Public health issues in Asia

Bangkok’s transgender community finally gets the health services it wants

At a HIV conference a while ago I was chatting to one of the other participants, a transgender woman, about why in the HIV world, transgender people are typically lumped in with men who have sex with men. This makes little sense. As my coffee break companion said, with a ‘look at this’ gesture from her high heels, to her fitted dress, all the way up to her long, wavy hair: “In what way does this say I am a man, having sex with men?”

Whilst both gay men and transgender people are known to be at especially high risk of acquiring HIV, for transgender people the risk is far more extreme: 49 times higher than for the general population, in fact. Moreover, they face a degree of marginalization and exclusion from the educational and employment opportunities that men who have sex with men rarely have to grapple with. The lack of a separate ‘key population at increased risk of HIV’ category for transgender people also does nothing to address the lack of data on the HIV epidemic, and what services the transgender community needs, making it difficult to get dedicated funding for HIV programmes for transgender people.

The highly restricted work options for transgender people in many countries see a disproportionate number entering into sex work .What sexual health and HIV prevention services there are tend to focus on transgender sex workers, while stigma and discrimination make the transgender community often extremely difficult to reach with HIV testing, treatment and care services.

Until recently, folding transgender people in with men who sex with men, despite the fact that the two communities have very different needs, was what was happening in Bangkok.

In 2008 the Thai Red Cross AIDS Research Center changed its approach from offering HIV testing to offering anal cancer screening, as a way to get gay men and other men who have sex through the door, and then offer them HIV testing too. It worked: client numbers went up and 80% who came in for anal cancer screening also accepted the offer of HIV testing. Five years on, it was clear that this approach was highly successful in increasing demand for the clinic’s services, but the number of transgender people accessing the clinic remained unchanged. The clinic was missing something if it wanted to appeal to transgender people.

“Through extensive consultations with the transgender community we understood the barriers they face when accessing health services,” Nittaya Phanuphak, Chief, Prevention Department, Thai Red Cross AIDS Research Centre told me. These extensive consultations were with diverse members of the transgender community – including those working as advocates, healthcare providers, within the fashion industry, as well as those working with transgender sex workers – revealed that transgender people face obstacles in accessing hormone level testing and therapy, the most basic health services that they regularly require to affirm their gender identity. What services there are typically are not from transgender-friendly providers, or even worse are provided outside the medical profession entirely.

Hormone therapy services were identified as the entry point to make the clinic attractive to its target population. The Tangerine Community Health Centre opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. The name was carefully chosen. “We knew the clinic’s name should be one that makes everyone feel comfortable, with nothing that can be considered stigmatizing, Tangerine is a play on transgender, and was chosen because it a fruit that is not too sweet not too sour, just the right blend.

Most of the clients have since come seeking hormone level testing and injections, but they are also offered a package of services including anal and neo-vaginal pap smears, cervical smear tests for transgender men, testing for sexually transmitted infections and a free HIV test (all Thai nationals are entitled to two free HIV tests a year). The centre provides both pre and post-exposure HIV prophylaxis and harm reduction interventions for safe injection.

Funding from USAID covered the costs of the community consultation, start-up, and sensitization training for staff, but services are fee-based, with the cost set at a level that makes them affordable to most clients. As the clinic becomes established, should the fees prove to be prohibitive to some, one option is to introduce a co-pay mechanism, but the aim of the clinic is to be self-financing. A clinic that covers its own costs is a sustainable and replicable role model for other cities trying to close the gap between their transgender communities and HIV services.

Tangerine’s catchment area is Bangkok and it surrounding four provinces, although approximately a fifth of its clients so far have travelled from other provinces to access services and a handful were from overseas. The clinic has a target to see over 400 clients in the first year of operation, with at least 600 consultations. From November 27 2015 to February 23 2016, it had seen 84 male-to-female clients, of whom 61 had received HIV testing, with 11% testing positive. Of the 25 female-to-male clients, 16 had been tested for HIV. Most clients also received testing for syphilis, over half of the transgender women requested hormone level measurement, as did four out of five transgender men.

The Tangerine Community Health Center’s key strengths are its foundations built on extensive community engagement, and its model of integrated health services with a self-sustaining funding model. The clinic’s two transgender staff have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves. In time, its usage data will also become an invaluable database of the transgender community’s health profile, overcoming the current invisibility of transgender people in the national AIDS database, and this community’s unique HIV and other health-related needs will be better understood.

Public health issues in Asia

Hong Kong needs its own Conchita Wurst

I woke up today to the news that Conchita Wurst had won the 2014 Eurovision song contest, by a mile, and contrary to expectations. I was thrilled, partly because I’m a fan, she’s got a great voice and deserved to win, but mostly because it was such a strong statement from Europe about tolerance, acceptance of diversity, and reason.

Homophobic St Petersburg legislator Vitaly Milonov (the one who sponsored a local law against homosexual propaganda in 2011, which was followed by similar federal law in 2013) tried to mobilise a Russian boycott of the competition, and tried to exclude Tom Neuwirth, in his Conchita persona, from participating.

All to no avail. In fact, the extra publicity was welcomed by Conchita, it raised her public profile and probably helped her win. “I can only say thank you for your attention!” she told Associated Press. “If this is only about me and my person, I can live with it. You know, I have a very thick skin. It’s just strange that a little facial hair causes that much excitement. I also have to add that 80% of the autograph requests that I get are from Russia and eastern Europe — and that’s what is important to me,” she said “Hey, I’m just a singer in a fabulous dress, with great hair and a beard.”

As Conchita’s win, for herself, for her country and for a tolerant Europe, plays out against the backdrop of homophobia in Eastern Europe, elsewhere this year we have seen backwards steps towards institutionalized and legally sanctioned homophobia in Nigeria and Uganda, which were followed almost immediately by crackdowns on the LGBT communities in both countries.

All this might seem very distant from Hong Kong, but homophobia, although a little more low key than in Eastern Europe, is an insidious and dangerous force here too. Although Hong Kong has laws protecting the civil and employment rights of citizens, making it illegal to discriminate against someone on the basis of their gender or race, there is no such protection against sexual orientation discrimination. This is why a fundamentalist Christian international school here can blatantly make the jaw-dropping statement that it will not hire gay teachers.

Other homophobic local Christian groups are also actively lobbying against the introduction of a sexual orientation discrimination ordinance in Hong Kong. One of their insidious tactics is to make spurious links between the issue of discrimination in the public sphere and the issue of same-sex marriage.

After Hong Kong’s Court of Final Appeal ruled that “W”, a transgender woman has the right to marry her male partner, the government rushed to introduce the Marriage (Amendment) Bill that the case prompted. If passed, the bill will restrict the right to be defined as transgender only to those who have undergone full gender reassignment surgery, far from what the court recommended as a ‘compelling model” for Hong Kong: the UK’s Gender Recognition Act, and out of step not just with most Western countries but also with several in Asia Pacific. The stipulation was condemned by the chair of the Equal Opportunities Commission York Chow, as a denial of dignity that has no place in a civilized society.

Respect for basic human rights is enough to justify legal protection and full civil rights for all in Hong Kong, regardless of sexual orientation or gender identity, but there is a public health agenda to this too. The government’s rush to introduce misguided and inhumane marriage legislation, and the lack of progress on bringing in a sexual orientation discrimination law, are, at best, a sign of ignorance within the government.

This ignorance about sexuality and gender starts with the education system, and the parlous state of sex education in Hong Kong’s school system is a public health hazard in its own right. It seems we can’t rely on schools to deliver anything like the basic minimum package of youth sexuality education recommended by the UN. That package is based on evidence that has shown that “comprehensive sexuality education that is scientifically accurate, culturally and age-appropriate, gender-sensitive and life skills-based can provide young people with the knowledge, skills and efficacy to make informed decisions about their sexuality and lifestyle.” These, along with the other pressing human rights issues we are facing in Hong Kong, are issues that we will need to tackle society-wide.

Even if Conchita hadn’t won the Eurovision song contest this year, she would still have achieved one of her main goals, which was to bring the conversation, not just about gender identity, but about tolerance for difference, into family living rooms all across Europe. Maybe we need someone like Conchita here in Hong Kong, to step out of the shadows of the LGBT community and into the public arena, looking fabulous (with or without a beard), standing proud and helping to bring sexual and gender rights and legally protected tolerance for difference under the spotlight and into the public domain where they belong.