Lessons From The Front Lines - AmfAR
LessonsFrom theFront LinesTrans Health and RightsamfAR, The Foundationfor AIDS Research
In addition to amfAR,major support forthe GMT Initiative isprovided by:Cover photos (clockwise fromtop): Grantee partner colleaguesfrom Gender DynamiX in CapeTown, South Africa; The ThaiTransgender Alliance (ThaiTGA)in Bangkok, Thailand; andCentro de Orientación eInvestigación Integral (COIN)in Santo Domingo, DominicanRepublic.
Table of ContentsIntroduction. 1Organization Profiles. 2Red Nacional de Mujeres Travestis, Transexuales y Transgénerosde Bolivia (RED TREBOL) – Cochabamba, Bolivia. 2Chengdu Tongle – Chengdu, China. 3Comunidad de Trans y Travestis Trabajadoras Sexuales Dominicana(COTRAVEDT) – Santo Domingo, Dominican Republic. 4Silueta X – Guayaquil, Ecuador. 5Alfil Association – Quito, Ecuador. 6Asociación Solidaria Para Impulsar el Desarrollo Humano’s(ASPIDH) – San Salvador, El Salvador. 7Center for Information and Counseling on Reproductive Health(Tanadgoma) – Tbilisi, Georgia. 8The Institute of Studies in Health, Sexuality and Human Development(IESSDEH) – Lima, Peru. 9Transgender and Intersex Africa (TIA) – Pretoria, South Africa. 11Insight – Kiev, Ukraine. 12Conclusion. 13
IntroductionAll around the world there are people who self-identifywith a different gender than the one assigned to them atbirth. Very often, these people also challenge normativeassumptions about gender expression and contradictcultural expectations about bodies, behaviors, andappearances. A variety of names have been used to identifythese people in different countries and cultures, includingthose of two spirits, transmen and transwomen, travestis,fa’afafines, transsexuals, and hijras. In the context of theglobal HIV response, they are internationally recognized astransgender or trans people.to the pervasive combination of stigma and discrimination,lack of access to healthcare, stable housing, andemployment, substance abuse, and being subjected tosexual violence. These same factors also prevent transindividuals, and trans sex workers in particular, fromaccessing HIV information, prevention, and treatment. Inmany countries, little data exits on the trans population andHIV, but when it is available, the reported prevalence of HIVamong the trans community is often higher than among gaymen and other men who have sex with men (MSM) and farhigher than among the general population.Trans people face very similar challenges across the globe.These challenges include early rejection and exclusionfrom family, society, and community life. Many trans peopletherefore lack access to education, and a high numberof trans adolescents are homeless. Many are forced toleave their families, communities, towns, and countriesto survive, and many become legal or illegal sex workers.Trans people in general, and trans sex workers in particular,are constantly exposed to discrimination, harassment,persecution, arbitrary detention and incarceration, torture,and murder—and these human rights violations againstthem are usually not investigated.However, as this report will demonstrate, trans individualsworldwide have responded to the epidemic with a processof intense political organizing on the local, national, regional,and international level. Trans community organizing hasbeen the key to differentiating between the epidemiological,prevention, treatment, and political issues faced by MSMfrom those faced by trans individuals and to then developinga response designed to specifically target trans individuals’HIV needs.This report profiles ten organizations committed toimproving trans people’s living conditions by challengingsocial and institutional constraints, supporting communityempowerment and leadership, and developing a responseto HIV designed for and by trans individuals. Most of theorganizations are led by trans people themselves. All ten arecurrent or former grantee partners of amfAR’s GMT Initiativeand are located in Africa, the Asia-Pacific, the Caribbean,Eastern Europe and Central Asia, or Latin America.In most countries, trans individuals cannot get legalrecognition of their gender identities. When legal recognitionis available, it usually requires psychiatric diagnosis ofgender dysphoria or a similar condition, sterilization,surgeries and hormonal treatments that may not be wanted,forced divorce for individuals who are currently married,and other requirements that are blatantly incompatible withhuman rights standards. Many of the same discriminatoryrequirements often apply to those who want to accessgender affirming procedures, such as surgeries andhormone treatment. As a consequence, many trans peoplearound the world modify their bodies through dangerousmethods, such as self-injecting industrial silicone or oil, oraccessing surgeries or hormones through illegal markets.Members of each organization were interviewed by MauroCabral, the co-director of Global Advocacy for TransgenderEquality (GATE). They offered accounts of their project goalsduring the period they were funded by the GMT Initiative,the challenges they faced in achieving those goals, how thechallenges were confronted, solved, or incorporated intonew strategies, results from amfAR-funded studies theyperformed when available, and the lessons they learned.These social and institutional barriers make trans peopleextraordinarily vulnerable to depression, substance abuse,suicide, and HIV infection. Their HIV risk is heightened due1
government authorities, foreign officials, and advocates fromother countries. “It was a milestone for the trans population in theregion,” says RED TREBOL’s director, Rayza Torriani.Organization ProfilesYear 2:Red Nacional de MujeresTravestis, Transexuales yTransgéneros de Bolivia(RED TREBOL)Meanwhile, the female trans population’s right to health in Boliviaremained a pressing problem, and trans women continuedto experience abuse from health providers. The hostility ofthe medical system not only prevented many trans peoplefrom accessing HIV treatments, but also caused them to selfadminister industrial silicone to change their body to expresstheir gender—a practice that can be deadly.Cochabamba, BoliviaRED TREBOL is a network of trans people that consists of over1,000 participants and six facilitators who work in six areas ofBolivia (Beni, La Paz, Cochabamba, Potosí, Oruro, and SantaCruz). The network was created in 2008 during the first nationalmeeting of trans advocates held in Santa Cruz de la Sierra. REDTREBOL performs strong advocacy work for the legal recognitionof gender identity and for trans access to education, health, andemployment. It also provides legal advice and HIV information,prevention materials, and counseling.As a result, RED TREBOL recognized the need to establish its ownspace to provide healthcare. “It is not only a space for physicalhealth, but also for mental health, and for the sisters to find aplace that includes them, because you cannot fight against HIV ifyou are made to believe that you are worthless,” says Rayza.Using amfAR’s support, RED TREBOL opened a clinic this yearat its headquarters in Cochabamba that provides HIV and othermedical care and specialized information on hormone treatments,and also addresses other health issues, including complicationswith silicone implants and alcoholism.Results:The clinic operates three days a week and staffs a nurse whoprovides medical services and psychological and emotionalsupport. Unlike at other health centers, identity and genderexpression is respected and the patients receive warmheartedservices. RED TREBOL’s clinic works in coordination with othergovernment-run health centers. The project is not intended tocompete with the state, but to help expand trans individuals’access to healthcare, when state facilities do not providetransphobia free services. The office has the endorsement of theNational Health Program.Rayza Torriani, directorof RED TREBOL, beinginterviewed abouta proposed GenderIdentity Bill.The project also includes continued training for healthprofessionals; however, as Rayza warns, “It is necessary that thestate takes responsibility and intervenes in the training of healthprofessionals, because doctors trained by us are then replacedby others, and who will ensure their training when we cannotdo it?” Meanwhile, RED TREBOL continues its work to promotesustained trans leadership. “For us, it is fundamental to believethat this can be done and that we can do it, so we lose the fear,”says Rayza.Year 1:RED TREBOL first received amfAR support to organizeworkshops to train and empower trans leaders and encouragetheir participation in decision-making processes. They alsoorganized workshops on gender identity for media, grassrootsorganizations, and educational institutions, and trainings onhealth issues for medical professionals. As part of the project,the organization also conducted strong advocacy work withgovernment officials and created a sustained media visibilitythrough posters, videos, and radio ads.Lessons: Training health personnel is not enough. Continuousengagement is essential to provide trans-friendly healthservices.Results: Activists cannot and must not replace the government’sresponsibilities. They should lobby for their government tomeet its responsibilities in servicing all people, including thetrans community.With the support from amfAR (and other agencies, includingUNDP, UNAIDS, and UNFPA) RED TREBOL worked with a NationalWorking Group on HIV and Sexual Minorities to organize thefirst national meeting on Human Rights and Gender Identity.It took place in October 2013 and was attended by over 60representatives, including senators, both national and local Progress begins and is sustained by strengthening transleaders.2
Chengdu TongleResults:Chengdu Tongle was able to recruit participants because of itslong-standing relationship with the local trans community andits close proximity to bars where trans people often meet andwork. Chengdu Tongle involved more than 60 trans participantsin designing a participatory assessment of their needs,expectations, and resources. This included different sub groups,such as cross dressers and trans sex workers.Chengdu, ChinaChengdu Tongle started in 2002 as a gay organization andhas grown to focus on providing services for HIV prevention,testing, and counseling; organizing cultural activities; andpromoting advocacy on LGBT issues in China. Chengdu Tonglehas extensive experience in mobilizing the LGBT communitythrough outreach activities, trainings, and peer support. It’s alsoan organization with a solid background in advocating againstinstitutional homophobia and transphobia in healthcare settingsin the region.This assessment process combined face-to-face interviewswith focus group discussions to provide an accurate overviewof the challenges and opportunities faced by trans people.The experience produced much-needed knowledge about thecommunity, including their needs for respect and recognitionand for doctors trained to deal with their specific issues. Italso empowered them, opening the way to the next step in theprocess—the creation of the first trans organization in Chengdu.Years of working with LGBT in the field demonstrated to ChengduTongle that the trans community’s situation was different thanthat of gay men and other MSM, due to challenges associatedwith gender identity and expression, sex work, stigma,discrimination, and exclusion, and that they needed to developprograms and strategies specific to the trans community.Chengdu Tongle decided that the only way to seriously addressthe challenges faced by trans people in Chengdu was to involvethe trans community as the primary participants and leaders inthe process. In 2010, Chengdu Tongle received an award fromChengdu Tongle had envisioned establishing a specificorganization that addresses trans issues at the beginning of theproject, and the participatory research created the communityinvolvement needed for the organization to succeed. The nameof the organization is New Beauty, and its mission, goals, andwork plan were developed by the involved trans activists, withChengdu Tongle contributing as a facilitator. “This is theirorganization, and not ours,” said Yu Fei. However, New Beautyhas not been able to legally register as a formal and independentorganization, and, therefore, Chengdu Tongle has continued tooperate as a host, and the trans people involved in New Beautyas volunteers. For Chengdu Tongle, this is a clear example of thediscrimination against trans people in China.The project faced a similar challenge in terms of advocacy. Evenwith the well-researched knowledge and suggestions aboutthe specific healthcare needs of trans people produced by theproject, the organization is still struggling with the government’sreluctance to incorporate that knowledge into official strategiesfor HIV prevention.Lessons: Community mobilization requires building knowledge throughparticipatory research processes that involve the community. Separate strategies need to be implemented for MSM andtrans people, and the diversity among trans people needs tobe recognized.Members of Chengdu Tongle at their offices Political solidarity within the entire LGBT community isnecessary to overcome expected and unexpected challenges.amfAR for a groundbreaking project focused on the Chengdutrans population. “They deserved to be considered as what theyare, trans people and not gay men,” said Yu Fei, chief executiveofficer of Chengdu Tongle. Despite the government’s unwillingness to accept results andimplement programs, Chengdu Tongle’s work is still vital toproviding these important services to trans people.Chengdu Tongle developed a project that articulated threemain strategies: performing participatory research, improvingorganizational capacity, and advocating the government toaddress trans issues. Developing this project required learninghow to work with the trans community to distinguish andappreciate its diversity, the particularity of its needs, and its ownroad to empowerment.3
Comunidad de Trans yTravestis TrabajadorasSexuales Dominicana(COTRAVETD)The organization trained 12 trans health outreach workers to visitcommunity members living with HIV in their own homes. Eachworker is accompanied by a community volunteer who providesadditional support. “To many of them, it is very hard to copewith being HIV positive and to look for help,” says Carlos, whoadded that it is important to link this difficulty coping with HIV tothe internalization of societal stigma and hostility towards transpeople, sex workers, people living with HIV, and immigrants fromHaiti. Often, one person embodies all these forms of vulnerabilityand having a safety net becomes essential for survival.Santo Domingo, Dominican RepublicCOTRAVETD promotes the human rights of the female transpopulation in the Dominican Republic. Its activities are focusedon providing HIV prevention, support, and treatment accessand community and societal awareness about the stigma,discrimination, and violence trans people, people living with HIV,sex workers, and Haitian immigrants to the Dominican Republicoften face.COTRAVETD also works with the Centro de Orientacióne Investigación Integral (COIN), another Dominican transorganization, to provide HIV-positive people and their familieswith accompaniment and support when they go to get themedical services and legal advice they need.Results:COTRAVETD also performs advocacy work for the recognitionof the right to gender identity in the Dominican Republic. Everymonth, the female trans community in Santo Domingo meets atthe COTRAVETD headquarters to discuss various topics, includingHIV prevention strategies, HIV treatment adherence, body issuesand gender identity, romantic relationships, and how to dealwith everyday situations in which family, social, or communityrejection is expressed. “It’s a place to talk about what you wantor need to talk about,” says Carlos Laureano, project assistant atCOTRAVETD.COTRAVETD staff and volunteers have accompanied 37 transindividuals with HIV as they sought out the services they neededand many began treatment due to this peer support. “Thisemotional support is as, or more, important than information,”says Carlos. As part of this project, COTRAVETD also organizesmeetings aimed at training trans individuals to address the HIVphobias found within their community and among the generalDominican population.Year 2:COTRAVETD is now conducting advocacy work to promotelegislative change using funding from amfAR. The organizationis leading an effort to improve a draft Gender Identity Law.Regardless of if the law passes or not, the process of draftingand proposing it serves as a tool for movement building andpolitical visibility. “It’s not just a matter of whether it is approvedor not,” says Charles. “It is essential to put the law on the agendafor discussion and talk about the topic, so it becomes visible.”Lessons: Effectively caring for people living with HIV does not onlyinvolve providing them with information and access toservices, but also recognizing their emotional needs.A COTRAVETD community trainingThe organization also trains trans health outreach workers to givelectures on HIV prevention and distribute a “battle kit” containingcondoms, lubricant, and an informative flyer. In recognitionof the profound need to produce real and lasting changes inthe community’s living conditions, COTRAVETD also organizesmeetings with the trans women’s partners to help them becomemore aware of the issues their partners are facing and preventdomestic violence. Peer support and, if possible, family involvement is essentialto ensure that services are successfully accessed. Awareness raising and support work is an extended processand a one-year period is too short to produce long-termchanges. Stigma and discrimination towards people living with HIV arenot only rooted in society in general, but are also found withinthe community itself, and that internalization compromisesthe survival of people living with HIV.Year 1: Many trans people face multiple forms of stigma anddiscrimination at the same time, so effective support mustaddress all their vulnerabilities, including sex work, HIV, andnationality.COTRAVETD concluded that a meeting space and workshopspromoting health access and knowledge did not have a largeenough impact because many HIV-positive trans individuals didnot participate in these activities or get access to the healthservices they needed. The organization designed its Pills for Lifeproject, which obtained support from amfAR in 2013, to providesupport for people in their homes. Processes of legislative change also cause cultural change.4
Silueta Xof LGBT in Ecuador’s law to prevent and punish harassment,intimidation, and violence in schools and its law supportingintercultural education.Guayaquil, EcuadorSilueta X was founded in 2009 and legally registered in 2010.The organization works to promote legislative
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Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
