgender people may identify as lesbian, gay, bisexual, heterosexual, pansexual or asexual or queer the distinction is not related to their genitals but to their gender identity.
All transgender people, but most especially transwomen are highly vulnerable to HIV. Marginalisation, limited access to employment, the resulting poverty, and related higher rates of sex work all place transgender men and women in an especially vulnerable position. “Unresolved sexual identity often results in high risk sexual experimentation.
Female gender roles are often associated with abuse by a partner. Transwomen, due to stigma are highly vulnerable to sexual assault and punitive rape.” Similarly for transmen in Africa transphobic “corrective” rape is an ongoing human rights issue.
Transgender individuals face barriers in accessing healthcare, and due to the fact that the very nature of those health needs are specific even more so. Very seldom do any sexual and reproductive health and rights programmes address the needs of transgender individuals. “Transgender people have very specific needs for e.g. (among others) cross gendered hormone treatment and possible interaction with ARV’s and other medicine are not known. Prostate cancer in post operative transwomen and cervical cancer with transmen are often ignored because of pre-conceived notions of transgender bodies.”
All too often reports on transgender people do not specify whether the information refers to transgender men (female bodied people with a male gender identity) or transgender women (male bodied people with a female gender identity). However, their health care needs are significantly different, with transgender men requiring medical care for issues such as cervical cancer screening when applicable. Healthcare workers are not trained on providing these services as they often operate on traditional male/female gender identities and cisgender people.
Men who have sex with men, bisexual men and gay men
Unsafe sex between men was the main driver as the global epidemic began in the early 1980s, and it remains a central feature of the epidemic in several low-prevalence and concentrated epidemics across the world. The response to the needs of MSM in the context of HIV/AIDS has been relatively effective when compared to other groups among LGBT people. This is due in parts to the centrality of MSM in the early epidemic and successful political advocacy from MSM stakeholders. But those gains apply unequally across the world. MSM still face criminalization, discrimination and violence in many countries, with little hope for adequate access to prevention, treatment and care and support. Several elements of the LGBT Scorecard will reflect the fact that MSM remain marginalized in, if not completely absent from, the response to AIDS in many countries, even though data show high HIV prevalence and that human rights abuses against MSM are rife. In addition there is a need to better understand the role, the needs and the vulnerabilities of MSM in countries with generalized epidemics and hyper-endemic HIV.
Men who have sex with men are at an increased vulnerability for a variety of reasons, not least of which are:
• HIV is more easily transmitted through unprotected anal sex than through unprotected vaginal sex.
• In countries and cultures where MSM are stigmatized they are reluctant to seek healthcare for other STIs resulting in genital lesions and sores that further increase the risk of transmission.
• Criminalization of same sex practices pushes gay men into marriages with women to disguise their sexual orientation thus heightening their risk of transmitting the virus to their wives or girlfriends.
• Criminalization and marginalization also drives these individuals away from accessing timeous, accurate, full health care and diagnosis. The lack of adequate training of healthcare personnel worsens this.
• Low self-confidence, lack of self-acceptance or family and social acceptance of sexual orientation often leads to high stress and a lack of psychological support for gay men. This may lead to the abuse of substances, having multiple sexual partners to lift esteem, inability to negotiate safe sex, and entering into sex work for financial reasons. All of these behaviors place gay men in a higher risk category for transmission of HIV.
The Global Forum states that: “Despite elevated HIV prevalence rates and heightened vulnerability to factors that drive HIV transmission, MSM have been under-recognized, under-studied, under-funded, and under-served historically in the global response to HIV & AIDS. There is therefore an urgent need to prioritize outreach to MSM with HIV-related services and information that effectively meet their needs in the context of global public health and human rights.”