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FOCUS September 2012 Volume Vol. 69

Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region

Sam Winter

The Asia-Pacific region is home to a large number of transgender (trans*) people; individuals whose gender identity, and/or expression of their gender, differs from social norms related to their gender of birth.1 Across the region it can be speculated that there are possibly 9-9.5 million trans* people, though existing research is scattered and small-scale, and is largely limited to trans* women.2 Asia-Pacific research, again scattered and small-scale, indicates alarming numbers of trans* women who are Human Immuno-Deficiency Virus (HIV) positive, with prevalence rates as high as 49 percent. There appear to be no data at all on HIV rates among trans* men, an emerging identity group. The number of trans* people of either gender who have died of Acquired Immuno-Deficiency Syndrome (AIDS), or what proportion they represent of overall AIDS-related deaths, is unknown.

The regional HIV epidemic among trans* people is strongly linked to stigma and prejudice.

Research on Asia-Pacific trans* people, scattered and often small-scale, has tended to focus on young and urban communities of trans* women, and has neglected the elderly and rural, as well as trans* men.3 That said, the research indicates that stigma and prejudice are major problems for trans* people, and are rooted in a range of beliefs (either traditional or modern, depending on the culture concerned) about sexuality, gender norms and nonconformity. The stigma and prejudice appear to put large numbers of trans* people onto a slope (a ‘stigma-sickness slope’), 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 more broadly (including in the law and law enforcement). Trans* people commonly report dropping out of or being excluded from education, and experiencing difficulty in finding, keeping and advancing in employment. Trans* people become marginalized, both socially and economically. Asia- Pacific legal environments serve to marginalize trans* people further, failing to offer trans* people sufficient protection against discrimination (or indeed against the more serious forms of sexual assault), and discriminating by withholding either practical or legal recognition of self-affirmed gender, criminalizing trans* people’s sexual or gendered behaviors, and subjecting trans* people to gender-inappropriate detention or incarceration practices, as well as contributing to police abuses.

There is good reason to believe, in the absence of much Asia- Pacific research in this area, that these experiences can damage trans* people’s psychological and emotional wellbeing, conspiring with other factors such as poverty to tilt them into life situations and patterns of behavior that put them at risk of HIV (as well as risk of other threats to their physical health and well-being). Unsafe sexual practices and engagement in sex work appear common among communities of trans* women.

It is known that Asia-Pacific trans* women commonly engage in unprotected receptive anal intercourse (URAI), but we know little about any safer sex behaviors (other than condom use) in which they engage (either in or out of sex work). Although many trans* women in the region appear quite badly informed about HIV risks, it is clear that many of those who are well-informed nevertheless engage in unsafe sexual practices. There is little research to indicate why. The lack of information on these matters mirrors more general (and global) ignorance on risks associated with neo-vaginal intercourse and lubricants (especially those that are not water-based and developed for lubrication during sex), and of how trans* women’s use of cross-sex hormones, hormone blockers and silicon injections, or their cis-male partners’ use of penile implants and drugs for erectile dysfunction might raise trans* people’s HI V vulnerability.4
Across much of the Asia-Pacific region, many trans* women engage in sex work at some point in their lives. It is likely trans* men also do sex work, providing services as female sex workers (FSWs) or as male sex workers (MSWs). In each case the numbers of trans* sex workers (TSWs) remain uncertain. It is highly likely that sex work raises their HIV risk, though little work has been done in this area, especially to examine the ways in which different reasons for and patterns of sex work might contribute to risk.
 
Across the region, there are numerous reports documenting problems in healthcare for trans* women - whether for general, transition or sexual health. The challenges facing trans* men remain severely under-researched. Trans* people approaching health services commonly report that providers are uncooperative or hostile with staff addressing or responding to the trans* person in a gender-inappropriate way, adopting a mocking or ridiculing attitude, withholding or refusing healthcare, or even offering ‘reparative’ treatments. Providers may lack competence in regard to trans* health care. Services are often difficult to access or costly. Costs, especially in regard to transition healthcare, serve to push trans* people towards sex work. Trans* people often seek out whatever health services there may be, relying on word-of-mouth recommendations. They pay for whatever transition they can afford; gender affirming surgeries, implants and/or high quality silicone injections (for those trans* people that have the money), or (traditional or backyard) castration and/or industrial quality silicone from medically unqualified ‘fillers’ and ‘pumpers’ (for those on a budget). 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 that they are likely to be the most expensive procedures they ever undergo.
 
Requirements for psychiatric evaluation before provision of hormones and/or surgery may add to the expense. Public subsidies for gender affirming surgeries are rare. In many countries transition-related surgeries (especially gonado-genital5) are simply unavailable or else are prohibitively expensive. For some communities castration has proved to be a cheaper, and more easily available, route to feminization (or more precisely, emasculation).
 
Trans* people often find that sexual healthcare services are not suited to their needs, focused instead on female and (more recently) on gay men and other MSM. The challenges facing trans* men again remain severely under-researched. Trans* women are likely to be denied women’s services, and even turned away from MSM services. Confidentiality is not always assured, especially in regard to mandatory HIV testing for sex workers. HIV positivity often compounds the problems in accessing appropriate care. Trans* women (perhaps especially TSWs where sex work is stigmatized or illegal) are often reluctant to seek sexual healthcare services, unless and until they experience a symptomatic sexually transmitted infection (STI). Across the region, few trans* people step forward for HIV testing.
 
The failure to address trans* people’s sexual health needs is to some extent symptomatic of a more general failure extending across the broader sexual minority spectrum. However, it is also clear that throughout much of the history of the global HIV response, trans* people have been invisibilized; in that they have seldom been properly recognized as a distinct population for purposes of confronting the HIV pandemic. Trans* women attracted to males have often been subsumed, researched and reported as MSM, or as a subpopulation within that behavioral group. The portrayal of these persons as MSM is 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 withmen (TMSM), a group which (ironically, and unlike trans* women) are best thought of as a sub-group of MSM.
 
To some ext ent non-governmental organizations (NGOs) and community-based organizations (CBOs)6 have in recent years stepped in to provide sexual health services. However many in trans* communities region-wide remain out of the reach of these services, and the work of these organizations has sometimes been hindered through actions of police and officials who harass both the providers and recipients of these services, detaining outreach workers, confiscating materials, and raiding offices and events.
 
There is an increasing tendency for trans* people to be seen as communities distinct from MSM. The increasing ability of Asia-Pacific trans* communities, especially trans* feminine communities, to organize themselves for advocacy can only help this process along. In this regard trans* men lag behind their female counterparts.
 
A research agenda is proposed that can facilitate reduction in future HIV risk for trans* people, as well as promoting better access to treatment, care and support for transgender persons living with HIV in the Asia-Pacific region. Donors may want to bear this agenda in mind when making funds available for research, or assessing individual research proposals. Recommendations are that:
1. Researchers (particularly those involved in HIV-related health and rights research) should work to end the invisibility of trans* people, researching them in their own right and, when necessary, disaggregating them from other groups in a research study. This will enable the building of a database on trans* people’s HIV vulnerabilities and healthcare needs. Research should seek to recognize diversity within trans* communities, and the existence of hitherto under-researched communities of trans* people; in particular the elderly and rural, as well as trans* men, about whose life circumstances and needs little is known.
 
2. Researchers should avoid letting cisgenderism (a way of thinking that demeans trans* people and privileges those who are not transgender) enter their research work, and note it in other’s research, bearing in mind that such practices can reinforce stigma and prejudice, and undermine trans* people’s claims for gender rights.
 
3. Researchers should engage with trans* people as partners, involving them as key members of research teams, paid on an equal-pay-for-equal-work basis alongside their cisgender colleagues. This helps avoid cisgenderism, facilitates more informed and sensitive research, and helps build researcher capacity. Research capacity can also be enhanced by improved access to international research (translated and summarized where necessary).
 
4. Research is needed that attempts to ascertain or estimate how many trans* people there are across the region, including elderly and rural trans* people, trans* men, and trans* sex workers (male and female). With good population data for trans* people (including for TSWs), and good HIV prevalence data, it should be easier to plan targeted health services, including HIV prevention programs.
 
5. Research (especially multidisciplinary) is needed which seeks to understand the HIV vulnerabilities of trans* people, especially key populations like trans* sex workers, the young, the elderly, and the rural. Trans* men, hitherto little studied, are another key population. Among potentially important research studies are those which throw more light on patterns of sexual behavior, and some of the ways in which those patterns of behavior may impact on HIV risk. Another important initiative would be a central database documenting rights violations against trans* people, as well as research which aims to understand more fully the nature of life on the stigma- sickness slope. Multi-disciplinary, comprehensive, large-scale and longitudinal research may be particularly valuable, enabling a more thorough assessment of the effects of stigma, discrimination, harassment, abuse and marginalization upon trans* people’s lives, and making possible an examination of the impact of changes in laws and law enforcement.
 
6. Research is needed that goes beyond risk factors for trans* people and looks instead at protective factors and personal qualities conferring upon trans* people resilience against the effects of stigma and prejudice,discrimination, harassment and abuse, and consequent marginalization. Research of this sort may facilitate the development of programs that help trans* people avoid slipping down the stigma- sickness slope, as well as countering a view of trans* people as passive victims.
 
7. Research is needed that examines ways to make trans* CBOs and relevant NGOs more effective in work by and for trans* people. Local, national and regional organizations already serving the trans* communities should be mapped, perhaps building on earlier initiatives. A comprehensive mapping will identify service gaps, and provide a basis for recommendations aimed at extending services, and evaluating improvements in service provision. There is a particular need for research, perhaps longitudinal, examining ways in which the effectiveness of CBOs may be enhanced so as  to better meet local needs, including those of underserved populations such as rural communities, elderly trans* people, and trans* men, as well as trans* people in migrant and ethnic/cultural/religious minority groups. While it is difficult to generalize, it is likely that those needs will include any or all of the following four key components, as per the remaining four recommendations.
 
8. There is a need to document information about innovative and good practice in regard to efforts to help the public (and key social agents such as police, judiciary, health workers, teachers, and various media, etc.) become better informed regarding trans* people, and more sensitive to their needs. Such research, properly disseminated, may prove useful in helping CBOs to develop more effective (and scaled up) education campaigns.
 
9. It is important to document the ways in which key conventions, declarations, court judgments and juridical and jurisprudential reports can be used to advance the rights of trans* people across the Asia- Pacific, and to find ways in which transgender communities across the region (and their advocates) can use that information in ways that make sense in the societies in which they live.
 
10. It is important to document means (both well-established and innovatory) by which trans* communities can effectively get access to important health information. Also useful would be research aimed at identifying ways of getting health information to the hard to reach trans* communities – particularly the elderly and the rural, who may neither be members of community groups nor linked to the internet, and may have limited literacy.
 
11. Research is needed which documents good practice in the provision of trans* positive, competent, comprehensive and accessible healthcare, that is out there.7 Especially useful is research which helps CBOs and other key stakeholders work with healthcare providers to scale up existing services, and to develop new initiatives, adapted to local context but drawing on what has been learned elsewhere (particularly in relation to behavioral interventions in the field of HIV).

This is the slightly edited version of the executive summary of the report of the same title published by the Asia Pacific Transgender Network (APTN) and the UNDP Asia-Pacific Regional Centre. The whole report can be downloaded at www.undp.org/content/undp/en/home/librarypage/hiv-aids/lost-in-transition--transgender-people--rights-and-hiv-vulnerabi/.

Dr. Sam Winter is an Associate Professor at the Faculty of Education of University of Hong Kong.

For further information, please contact: Sam Winter, Faculty of Education, Room 419,4/F, Run Me Shaw Building, Main Campus, University of Hong Kong, Pokfulam Road, Hong Kong; ph (852) 2859 1901; e-mail: sjwinter@hkusua.hku.hk.
TransgenderASIA website at www.transgenderASIA.org

Endnotes

1.  Following the practice of organizations such as GATE (Global Action for Trans*-Equality) the term trans* people is used as an open-ended social umbrella term, rather than a descriptor of a specific identity or cultural classification acknowledging the wide range of identities, and identity-based communities, within this population and across the Asia-Pacific region.
2.  Based upon 2010 United Na- tions population data for the region, and an estimate that 0.3 percent region wide may fall within the definition for being transgender. See main body of report for more detail.
3.  Trans* women here are birth-assigned males identifying and/ or presenting as female, or (in those cultures in which it is accepted that there are more than two genders) as members of another broadly feminized gender. Trans* men are birth-assigned females identifying and/or presenting as male or as another broadly masculinized gender.
4.  Cisgender people identify and present in a way that is congruent with their birth-assigned sex. Cis-male refers to birth-assigned male who identifies and presents as male.
5.  Gonado-genital surgery is ‘downstairs’ surgery. It can involve (in the case of a birth-assigned male) removal of testicles and penis, and perhaps construction of a vagina, labia and clitoris. In the case of a birth-assigned female it can involve removal of the ovaries and uterus, and perhaps surgery to create a penis.
6.  CBO as defined here includes non-registered networks and groups, as well as more formal and/or funded organizations.
7.  Trans* positive here refers to practice that affirms trans* people’s rights to their gender identities and expression, and support their ability to lead their lives with respect, equality and dignity.


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