Anti-LGBTI Discrimination Harms Efforts to Fight HIV/AIDS

AIDS worlds AIDS Day

Originally published on The Advocates Post

I went to Mwananyamala Hospital (a government facility) for HIV testing. During the pre-counseling, I came out as gay to the health staff (counselor) and immediately he condemned me saying that it was my fault to catch the virus because of my behavior of practicing anal sex. The counselor used abusive words and told me that I have to suffer both punishments being HIV positive and also going to hell because of my sins. That made me leave the Centre without testing. I developed a negative attitude and decided not to go for HIV anymore until my friend from a LGBT advocacy organization helped me go to user friendly Centre [private] and was tested positive. I am now on treatment.”

― 27-year old gay man interviewed in
Dar es Salaam, Tanzania

Through The Advocates for Human Rights’ work promoting LGBTI rights around the world, we routinely hear stories like this of the struggle to access health care and health information.  On World Aids Day (December 1), it is particularly important that we draw attention to the fact that anti-LGBTI discrimination harms efforts to combat HIV/AIDS worldwide.

Tanzania, where The Advocates has partnered recently with LGBTI human rights organizations, provides a good example of the problem. Due to widespread discrimination based on sexual orientation and gender identity, LGBT individuals in Tanzania fear disclosing their sexual orientation to health care providers.  Further, health care providers often refuse needed services to LGBT individuals. In its Third National Multi-Sectoral Strategic Framework for HIV and AIDS (NMSF III), the Government of Tanzania recognized the barrier that anti-LGBT discrimination can pose to health care access: “Stigma and discrimination against MSM [men who have sex with men] remains high, posing a significant challenge to outreach and delivery of friendly health services.”[1] Indeed, some non-governmental organizations estimate that over 2 million LGBT Tanzanians lack access to quality health services.

Anti-LGBT discrimination in the health sector includes denial of services, verbal harassment and abuse, and violations of confidentiality.[2] In particular, health care providers deny treatment to openly LGBT individuals seeking treatment for sexually transmitted infections (STIs) and HIV/AIDS.[3] Hostility from health care providers drives gay men outside of the health care system, depriving them of both services and information.[4]

In response to this discrimination, many LGBT Tanzanians choose to hide their sexual orientation or gender identity from their health care providers.[5] . Such nondisclosure, however, may prevent health care providers from addressing needs specific to LGBT patients. For example, a recent study assessing HIV and STIs among gay men in Tanzania found that they often do not disclose their sexual orientation to health care providers, hindering detection of rectal STIs.[6]

Tanzania’s legal system imposes some of the harshest penalties on homosexual conduct in all of Africa. Homosexual conduct has been illegal on mainland Tanzania since the implementation of the Tanzanian Penal Code in 1945.[7] Homosexual conduct has been illegal under the Zanzibar Penal Code since 1934.[8]

As a result, LGBT individuals decline to seek health care due to fear of revealing criminal conduct to health care providers.[9] Similarly, health care providers cite the criminalization of same-sex sexual conduct as a basis for denying services to LGBT people.[10] Moreover, criminalization perpetuates stigma, and stigmatization prevents lawmakers from addressing LGBT-specific health needs.[11]

In addition to obstructing health care access generally, anti-LGBT discrimination undermines efforts to fight HIV/AIDS. NMSF III recognizes men who have sex with men (MSM) as a population “at high risk for exposure to HIV or for transmitting HIV.”[12]  In fact, multiple sources recognize that the rate of HIV/AIDS among MSM is higher than that of the general population of Tanzania.[13]

Criminalization of same-sex conduct in Tanzania hurts all Tanzanians, because it hinders efforts to fight the harm that HIV/AIDS inflicts on all populations. Criminalization encumbers HIV/AIDS-related public health campaigns and research.[14] The International Lesbian Gay Bisexual Trans and Intersex Association recognizes that anti-LGBT discrimination drives LGBT people “underground,” impeding implementation of effective HIV/AIDS-related education program.[15] Criminalization also harms outreach efforts by NGOs that do not wish to violate Tanzanian laws.[16] Around the world, countries that criminalize same-sex conduct demonstrate higher rates of HIV among gay men than those that do not criminalize such conduct.[17]

A gay man from Mwanza stated:

I was very sick and some of my friends advised me to have an HIV test. I went to the nearest Centre where almost everyone knew me. A queue of people were pushing me away because they never wanted me near them. An officer came out and told me to find another place to go, because I was not welcome in that hospital because of my behavior. I had no choice but to leave the Centre ashamed and I planned to commit suicide. My friend learned about my plan before I poisoned myself and called [name withheld] who helped me go through that moment, he also referred me to a user friendly facility.[18]

Even the Tanzanian Government acknowledges that criminalization of same-sex conduct complicates Tanzania’s response to HIV/AIDS: “Given the criminalization of consensual adult homosexual intercourse, the multi-sectoral national response requires significant cooperation from all key stakeholders to ensure that MSM are reached with HIV and AIDS services.”[19]

Unfortunately, the Tanzanian Government has yet to take concrete action to amend the National Multi-Sectoral Strategic Framework for HIV and AIDS to establish that reducing the transmission of HIV among gay men is a central part of the national AIDS strategy and develop an implementation strategy to meet this objective.

On World AIDS Day, The Advocates for Human Rights calls upon all governments to ensure access to health care and health information for all LGBT individuals by:

  • Requiring all public health care workers to receive comprehensive diversity training, including training on sexual orientation, gender identity, and the rights of LGBT people.
  • Establishing and identifying LGBT-friendly health care facilities where LGBT people will feel free and comfortable to access services.
  • Advancing national Standards of Practice for providing health care to LGBT individuals. These standards should:
    • Prohibit discrimination in the delivery of services to LGBT clients and their families.
    • Require visible posting of non-discrimination policies and inclusion of policies in organizational brochures and informational and promotional materials.
    • Establish comprehensive and easily accessible procedures for clients to file and resolve complaints alleging violations of these policies.
    • Designate of one or more persons within each health care provider to ensure compliance with the Standard of Care.
    • Require all reception, intake, and assessment staff to be familiar with providers within the health care organization with expertise in and sensitivity to LGBT issues, and appropriately convey this information to patients.
    • Provide comprehensive ongoing training for direct care staff to identify and address basic health issues within their field of expertise that may particularly affect LGBT clients.
    • Develop a comprehensive resource list for appropriate referrals for special gay, lesbian, bisexual, and transgender health concerns.
    • Develop written confidentiality policies which explicitly include sexual orientation and gender identity, indicating that such information is to be considered highly sensitive and treated accordingly.[20]
  • Developing a public outreach and education campaign directed toward the LGBT community that educates LGBT Tanzanians on proper HIV/AIDS prevention and identifies LGBT-friendly health care resources.[21]

Jennifer Prestholdt is the Deputy Director and International Justice Program Director at The Advocates for Human Rights.

[1] United Republic of Tanzania, Prime Minister’s Office, Tanzania Third National Multi-Sectoral Strategic Framework for HIV and AIDS (2013/14-2017/18) (November 2013).

[2] Human Rights Watch, “Treat Us Like Human Beings”: Discrimination against Sex Workers, Sexual and Gender Minorities, and People Who Use Drugs In Tanzania (2013).

[3] Canada: Immigration and Refugee Board of Canada, Tanzania: Treatment of sexual minorities by society and government authorities; recourse and protection available to those who have been subject to ill treatment (2007-July 2014), 8 August 2014, TZA104923.E; Human Rights Watch, “Treat Us Like Human Beings”: Discrimination against Sex Workers, Sexual and Gender Minorities, and People Who Use Drugs In Tanzania (2013).

[4] George Ayala et al., Social Discrimination Against Men Who Have Sex With Men (MSM): Implications for HIV Policy and Programs (May 2010).

[5] Canada: Immigration and Refugee Board of Canada, Tanzania: Treatment of sexual minorities by society and government authorities; recourse and protection available to those who have been subject to ill treatment (2007-July 2014), 8 August 2014, TZA104923.E.

[6] Ross MW, Nyoni J, Ahaneku HO, et al., High HIV seroprevalence, rectal STIs and risky sexual behaviour in men who have sex with men in Dar es Salaam and Tanga, Tanzania, BMJ Open 2014;4:e006175.doi:10.1136/bmjopen-2014-006175.

[7] Tanzania Penal Code of 1945 (as amended by the Sexual Offences Special Provisions Act, 1998), Sections 138A, 154-155. The Sexual Offenses Special Provisions Act of 1998 updated certain sections of the penal code, but kept the prohibitions on homosexual conduct.

[8] Tanzania’s heavy reliance upon its British based penal code stands in stark contrast to its neighbors—most of which have penal codes that impose significantly lower penalties on homosexual conduct or no penalties at all. Kenya, Zambia, and Malawi each have penalties of up to 14 years in prison for homosexual conduct, and Uganda’s criminal code mandates life imprisonment. Though homosexual conduct is illegal in Burundi, penalties only range from 3 months to 2 years. Homosexual conduct is legal in Mozambique, Rwanda, and the Democratic Republic of the Congo.

[9] United Nations Human Rights Office of the High Commissioner, Born Free and Equal: Sexual Orientation and Gender Identity in International Human Rights Law, HR/PUB/12/06 (2012).

[10] Id.

[11] Id.

[12] United Republic of Tanzania, Prime Minister’s Office, Tanzania Third National Multi-Sectoral Strategic Framework for HIV and AIDS (2013/14-2017/18) (November 2013).

[13] Human Rights Watch has indicated that HIV prevalence among MSM in Dar es Salaam is as high as 40 percent. Human Rights Watch, “Treat Us Like Human Beings”: Discrimination against Sex Workers, Sexual and Gender Minorities, and People Who Use Drugs In Tanzania (2013). Tanzania’s NMSF III cites a study in which 41 percent of 271 Tanzanian MSM tested seropositive for HIV. United Republic of Tanzania, Prime Minister’s Office, Tanzania Third National Multi-Sectoral Strategic Framework for HIV and AIDS (2013/14-2017/18) (November 2013). Further, a 2014 study found that MSM in Dar es Salaam had an HIV rate 2.5 times that of the general population. Ross MW, Nyoni J, Ahaneku HO, et al. High HIV seroprevalence, rectal STIs and risky sexual behaviour in men who have sex with men in Dar es Salaam and Tanga, Tanzania. BMJ Open 2014;4:e006175.doi:10.1136/bmjopen-2014-006175.

[14] Human Rights Watch, “Treat Us Like Human Beings”: Discrimination against Sex Workers, Sexual and Gender Minorities, and People Who Use Drugs In Tanzania (2013).

[15] Itaborahy, LP & Zhu, J, State-Sponsored Homophobia: A world survey of laws: Criminalisation, protection and recognition of same-sex love (8th ed. 2013); see also UN Office of the High Commissioner for Human Rights, Born Free and Equal: Sexual Orientation and Gender Identity in International Human Rights Law, HR/PUB/12/06 (2012).

[16] Human Rights Watch, “Treat Us Like Human Beings”: Discrimination against Sex Workers, Sexual and Gender Minorities, and People Who Use Drugs In Tanzania (2013).

[17] George Ayala et al., Social Discrimination Against Men Who Have Sex With Men (MSM): Implications for HIV Policy and Programs (May 2010).

[18] Personal interview with LGBT advocacy organization. The victim’s identity is being withheld for security reasons.

[19] United Republic of Tanzania, Prime Minister’s Office, Tanzania Third National Multi-Sectoral Strategic Framework for HIV and AIDS (2013/14-2017/18) (November 2013).

[20] These recommendations are based on standards developed by the GLBT Health Access Project. More information on these standards are available at: http://www.glbthealth.org/CommunityStandardsofPractice.htm

[21] See, e.g., Republic of Kenya, Ministry of Education, Science and Technology, Education Sector Policy on HIV and AIDS (2d ed. 2013), https://www.usaid.gov/sites/default/files/documents/1860/Final%20policy%20HIV%20and%20AIDS%202013.pdf

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News You May Have Missed (17-23 January)

A student at the Hamar Jajab School in Mogadishu holds a peace-themed comic book for children produced by UNSOM during the commemoration of Somalia’s ratification of the Convention on the Rights of the Child on 20 January 2015. UN Photo/Ilyas Ahmed
A student at the Hamar Jajab School in Mogadishu holds a peace-themed comic book for children produced by UNSOM during the commemoration of Somalia’s ratification of the Convention on the Rights of the Child on 20 January 2015. UN Photo/Ilyas Ahmed

There was some good news about human rights around the world this week.  

SOMALIA has become the 195th state party to ratify the Convention on the Rights of the Child (CRC). A ceremony was held to mark the ratification at a local school in the Somali capital of Mogadishu.  In agreeing to be bound by the treaty, the government of Somalia is obligating itself to take steps to improve the lives of its youngest citizens.   The CRC is the most widely ratified human rights treaty in existence.  Once Somalia’s ratification is officially deposited with the UN, the United States and South Sudan will be the only countries in the world that have not yet ratified the CRC.  (The US has signed but not ratified the CRC and South Sudan – the world’s newest country, established in 2011 – has taken no action on the CRC yet.  If you are wondering why the US hasn’t ratified the CRC, you can read more here.)

In SAUDI ARABIA, the public flogging of blogger Raif Badawi has been postponed for a second consecutive week.  As I previously reported, Raif Badawi, founder of Free Saudi Liberals blog, was brought to a public square in Jeddahon on January 9 and flogged 50 times before hundreds of spectators – the first of 20 weeks of punishment with 50 lashes.  Protests and vigils have been held in public places and outside Saudi embassies across the world, keeping up the momentum after a medical committee said last week that he should not undergo a second round of 50 lashes on health grounds.  There is widespread belief that the postponements are not based solely on medical assessments, but also reflect increasing pressure on the Saudi government from the international community.  

In GUATEMALA,  a former police chief has been sentenced to 40 years in prison for his role in the 1980 deadly raid on the Spanish embassy in Guatemala City. A group of indigenous rights activists had occupied the embassy to draw attention to government repression during Guatemala’s civil war. (According to United Nations estimates, almost a quarter of a million people, mostly indigenous and rural, were killed or forcibly disappeared during the 36-year-long conflict.) Thirty-seven people burned to death in a fire triggered by the police when they stormed the embassy; Vicente Menchu, the father of indigenous rights activist and Noble Peace Prize winner Rigoberta Menchu, was one of those killed in the fire.  Pedro Garcia Arredondo was found guilty this week of ordering officers to keep anyone from leaving the building as it burned. Indigenous rights activists and relatives of the victims, who have been waiting more than 3 decades for justice, celebrated a sentencing.

Indigenous activists and relatives of the victims welcomed the sentence. Photo (c) REUTERS
Indigenous activists and relatives of the victims welcomed the sentence. Photo (c) REUTERS

U.N. peacekeepers in the CENTRAL AFRICAN REPUBLIC have arrested Rodrigue Ngaibona, (known as Andilo), a senior leader of the anti-balaka militia, wanted for crimes including murder, rebellion, rape and looting.  In 2013,  the mostly Muslim Seleka rebels seized power in the majority Christian CAR.  Their brief rule spawned a backlash from the Christian and animist anti-balaka militia.  The U.N. has documented that the anti-balaka used ethnic cleansing in their attacks on the Muslim minority, and reported that “Andilo is currently the most enigmatic, feared and powerful military commander of the anti-balaka.”  Andilo could potentially be tried at the International Criminal Court in The Hague, which is investigating the violence in Central African Republic.

One piece of negative human rights news that has not received much mainstream media attention:  BAHRAIN sentenced Nabeel Rajab, one of the highest-profile democracy campaigners in the Arab world, to six months in jail on Tuesday over remarks critical of the government.  The founder of the Bahrain Center for Human Rights, Rajab took a leading role in Shi’ite-led demonstrations in Bahrain in 2011 that demanded reforms in the Sunni-ruled Gulf Arab Kingdom.  

I noted a couple of items of good news on LGBT rights this week:

  1. In CHILE, the House of Representatives on Tuesday approved a bill that would allow same-sex couples to enter into civil unions.  The bill passed by a wide margin with 86-23 vote with two abstentions. The Chilean Senate last October advanced the measure, known by the Spanish acronym AVP that roughly translates into “life partner agreement” in English. –President Michelle Bachelet has said she will sign the civil unions bill into law.
  2. In the UNITED STATES, President Obama made history by using the terms “lesbian”, “transgender” and “bisexual” for the first time in a State of the Union address. President Obama was the second US president to use the word “gay” (somewhat generically) in the 2010 State of the Union address; President Clinton was the first.

Finally, I read an inspiring story this week about teens in BANGLADESH called “Golden Girls” who are volunteering their time to ensure that Bangladeshi women have access to maternal health care.  Bangladesh has been working to reduce maternal mortality by training government female health workers as highly skilled birth attendants, but only 27 percent of pregnant women have access to these birth attendants. To fill the gap, the Community Health Foundation, a nonprofit based in Dhaka, educates nearly 300 girls in grades 9 to 12 about pregnancy and childbirth and then links them to pregnant women in their community through the government birth attendants.  

The Golden Girl Project volunteers help increase awareness among pregnant women and facilitate access to skilled birth attendants, bringing down maternal mortality risks.  Their efforts are proving critical in a country where 7,000 women die of pregnancy-related causes every year. For example, when a woman in her village went into labor in the middle of the night her panicked family turned to 14-year-old Khatun, a grade 10 student who lived nearby and was able to arrange for the community’s skilled birth attendant to come in time, saving the lives of the mother and newborn. In addition to their training in reproductive and sexual health, the Golden Girls themselves also commit to completing high school and campaigning to end early marriage and delaying motherhood. Volunteers’ parents consent to the training and affirm their daughters will not be married before graduation. This contributes to reducing dropouts as well as early marriage. You can read more about the Golden Girls here

I’ll close with a powerful advertisement from AUSTRALIA called “The Invisible Discriminator” which reminds us that subtle or ‘casual’ racism can be just as harmful as more overt forms. #StopThinkRespect encourages everyone in Australia to check their behaviour.

Forward Movement: LGBT Rights in Cameroon

Motorcycle taxis speed toward Douala, Cameroon's major port and commercial center
Motorcycle taxis speed toward Douala, Cameroon’s major port and commercial center

In response to this week’s Photo Challenge: Forward, I thought I would simply post this photo, taken two weeks ago today, of motorcycle taxis speeding towards Douala, Cameroon.  But there is another kind of movement going on right now in Douala, one that is attempting to move the country forward towards acceptance of the rights of LGBT persons.  These courageous activists, who are risking their lives to end discrimination and persecution based on sexual orientation or gender identity in Cameroon, deserve more than a photo.  They deserve to have their stories told.

In Cameroon, people who are LGBT face pervasive societal stigma, discrimination,and  harassment.  They also face the possibility of imprisonment – Article 347 of the Cameroonian penal code criminalizes “sexual relations with a person of the same sex”.  At least 28 people have been prosecuted under the law since 2010. One of them is Roger Jean-Claude Mbede, who was arrested and convicted of homosexuality in March 2011 after sending another man a text message reading, “I’ve fallen in love with you.”  In December 2012, the Cameroonian court of appeals upheld the conviction and sentenced him to three years in prison.

Gay, lesbian, bisexual, and transgender people have a high risk of HIV/AIDS infection.  They are often rejected by their families, who force them out of the home.  When targeted by law enforcement, they have more difficulty in obtaining legal protection.Due to the social stigma and intense climate of fear, most LGBT people are forced to live out their lives in secrecy.  Yet there are several impressive non-governmental organizations  – Alternatives-Cameroun, the Association for the Defense of Gay and Lesbian Rights (ADEFHO), Cameroonian Foundation for AIDS (CAMFAIDS), and Evolve, to name a fewwhich are working hard to raise awareness about and provide services to the LGBT community.

When I was in Douala, I was able to visit Alternatives-Cameroun.  Security is, understandably, a big concern.  There is no sign that marks their center on boulevard de la Liberté, and when you arrive, you have to sign in and show your ID.  Alternatives-Cameroun has one doctor at the center who provides HIV/AIDS treatment and medical services to approximately 75 patients.  In addition, Alternatives-Cameroun provides a small community pharmacy, as well as safe, confidential and free HIV testing.  In 2012, they provided 720 HIV tests.

Staff at Alternatives-Cameroun centre in Douala
Staff at Alternatives-Cameroun centre in Douala

Equally important are the services provided by a psychologist and two social workers.  Alternatives-Cameroun also provides public education and outreach, both at the center and through peer educators.  On the day I visited, all of the peer educators were at work out “in the field” in Douala.

What touched me most, though, was the real sense of community that is provided by Alternatives-Cameroun.  I saw a small group of young people sitting on plastic chairs around a table in “William’s Hall” (named after one of the organization’s founders, who died in the Kenya Air plane crash).  I could feel that they were providing each other with comfort and support, a feeling so strong that I could see the connection between them almost as clearly as I could see the young man holding the hand of the woman beside him.

As a way to join the community and to connect with the neighbors around them, Alternatives-Cameroun started a small restaurant that serves a very inexpensive daily lunch. This anti-discriminatory gambit has paid off; the neighbors now come to the restaurant to eat and talk together with the staff and patients.  Often the patients are very poor, so the restaurant means they can offer them a meal or two a day.  The restaurant also provides meals for LGBT detainees in prison.  Prison conditions in Cameroon are notoriously bad, with severe overcrowding and inadequate food.  Most detainees rely on family members to bring them meals.  As LGBT detainees have often been rejected by their families, they have no other access to food.

Restaurant

Activists working on LGBT issues in Cameroon told me that one of their main needs is for more lawyers. One of the very few Cameroonian lawyers who is willing to take on these “homosexuality” cases is Alice Nkom.  The first black woman admitted to the Cameroonian bar, Alice has been courageously fighting for the rights of LGBT Cameroonians for many years.  In spite of serious death threats, Alice Nkom continues her work.  “Threats like these show us that the fight must continue,” said Nkom.

with alice in douala

Cameroon has been receiving a lot of criticism recently from the international community, particularly the European Union. The issues of LGBT rights will certainly come up again at the Human Rights Council’s Universal Periodic Review of Cameroon this spring.  On January 31, Cameroonian President Paul Biya told reporters that attitudes are changing in his country about the criminalisation of homosexuality.  “Now I can say that discussions are under way. People are talking, minds can change one way or another but currently it’s a crime.”  

The government of Cameroon must do more than discuss.  The government must protect the rights of all Cameroonians, regardless of sexual orientation or identity. And when things do change, as they will one day, the credit will go to the brave men and women who have put their heart and souls – not to mention their lives – into moving their country forward on LGBT rights.

To read more about LGBT rights in Cameroon:

Human Rights Watch, Criminalizing Identities (2010)

Joint Stakeholder Submission on LGBT Rights for the Universal Periodic Review of Cameroon (2012)

International Gay & Lesbian Human Rights Commission, Cameroon