Report on Rights of Transgender people and HIV vulnerability

A study titled Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region was released in Bangkok today (17th May, 2012) to mark the International Day Against Homophobia and Transphobia. According to this research, which was jointly released by the United Nations Development Programme (UNDP) and the Asia Pacific Transgender Network (APTN), transgender persons are among the most socially ostracized in this region and lack fundamental rights, including basic access to health care and social protection schemes. So there is need for concerted action by governments, civil society, development partners and the transgender community itself to design and conduct further research to fill the lack of information about transgender people and their environments.

The report seeks to examine literature on laws, regulations, policies and practices that prompt, reinforce, reflect or express stigma and prejudice towards transgender people. It seeks to identify vulnerabilities to HIV and barriers to access or uptake of HIV related healthcare services, and attempts to establish a research agenda aimed at providing the sort of data that will enable a reduction in future risk, as well as better access to treatment, care and support for transgender people living with HIV. 
According to Dr. Sam Winter from the University of Hong Kong, the author of this report and a noted expert on the challenges of transgender people, “For too long, trans people have been lost in transition. Pushed to the social, economic and legal margins in a majority of countries in this region, trans people often suffer from poor emotional health and well-being. Many find themselves involved in risky behaviours and situations, such as unsafe sex and involvement in sex work.  Social exclusion, poverty and HIV infection contribute to what we call a ‘stigma-sickness slope’, a downward spiral that is difficult to reverse. We hope that this report will demonstrate the burning need to address a very human crisis, viewed through the prism of HIV, which has taken a devastating toll on millions of our fellow citizens in our region and beyond”.
Although national reported data remains limited, there is growing anecdotal evidence that HIV prevalence rates among transgender people in the region have reached critical levels. These reported numbers commonly exceed the prevalence rates among men who have sex with men, and young transgender women are thought to be at particular risk. Data from one Southeast Asian city suggests that over the four year period from 2003-2007, HIV prevalence among transgender people rose from 25% to 34%.

The Asia-Pacific region is home to a large number of transgender people-- individuals whose gender identity, and/or expression of their gender, differs from social norms related to their gender of birth. Trans women here are birth-assigned males identifying and/or presenting as female, or (in those cultures, where it is accepted that there are more than two genders) as members of another broadly feminised gender. Trans men are birth-assigned females identifying and/or presenting as male or as another broadly masculinised gender. There are possibly 9-9.5 million trans people across this region, but the existing small scale research is largely limited to trans women, an alarming number of who are estimated to be HIV positive, with prevalence rates as high as 49%. There appears to be no data at all on HIV rates among trans men, and the number of trans people of either gender who have died of AIDS is also unknown.

Another challenge is that throughout much of the history of the global HIV response, transgender people have remained invisible and have seldom been properly recognised as a distinct population for purposes of confronting the HIV pandemic. They often find that sexual healthcare services are not suited to their needs and are focused instead on females and on MSMs. Even when it comes to national HIV programming and funding they are usually treated similarly as MSMs. “We are most definitely not MSM,” stressed Prempreeda Pramoj Na Ayutthaya, a noted Thai transgender researcher and activist. 
“Many of us are physically very different, either as a result of hormone replacement therapy or other medical procedures.  Some of us have had a complete sex change.  There is much we still don’t know about our particular vulnerability to HIV, and that needs to change.”

The regional HIV epidemic among transgender people is strongly linked to stigma and prejudice which results in prompting patterns of discrimination, harassment and abuse (verbal, sexual and physical) in the family, at school, in the workplace, in the provision of services (including health) and in society as a whole. Transgender people become marginalized, both socially and economically, with the Asia-Pacific legal environments further failing to offer them sufficient protection against discrimination and serious forms of sexual assault by withholding legal recognition of self-affirmed gender, criminalising their sexual behaviours, and subjecting them to gender-inappropriate detention practices, as well as contributing to police abuses. These experiences can damage their psychological and emotional wellbeing, conspiring with other factors, (such as poverty) to tilt them into situations that put them at risk of HIV as well as risk of other threats to their physical and mental well-being. Unsafe sexual practices appear to be common among them and most of them are quite badly informed about the associated HIV risks. Even the few who are well-informed nevertheless engage in unsafe sexual practices. 

Ban Ki Moon, United Nations General Secretary is worried that, “We see a pattern of violence and discrimination directed at people just because they are gay, lesbian, bisexual or transgender. There is widespread bias at jobs, schools and hospitals, and appalling violent attacks, including sexual assault. People have been imprisoned, tortured, even killed. This is a monumental tragedy for those affected – and a stain on our collective conscience. It is also a violation of international law.”

Transgender people approaching any type of health services commonly report that services are often difficult to access. Healthcare providers are uncooperative and respond to them in a gender inappropriate way, adopt a mocking or ridiculing attitude, and withhold/ refuse healthcare. So, some take care of their own healthcare needs as best they can (e.g. getting hormones wherever and whenever they can, and taking them with little or no medical supervision). Those who seek gender affirming surgeries find them to be the extremely expensive procedures. Confidentiality is not always assured, especially in regard to mandatory HIV testing for sex workers, which compounds the problems in accessing appropriate care. 

Despite the dismal scenario, the report points out at some encouraging developments too. Among these is a developing transgender identity, a growing pride and an increasing willingness on the part of transgender communities to advocate for increased participation in policy processes and organize peer support services at a national and regional level. The Asia Pacific Transgender Network has been recently established to advocate for the right to access health services, to demand that laws which criminalize transgender people be repealed and to reiterate that vulnerability to HIV is couched within the larger context of human rights. 

“The creation of advocacy networks, community-based organisations and non-government organisations devoted to empowering and strengthening our communities is a source of joy. You cannot separate our social well-being and human rights from our efforts to address HIV within our communities. We are pleased that the UNDP report recognizes this.” said Prempreeda.  

The report emphasizes that inclusive research, designed and implemented in partnership with the transgender community, is critical to enable governments, community based organisations and supporting organizations to enhance HIV and sexual healthcare services specific to the needs of transgender people, and foster action by governments to adopt more socially equitable policies and practices to protect their rights.

Shobha Shukla - CNS
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org) 

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