01.11.2013 Sexual health and transgender people: uncharted waters?
A neglected and vulnerable group. Many international studies reveal a high level of vulnerability in the health of the transgender community, especially to HIV and other sexually transmitted infections.
A current meta-analysis of 29 North American studies estimates that the prevalence of HIV among trans women (male to female) in large cities of the United States ranges from 11.8 to 27.7 per cent and can be as high as 35 per cent among trans sex workers. The equivalent estimate for trans men (female to male) is only 2 to 3 per cent.
No epidemiological data are available on the prevalence of STIs in Switzerland's transgender community. Only a 2008 study conducted by the Agnodice Foundation in trans women active as sex workers in Lausanne presents a worrying picture of the risks facing this population group and exposes its specific vulnerabilities. In particular, these concern the sharing of needles for injecting hormones or silicone to give the body a more female appearance, and unprotected sexual contacts in the course of their work. Trans sex workers are often highly marginalised and they are frequently victims of blackmail and violence – including police violence. Excessive drug and alcohol use due to pressures on the part of their clients is widespread. Their mental health is particularly at risk. On average, depression and attempted suicide occur more frequently than in the population as a whole. The clients of trans women sex workers have a distinct profile: they look for a female body, that has a functioning penis capable of erection and ejaculation. The Agnodice Foundation's study came to the conclusion that the 50 trans women active as sex workers in the Lausanne region engaged in about 30,000 sexual contacts a year.
These findings prompted the Federal Office of Public Health (FOPH) in 2012 to commission a "Rapid Assessment" of the scale of the risks to which this population group is exposed from the University of Lausanne's Institute of Social and Preventive Medicine (IUMSP). In addition, recommendations were to be drawn up on how the group's health needs could be satisfied.
Towards better recognition of human and sexual rights of trans people in Switzerland?
In the same year, the Federal Office of Justice announced that official gender status could also be changed if the necessary irreversible sex reassignment and loss of reproductive capacity could be achieved without surgical interventions (sterilisation; construction of sexual organs), for instance by long-term hormone treatment. In Switzerland, transsexuals can ask to have their official gender status brought into line with their gender identity, even if it does not tally with their genitalia. In other words, there are – quite legitimately – increasing numbers of men with female sex organs and women with male sex organs in Switzerland.
In order to link up its National Programme on HIV and Other Sexually Transmitted Infections 2011–2017 with the Declaration of Sexual Rights formulated by the "International Planned Parenthood Federation (IPPF)", the Federal Office of Public Health hosted a Swiss HIV & STI forum on the sexual health of trans people in Biel/Bienne on 24 April 2013. The objective of the forum was to raise awareness and promote further training of sexual health professionals (physicians, nursing staff and counsellors) in relation to transgender issues and to present the findings of the Rapid Assessment carried out by the IUMSP Lausanne.
Swiss HIV & STI forum 2013: sexual health for transgender people
The focal point of the Swiss HIV & STI forum 2013 was the presentation by Dr. Viviane Namaste, professor at the Simone de Beauvoir Institute of Concordia University in Montreal. Her research demonstrates the invisibility of trans people in health policy, the difficulties they have in accessing institutions, the lack of epidemiological monitoring and the vulnerability of migrant or sex-worker trans people at various different levels. According to a number of estimates, the prevalence of HIV in these groups is significantly elevated.
The findings of the Rapid Assessment were presented by Dr. Raphaël Bize. They confirm the need to develop HIV/STI prevention measures for trans sex workers. They also reveal gaps in the existing health data and emphasise the hostility frequently encountered in the sociocultural and institutional context towards trans women and trans men. The IUMSP recommends launching prevention measures within the community of trans sex workers and among their clients. It also recommends continuing education for health professionals on transgender issues and integration of the variable "transgender" into the HIV/STI notification system, the statistical recording tools of the VCT centres (BerDa) and the health surveys of the general population.
The second part of the forum consisted of three workshops. The first workshop targeted healthcare providers and
highlighted ways, in which they could improve the services they offer trans people. The second reported on the difficulties trans people experience in constructing their identity and the risks this entails. The final workshop was concerned with trans sex workers. It highlighted shortcomings in specialists' knowledge and skills, poor access to healthcare and inappropriate or non-existent prevention work.
The presentations of the Swiss HIV & STI forum and the summaries of the workshop discussions can be found on the website of the Federal Office of Public Health: http://www.bag.admin.ch/hiv_aids/05464/05465/12491/index.html?lang=en
So what comes next?
Through the National Programme on HIV and Other Sexually Transmitted Infections 2011-2017, transsexual people are now unreservedly recognised as a vulnerable group. The Zurich and Vaud Checkpoints have developed services tailored to their needs. The Federal Office of Public Health has included trans people and people with variations of sexual development (intersex) in its supplementary forms for notifiable sexually transmitted infections. And it will in future encourage its partners to develop and implement activities aimed at combating HIV/STI particularly in the target group of trans sex workers.
Steven Derendinger, Prevention and Promotion Section, firstname.lastname@example.org