Introduction: Transgender women are disproportionately impacted by HIV.

Transgender women involved in sex work may experience exacerbated

violence, social exclusion, and HIV vulnerabilities, in comparison with non-sex
work-involved transgender women. Scant research has investigated sex work
among transgender women in the Caribbean, including Jamaica, where
transgender women report pervasive violence. The study objective was to
examine factors associated with sex work involvement among transgender
women in Jamaica.

Methods: In 2015, we implemented a cross-sectional survey using modified

peer-driven recruitment with transgender women in Kingston and Ocho Rios,
Jamaica, in collaboration with a local community-based AIDS service
organization. We conducted multivariable logistic regression analyses to
identify factors associated with paid sex and transactional sex. Exchanging oral,
anal or vaginal sex for money only was categorized as paid sex. Exchanging sex
for survival needs (food, accommodation, transportation), drugs or alcohol, or
for money along with survival needs and/or drugs/alcohol, was categorized as
transactional sex.

Results: Among 137 transgender women (mean age: 24.0 [SD: 4.5]), two-thirds
reported living in the Kingston area. Overall, 25.2% reported being HIV-
positive. Approximately half (n = 71; 51.82%) reported any sex work
involvement, this included sex in exchange for: money (n = 64; 47.06%);
survival needs (n = 27; 19.85%); and drugs/alcohol (n = 6; 4.41%). In
multivariable analyses, paid sex and transactional sex were both associated
with: intrapersonal (depression), interpersonal (lower social support, forced sex,
childhood sexual abuse, intimate partner violence, multiple
partners/polyamory), and structural (transgender stigma, unemployment)
factors. Participants reporting transactional sex also reported increased odds of
incarceration perceived to be due to transgender identity, forced sex,
homelessness, and lower resilience, in comparison with participants reporting
no sex work involvement.
In recent years, transgender people around the world have made tremendous
strides toward achieving legal recognition.

Argentina broke ground in 2012 with a law that is considered the gold standard
for legal gender recognition: anyone over the age of 18 can choose their gender
identity, undergo gender reassignment, and revise official documents without
any prior judicial or medical approval, and children can do so with the consent
of their legal representatives or through summary proceedings before a judge.

In the subsequent three years, four more countries—Colombia, Denmark,

Ireland, and Malta—explicitly eliminated significant barriers to legal gender
recognition. This evolution sets them apart from countries that either do not
allow a person to change their “male/female” designation at all, or only allow
them to do so when certain conditions have been met, which may include
surgery, forced sterilization, psychiatric evaluation, lengthy waiting periods, and
divorce. For the first time, people can change their gender marker on documents
simply by filing the appropriate forms.

This progress, long in the making, has often come on the backs of courageous
individuals willing to have their lives and identities adjudicated by often
unfriendly courts.

For instance, Ireland’s 2015 Gender Recognition Bill was the product of a 22-
year legal fight by Lydia Foy, a now-retired dentist. Braving a gauntlet of legal
procedures, she made her case to be recognized as a woman before Ireland’s
High Court in 1997, and again in 2007, backed by domestic and international
human rights bodies that called on Ireland to institute a gender recognition
procedure based on identity and human rights, not surgeries and expert
opinions. Despite the consistent pressure, it was not until 2015, after an
overwhelming victory on a same-sex marriage referendum, that the government
instituted identity-based legal gender recognition.
In South Asia—where hijras, an identity category for people assigned male at
birth who develop a feminine gender identity, have long been recognized
culturally, if not legally—activists have pursued a related aim: the formal
recognition of a third gender. Hijras’ traditional status, which included
bestowing blessings at weddings, had provided some protection and a veneer of
respect. But rather than being viewed as equal to others before the law, they
were regarded as exotic and marginal—an existence dictated by boundaries and
limitations, not rights.

Then Nepal’s Supreme Court, in a sweeping 2007 ruling, ordered the

government to recognize a third gender category based on an individual’s “self-
feeling.” The ruling rested largely on the freshly minted Yogyakarta
Principles—the first document to codify international principles on sexual
orientation, gender identity, and human rights. Armed with the ruling, activists
successfully advocated with government agencies to include the third gender
category on voter rolls (2010), the federal census (2011), citizenship documents
(2013), and passports (2015).

Similarly, in 2009, the Supreme Court in Pakistan called for a third gender
category to be recognized, and in Bangladesh, the cabinet issued a 2013 decree
recognizing hijras as their own legal gender. In 2014, India’s Supreme Court
issued an expansive judgment recognizing a third gender, affirming “the right of
every person to choose their gender,” and calling for transgender peoples’
inclusion in state welfare programs.

In a few countries, the very purpose of gender markers is now being

interrogated. New Zealand and Australia now offer the option to have gender
listed as “unspecified” on official documents, while the Dutch parliament has
begun considering whether the government should record a person’s gender on
official identification documents at all.

A Matter of Dignity
The right to recognition as a person before the law is guaranteed in numerous
human rights treaties, and is a fundamental aspect of affirming the dignity and
worth of each person. However, even in countries that allow for people to be
recognized in the gender with which they identify, the requisite procedures may
subject applicants to humiliating and harmful treatment.

For example, transgender people in Ukraine who wish to be legally recognized

must undergo a mandatory in-patient psychiatric evaluation lasting up to 45
days to confirm or reject a diagnosis of “transsexualism”; coerced sterilization;
numerous medical tests, which often require extensive time commitment,
expense, and travel, and that are unrelated to the legal gender recognition
procedure requirements itself; and a humiliating in-person evaluation by a
government commission to further confirm the diagnosis of “transsexualism”
and authorize the change in legal documents. These procedures fail to respect
the right to health and may expose transgender people to prohibited inhuman or
degrading treatment.

Tina T., a 38-year-old Ukrainian transgender woman, told Human Rights Watch
that during her stay in a psychiatric institution, the staff forced her to live in a
high security male ward with bars and metal doors. She said she was only
allowed to walk around the perimeter of a 30 square meter yard for 45 minutes
each day; the restrooms did not have locks, making her feel unsafe; and doctors
did not allow her to take female hormones while she was under their care.

It may seem obvious: subjecting people to unwanted or unnecessary medical

procedures has no place in a recognition process for an identity. However, even
in countries that consider themselves progressive with regards to LGBT rights,
including some Western European and Latin American countries and the US,
transgender people are still forced to undergo demeaning procedures—even
sterilization—to change the gender marker on their identity documents. These
negative consequences of seeking legal gender recognition seriously and
harmfully limit individuals’ ability to access crucial services and live safely,
free of violence and discrimination.
Growing recognition of transgender health

Stigma, discrimination and lack of legal recognition remain major barriers for
transgender people to access the health services they need. Vijay Shankar
Balakrishnan reports.
Olga Aaron was registered male at birth, but always felt that she was a
woman. Following a mental health assessment and with the support of her
family, at 18 years Aaron underwent surgery and hormone therapy (and a
name change) to become a woman.

Olga Aaron providing education and raising awareness about transgender issues
in India
Courtesy of Olga Aaron
Two decades later, Aaron is campaigning for the social acceptance and
recognition of transgender women, like herself, and to raise awareness about
their specific health issues in India.
“Transgender women are marginalized and denied basic human rights,” says
Aaron, who lives in the city of Chennai.
“I was lucky to have an understanding family who supported me while I
studied at university,” says Aaron, who managed to obtain a bachelor’s degree
in English literature and a master’s degree in public administration from
Madras University by distance learning.
Aaron is one of an estimated 25 million people, or 0.3 to 0.5% of the global
population, who are transgender. This first global estimate of their numbers
was published in a study in the Lancet in June.
“Transgender is an umbrella term for people whose gender identity is different
from the sex they were assigned at birth,” says Annette Verster, a technical
officer in the HIV Department at the World Health Organization (WHO) in
Geneva.
A person’s gender identity is their own sense of whether they are male or
female, or neither. Some transgender people identify themselves with their
changed gender: from male to female or female to male. Others see
themselves as members of a third sex.
In Thailand transgender people are known as kathoey, in Indonesia waria, in
Mexico muxe and in Bangladesh and Pakistan hijra, (in India the term refers
to transgender women).
“Identity documents that do not match a person’s gender can hinder access to
health services, social protection and employment,” Verster says.
“Transgender women may also be subject to punitive laws and discriminatory
policies affecting men who have sex with men.”
WHO’s Member States have committed themselves to providing universal
coverage of health services in their efforts to achieve the sustainable
development goals by 2030. “Reaching marginalized groups, such as
transgender people, will be essential,” Verster says.
Transgender people are one of five groups that are disproportionately affected
by HIV globally, according to WHO’s Guidelines on HIV prevention,
diagnosis, treatment and care for key populations released in 2014. The others
are: people who inject drugs, men who have sex with men, sex workers and
prisoners.
“These groups are defined as key populations for the HIV response because
they are at increased risk of HIV infection. In addition, they are often
marginalized, stigmatized and criminalized which affects their ability to
access health services, including HIV prevention, testing and treatment,”
Verster says.
“It is estimated that in low- and middle-income countries transgender women
are around 49 times more likely to be living with HIV than other adults of
reproductive age,” says Verster, citing a 2013 study published in The
Lancet infectious diseases –the first to estimate the HIV burden among
transgender women outside the United States of America (USA).
The authors found that data on HIV prevalence in transgender women were
only available for 15 countries and, of those, India had the highest prevalence
with 43.7% of the 135 study participants living with HIV.
Transgender people in India are considered to be of low status according to
Hindu mythology. “Many transgender women are rejected by their families in
India. Even if they have an education, they struggle to find employment and
often end up as sex workers and beggars,” Aaron says.
Following the WHO key populations guideline released in 2014, WHO
published a technical brief with its partners, in 2015 entitled HIV and young
transgender peopleon how best to provide health services, programmes and
support for young transgender people. In the same year a WHO Policy Brief
on Transgender people and HIV was published summarizing relevant WHO
recommendations.
In addition, WHO and its partners developed a guide on how to use the
technical guidance, entitled Implementing comprehensive HIV and STI
programmes with transgender people, which was published this year by the
United Nations Development Programme.
While preparing the WHO guidance, Verster and her colleagues did a
qualitative survey with transgender people from around the world.
“We found that transgender people tend to have health priorities other than
HIV,” Verster says, adding: "Unless health services are designed in
accordance with the needs of transgender people and in consultation with
them, it may be difficult to reach them with HIV prevention and care.”
Not all transgender people seek gender affirming treatment. For those who do,
hormone therapy is the main medical intervention to acquire sex
characteristics aligned with the individual's gender identity, according to the
Center of Excellence for Transgender Health at the University of California in
San Francisco.
Transgender people may seek a range of gender affirming surgeries, including
procedures that are also performed in non-transgender populations.
“Not everyone who wants gender affirming surgery in India can access it.
Some transgender people remove their genitals by self-mutilation, others go to
‘quacks’,” says Aaron, who campaigns to raise awareness about transgender
issues in India.
“HIV is not the only health issue that transgender people face,” says Aaron,
adding that they face mental health issues including depression, mood and
anxiety disorders and suicidal ideation. Studies from the Islamic Republic of
Iran and Nepal highlight the prevalence of mental health issues in transgender
people.
Dr Sari Reisner, an epidemiologist at the Boston Children's Hospital in the
USA and a transgender man himself, agrees that there are many health issues
that transgender people face other than HIV infection, but that there is very
little research on these other health issues.
Indeed, this is what Reisner and his fellow researchers discovered when they
reviewed the scientific literature on transgender people’s health over the last
five years.
In their findings published in a Lancet series on the subject in June, Reisner
and his colleagues found that most health research divides the human
population into male and female, although recently studies started to include a
third category for transgender people.
Most of the health data they found on transgender people were on HIV
infection, mental health, sexual and reproductive health, substance use
disorders, violence and victimization, and on the effects of stigma and
discrimination such as mental health issues.
The data revealed major health inequities between transgender people and
many other members of society and that transgender people were often unable
to access the health services they need because of their social and economic
marginalization.
Reisner and his colleagues proposed four ways forward: count the transgender
population globally; address stigma and other issues that make transgender
people vulnerable to health risks; recognize their human and legal rights so
that they can be covered by health services; and do health
research with transgender people rather than on them.
Several countries – including Argentina, Australia, Bangladesh, India, Nepal,
New Zealand, Pakistan, Portugal and Thailand – have legislation recognizing
the rights of transgender people in some way.
In India, the government started offering free gender affirming surgery in
2009, although this is still not accessible everywhere in the vast country of 1.2
billion people.
In Argentina, a 2012 law – the first of its kind according to Reisner – allows
transgender people to change their legal gender identity from male to female
or vice versa through a simple administrative process.
In Canada, gender affirmation surgery and treatment are covered by the
publicly-funded health insurance system and some universities are integrating
transgender health into the medical curricula.
“There is a broader acceptance and a desire on the part of health-care
providers to learn about lesbian, gay, bisexual, transgender and queer
(LGBTQ) health issues,” says Dr Ed Kucharski, who is responsible for
incorporating these issues into the curriculum at the University of Toronto.
“Few textbooks include LGBTQ health issues, so we use materials from
LGBTQ community centres and from the web,” says Kucharski.
The university is developing traditional and online content that medical
students can use to learn how to care appropriately for transgender patients.
Kucharski explains: “In the next year or so we will be developing a virtual
patient that students can interact with.”
Another key development in gaining wider recognition for transgender health
issues is the revision of the International statistical classification of
diseases and related health problems (ICD), the standard diagnostic reference
book for epidemiology, health management and clinical practice.
In the original version of the current edition, ICD-10, “gender identity
disorders” were classified under “mental and behavioural disorders”. But in
the next edition, ICD–11, which was released for Member State comments last
month and is due to be published in 2018, transgender health issues appear in
a new category of “gender incongruence”.
For Reisner this classification shift reflects the struggle for transgender health
issues to find their place. “There are many opinions from many sides on this,”
Reisner says, welcoming the shift: “I don’t think transgender issues need to be
seen as a mental disorder.
Spain is the country most supportive of transgender rights, according to a poll
published in December 2016. The survey was conducted as a collaboration
between BuzzFeed News, polling firm Ipsos and the UCLA Law School’s
Williams Institute. Buzzfeed has called the survey the “first of its kind”.

Participants from 23 countries were asked their opinion on a variety of

transgender issues ranging from protection against discrimination to more
specific rights such as marriage and adoption. Countries were ranked with an
overall score out of 100 points.

Those who were younger and those with higher levels of income or education
were generally more supportive of trans people. Women also showed more
support for transgender rights than men.

Spain topped the list with a score of 81, ahead of Sweden (77) and Argentina
(76), despite the fact that only 23% of Spanish people said they even knew a
transgender person (9th place).

Actually knowing a transgender person makes a big difference. The Williams

Institute explains that: “Having transgender friends and family members has a
strong effect on support for transgender rights. Those who report having such
relationships are significantly more supportive of transgender rights than those
who report not having such relationships.”

The survey found that those who knew a transgender person were 24.6% more
likely to support transgender rights.

Those findings echo a study published in Science Magazine last year which
showed that a 10-minute conversation about transgender rights can not only
influence people’s opinions, but can also make them less likely to believe
negative portrayals of trans people in the future.
The difficulty remains that most people do not know anyone who is
transgender. While the community is growing rapidly, the number of people
who say they know a trans person stands at 26%. That number is actually
down slightly from a Pew Survey conducted in 2016.

Worldwide, not a single country had a majority of people who said they knew
a trans person. Brazil scored highest, with 50%.
Conclusions: Findings reveal high HIV infection rates among transgender
women in Jamaica. Sex work-involved participants experience social and
structural drivers of HIV, including violence, stigma, and unemployment.
Transgender women involved in transactional sex also experience high rates of
incarceration, forced sex and homelessness in comparison with non-sex
workers. Taken together, these findings suggest that social ecological factors
elevate HIV exposure among sex work-involved transgender women in
Jamaica. Findings can inform interventions to advance human rights and HIV
prevention and care cascades with transgender women in Jamaica.

Keywords: transgender, transgender women, HIV, sex work, transactional sex,

structural drivers, Jamaica, violence