Gender Affirming Health Care Drawing from a Zambian, Zimbabwean & South African context Presenter: Ricky Nathanson - Sexual Rights Centre ICASA 2015 KEY POPULATIONS PRE-CONFERENCE 28 – 29 November 2015 – Harare, Zimbabwe

Background & Introduction 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 or create breasts, hysterectomies, and a range of genital reconstruction surgeries. These services are to be conducted in a welcoming, non-discriminatory and humane manner, recognising the fundamental rights and dignity of each individual.

Description Gender affirming care [or the lack thereof] was researched in Zambia, Zimbabwe and South Africa, using the following methods: Zambia – online research; Zimbabwe – face to face interviews with trans individuals and medical practitioners; South Africa 1. “Rooted in the Past, Reaching for the Future”, report of the 2 nd Trans* Health, Advocacy & Research Conference, Cape Town, 31 May – 2 June “Sexual & Reproductive Health for transgender and gender non- conforming people: Guidelines for health care workers in primary care” – Dr. Alex Muller 3.“Lack of access to transgender healthcare in South Africa. What funders should know” - Transfeminists

Lessons Learned Zambia & Zimbabwe - challenges 1.Because being transgender in Zambia and Zimbabwe is not recognised; trans* women are taken as femme gay men and, therefore, are subject to punitive anti sodomy laws. 2.There is no anti-discrimination provision to protect individuals from being discriminated against on the basis of their sexual orientation and/or gender expression or identity, thereby subjecting transgender persons to stigma and discrimination at the hands of medical practitioners and institutional violence. 3.The transgender people have no access to gender-affirming health services, i.e. hormones or surgeries. This leads to individuals resorting to accessing black market drugs and procedures with extremely potential health hazards, which may sometimes prove to be fatal. Zimbabwe – breakthrough 1.Talks have begun with medical practitioners in the city of Bulawayo, as a starting point to provide affirming health care for trans* persons

Lessons Learned [cont’d] South Africa - challenges 1.Gender affirming procedures, treatments and services although available are still largely lacking, inaccessible and unaffordable in South Africa. 2.Self medication remains a huge problem, especially among trans* women. 3.Little to no research exists on the HIV vulnerability of bodies post sex reassignment surgery. 4.Little to no research exists on the cross drug interactions between certain hormone treatments and ART. 5.Rural trans* people’s access to gender affirming treatment is disproportionately affected in relation to those in the centres. 6.The concept of validative sex among trans women is ever increasing, which is problematic in the context of HIV vulnerability.

Lessons Learned [cont’d] South Africa - Successes 1.Groote Schuur Hospital, Cape town though offering friendly open approach service is severely underfunded with a 20 – 26 year waiting list. 2.Chris Hani Baragwanath Hospital, Johannesburg, facilitates a quicker gender affirming process. 3.SHE, Eastern Cape, is advancing the provision of gender affirming care for transgender persons through the Eastern Cape office of Commission for Gender Equality and Cecilia Makhiwane Provincial Hospital 4.GDX has undertaken parliamentary submission emphasising the need for gender affirming and trans* specific health care and inclusion in the National Health Insurance [NHI] programme, as well as expanding its database of medical and health practitioners. 5..TIA engages private medical service providers and psychologists in the Johannesburg area. It has also engaged the Gender Identity Interest Group in Jo’burg 6. Psychological Society of South Africa has established a Sexuality and Gender Division, issuing a Sexuality and Position Statement. 7. Awareness created about gender affirming therapies in the media.

Conclusion Stigma, discriminatory laws, marginalisation and social exclusion put transgender people at an increased risk of HIV. Generally, HIV prevalence among transgender women is higher than transgender men. However, very little is known about transgender men and their vulnerability to HIV. Globally, it is estimated that around 19% of transgender women are living with HIV. They are also 49 times more likely to acquire HIV then all adults. This is due mainly to:- 1.Sex work due mainly to social exclusion, economic vulnerability and a lack of employment opportunities ; 2.There are high rates of unprotected anal sex among transgender women, which carries a high risk of HIV transmission. Stigma and discrimination, leading to low-self esteem and disempowerment, can make it harder for transgender people to insist on condom use. Looking at issues in isolation is problematic. “My race, my homelessness, my HIV positive status” is all one struggle and integration of these intersectionalities should be key in the HIV response.

Recommendations 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.

Final Message