On vous parlait récemment du document du Programme des Nations unies pour le développement sur la santé trans : « Transgender Health and Human Rights », voici le chapitre concernant le VIH-sida :
HIV AND AIDS
As described above, violence, stigma, social exclusion and discrimination harm trans people’s health and well-being.117 They also deter trans people from seeking HIV prevention, treatment, care and support services.118
“After my friend was raped by those men because she was discovered [to be trans] she cametome….we went to the clinictoget post HIV exposure prophylaxis. The nurse told her to go home, take off her women’s clothes and come back. She was already so traumatized she could not return. I believe that is why she is HIV-positive today.” —Transgender Sex Workers Cape Town, South Africa, Regional Dialogue (3–4 August 2011).119
There are significant gaps in data about HIV prevalence rates for trans wom- en and very little data about trans men. Studies typically use the term ‘trans- gender people’ but focus solely on trans women (often as a subset of ‘men who have sex with men’). Age breakdowns in the data are extremely limited, compromising understanding of the HIV burden among young trans people.
A 2013 meta-analysis of HIV infection rates studies found that “transgender women are a very high burden population for HIV and are in urgent need of prevention, treatment, and care services.”120 These findings were “remarkable for the severity and consistency of disease burdens” across all four regions where data was available (Latin America, Asia Pacific, Europe and the United States).121 It is of significant concern that there is no such data for other re- gions, including Africa and the Pacific.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) have noted that trans women frequent- ly experience HIV prevalence rates in excess of 60 percent.122 In Asia, data on other sexually transmitted infections shows very high rates of infection for trans women, with syphilis sometimes affecting more than 40 to 50 percent of the trans population.123
“Transgender Africans . . . may or may not be inaccessible, but they are currently invisible in epidemiological research, and they are almost certainly being ignored.”124
Current HIV monitoring and prevention interventions for trans people are inadequate.125 Many trans people cannot access existing effective interven- tions. In addition, there are few programmes targeted specifically at trans women, trans men and other gender non-conforming individuals, and evi- dence of what works best for them is scant. Consistent access to competent prevention, treatment or care services is rare for trans people.126 Services that are neither accessible nor acceptable for trans people undermine their right to health.
Inadequate country data compounds these problems. UNAIDS guidelines are designed to help countries collect data and report on their na- tional HIV response as effectively as possible. Yet, unlike other key affected populations, there is no guidance on collecting and reporting data about trans people.127
Structural risks for HIV infection, such as social exclusion, economic marginalization, and unmet health care needs, are likely to contribute to high HIV rates in trans women compared with other adults.128 The downwards spiral of the ‘stigma-sickness slope’ pushes trans people to the outer margins of society, leaving them more vulnerable to risky situations. Marginalization impacts negatively on trans people’s individual self-esteem and well-being, results in high rates of substance use,129 and limits their negotiating power within an intimate relationship. It may lead trans people to settle for partners who are abusive or encourage risk-taking behaviours, such as illicit drug use or unsafe sex.
Extreme poverty and high levels of employment discrimination leave many trans women with no choice but to exchange sex for money or necessities.130 Others may be sex workers by choice, perhaps because it is the only occupation where they are able to dress and be treated as female.131 Trans sex workers may face pressure to modify their bodies to attract clients. The dangerous practice of injecting industrial silicone, commonplace among travesti sex workers in Brazil, has been attributed to this pressure.132
Sex work is associated with high risk of HIV infection. Typically trans sex workers are marginalized among other sex workers, forced to work in unsafe areas at night. They face the added risk that a client may react violently when he realizes a sex worker is trans.133 A 2008 meta-analysis of HIV risk internationally found that trans women who were sex workers were significantly more likely to be living with HIV than male or other female sex workers.134
Street-based sex work carries risk of extremely brutal and cruel forms of transphobic violence, including killings.135 This includes harassment by police or vigilante groups.136 Societal prejudice against sex workers compounds the stigma and violence against trans women generally. The assumption that trans women are sex workers can have a negative impact on trans women’s access to safe sex generally. In countries where sex work is criminalized, carrying a condom can place any trans women at risk of being detained as a sex worker.
In the absence of data, trans men have been considered at low risk of HIV infection. Recent studies challenge this assumption and highlight the dangers of invisibility. While there is limited data on HIV risks for trans men, there are known anecdotal risk factors. For example, many trans men exclusively or predominantly have receptive anal sex, including with other men.137 Between 2006 and 2010, 11 (6 percent) of the 183 newly diagnosed HIV cases among trans people in New York City were in trans men.138 In a retrospective analysis of people who attended sexual health clinics from 2006 to 2009 in San Francisco, HIV infection rates were similar for trans men (10 percent) and trans women (11 percent).139 Recent US research suggests that another invisible risk factor for trans men is their participation in sex work.140
“Throughout much of the history of the global HIV response, trans people have been invisibilised; in that they have seldom been properly recognised as a distinct population for purposes of confronting the HIV pandemic. Trans women attracted to males have often been subsumed, researched and reported as [men who have sex with men] . . . often in direct conflict with their own identities as female or third gender. It undermines their frequently voiced claims to be treated as female. It often conflicts with the identities of their partners as heterosexual, or ‘real men’. Trans men again have been completely left out of any kind of reporting; even trans men who have sex with men.” —Sam Winter (2012).141
Sam Winter recommends a comprehensive research programme to address such glaring gaps. Notably, he proposes going beyond risk factors for trans people and recommends looking at protective factors and personal qualities that result in resilience against the effects of stigma discrimination, abuse and consequent marginalization.
Similarly, others have highlighted the need for trans people to be involved as active partners in the design and implementation of health research studies about their communities.142 Such research is necessary to inform responses to HIV and AIDS that meet the needs of trans people. It is also essential to address the other pressing health issues that trans people face. The following section focuses on the health challenges for trans people who wish to med- ically transition.
GENDER-AFFIRMING HEALTH SERVICES
Gender-affirming health services are medical or surgical interventions that many, but not all, trans people seek in order to change parts of their body to affirm their gender identity. These procedures include, for example, hormone treatment, electrolysis, surgeries to create or remove breasts, hysterectomies, and a range of genital reconstruction surgeries.143
For many, but not all, trans people it is distressing to have a body that does not match their sense of self. This mismatch has been termed ‘gender identity disorder’ in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and in the WHO’s International Classification of Diseases (ICD).
The DSM has recently moved to a new term, ‘gender dysphoria’, and the ICD is currently being revised.144
Many trans people do not wish their identity to be pathologized as a disorder or dysphoria. Instead they seek access to gender-affirming health services based on a model of informed consent.145 Therefore many trans people have welcomed the WHO’s proposals to remove diagnoses currently in the ‘mental and behavioural disorders’ chapter of the ICD.
There is a proposal to create a ‘gender incongruence in childhood’ diagnosis within the ICD. Many trans people and health professionals con- sider the proposed diagnosis inappropriate as it could stigmatize rather than support children who are exploring issues of gender identity and expression.146 Such a diagnosis is also inconsistent with the WHO’s proposals related to individuals exploring issues of sexual identity and expression. Given these concerns, opposing a child diagnosis was chosen as the theme for the 2013 International Day of Action against Trans Pathologization.147
Hormone treatment is a pivotal health procedure for many trans people. This is because hormones affect secondary sex characteristics such as body shape and body hair, as well as the masculinization of vocal chords. These bodily features, along with the absence or presence of breasts or an Adam’s apple, are often subconsciously noted by others as ‘gender markers’, and used to support assumptions about someone’s sex. They have a significant impact on whether a person is recognized as male, female or neither/other.
Testosterone is a particularly powerful hormone and many of its effects are irreversible. These include hair growth, male pattern baldness, and thickened vocal chords that produce a lower voice. Trans men who take testosterone to transition typically desire these changes. Conversely, many trans woman who transitioned after puberty seek to reduce these effects. Hormone replacement therapy for trans women will soften the skin and change the body shape, but it does not remove body hair. For many, this requires extensive, costly and painful laser treatment or electrolysis.
While many trans people do not need surgery to be comfortable in their gender identity, role and expression, the World Professional Associa- tion for Transgender Health (WPATH) standards of care note that“for many others surgery is essential and medically necessary.”.148 For trans men, often the most pressing surgery is a mastectomy to create a male chest. For trans women, the most important initial surgical procedures may be those that feminize outward appearances, such as breast augmentation, facial feminization or contouring the hips and buttocks. While gen- ital reconstructive surgery is vital for some trans people, others may not find it as important for their daily lives. There is robust clinical evidence that hormone treatment and gender-affirming surgeries improve trans people’s well-being and psychosocial outcomes.149
The WPATH standards of care are a voluntary, best practice consensus document. Unfortunately they are far ahead of current practice in many countries around the world.150 The right to health requires health services that are accessible, available, acceptable and of good quality. States are required to progressively achieve the full realization of the right to health, to the maximum of their available resources.151 The reality for trans people around the world routinely falls far short of these requirements.152
The vast majority of trans people worldwide have no access to gender-affirming health services. Hormones or some surgeries may be available in the public health system for other medical reasons (such as contraception or cancer treatment) but not for trans people wishing to transition. This denial of treatment is typically based on the unfounded assumption that gender-affirming health services are cosmetic procedures or are not medically necessary. Where they are available, it is usually only through private health providers and they are prohibitively expensive, particularly for surgeries required by trans men. Insurance coverage often excludes any gender-affirming procedures, despite the fact that there is virtually no added cost per insured person in a large enough insurance pool.153
In the absence of public health provisions, trans people are forced into unsafe alternative measures to change their bodies to match their gen- der identity. In many countries, this includes the unregulated use of hormones and the dangerous practice of injecting silicon orindustrial oil by non-medical providers (particularly in Latin America).
- Ask trans people, including those who identify as a third gender, about their specific health needs.
- Be sensitive to the terms trans people use to describe their gender identity and their bodies, and the individual choices they make about whether to seek hormones, surgeries or other medical treatments to modify their body.
- Enable trans people to access gender-affirming health services through models of informed consent, without requiring a mental health diagnosis.
- Notice gaps in data about trans health needs (including HIV-related information and services) and work in partnership with trans people to fill them.
- Understand the health needs of trans women, separate from those of men who have sex with men, including in the context of HIV.
- Be aware of health issues specific to trans men, including how gay and bisexual trans men might be included within the category of men who have sex with men.
- Recognize that effective, sustainable responses to HIV should address human rights violations against trans people and enable access to gender-affirming health services.
- 117. Whittle S., Turner, L. and Al-Alami, M. (2007).
- 118. Godwin, J. (2010) Legal Environments, Human Rights and HIV Responses Among Men Who Have Sex with Men and Transgender People in Asia and the Pacific: An Agenda for Action, Bangkok: United Nations Development Programme; Khan, S., Hussain, M., Parveen, S. et al. (2009) ‘Living on the extreme margin: social exclusion of the transgender population (hijra) in Bangladesh’ in Journal of Health Population and Nutrition; Volume 27, pp. 441–51; Global Commission on HIV and the Law (2012) p. 53.
- 119. Global Commission on HIV and the Law (2012) p. 52.
120. Baral, S., Poteat, T., Strömdahl, T., Wirtz, A., Guadamuz, T. and Beyrer, C. (2013) ‘Worldwide burden of HIV in transgender women: a systematic review and meta-anal-
ysis’ in The Lancet Infectious Diseases 13: p. 214.
- 121. Ibid.
- 122. UNAIDS / WHO (2011) Technical Guidance for Global Fund HIV Proposals Round 11, accessed 18 August 2013 at: http://goo.gl/KvpMND
- 123. WHO (2013) Joint Technical Brief: HIV, Sexually Transmitted Infections and Other Health Needs among Transgender People in Asia and the Pacific, accessed 11 October 2013 at: http://goo.gl/IYoOHW
- 124. Jobson, G., Theron, L., Kaggwa, J. and Kim, H-J (2012) ‘Transgender in Africa: invisible, inaccessible, or ignored?’ in SAHARA Journal of Social Aspects of HIV/AIDS Research Journal 2012; Volume 9, pp. 160–63, accessed 11 October 2013 at: http://goo.gl/tPmRmU
- 125. Baral, S. et. al. (2013) p. 220.
- 126. Jobson, G., Theron, L., Kaggwa, J. and Kim, H-J (2012).
- 127. UNAIDS (2012) Global AIDS Response Progress Reporting: Monitoring the 2011 Political Declaration on HIV/AIDS: Guidelines on Construction of Core Indicators: 2012 Reporting, accessed 3 October 2013 at: http://goo.gl/XiKy69
- 128. Pinto, R.M., Melendez, R.M. and Spector, A.Y. (2008) ‘Male-to-female transgender individuals building social support and capital from within a gender-focused net- work’ in Journal of Gay Lesbian Social Services; Volume 10, pp. 203–20.
- 129. Nemoto, T., Iwamoto, M., Perngparn, U., Areesantichai, C., Kamitani, E. and Sakata, M. (2012) ‘HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand’ in AIDS Care, Volume 24, pp. 210–19; De Santis, J.P. (2009) ‘HIV infection risk factors among male-to-female transgender persons: a review of the literature’ in Journal of The Association of Nurses in AIDS Care, Volume 20, pp. 362–72; Collumbien, M., Chow, J., Qureshi, A.A., Rabbani, A. and Hawkes, S. (2008) ‘Multiple risks among male and transgender sex workers in Pakistan’ in Journal of LGBT Health Research, Volume 4, pp. 71–79; Baral, S. and Phaswana-Mafuya, N. (2012) ‘Rewriting the narrative of the epidemiology of HIV in sub-Saharan Africa’ in SAHARA-Journal of Social Aspects of HIV/AIDS Research Alliance, Volume 9, pp. 127–30, accessed 26 August 2013 at: http://goo.gl/myPL8J
- 130. Grant, J.M. et al (2011); Instituto Runa (2007) Realidades Invisibles: Violencia contra Travestis, Transexuales y Transgeneros que Ejercen Comercio Sexual en la Ciudad de Lima, Lima: Instituto Runa
- 131. Winter, S. (2012); New Zealand Human Rights Commission (2008); Balzer, C. and Hutta, J. (2012) p. 64.
- 132. Balzer ,C. and Hutta, J. (2012) p. 48.
- 133. Baral,S.D.,Beyrer,C.andPoteat,T.(2011)p.6.
- 134. Operario, D., Soma, T. and Underhill, K. (2008) ‘Sex work and HIV status among transgender women: systematic review and meta-analysis’ in Journal of AIDS; Volume 48, pp. 97–103.
- 135. Balzer, C. and Hutta, J. (2012).
- 136. Global Commission on HIV and the Law (2012) p. 51.
- 137. Rowniak, S., Chesla, C., Rose, C.D. and Holzemer, W.L. (2011) ‘Transmen: the HIV risk of gay identity’ in AIDS Education and Prevention, Volume 23, pp. 508–20.
- 138. New York City Department of Health and Mental Hygiene (2012) New York City HIV/AIDS surveillance slide sets, 2010 (updated March 2012).
- 139. Stephens, S.C., Bernstein, K.T. and Philip, S.S. (2011) ‘Male to female and female to male transgender persons have different sexual risk behaviors yet similar rates of
STDs and HIV’ in AIDS and Behavior, Volume 15, pp. 683–86.
- 140. Grant, J. et al. (2011) p. 65.
- 141. Winter, S. (2012) p.3.
- 142. Baral, S. et al. (2013).
- 143. The term ‘sex reassignment surgery’ focuses more narrowly on surgical interventions, and often is assumed to refer solely to genital reconstruction. It is commonly abbreviated as ‘SRS’. The phrase ‘gender affirming’ is preferred by many trans people due to the breadth of interventions it encompasses and its positive focus on affirming someone’s gender identity.
- 144. Drescher, J., Cohen-Kettenis, P. and Winter, S. (2012) ‘Minding the body: Situating gender identity diagnoses in the ICD-11’ in International Review of Psychiatry, December 2012, Volume 24(6), pp. 568–577.
- 145. Open Society Foundations (2013).
- 146. These concerns were raised at a WPATH Consensus meeting in San Francisco in February 2013 and at a meeting of experts convened by GATE (Global Action for Trans* Equality) in April 2013 in Buenos Aires.
- 147. See the StopTrans Pathologization website at: http://goo.gl/j3ldcc
- 148. Coleman, E. et al. (2011) ‘The standards of care for the health of transsexual, transgender, and gender nonconforming people’ in International Journal of Transgende-
rism, Volume 13, p. 199, accessed 3 October 2013 at: http://goo.gl/Uy66cR
- 149. Ibid, Appendix D, pp. 229–230.
- 150. Personal communication with Sam Winter (July 2013).
- 151. ICESCR, Article 2(1).
- 152. OpenSocietyFoundations(2013).
- 153. OHCHR (2011) para. 57; State of California, Department of Insurance (13 April 2012) Economic Impact Assessment: Gender non-discrimination in health insurance, ac- cessed 3 October 2013 at: http://goo.gl/4EjB0P