Know Violence
Exploring the links between violence, mental health and HIV risk among men who have sex with men and transwomen in South Asia Know Violence
Proposed citation:
UNDP, ICRW and APCOM (2018). Know Violence: Exploring the links between violence, mental health and HIV risk among men who have sex with men and transwomen in South Asia.
The views expressed in this publication are those of the authors and do not necessarily represent those of the United Nations, including UNDP, or UN Member States.
UNDP partners with people at all levels of society to help build nations that can withstand crisis, and drive and sustain the kind of growth that improves the quality of life for everyone. On the ground in more than 170 countries and territories, we offer global perspective and local insight to help empower lives and build resilient nations.
Copyright © UNDP 2018
United Nations Development Programme Bangkok Regional Hub 3rd Floor United Nations Service Building Rajdamnern Nok Avenue Bangkok 10200, Thailand Tel: +66 2 304-9100 Fax: +66 2 280-2700 Email: [email protected] Website: http://www.asia-pacific.undp.org/ Know Violence
Know Violence
Exploring the links between violence, mental health and HIV risk among men who have sex with men and transwomen in South Asia. Know Violence
Contents
Forewords 6
Acknowledgements 10
Acronyms and abbreviations 12
Glossary 13
List of tables, figures and boxes 16
Executive summary 18 Background 19 Study 20 Study results 20 Recommendations 22
Chapter 1: Introduction 24 1.1 Violence, mental health and HIV among sexual and gender minorities 25 1.2 About the study 25 1.3 Objectives and methods 26
Chapter 2: Regional context 28 2.1 Laws and policies related to sexual and gender minority groups 29 2.2 SOGIE-based violence 39 2.3 HIV prevalence 42 2.4 Mental health among sexual and gender minorities 44 2.5 Research gaps 44
Chapter 3: Methodology 46 3.1 Conceptual framework 47 3.2 Study design 49 3.3 Sample, recruitment and data collection 50 3.4 Ethics and safety measures 52 3.5 Strengths and limitations 53 3.6 Sample demographics 55
Contents Know Violence
Chapter 4: SOGIE-based violence: Forms, impact and coping 58 4.1 Types of SOGIE-based violence 59 4.2 Sources of SOGIE-based violence 62
Chapter 5: Resilience and coping strategies 74 5.1 Living a dual life 75 5.2 Coming out 75 5.3 Self-exclusion and leaving the community 77 5.4 Resilience 78
Chapter 6: SOGIE-based violence, HIV and mental health 82 6.1 SOGIE-based violence and mental health 83 6.2 SOGIE-based violence and HIV risk 84
Chapter 7: Life course pathways between violence, mental health and HIV 90 7.1 Power and status in society 92 7.2 Family context 92 7.3 Trajectories into a dual life, or not 93 7.4 Mental health problems, substance abuse and unprotected sex 94
Chapter 8: Recommendations 96
Bibliography 106
Appendices 110 Appendix I: Rationale for site selection at each study site 111 Appendix II: Ethical review procedures across study countries 113 Appendix III: Focus group discussion guidelines for men who have sex with men 114 Appendix IV: Focus group discussion guidelines for transwomen 120 Appendix V: Key Informant Interview guidelines 125
Contents Know Violence
Forewords
Violence based on sexual orientation, organizations and community activists, gender identity and expression along with support from legislators (SOGIE) is a grave violation of the and policymakers, international human rights of sexual and gender development partners, UN agencies and minorities worldwide. It has severe others who work to advance the rights consequences for the survival, safety of sexual and gender minorities. and freedom of gender and sexual minorities, disrupts development The United Nations Development opportunities, and can also increase Programme (UNDP) initiated this HIV risk and prevalence, particularly regional study to better understand among men who have sex with men the lived and perceived experiences of and transwomen. SOGIE-based SOGIE-based violence among men who violence also impacts the mental have sex with men and transwomen in health and well-being of members of South Asia, and to explore the effects of sexual and gender minority groups. this violence on mental health and HIV While there are well-documented vulnerability. The results are integral trends in some regions of the world, to informing evidence-based policy and less is known about SOGIE-based programme work to prevent SOGIE- violence, HIV risk and mental health based violence, reduce HIV prevalence among sexual and gender minority and incidence, and enhance the mental groups in South Asia. health of sexual and gender minorities in the region. This type of violence reflects homophobic and transphobic beliefs, The UNDP Strategic Plan 2018–2021, norms and institutions prevalent in which sets out the direction for a new all countries. Beliefs that same-sex UNDP and is optimized to help countries sexual activities, preferences and achieve the 2030 Agenda for Sustainable identities are deviant or pathological Development, emphasizes that reducing are commonly held across the Asia- gender inequalities and empowering Pacific region. These beliefs permeate vulnerable groups is vital to achieving all levels of society – from institutions the Sustainable Development Goals. and communities to families and This report is aimed at supporting individuals – and constrain the ability these efforts and contributing to action of sexual and gender minorities to live to create a world in which sexual and free from violence, harassment and gender minorities live free of violence, discrimination. and enjoy good health and well- being and in doing so, deliver on the Some progress has been made to commitment to “leave no one behind”. advance the rights and protections of sexual and gender minority groups in the Asia-Pacific region. Recent legislative progress is the result of Valerie Cliff – Deputy Regional decades of activism by grassroots Director for Asia & the Pacific – Director, Bangkok Regional Hub
6 Forewords Know Violence
Globally, there has been great While instances of violence faced progress over the past few years with by men who have sex with men respect to the acknowledgement and transgender persons and the and recognition of issues relating to impact of such experiences on the sexual orientation and gender identity lives of these communities have and expression. There is greater been documented both by media and acceptance of gender fluidity and research, there is an urgent need lesbian, gay, bisexual, transgender for enquiry in order to understand and intersex (LGBTI) communities the impact and complexity of such across the world. While awareness of experiences, and the threat they pose SOGIE-based matters has increased to individuals and communities. phenomenally, the resources available to address SOGIE-based This cross-cultural qualitative study is violence and its drivers and to a first such attempt to understand and ensure redress for individuals and identify various patterns of violence communities that face such abuse experienced by men who have sex have been limited, particularly in with men and transwomen and the regions such as South Asia. linkages of such experiences and drivers with HIV and mental health Many definitions of gender-based across seven countries in South Asia: violence focus on women as victims Afghanistan, Bangladesh, Bhutan, of such violence; for example, the India, Nepal, Pakistan and Sri Lanka. Committee on the Elimination of Discrimination Against Women The scope of the present study limits (CEDAW) states that gender-based itself to uncovering experiences violence is “violence that is directed of men who have sex with men against a woman because she is and transwomen, through their a woman or that affects women narratives, at several levels with disproportionately.” Definitions of respect to their exposure to violence, gender-based violence are also its impact on their mental health pertinent to all forms of violence that and how such experiences are both are related to social expectations directly and indirectly linked to and social positions based on gender, increasing their vulnerability to HIV. or to not conforming to a socially accepted gender role or expression. We hope that the recommendations that emerged from the study’s In South Asia, gender expression, insights pave the way for more such sexual orientation and identity, as efforts and endeavours in the future. well as sexual behaviour are diverse, which makes it crucial to have an informed definition of violence to Ravi Verma – Regional Director, Asia ensure inclusivity and redress for all – International Center for Research individuals who are vulnerable. on Women
Forewords 7 Know Violence
APCOM Foundation began its work how these individuals are not only over a decade ago to respond to affected but made invisible. the HIV epidemic among gay men, bisexual men and transgender The direct impact this has on the persons in Asia and the Pacific. Along health of those who experience the way, these communities taught SOGIESC-related violence and us two important lessons that are prejudice is painfully obvious. relevant for our work today. The first However, there is also an indirect is that we will not be able to address impact on the mental health of large public health issues without SOGIESC persons more broadly, addressing the issues that impact as their experience of violence and the rights of these communities. The discrimination can impact the way second is that we need to adopt a these individuals engage with services more intersectional approach that meant for them and service providers speaks to the lived experiences who engage with them. Among other of all individuals of diverse sexual things, we hope this study will provide orientation, gender identity and insights on how SOGIESC persons expression, and sex characteristics can be reached and served better by (SOGIESC). recognizing their experiences with violence and speaking to their needs The violence, discrimination and for improved health and well-being. exclusion experienced by many SOGIESC people across Asia and the The gaps in provision of HIV Pacific is one such burning issue. prevention, testing and treatment It has an immensely deleterious services for transwomen and effect on these communities. Just transmen who have sex with men because of how they express love or in South Asia is a prime example. their gender identity, many people Across the region, these communities across our region are separated account for the majority of new HIV from family and friends, harassed infections. However, the violence, in their workplaces, abused by their persecution and discrimination intimate partners, ostracized by experienced by men who have sex their neighbours or assaulted on the with men and transgender women in street. Many suffer physical injuries many places throughout South Asia and mental anguish. Some are killed means low or no access to effective and others harm themselves. Both service provision. This, in turn, empirical and anecdotal evidence drives the HIV epidemic among these suggests that young people are communities to even higher levels. especially vulnerable. APCOM’s work around sexual and gender-based It is a bleak picture to have to paint, violence against SOGIESC persons but sadly this is the distressing in humanitarian settings is exploring everyday reality for hundreds of
8 Forewords Know Violence
thousands of people across South Asia as well as the rest of the Asia- Pacific region. However, due to the hard work and dedication of activists, advocates and allies, progress is being made. Reports such as this are vital to creating an informed response to this very serious issue and APCOM commends all involved for their contributions. As we move towards the goal of ending HIV by 2030, I urge all relevant agencies and authorities throughout Asia and the Pacific to help us create an HIV-free future by ensuring that all people across the region have the health and safety to which they are entitled as citizens of their countries, and the compassion and dignity to which they are entitled as human beings.
Midnight Poonkasetwattana – Executive Director – APCOM Foundation
Forewords 9 Know Violence
Acknowledgements
Know Violence: Exploring the links Technical reviews and substantive between violence, mental health and contributions were provided by HIV risk among men who have sex Nadia Rasheed, Team Leader; with men and transwomen in South Edmund Settle, Policy Advisor; Asia was developed by the United Vipat Kuruchittham, Monitoring Nations Development Programme & Evaluation Analyst; Kathryn (UNDP), the International Center Johnson, Human Rights and Gender for Research on Women (ICRW) and Consultant; Jensen Byrne, LGBTI the APCOM Foundation to better and Human Rights Project Officer; understand the lived and perceived and, Angel Treesa Roni, Programme experiences of SOGIE-based violence and Research Officer from the UNDP among men who have sex with men Bangkok Regional Hub; Suki Beavers, and transwomen across seven South Policy Advisor and Cluster Leader Asian countries, and to explore the and Boyan Konstantinov from UNDP effects of this violence on mental New York; and Dr Chloe Schwenke, health and HIV risk. Executive Director, ICRW Washington, DC. Addition reviews and inputs were Special thanks to Dr Priti Prabhughate provided by the UNDP Country Offices for spearheading the research in Afghanistan, Bangladesh, Bhutan, initiative and Ms Ketaki Nagaraju for India, Nepal, Pakistan and Sri Lanka. editorial support from ICRW. Special thanks to Ryan Figueiredo, An independent expert review of the Deputy Director and Shankar Silmula, publication was provided by Stephanie Programme Manager from the Miedema, Emory University. Andy APCOM Foundation for their input Quan and Edmund Settle, Policy and for coordinating national-level Advisor, UNDP Bangkok Regional Hub community participation and input edited the report. during the research phase.
The study also benefited from two The report team would also like to APCOM South Asia Strategic Advisors thank the national sub-recipients of (ASASIA) meetings convened in 2015 the Multi-Country South Asia Global and 2016 in Bangkok, Thailand. The Fund HIV Programme – Bandu Social advisory group consisted of regional Welfare Society, Blue Diamond experts with experience in policy, Society, Family Planning Association research, programme development of Sri Lanka, Humsafar Trust, Lhak- and organizational management Sam, Naz Male Health Alliance, including Dr Tasnim Azim, Voluntary Health Services and Youth Bangladesh; Bushra Rani, Pakistan; Health and Development Organization Siddharth Dube, India; Shambhu – for supporting the research team Kafle, Nepal; and Dr Venkatesan to adapt the study to each country’s Chakrapani, India. context, providing safe spaces for
10 Acknowledgments Know Violence
conducting focus group discussions intersex status, which promotes and supporting the fieldwork. universal access to health and social services. It is a collaboration In addition, the team would like between governments, civil society, to thank the participants in each regional institutions and other of the study countries for their stakeholders to advance the social contributions in sharing knowledge inclusion of lesbian, gay, bisexual, and experiences, and for adding transgender and intersex people. value to the recommendations The programme is supported by developed to address violence. We are UNDP, the Embassy of Sweden also thankful to the local research in Bangkok, the U.S. Agency for interviewers who played a vital role in International Development, the gathering data for the study. Australian Department of Foreign Affairs and Trade and the Faith in The development of the report was Love Foundation (Hong Kong). supported by UNDP through the Multi-Country South Asia Global Fund HIV Programme (MSA-910- G02-H), a regional programme that operated in seven South Asian countries: Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka. The overall goal of the programme was to reduce the impact of, and vulnerability to, HIV of men who have sex with men, hijras and transgender people through community systems strengthening. In Afghanistan, the programme focused on HIV prevention services for men with high-risk behaviour. The UNDP Bangkok Regional Hub served in the role of Principal Recipient for the programme from 2014 to 2016.
The report was also supported by the UNDP Being LGBTI in Asia programme, a regional programme aimed at addressing inequality, violence and discrimination on the basis of sexual orientation, gender identity and expression or
Acknowledgments 11 Know Violence
Acronyms and abbreviations
AIDS Acquired Immunodeficiency Syndrome
APF Asia Pacific Forum of National Human Rights Institutions
CBO Community-based organization
FGD Focus group discussion
HIV Human Immunodeficiency Virus
ICRW International Center for Research on Women
IDLO International Development Law Organization
ILO International Labour Organization
KII Key informant interview
LGBTI Lesbian, gay, bisexual, transgender and intersex
MHRB Men with high-risk behaviour
NGO Non-government organization
NHRI National Human Rights Institution
OHCHR Office of the United Nations High Commissioner for Human Rights
SOGIE Sexual orientation, gender identity and expression
SOGIESC Sexual orientation, gender identity and expression, and sex characteristics
UNESCAP United Nations Economic and Social Commission for Asia and the Pacific
UNDP United Nations Development Programme
12 Acronyms and abbreviations Know Violence
Glossary
Chhalla and Terms used to describe various livelihood options practised by Badhai transwomen who identify as hijra. Chhalla is clapping and seeking alms. Badhai is a ritualistic blessing for newborns and dancing at weddings.
cisgender Relating to a person whose sense of gender and personal identity corresponds with their birth sex.
Hijra (Kinnar) Hijra is one of the terms used in South Asia among a specific group of assigned-male-at-birth, transfeminine or (less often) intersex individuals, who identify either as women, not men, in-between men and women or neither man nor woman. Contrary to popular belief, all hijras are not castrated, and ‘eunuch’ is not an appropriate translation.
Hijras have traditional matrilineal communities, by which the ritual of reet (christening ceremony) formalizes a person’s membership. There are several hijra clans or gharanas or deras across South Asia. Hijra clans consist of gurus (leaders) and chelas (disciples) who often live in close-knit, governed, self-created families.
Hijras are mentioned in several Hindu legends and folklore. They once occupied key positions in the royal courts. However, they were removed from their esteemed positions and criminalized during the time of British colonialism.
Apart from the traditional occupations of chhalla and badhai, many hijras are compelled to rely on sex work (often exploitative) for a living. The term ‘hijra’ itself has many regional variations, for example, kinnar in parts of India.
While hijra are usually transgender women, the two expressions are not interchangeable.
Khwajas These are terms used to describe male-assigned-at-birth, siras, transfeminine individuals in Pakistan.
Khusras, While Khwajas siras, Khusras and Zenanas are usually Zenanas transgender women, the expressions are not interchangeable.
Kothis, Metis Kothis is the term used in South Asia to describe individuals assigned male at birth who show varying degrees of femininity and who often (but not always) play a receptive role in sex with men.
Metis are considered the counterparts of Kothis in Nepal.
While Metis and Kothis are usually transgender women, the expressions are not interchangeable.
Glossary 13 Know Violence
Men who For the purpose of this study, the following definition is used: 1 Afghanistan National AIDS Control Program. National have sex with Men who have sex with men is an umbrella term used to categorize Strategic Plan – Investing in the men (MSM) Response to HIV 2016–2020. men who engage in sexual behaviours with other men. The term is most often used in public health. Some men who have sex with men may also have sex with women, so the term does not indicate sexual orientation.
Although the term ‘men who have sex with men’ is used to denote behaviour, in some South Asian countries, the acronym ‘MSM’ has increasingly being used to denote a sexual identity. For example, sometimes men use the term ‘MSM’ interchangeably with ‘gay’ to describe their sexual identity.
As men who have sex with men include a heterogeneous group of males that have varied gender expressions ranging from masculine-presenting to feminine-presenting males, different subgroups may be at different levels of risk of violence compared to others.
In the context of Afghanistan, the phrase ‘men with high-risk behaviour’ is used for this key population, in line with the Afghanistan National Strategic Plan: Investing in the Response to HIV 2016–2020.1
In this report, the term ‘men who have sex with men’ excludes transmen who have sex with men, not because of a belief that transmen are not men but because not enough information is available about this subgroup. The report also distinguishes between men who have sex with men and transwomen. While transwomen are often conflated with men who have sex with men in public health literature, they face unique challenges and experiences based on their gender identity. This report distinguishes between the two subgroups, highlighting issues pertinent to each specific subgroup and pointing out commonalities only where relevant.
Panthi, Terms used to describe penetrative male sexual partners. Giriya, Parikh
Sexual and A sexual minority is a group whose sexual identity, orientation gender or practices differ from the majority of the surrounding society. A gender minority is a group whose gender identity, expression minorities and practices differ from the majority of the surrounding society. Examples of sexual and gender minorities include men who have sex with men, women who have sex with women, and transgender women and men.
14 Glossary Know Violence
Transgender/ An umbrella term for people whose gender identity does not Transgender coincide with the sex they were assigned at birth. It may include people who identify as a man, a woman, or alternative genders, a Person(s) combination of genders or no gender at all. Common terms used to describe transgender identities include transmen and transwomen. Other definitions of transgender also include people who belong to a ‘third gender’ or conceptualize transgender as a third gender.
Transgender A term used to refer to a transgender person who identifies as women female (i.e. a person whose sex was assigned male at birth who identifies as female). The term does not denote sexual orientation. (Transwomen) ‘Transgender women’ (or transwomen) is often used as an umbrella term for all types of transfeminine identities, regardless of their sexual orientation. For the purpose of this study, the term ‘transwomen’ has been used for male-assigned-at-birth transfeminine individuals who have sex with men.
Glossary 15 Know Violence
List of tables, figures and boxes
Table 1 Snapshot of country contexts with regard to 35 SOGIE concerns Table 2 Participant profile: MSM and MHRB 56 Table 3 Participant profile: Transwomen 57 Table 4 Forms of SOGIE-based violence mentioned in 60 focus group discussions Box 1 United Nations entities call on States to act 30 urgently to end violence and discrimination against lesbian, gay, bisexual, transgender and intersex (LGBTI) adults, adolescents and children (excerpts) Box 2 SDG commitments particularly applicable to the 33 context of SOGIE concerns Figure 1 Timeline of global commitments in the context of 31 SOGI-related rights Figure 2 HIV prevalence among MSM and transgender 43 people Figure 3 Types of SOGIE-based violence 47 Figure 4 Socio-ecological model 49 Figure 5 Sources of SOGIE-based discrimination based 62 on focus group discussions in Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka Figure 6 Coping strategies 80 Figure 7 Connections between SOGIE-based violence, HIV 91 and mental health across the life course
16 List of tables, figures and boxes Know Violence
List of tables, figures and boxes 17 Know Violence
Executive summary
18 Know Violence
Background men who have sex with men was 14.7 percent compared to 2 Beyrer, C. et al. (2012). Global epidemiology of HIV infection While some progress has been close to 1 percent in the general in men who have sex with men. made on the legal and human rights population.2 Transwomen are likely Lancet, 380, pp. 367–77. of sexual and gender minorities to experience higher rates of HIV 3 Miedema, S. et al. (2017). in South Asia, members of these prevalence compared to men who Integrating male sexual diversity into violence groups continue to face persecution, have sex with men or the general prevention efforts with men and harassment and discrimination in this population. Comparable regional boys: evidence from the Asia- data is still difficult to come by, as Pacific Region.Culture, Health region. Their exposure to adversity & Sexuality, 19(2), pp. 208–224. can lead to greater risk of HIV and transwomen are often subsumed 4 Sivasubramanian et al. (2011). mental health disorders. under the category of men who Suicidality, clinical depression, have sex with men, rather than and anxiety disorders are highly Across South Asia, there is a common being disaggregated. However, in prevalent in men who have sex with men in Mumbai, India: belief that homosexuality is abnormal countries where disaggregated data Findings from a community- or pathological. Often, these beliefs exists, transwomen have the highest recruited sample. Psychology, Health & Medicine, 16(4), pp. are sanctioned by influential prevalence of HIV. 450–462. religious, political and community 5 Logie et al. (2012). Adapting leaders. Sexual and gender minorities Men who have sex with men and the minority stress model: face violations of their human rights transwomen also experience Associations between gender non-conformity stigma, HIV- due to their actual or perceived considerable mental health issues. related stigma and depression sexual orientation, gender identity One regional study found that men in among men who have sex with and/or gender expression (SOGIE). Asia-Pacific from sexual minorities men in South India. Social are more likely to report symptoms of Science & Medicine, 74, pp. SOGIE-based violence occurs at 1261–1268. depression compared to heterosexual multiple levels of society. Individuals 6 Reisner et al. (2016). Global 3 might experience violence from family men. Men who have sex with men health burden and needs of or friends, in health care institutions, and transwomen also report high transgender populations: A review. Lancet, 388, pp. 412–36. by law enforcement and by the rates of alcohol and substance judiciary system. As well as a human abuse, anxiety-related disorders, rights violation on its own, exposure and thoughts of suicide.4, 5, 6 Little to SOGIE-based violence can lead to is understood about the pathways increased mental health problems by which SOGIE-based violence and HIV risk behaviours among impacts both mental health and HIV sexual and gender minority groups. risk across the culturally diverse Addressing discrimination, therefore, countries of Asia. is crucial for improving the public health of a nation.
Men who have sex with men and transwomen bear a disproportionate burden of HIV compared to the general population. In 2010, the regional prevalence of HIV among
Executive summary 19 Know Violence
Study programme and policy efforts in the study countries. This study was commissioned by the United Nations Development The study used qualitative methods Programme (UNDP) under the Multi- to collect in-depth data on the Country South Asia Global Fund HIV experiences and perceptions of Programme to better understand SOGIE-based violence among the lived and perceived experiences men who have sex with men and of SOGIE-based violence among transwomen in the seven countries. men who have sex with men and A total of 12 focus group discussions transwomen across seven South (FGDs) were conducted with men Asian countries, and to explore the who have sex with men and 9 focus effects of this violence on mental group discussions were conducted health and HIV risk. The study was with transwomen across the seven implemented by the International countries. The study underwent Center for Research on Women ethical review at the regional and (ICRW) from November 2015 to national levels. February 2016. The seven countries are Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka. Study results The study was conducted in 12 sites Men who have sex with men and across these 7 countries. transwomen face multiple forms of SOGIE-based violence across their The objectives of this study were to: life course 1 Map the experiences of SOGIE- Participants discussed various based violence among men forms of psychological, physical and who have sex with men and sexual violence faced by men who transwomen have sex with men and transwomen, 2 Explore the connections between including, but not limited to verbal SOGIE-based violence, mental abuse, being hit, slapped and thrown health and HIV transmission risk out of running buses, assault by among men who have sex with weapons, and sexual harassment. The men and transwomen most commonly discussed forms of 3 Identify violence prevention and violence facing men who have sex with response priorities targeted men and transwomen communities toward these populations were sexual harassment in college, 4 Develop recommendations to blackmail and/or extortion, violence mitigate and minimize the effects in public places, sexual assault by a of violence on mental health sexual partner and sexual harassment and HIV vulnerabilities through in the workplace. Transwomen tended
20 Executive summary Know Violence
to discuss sexual harassment in the religious spaces, health care, workplace and sexual assault by a employment and the wider partner more often than men who community. Police were commonly have sex with men. discussed as a source of violence. In communities, men who have sex with Variation in SOGIE-based violence men and transwomen reported abuse emerged across countries. by the general public (for example, on Participants in Bhutan reported buses), intimate male partners, and the fewest forms of SOGIE-based the family; housing discrimination; violence, while participants in harassment and abuse in schools Pakistan reported the most. These as children; and workplace-related results do not suggest that SOGIE- discrimination. based violence is more prevalent in one country compared to the other, but rather that participants are Implications for HIV risk and mental more aware of this type of violence health issues occurring. In Bhutan, in particular, Men who have sex with men and limited community outreach means transwomen reported that in their that men who have sex with men and communities, they see how SOGIE- transwomen are relatively isolated based discrimination causes mental from one another and have limited health problems, and also leads knowledge of community-level to conditions in which behaviour issues. Thus, awareness of what that increases HIV risk is more types of SOGIE-based violence face likely. The participants said that a their communities is contingent on lifetime exposure to violence and the level of community organization discrimination, including social among men who have sex with men exclusion and marginalization and transwomen in a given context. negatively impacts the mental health and well-being of men who have sex Men who have sex with men and with men and transwomen. According transwomen face SOGIE-based to the data, psychological issues violence from diverse sources ranged from poor self-esteem and self-doubt to attempts at suicide, and Participants report that their occurred due to the gradual build- communities face SOGIE-based up of stress, coupled with a lack of violence across multiple domains of recourse, acceptance or support their lives. In particular, key domains systems in face of discrimination in which men who have sex with or abuse. men and transwomen communities experience discrimination and Participants also described a number violence included legal and law- of situations in which SOGIE-based related institutions, education, violence led to greater HIV risk.
Executive summary 21 Know Violence
Three major themes that emerged Recommendations were (1) SOGIE-based violence and discrimination driving men who have The results of this study point sex with men and transwomen into towards a number of key sex work and risky sexual situations recommendations for action. The full with clients and police; (2) barriers set of recommendations, by target to accessing health care in cases of group, can be found in Chapter 8: sexual assault; and (3) the processes Recommendations. of finding sexual partners in contexts where same-sex activities were Policymakers can: illegal or socially unacceptable. —— Repeal laws criminalizing same- sex behaviour Strategies for resilience and coping —— Provide legal gender recognition Despite the multiple challenges that of third gender and transgender men who have sex with men and groups transwomen in the seven countries —— Pass anti-discrimination policies face, they all reported various to support the rights of sexual and forms of resilience and coping. gender minorities Transwomen participants from countries like Bangladesh, India and The health care industry can: Pakistan stated the support of their own community was their biggest —— Train and sensitize health care resource and instrument of coping. providers around SOGIE-based Often, transwomen discussed leaving health issues home and joining the “family of [their] —— Integrate the rights of sexual and choice”, in order to fully embrace gender minority patients into their identities. Community-based professional codes of ethics organizations were another major —— Foster supportive and welcoming form of support for participants, health care environments in terms of social connections, —— Strengthen networks of economic support, and access to community organizations with the health care and legal support. formal health care system
The education system can:
—— Develop and implement policies to prohibit SOGIE-based violence in schools —— Build the capacity of teachers, faculty, administrators and staff
22 Executive summary Know Violence
to respond to and prevent SOGIE- —— Conduct research not only among based violence men who have sex with men and —— Integrate sexual orientation and transwomen, but also sexual gender identity topics in school minority women and transmen curricula
Workplace managers and industry professionals can:
—— Implement inclusive policies and practices in the workplace —— Develop and implement response mechanisms against discrimination in the public and private sector
Programme teams that address gender-based violence, sexual and reproductive health and HIV can:
—— Promote definitions of gender- based violence that acknowledge the specific experiences of gender and sexual minorities —— Sensitize practitioners to the overlaps between gender-based violence and SOGIE-based violence —— Build gender-based violence response services tailored to the needs of sexual and gender minorities —— Synchronize gender-based violence prevention and HIV prevention work, rather than keeping them siloed
Researchers can:
—— Conduct more research on the connections between SOGIE-based violence, HIV and mental health
Executive summary 23 Know Violence
Chapter 1: Introduction
24 Know Violence
1.1 Violence, mental identity and/or gender expression. This violence occurs at multiple 7 Miedema, S. et al. (2017). health and HIV among Integrating male sexual levels of society – from family and diversity into violence sexual and gender friends to health care institutions, law prevention efforts with men and minorities enforcement and the judiciary system. boys: evidence from the Asia- Pacific Region.Culture, Health Under conditions of daily risk of & Sexuality, 19(2), pp. 208–224. Members of sexual and gender trauma and violence, men who have 8 Chakrapani, V., Newman, P.A., minority groups face considerable sex with men and transwomen may Shunmugam, M., McLuckie, A. discrimination, abuse and trauma have little power to negotiate safer and Melwin, F. (2007). Structural violence against Kothi-identified across their life courses.7, 8 This conditions and have poor access to men who have sex with men violence is often a result of their health services and health education, in Chennai, India: a qualitative investigation. AIDS Education sexual orientation, gender identity or which can heighten their vulnerability and Prevention, 19(4), pp. 346. expression. The term ‘SOGIE-based to HIV. Depression and other mental 9 Andersson, N., Cockroft, A. and violence’ is used to refer to all acts health disorders due to violence may Shea, B. (2008). Gender-based of violence related to (a) the social exacerbate HIV vulnerability. violence and HIV: Relevance for status of one’s gender identity, (b) HIV prevention in hyperendemic countries of southern Africa, not conforming to socially accepted AIDS 22 Suppl 4, pp. S37–86. gender roles, and (c) non-binary 1.2 About the study 10 Safren et al. (2009). Depressive gender identities. symptoms and human This study was commissioned by immunodeficiency virus risk Global evidence over two decades has UNDP under the Multi-Country South behaviors among men who have sex with men in Chennai, India. shown that SOGIE-based violence is Asia Global Fund HIV Programme Psychology, Health & Medicine, linked to the spread of HIV through to better understand the lived and 14(6), pp. 705–715. factors including trauma to the perceived experiences of SOGIE- 11 In Afghanistan, the study focused on men with high-risk body and an increase of sexual risk based violence among sexual and behaviour. behaviours.9 SOGIE-based violence gender minorities across seven South can also lead to poor mental health Asian countries, and to explore the outcomes, including depression, effects of this violence on mental anxiety and suicidality. Mental health and HIV risk. health challenges often occur at the same time as HIV risk behaviours The study was implemented by the and situations.10 So, reducing and International Center for Research eliminating discrimination is critical on Women from November 2015 to for addressing the HIV epidemic, and February 2016. The seven countries more broadly for improving the public are Afghanistan, Bangladesh, Bhutan, health of a nation. India, Nepal, Pakistan and Sri Lanka. The study focuses specifically on Currently in South Asia, men who the experiences of men who have have sex with men and transwomen sex with men and transwomen.11 often experience violations of their There are important distinctions human rights due to their actual or between these two subgroups. While perceived sexual orientation, gender transwomen are often conflated
Chapter 1: Introduction 25 Know Violence
with men who have sex with men in 3 Identify violence prevention and public health literature, they face response priorities targeted unique challenges and experiences toward men who have sex with based on their gender identity. This men and transwomen report distinguishes between the 4 Develop recommendations to two subgroups, highlighting issues mitigate and minimize the effects pertinent to each specific subgroup of violence on the mental health and pointing out commonalities only and HIV vulnerabilities of men where relevant. who have sex with men and transwomen through programme This study uses qualitative research and policy efforts in the study methods to explore links that have countries so far not been explored enough between experiences of SOGIE- based violence, its impact on mental health and how violence directly and indirectly increases vulnerability to HIV among the study populations in seven Asian countries. This study serves as an important cross- country comparison of SOGIE-based violence among groups that are underresearched and marginalized.
1.3 Objectives and methods
The objectives of this study were to:
1 Map the experiences of SOGIE- based violence among men who have sex with men and transwomen 2 Explore the connections between SOGIE-based violence, mental health and HIV transmission risk among men who have sex with men and transwomen
26 Chapter 1: Introduction Know Violence
Chapter 1: Introduction 27 Know Violence
Chapter 2: Regional context
28 Know Violence
This study explores the connections grounds of sexual orientation.13 between SOGIE-based violence, Specifically, the Committee held 12 Nicholas Toonen v. Australia, Human Rights Committee, 50th mental health and HIV risk in seven that “the reference to sex in Article Sess., Case No. 488/1992, UN countries across the Asia region. This 2(1) and Article 26 is to be taken Doc. CCPR/c/50/D/488/1992. section provides the regional context as including sexual orientation.”14 13 Human Rights Committee: including regional and national This was later reaffirmed in United Views of 31 March 1994, Case of Nicholas Toonen v. laws and policies related to the Nations Human Rights Council Australia, Communication human rights of sexual and gender (UNHRC) resolutions in 2011 and No. 488/1992, paras. 8.2–8/7. minorities; the state of evidence on 2014.15 In 2015, the United Nations See also: Views of 6 August 2003, Case of Edward Young v. violence against sexual and gender issued a joint agency statement Australia, Communication No. minorities; and up-to-date HIV demonstrating commitment to 941/2000, para. 10.4; and Views of 30 March 2007, Case of X v. prevalence statistics for each of the upholding the human rights of sexual Colombia, Communication No. study’s countries. and gender minority populations and 1361/2005, para. 7.2. providing a framework to end human 14 Nicholas Toonen v. Australia, rights violations, such as violence and Human Rights Committee, 50th Sess., Case No. 488/1992, UN 2.1 Laws and policies discrimination, against these groups Doc. CCPR/c/50/D/488/1992. related to sexual and (See Box 1 for excerpts).16 15 Human Rights Council, Human gender minority groups rights, sexual orientation and gender identity. A/HRC/17/L.9/ Since UNHRC’s first resolution in Rev.1, 17 June 2011. Human 2.1.1 Global state of SOGIE 2011 to bring specific focus to human Rights Council, Human rights, human rights sexual orientation and gender rights violations against sexual identity. A/HRC/27/L.27/Rev.1, and gender minorities, attention to 26 September 2014. The human rights of sexual and SOGIE-related rights continues to 16 The statement titled Ending gender minorities are increasingly increase exponentially. The 2011 Violence and Discrimination being considered and included against Lesbian, Gay, Bisexual, UNHRC resolution led to a ground- in international instruments and Transgender and Intersex breaking study that shed light on People was issued by ILO, human rights standards. Figure 1 the wide range of discriminatory OHCHR, UNDP, UNESCO, provides a timeline of global UNFPA, UNHCR, UNICEF, practices and laws being used against UNODC, UN Women, WFP, WHO commitments related to SOGIE lesbian, gay, bisexual, transgender and UNAIDS rights. Notably, in 1994, in Toonen and intersex people around the world. 17 OHCHR (2011). Discriminatory v. Australia, the United Nations It showed that violence, including Laws and Practices and Acts Human Rights Committee held that of Violence against Individuals sexual violence, perpetrated by law based on their Sexual “sexual orientation” was a status enforcement authorities and society Orientation and Gender Identity. protected from discrimination under OHCHR. Available at: http:// at large, was a pervasive problem in the International Covenant on Civil www.ohchr.org/Documents/ many countries.17 In 2012, the Global HRBodies/HRCouncil/ and Political Rights (ICCPR) equality Commission on HIV and the Law RegularSession/Session19/A- clauses.12 Additionally, the Human HRC-19-41_en.pdf. report went further to acknowledge Rights Committee has held that the that while the law has the power to reference to “equal and effective protect the dignity of those living with protection against discrimination HIV, it also has the potential to harm, on any ground” in Article 26 of the by perpetuating discrimination and ICCPR includes discrimination on
Chapter 2: Regional context 29 Know Violence
isolating those most vulnerable, so Expert dedicated to monitor human 18 Global Commission on HIV and that they cannot access the preventive rights violations on the grounds the Law (2012). HIV and the Law: Risks, Rights and Health. or curative services they critically of SOGIE strengthened the UN’s UNDP. need.18 The adoption of the latest commitments on the protection of UNHRC resolution on 30 June 2016 SOGIE-related rights. on the appointment of an Independent
Box 1: United Nations entities call on States to act urgently to end violence and discrimination against lesbian, gay, bisexual, transgender and intersex (LGBTI) adults, adolescents and children (excerpts)
“All people have an equal right to live free from violence, persecution, discrimination and stigma. International human rights law establishes legal obligations on States to ensure that every person, without distinction, can enjoy these rights. While welcoming increasing efforts in many countries to protect the rights of LGBTI people, we remain seriously concerned that around the world, millions of LGBTI individuals, those perceived as LGBTI and their families face widespread human rights violations. This is cause for alarm and action.
“Failure to uphold the human rights of LGBTI people and to protect them against abuse, such as violence and discriminatory laws and practices, constitute serious violations of international human rights law, having a far-reaching impact on society. It contributes to increased vulnerability to ill health including HIV infection, social and economic exclusion, putting strain on families and communities, and impacting negatively on economic growth, decent work and progress towards achievement of future Sustainable Development Goals. States bear the primary duty under international law to protect everyone from discrimination and violence. These violations, therefore require urgent response by governments, parliaments, judiciaries and national human rights institutions. Community, religious and political leaders, workers’ organizations, the private sector, health providers, civil society organizations and the media also have important roles to play. Human rights are universal – cultural, religious and moral practices and beliefs and social attitudes cannot be invoked to justify human rights violations against any group, including LGBTI persons.”
30 Chapter 2: Regional context Know Violence
Figure 1: Timeline of global commitments in the context of SOGI-related rights
Universal Declaration of Human Rights (Article 1 – equality, 1948 dignity and rights; Article 2 – non-discrimination; Article 7 – equal protection under law)
International Covenant on Economic, Social and Cultural Rights International Covenant on Civil and Political Rights (Article 1 – right (Article 7 – employment and workplace rights; Articles 11 and 12 1966 to self-determination; Article 17 – right to privacy; Article 26 – non- – State commitment to ensuring minimum standard of living and discrimination and equal protection under law) highest standard of health for all)
The Paris Declaration on the fight against HIV/AIDS and commitment 1994 to protect the rights of those living with HIV and those particularly at risk of HIV infection
Millennium Development Goals (MDG 6 on combating HIV/AIDS, malaria and other diseases – particularly Target 6.A on halting 2000 and reversing the spread of HIV/AIDS and Target 6.B on ensuring universal access to HIV treatment)
2001 UNGASS Declaration on HIV/AIDS
UN General Assembly resolution on combating and eliminating extrajudicial, summary or arbitrary executions, including on grounds 2002 of sexual orientation (in a continuing series of resolutions in this matter, gender identity was added as a ground in 2012)
2006 Political Declaration on HIV/AIDS
Yogyakarta Principles – set of principles on the application of human rights laws in relation to SOGI (they affirm binding international legal 2007 standards that all States are obligated to comply with)
The Global Fund Strategy in Relation to Working with Sexual UNAIDS Action Framework – universal access to HIV services for 2009 Orientation and Gender Identities men who have sex with men and transwomen
PEPFAR Technical Guidance on Combination Prevention for men who Getting to Zero, UNAIDS 2011–2015 Strategy 2010 have sex with men (adoption of best practices in HIV interventions meant for men who have sex with men)
UNHRC resolution on commissioning a study to document Political Declaration of HIV and AIDS: Intensifying Our Efforts to discriminatory laws and practices and acts of violence in relation to 2011 Eliminate HIV and AIDS SOGI, in all regions of the world, and how international human rights law can be used to end violence and related human rights violations Human Rights Considerations in Addressing HIV among men who based on SOGI have sex with men (USAID/AIDSTAR 1)
2012 Global Commission on HIV and the Law – Risk, Rights and Health
UN Committee recommends LGBT organizations for ECOSOC 2013 consultative status
UN decision on according equal rights to same-sex partners of 2014 UN staff
Joint UN statement on Ending violence and discrimination against Adoption of Sustainable Development Goals 2030 2015 lesbian, gay, bisexual, transgender and intersex people
UN General Assembly resolution on establishment of an Independent Expert on documentation of and facilitating protection 2016 against human rights violations in relation to SOGI
Sources: South Asia Regional Advocacy Framework and Resource Guide: HIV, Human Rights and Sexual Orientation and Gender Identity, UNDP, SAARCLAW, 2014; various UN website links.
Chapter 2: Regional context 31 Know Violence
Unfortunately, these concerns do not (OHCHR), SOGIE issues received 19 Mills, E. (2015). Gender, seem to have informed the adoption some attention in the SDGs. The Sexuality and the SDGs: An Evidence-base for Action, of the Sustainable Development Goals SDG Outcome Document 2015 states Institute of Development (SDGs) in August 2015, which initially in paragraph 19 that the language Studies. Available at: http:// failed to explicitly acknowledge the of non-discrimination should be www.ids.ac.uk/opinion/gender- sexuality-and-the-sdgs-an- relationship between SOGIE and applicable to persons of “other evidence-base-for-action development.19 After strong advocacy status”. “Other status” reflects two by global civil society actors and resolutions passed by the UNHRC the United Nations Office of the in 2009 – the first resolution stated High Commission on Human Rights that “other status” included sexual
Box 2: SDG commitments particularly applicable to the context of SOGIE concerns
SDG 1: End poverty in all its forms everywhere
SDG 3: Ensure healthy lives and promote well-being for all at all ages – particularly targets 3.3–3.5, 3.7, 3.8, 3.b and 3.c
SDG 4: Ensure inclusive and equitable quality education and promote learning opportunities for all
SDG 5: Achieve gender equality and empower all women and girls
SDG 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all – particularly targets 8.3, 8.5–8.10
SDG 10: Reduce inequality within and among countries – particularly targets 10.1–10.4
SDG 11: Make cities and human settlements inclusive, safe, resilient and sustainable
SDG 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels – particularly targets 16.1–16.3, 16.9, 16.10 and 16.b
Source: Sustainable Development Goals Knowledge Platform
32 Chapter 2: Regional context Know Violence
orientation and the second resolution the lives of LGBTI people; dialogue extended this to include gender and awareness-generation on 20 Sustainable Development Knowledge Platform. (2015). 20 identity. Based on this inclusion, SOGIE involving key institutions and Transforming Our World: The a number of SDGs and respective stakeholders; and advocacy for legal 2030 Agenda for Sustainable sub-topics become applicable to the reform.24 Development, United Nations. Available at: https:// context of SOGIE (See Box 2 for a brief sustainabledevelopment.un.org/ summary).21 In 2010, attention towards SOGIE post2015/transformingourworld concerns at the regional level grew 21 Ibid. when the United Nations Economic 22 Asia Pacific Forum of National 2.1.2 SOGIE rights across the and Social Commission for Asia Human Rights Institutions (2009). Conclusions of the Asia region and the Pacific (UNESCAP) passed Workshop on the Role of a regional resolution to situate National Human Rights At the regional level, men who have universal access to HIV prevention, Institutions in the Promotion sex with men and transwomen and Implementation of the care, support and treatment services Yogyakarta Principles. Asia communities face a crossroads in in the context of human rights, and Pacific Forum of National terms of the socio-economic, health undertake measures to address Human Rights Institutions. and legal environment. In May Available at: https://www. stigma and discrimination, as well as outrightinternational.org/sites/ 2009, in response to the Yogyakarta policy and legal barriers to effective default/files/316-1.pdf. Additional Recommendations,22 the HIV responses, in particular with 23 The Yogyakarta Principles plus Asia Pacific Forum (APF) of National regard to key affected populations. 10 (YP+10) were adopted on 10 Human Rights Institutions (NHRI) November 2017 to supplement the Yogyakarta Principles. The facilitated a workshop of member In 2011, UNESCAP passed another YP+10 document emerged commissions to discuss their role resolution for an Asia-Pacific from the intersection of in promoting the implementation developments in international regional review of the progress human rights law with the 23 of the Yogyakarta Principles. The achieved in realizing the Declaration emerging understanding of APF recommended practical ways of Commitment on HIV/AIDS and violations suffered by persons on the grounds of sexual in which the NHRIs could use their the Political Declaration on HIV/ orientation and gender identity functions and powers to better AIDS made in 2006. It called upon its and the recognition of the distinct and intersectional protect and promote the rights members and associate members grounds of gender expression of people of diverse SOGIE. The to further intensify the full range of and sex characteristics. workshop resulted in the Advisory actions to reach the unmet goals and Available at: https:// yogyakartaprinciples.org/ Council of Jurists (ACJ) of APF targets under these commitments issuing a comprehensive set of 24 UNDP, IDLO (2013). Regional through strategic plans, operational Report: The Capacity of National recommendations in line with the partnerships at national and Human Rights Institutions mandate of NHRIs, which have an community levels, legal reviews and to Address Human Rights in important function in the protection Relation to Sexual Orientation, high-impact HIV interventions for Gender Identity and HIV. and promotion of human rights. key populations – the key target in Bangkok, UNDP. These recommendations related question being 80 percent coverage 25 UNDP, SAARCLAW (2014). to the capacity-building of NHRIs; for key affected populations towards South Asia Regional Advocacy Framework and Resource research and documentation in the 25 the goal of universal access. Guide: HIV, Human Rights and area of human rights violations Sexual Orientation and Gender around SOGIE and their impact on Identity, UNDP.
Chapter 2: Regional context 33 Know Violence
Further, in November 2011, UNDP, Code criminalizes same-sex sexual 26 Mago, A. (2012). South Asia the International Law Development activity as well as sex work. Roundtable Dialogue: Legal and Policy Barriers to the HIV Organization (IDLO) and SAARCLAW Response, IDLO. partnered with the World Bank and Bangladesh: The National Human 27 UNDP, APF (2016). Promoting UNAIDS to co-host the South Asian Rights Commission of Bangladesh and Protecting Human Roundtable Dialogue: Legal and (JAMAKON) has engaged with Rights in relation to Sexual LGBT communities (more so with Orientation, Gender Identity Policy Barriers to the HIV Response and Sex Characteristics: A (South Asian Roundtable). The South transwomen), but mainly from Manual for National Human Asian Roundtable brought together a public health perspective of Rights Institutions; UNDP, APTN (2017), Legal Gender community leaders and advocates, vulnerability to HIV. JAMAKON has Recognition: A Multi-Country representatives of the judiciary, human established a thematic committee Legal and Policy Review in Asia. rights institutions, parliamentarians, focused on human rights issues 28 Ibid. government officials, lawyers and faced by excluded minorities, 29 However, not all hijras and law students to address HIV and key specifically includinghijras .27 The other transgender persons committee monitors and reports, seek “third gender” status, but affected populations. The South Asian instead seek legal recognition Roundtable stimulated participants contributes to policy dialogues, and of their perceived authentic to undertake initiatives designed to provides feedback on draft laws and gender (within the gender 28 binary). strengthen the rights-based response strategic guidance to JAMAKON. 26 30 Transgenders Officially a to HIV in their countries. In November 2013, the Bangladesh ‘Third Gender’ in Bangladesh government recognized hijras as (2013). Firstpost, 14 November. 2.1.3 Progress and gaps toward a separate gender.29 Yet, the same Available at: http://www. firstpost.com/world/ SOGIE rights across the seven year, Parliament refused to consider transgenders-officially-a-third- countries the United Nations Human Rights gender-in-bangladesh-1229221. Commission recommendations html Across the seven countries included to decriminalize same-sex sexual 31 In 2016, JAMAKON together 30 with Bandhu Social Welfare in this study, progress towards the relations. Despite state recognition Society called for the immediate fulfilment of SOGIE human rights is of hijras, they continue to face enactment and implementation discrimination in many ways. of the draft legislation. See: uneven. Much of this progress has Bandhu Social Welfare Society been made in the past few years, (2017). Consultation Meeting on from 2012 to 2016. Box 4 provides a In 2014, the Law Commission drafted Anti-Discriminatory Law; UNDP an Anti-Discrimination Law, which and APTN (2017). Legal Gender snapshot by country of the existing Recognition: A Multi-Country laws and policies related to SOGIE included a person’s status as hijra Legal and Policy Review in Asia. concerns, including laws related to as one of the possible grounds of 32 Karim, H. (2017). How effective criminalization, sex work and HIV. This discrimination. The law has yet will the anti-discrimination law to be enacted though JAMAKON be? The Daily Star, 20 October. is followed by a summary of progress Available at: https://www. specifically related to laws and has continually advocated for its 31 thedailystar.net/star-weekend/ policies on SOGIE in each country. passage. If the law is passed, it is a human-rights/how-effective- first in Bangladesh’s history and will will-the-anti-discrimination- law-be-1478878 Afghanistan: Recognition of criminalize discrimination; however, SOGIE-related concerns remains it was reported in late 2017 that the underprioritized in Afghanistan. process to pass the law “hasn’t even Article 427 of the Afghanistan Penal begun”.32
34 Chapter 2: Regional context Know Violence
Table 1: Snapshot of country contexts with regard to SOGIE concerns
Explicit Criminalization of Transgender rights Laws against sex Country constitutional same-sex sexual HIV legislation legal recognition work recognition relations Afghanistan None Yes, Article 427 of None Article 427 None, but national Afghanistan Penal Afghanistan Penal HIV response covers Code Code MHRB Bangladesh None, though Yes, Section 377 Hijras received SITA 1933 and OWC None, but national specific articles Bangladesh Penal recognition as third Act 1995 – sex work HIV response covers could be supportive Code gender in 2013 per se is not criminal MSM and hijras but associated practices are Bhutan None Yes, Sections None Criminalized under None, but national 213–214* Bhutan Penal Code 2004 HIV response covers Penal Code MSM India None, but specific Yes, Section 377 Recognition via ITPA 1986 – sex work National legislation articles are seen to Indian Penal Code Supreme Court per se is not criminal drafted but not be supportive (read down by verdict in 2014; but associated tabled in Parliament; Delhi High Court in draft bill tabled in practices are national HIV 2009, reinstated by Parliament in 2016; response covers Supreme Court in welfare boards set up MSM, transwomen 2013) in 5 states Nepal Yes, protection Decriminalised by Third (or other) Penal Code 119–120: None, but national for equal rights Supreme Court since gender recognized Sex work per se HIV response covers enshrined in 2007 is not criminal but MSM, transwomen Constitution since associated practices 2015 are Pakistan None, negative Yes, Section 377 Supreme Court Sections 371A, 371B Only Sindh province influence of religious Pakistan Penal Code granted several criminalize sex work has legislation; law, but specific rights from 2009–12 and related activities national HIV articles could be Transgender Persons response covers supportive (Protection of Rights) MSM, transwomen Act passed by Senate Sri Lanka None Yes, Sections 365, Recognition via Sex work per se Yes, HIV 365A and 399 Sri MOH circular to is not criminal but discrimination Lanka Penal Code health and education associated practices prohibited in departments are – this is reflected 2016; national HIV in terms of Vagrants response covers and Brothels MSM Ordinances
Chapter 2: Regional context 35 Know Violence
Bhutan: Sections 213 and 214 of the in line with the NALSA judgment.36 33 Lawyers Collective (2016). Bhutan Penal Code criminalize same- However in 2016, the government Supreme Court Recognizes the Right to Determine and Express sex sexual activity. Sex work is also introduced a different version of a One’s Gender; Grants Legal criminalized under various sections Transgender Persons (Protection Status to ‘Third Gender’. of the Penal Code 2004. of Rights) Bill, which contained 34 Lawyers Collective (2016). problematic definitions of the Supreme Court Sets Aside the India: The National Human Rights 37 High Court Decision on Anti- term ‘transgender’. The bill has Sodomy Law: Huge Setback for Commission of India engages with been subject to criticism from the LGBT Rights, Activists Vow to LGBT communities largely in the community.38 This bill is currently Continue the Fight. context of public health. Some state under consideration, but has not 35 Supreme Court to review commissions of the National Human Section 377 which criminalises yet been passed. The transgender gay sex (2018). Times of India, Rights Commission of India did protection bill has since been revised 8 January. Available at: https:// intervene in matters of the right to based on recommendations from the timesofindia.indiatimes.com/ india/supreme-court-to-review- vote, discrimination in employment, Parliamentary Standing Committee. article-377-which-criminalises- and illegal detention and police abuse The Social Justice ministry has gay-sex/articleshow/62412768. faced by transwomen. In April 2014, sent a bill on transgender rights cms the Supreme Court of India followed to the Cabinet after finalizing nine 36 The Rights of Transgender Persons Bill, (India) (2014) Bill the suit of neighbour, Pakistan, when amendments, including those on the No. 49 of 2014; UNDP, APTN it passed a landmark verdict on definition of the term ‘transgender’, (2017) recognizing transgender identities keeping with the recommendations of 37 The Transgender Persons and their citizenship rights (the a parliamentary panel.39 (Protection of Rights) Bill (India) 33 (2016) Bill No. 210 of 2016; NALSA judgment). In July 2009, the UNDP, APTN (2017). Delhi High Court held the application Nepal: In 2007, the Supreme Court 38 All you need to know about of Section 377 of the Indian Penal of Nepal formally recognized the the Transgender Persons Bill Code, which criminalized “carnal rights of sexual and gender minority (2016). The Hindu, 30 November. Available at: http://www. intercourse against the order of groups. As part of this ruling, the thehindu.com/news/national/ nature” between consenting adults, Court decriminalized homosexuality, all-you-need-to-know-about- to be unconstitutional. This decision noted that the fundamental rights the-transgender-persons- bill-2016/article21226710.ece was reversed in December 2013, to equality and non-discrimination 39 Bill on transgender rights when the Supreme Court held that applied to all citizens, and ordered sent to Cabinet (2018). Indian decriminalization of LGBT people that identity cards with a third gender Express, 18 March. Available should be part of the legislature’s be issued.40 The Muluki Ain (civil and at: https://indianexpress. 34 com/article/india/bill-on- remit. In January 2018, however, criminal code of Nepal) was updated transgender-rights-sent-to- the Supreme Court agreed to in 2017, but the official English cabinet-5102366/ reconsider its verdict from 2013 and translation has not been released. 40 Sunil Babu Pant and Others v. review Section 377 in light of the The last proposed set of amendments Nepal Government and Others (Nepal) (2007), Writ. No. 917 of fundamental right to privacy.35 in 2015 did not reflect the 2007 2064 BS (2007). judgment, and it was uncertain In 2015, the Upper House of if this last version that has been Parliament (Rajya Sabha) passed passed would reflect them either. a private member’s Rights of A 2013 IDLO assessment of NHRI Transgender Persons Bill, which was found that the Nepali NHRI had been
36 Chapter 2: Regional context Know Violence
the most proactive in establishing cannot be deprived of the right to steps toward national protection vote or run for office. It lays out their 41 UNDP, IDLO (2013). Regional Report: The Capacity of National and anti-discrimination policies for rights to inheritance, in accordance Human Rights Institutions sexual and gender minority groups.41 with their chosen gender. And it to Address Human Rights in In particular, the National Human obligates the government to establish Relation to Sexual Orientation, Gender Identity and HIV, Rights Commission Nepal created an “Protection Centers and Safe Houses” Bangkok, UNDP. LGBT focal point within the institution — along with separate prisons, jails 42 Article 12 (Citizenship Based on and put in place an institutional or places of confinement.45 Descent with Gender Identity), relationship with the country’s Article 18 (Right to Equality) and Article 42 (Right to Social Justice) national LGBT network. The Pakistan National Commission of the Constitution of Nepal for Human Rights is still at the early 43 Human Rights Campaign (2015). On 16 September 2015, Nepal stages of engagement on SOGIE In a Historic Step, Nepal Ratifies continued its progressive tradition of issues. However, between 2009 and New Constitution That Includes LGBT Protections. Available at: LGBT inclusion through the adoption 2012, the Supreme Court of Pakistan http://www.hrc.org/blog/in-a- of a new Constitution that provided granted a number of rights and historic-step-nepal-ratifies-new- explicit protections for LGBT people privileges to khwaja siras in a series constitution-that-includes-lgbt- prote ( accessed 4 June 2016) from discrimination, violence and of rulings, recognizing khwaja sira 44 UNDP and APTN (2017). abuse.42 With this move, Nepal as a distinct sex/gender in addition 46 45 Pakistan Passed Historic joined only a handful of countries, to male and female. The National Transgender Rights including Ecuador and South Africa, Human Rights Commission’s Sindh Bill (2018). NPR, 9 May. which have enshrined equal rights chapter is currently drafting a khwaja Available at: https://www. npr.org/sections/thetwo- protections for LGBT people in their sira protection bill to be introduced in way/2018/05/09/609700652/ national constitutions.43 In 2017, the the Sindh Provincial Assembly. pakistan-passes-historic- Supreme Court ruled that the Nepal transgender-rights-bill government must develop a policy to Sri Lanka: The Human Rights 46 Khan F.A. (2016). Khwaja Sira Activism – The Politics of Commission of Sri Lanka is similar enable transgender people to change Gender Ambiguity in Pakistan, their name.44 to Pakistan, in that it is in the early Transgender Studies Quarterly, stages of engagement on SOGIE Volume 3, No. 1–2, Duke University Press. Pakistan: In 2018, the Transgender issues. Notably, the Commission 47 Ministry of Health (Sri Lanka) Persons (Protection of Rights) Act intervened on a March 2015 complaint (2016). General Circular No: was passed by Pakistan’s Senate and from a transgender person resulting 01-34/2016 on Issuing of Parliament but is yet to be signed in the Ministry of Health issuing Gender Recognition Certificate for Transgender Community into law by the country’s president. a circular to health services and (16 June 2016); The Registrar- The act allows people to choose education institutions about issuing General (Sri Lanka) (2016). their gender and to have that identity gender recognition certificates to Circular No 06/2016 (28 June 2016). recognized on official documents, transgender people.47 At the end of 48 UNAIDS (2016). Sri Lanka’s including national IDs, passports and April 2016, the Supreme Court of Sri Supreme Court Makes driver’s licences. The bill prohibits Lanka made a landmark decision Landmark Decision Prohibiting discrimination in schools, at work, prohibiting HIV-based discrimination, HIV Discrimination, 4 June 2016. Available at: http://www.unaids. on public modes of transit and while which stands to benefit all of those org/en/resources/presscentre/ receiving medical care. The measure affected, including men who have sex featurestories/2016/ may/20160502_Srilanka_ also states that transgender people with men and transwomen.48 nodiscrimination.
Chapter 2: Regional context 37 Know Violence
The limits of legal and policy-related other sexual health concerns of 49 See, generally, Penal Code protections: Despite the progress LGBTI people vulnerable to punitive Section 377 in Bangladesh, India and Pakistan; Section 427 described above, there remain large action, including charges of abetment in Afghanistan, Section 213 in gaps in constitutional, legal and in relation to Section 377.53 The Indian Bhutan and Sections 365 and policy frameworks across the region. Supreme Court’s reversal on Section 365A in Sri Lanka. Discriminatory and contradictory 377 is similarly believed to have 50 Govt. agrees to remove ‘eunuch’ from Police Act (2016). Times of laws that criminalize or exclude LGBT caused a setback to the national HIV India, 13 January. Available at: people continue to remain as part of response by recriminalizing men who http://timesofindia.indiatimes. the legal and social environment in have sex with men and transwomen com/articleshow/50556225. cms?utm_ South Asia. Sections of penal codes and hampering their ability to access source=contentofinterest&utm_ throughout the region continue to be health care services. On the other medium=text&utm_ used to persecute, if not prosecute, hand, the Indian HIV/AIDS Act 2017 campaign=cppst LGBT people for consensual same- and its rules provide protections for 51 Sarkar, A. and Nath, P. (2013). 49 Preparing for Section 377 sex conduct. In contrast, recent NGOs and outreach staff providing Verdict, ‘Varta’, December. legislative processes in South Asia HIV prevention messages and Available at: http://varta2013. have largely focus on legal gender commodities.54 blogspot.in/2013/12/preparing- for-section-377-verdict.html recognition and citizenship rights 52 People’s Union for Civil for transwomen, and to a limited In fact, other than Sri Lanka, few Liberties (2003). Human extent, transmen. Other laws around countries in South Asian have legal Rights Violations Against the safeguards against HIV-related Transgender Community: A sex work, vagrancy and public PUCL Report. A study of Kothi nuisance also exist that allow the discrimination. Sri Lanka’s courts and Hijra Sex Workers in police to carry out arbitrary arrests have ruled to recognize the right Bangalore. and commit unjustified violence to non-discrimination in specific 53 Health Issues India (2013). contexts, including schools; and the Supreme Court Verdict on IPC against LGBT people, particularly Section 377 Impedes Fight transwomen (including transgender national HIV law was passed by the Against HIV/AIDS. Available at: sex workers). One example in the Parliament.55 http://www.healthissuesindia. com/2013/12/17/supreme- Indian context is Section 36A of the court-verdict-ipc-section-377- Karnataka Police Act, 1963 which In addition to a lack of protection impedes-fight-hivaids/ was introduced in 2011 to control the laws, discriminatory laws 54 National AIDS Control “objectionable activities of eunuchs”. significantly impede the realization Organisation, India (2017). of constitutional, legal or policy HIV/AIDS Act 2017. Available Fortunately, after concerted advocacy at: http://naco.gov.in/hivaids- and campaign, the word “eunuch” gains around SOGIE issues. Often, act-2017 was dropped from the law in 2016, governments fail to act on court 55 UNAIDS (2016). Sri Lanka’s but LGBT activists feel that the entire verdicts by enacting legislation which Supreme Court Makes 50 would clearly designate the actions to Landmark Decision Prohibiting section should go. HIV Discrimination. Available be taken by government departments, at: http://www.unaids.org/ Obscenity laws like Sections 292 to including service providers. In India, en/resources/presscentre/ 51 no law has been enacted to reflect featurestories/2016/ 294 of the Indian Penal Code (and may/20160502_Srilanka_ similar counterparts in the Pakistan the 2014 Supreme Court verdict on nodiscrimination. Penal Code) continue to restrict transgender identities and rights. In freedom of speech and expression,52 2015, the Ministry of Social Justice making NGOs working on HIV and and Empowerment prepared the
38 Chapter 2: Regional context Know Violence
Transgender Rights Bill, which was 2.2 SOGIE-based violence tabled in August 2016. However, LGBT 56 Orinam (2015). Telangana Hijra Intersex Transgender Samithi activists have criticized the draft bill 2.2.1 Gender-based violence and Responds to MSJE Transgender for not honouring the court’s directive SOGIE-based violence Rights Bill. Available at: http:// on a mechanism for self-identification orinam.net/telangana-samiti- response-msje-trans-rights- and instead, over-emphasizing There is some confusion over how bill/ “government certification of to define violence experienced 57 Only post-operative transgender identities”. Additionally, activists by sexual and gender minority women are covered by the have criticized the bill for failing sexual assault laws, but not groups. Gender-based violence other transwomen. to address the issues of violence has been traditionally understood 58 Available at: http://www.ohchr. and employment in a sensitive and as physical, sexual, psychological, org/EN/Issues/Women/WRGS/ comprehensive manner.56 emotional, economic and other Pages/VAW.aspx forms of violence experienced by Transgender rights have also women, most often at the hands received attention in other countries of men. OHCHR’s Committee on in recent years. However, a significant the Elimination of Discrimination gap remains throughout the region Against Women states that gender- (including Nepal) with regard to based violence is “violence that is easily accessible protocols for directed against a woman because safe and inexpensive feminization, she is a woman or that affects women and masculinization procedures disproportionately.”58 Therefore, (including gender-affirming surgery). in this definition, ‘gender-based Despite progress resulting from the violence’ refers to the violence caused legal recognition of the ‘third gender’, due to unequal power relations most other rights for LGBTI people between women and heterosexual are not recognized by law, such as men, assuming that men and same-sex relationships, alternative women engage in heterosexual family structures, adoption rights for relationships, and violence happens same-sex couples and transgender within the context of these unequal, individuals, and equal property rights. heterosexual power dynamics. Moreover, laws against sexual assault fail to protect transgender victims However, gender-based violence can by remaining gender-specific and also refer to violence experienced failing to recognize that a victim may by people belonging to other gender be transgender57 (let alone male) identities, such as transgender or in contravention of recent judicial non-binary gender people, or people rulings on transgender rights. who engage in same-sex activities. These people can experience gender- based violence due to their gender identity and/or expression, or their sexual behaviours. The experiences of violence among sexual and
Chapter 2: Regional context 39 Know Violence
gender minorities suggest that a 2.2.2 Experiences of 59 Hagan, J. (2016). Sexual broader definition of gender-based discrimination, abuse and orientation and gender identity as part of the Women, violence is needed to include a more violence Peace and Security Project. diverse range of experiences.59 Available at: http://blogs. Some definitions of gender-based Studies document extensive SOGIE- lse.ac.uk/wps/2017/01/10/ sexual-orientation-and-gender- violence now include acts of violence based violence faced by men who identity-as-part-of-the-wps- committed by either a man or a have sex with men and transwomen project/. woman against a man or a woman in South Asia, and beyond. The UN 60 Council of Europe. (2007). “with the purpose of maintaining Multi-country Study on Men and Chapter 2: Gender-based Violence. Gender Matters: A social power for (heterosexual) Violence in Asia and the Pacific found manual on addressing gender- men.”60 For example, the violence that sexual minority men were more based violence affecting young faced by men who have sex with men people. Available at: http://www. likely to experience multiple forms eycb.coe.int/gendermatters/ and transwomen often find their of lifetime adversity compared to chapter_2/1.html roots in homophobia (or the fear heterosexual men.61 Several studies 61 Miedema et al. (2017). of homosexuality) and transphobia across South Asia have documented 62 Logie et al. (2012). Adapting (or the fear of non-binary gender gross human rights violations the minority stress model: identities). In these cases, violence Associations between gender against those from sexual and non-conformity stigma, HIV- committed against sexual or gender gender minority groups, including related stigma and depression minority groups reflect power stigma and discrimination related to among men who have sex with men in South India. Social inequalities between the perpetrator gender identity, sexual orientation Science & Medicine, 74, pp. and the victim based on gender and or HIV status,62 pressure to marry 1261–1268. sexual identity. a woman,63 legal prosecution,64 63 Khan et al. (2005). Men who homophobic bullying and abuse,65 have sex with men’s sexual This report uses the term ‘sexual 66 relations with women in sexual violence, and rejection, Bangladesh. Culture, Health & orientation, gender identity and violence and isolation from family Sexuality, 7(2), pp. 59–169. expression (SOGIE)-based violence’ and community.67 Perpetrators range 64 Carroll, A. and Mendos, L.R. to discuss experiences of violence by from institutions such as hospitals, (2017). State-sanctioned people and communities who are not Homophobia (12th ed.). Geneva: police and workplaces to family International Lesbian, Gay, often considered under the umbrella members and intimate partners. Bisexual, Trans and Intersex of gender-based violence. For the Association. purpose of this study, SOGIE-based Further, not all men who have 65 Miedema et al. (2017). violence refers to all kinds of acts sex with men experience violence 66 Shaw, S.Y. et al. (2012). Factors of violence that are related to (a) uniformly. The forms, prevalence associated with sexual violence against men who have sex the social status of one’s gender and perpetrators of violence may with men and transgendered identity; (b) not conforming to socially differ within various subgroups or individuals in Karnataka, India. accepted gender roles, and (c) non- PLOS One, 7(3), p. e31705. identities of men who have sex with binary gender identities. men and transwomen. For example, 67 Chakrapani, V., Newman, P.A., Shunmugam, M., McLuckie, A. hijras in some South Asian countries, and Melwin, F. (2007). Structural considered a ‘third gender’ and who violence against Kothi-identified men who have sex with men are mostly transgender women, in Chennai, India: a qualitative hold marginal cultural recognition; investigation. AIDS Education however, they continue to face and Prevention, 19(4), pp. 346.
40 Chapter 2: Regional context Know Violence
extreme discrimination and abuse in marriage and inheritance rights, society.68, 69 and condemned violence against 68 Jayadeva, C. (2017). Understanding the mental transgender persons. The fatwa was health of the Hijra women of A study conducted with self-identified specific about marriage provisions, India. American Journal of men who have sex with men in noting that marriage would be Psychiatry, 12(5), pp. 7–9. Chennai, India, showed that those permissible only between two 69 Historical records of individuals who identified as kothis, transgender communities in partners if one showed bodily signs South Asia show that they did or who were “effeminate”, faced of maleness and one showed bodily hold social status, derived greater violence from police.70 A study signs of femaleness. Some activists from their performance of traditional and cultural conducted in Bangladesh and Papua in Pakistan cautiously welcomed rituals such as blessings at New Guinea found that men who have the decree while urging that social weddings and birthdays, or tales of transwomen in religious sex with men face multiple forms attitudes still need to change.72 mythology. This includes only of violence, including higher levels Overall, social norms that pathologize transgender women, known of violence against men engaged in and stigmatize homosexuality and as Hijra in many South Asian sex work and those with effeminate countries, and does not extend transgenderism are the underlying to transmen. gender expressions from family and root cause of SOGIE-based violence. 70 Chakrapani, V., Newman, P.A., 71 partners. Shunmugam, M., McLuckie, A. In Bangladesh, a high court banned and Melwin, F. (2007). fatwas in 2001 but the order was 71 FHI 360 (2013). Exploring 2.2.3 Factors driving SOGIE- stayed. The Supreme Court finally gender-based violence among based violence men who have sex with lifted the ban in 2011 but said they men, male sex worker and cannot be enforced. Effectively, this transgender communities in Many factors contribute to the high means that clerics cannot punish Bangladesh and Papua New rates of SOGIE-based violence Guinea. Available at: http:// people with a fatwa, and fatwas www.fhi360.org/sites/default/ experienced by men who have sex cannot be issued that contradict files/media/documents/GBV%20 with men and transwomen. Across Study%20report_Final.pdf. the existing laws of a country.73 In the region, homosexuality and 72 BBC (2016). Pakistan’s this way, fatwas cannot be used in transgender identities are considered Transgender Community Bangladesh to persecute sexual and Cautiously Welcomes Marriage abnormal, pathological or deviant and gender minorities. Fatwa, 28 June 2016. Available in these widely held beliefs are often at: http://www.bbc.com/news/ world-asia-36648141. sanctioned by religious institutions. Social expectations around men’s Across the region, religious 73 Bangladesh lifts fatwa ban but role in society, and the heterosexual forbids enforcement (2011). intolerance appears to strengthen framework of sexual relations, BBC, 12 May. Available at: legally sanctioned violence and hate also drive SOGIE-based violence. https://www.bbc.com/news/ world-south-asia-13379016 speech against sexual and gender Across South Asia, men are expected minorities. 74 Khan et al. (2005). Men who to be husbands and fathers, and have sex with men’s sexual continue the patrilineal line. A relations with women in However, there are also examples Bangladesh. Culture, Health & study in Bangladesh found that men of more tolerant approaches. In Sexuality, 7(2), pp. 159–169. who have sex with men were often Pakistan, a group of 50 clerics from forced to married women, against Lahore issued a fatwa (religious their desires, due to pressure decree) in June 2016 that while from family and community.74 non-binding, supported transgender
Chapter 2: Regional context 41 Know Violence
Furthermore, across the region, among men who have sex with 75 Fulu et al. (2013). Why do some there is a prevailing belief that “to men was approximately 15 percent men use violence against 75 81 women and how can we prevent be a man” means to be tough, and (between 2007 and 2011). Data from it? Quantitative findings from must demonstrate signs of maleness Bangladesh, India, Nepal, Pakistan the United Nations Multi- (e.g., toughness, aggression and and Sri Lanka show that men who country Study on Men and Violence in Asia and the Pacific. masculine behaviours). Men who fail have sex with men have higher HIV UNDP, UNFPA, UN Women and to demonstrate socially sanctioned prevalence compared to the general UN Volunteers: Bangkok. types of masculinity may face violence population.82 While HIV prevalence 76 Chakrapani, V., Newman, P.A., as a consequence.76 among men who have sex with men Shunmugam, M., McLuckie, A. and Melwin, F. (2007). has not been estimated across all Finally, socio-demographic factors 77 Logie et al. (2012). Adapting South Asian countries, it is likely to be the minority stress model: such as geographical context, caste, higher than in the general population Associations between gender class, religion, race and disability in all countries across the region.83 non-conformity stigma, HIV- related stigma and depression may also contribute to risk of violence among men who have sex with faced by men who have sex with men Transwomen are likely to show higher men in South India. Social and transwomen. However, less is rates of HIV prevalence compared Science & Medicine, 74, pp. 1261–1268. known about these factors. One study to men who have sex with men or 78 UNAIDS (2017). UNAIDS Data shows that urban men who have the general population. Comparable 2017. Available at: http://www. sex with men reported that they had regional data is still difficult to obtain, unaids.org/sites/default/files/ more social support, which reduced as transwomen are often subsumed media_asset/20170720_Data_ book_2017_en.pdf; Beyrer, C. et the effect of experiences of stigma under the category of men who have al. (2012). Global epidemiology on their mental health.77 Differences sex with men, rather than having a of HIV infection in men who between urban and rural experiences disaggregated category of their own. have sex with men. Lancet, 380, pp. 367–77. of SOGIE-based violence, along Global studies find that transwomen 79 UNAIDS (2016). Global AIDS with other key socio-demographic are significantly more likely to acquire Update 2016. Available at: variables, warrant greater attention in HIV compared to adult males and http://www.who.int/hiv/pub/ future research. females who are not transgender (up arv/global-AIDS-update-2016_ en.pdf?ua=1 to 50 times more likely according to 84 80 Beyrer, C. et al. (2012). one study). In 2016, the overall HIV 2.3 HIV prevalence 81 International AIDS Society prevalence in India was 0.3 percent (2014). Key Affected Populations compared to 4.3 percent and 7.2 – Men Who Have Sex with Men – Globally, men who have sex with percent among men who have sex Factsheet, March 2014. men bear a disproportionate burden with men and transgender people of HIV compared to the general (including hijras) respectively.85 population.78 In Asia and the Pacific, Previous studies show higher the distribution of new HIV infections prevalence. A 2015 study conducted among men who have sex with men among men who have sex with men was 18 percent.79 In 2010, the regional across 12 cities in India found a 7 prevalence of HIV among men who percent prevalence rate.86 A 2012 have sex with men was 14.7 percent study in major Indian cities found a compared to close to 1 percent in the 25 percent prevalence rate among general population.80 In South Asia transwomen (including hijras).87 more specifically, HIV prevalence
42 Chapter 2: Regional context Know Violence
Despite nearly two decades of reported experiencing sexual violence efforts to prevent and respond to compared to 12 percent among those 82 UNDP (2012). Country Snapshots: Bangladesh, India, 90 HIV, men who have sex with men who did not report it. Nepal, Pakistan and Sri Lanka. and transwomen are still often not Available at: http://asia-pacific. covered by HIV interventions, yet, Public health experts, policymakers, undp.org/practices/hivaids/; UNAIDS (2017). UNAIDS Data risky sexual behaviours contribute donors and governments increasingly 2017; and National AIDS Control to the high burden of HIV prevalence recognize that men who have sex Programme of Afghanistan within these communities.88 In 2016, with men and transwomen in South and Johns Hopkins University (2012). Integrated Behavioural condom use among men who have Asia are important risk groups in the and Biological Surveillance in sex with men was 45.8 percent in HIV epidemic. Yet the psychosocial Afghanistan. Kabul, Afghanistan. Bangladesh, 86 percent in Nepal, 22.4 and sociocultural issues specific 83 Van Griensven, F., de Lind van Wijngaarden, J.W. (2010). A percent in Pakistan and 47.1 percent to men who have sex with men and review of the epidemiology of in Sri Lanka.89 High rates of sexual transwomen require more research. HIV infection and prevention violence also drive HIV prevalence While more is specifically understood responses among men who about prevalence patterns, less have sex with men in Asia. AIDS rates. A study in South India found 24 Suppl 3, pp. S30–40. See that among men who have sex with is known about the connections also, Ministry of Health and men and transwomen, HIV prevalence between HIV prevalence and SOGIE- Population (2015). Nepal Country Progress Report on HIV/AIDS based violence. was 20 percent among those who Response 2014. 84 UNAIDS (2013). HIV in Asia and the Pacific – UNAIDS Report 2013. Available at: http://www. unaids.org/sites/default/files/ media_asset/2013_HIV-Asia- Figure 2: HIV prevalence among MSM and transgender people Pacific_en_0.pdf 85 According to UNAIDS, urban areas have higher HIV prevalence than rural areas. UN Habitat and UNAIDS (2015). Ending the Afghanistan MHRB 0.4% (IBBS, 2012) AIDS epidemic: the advantage of cities. United Nations Human Bangladesh MSM, hijras 0.7% (along with all key populations together (UNAIDS, 2012) Settlements Programme. Nairobi; UNAIDS (2017). 86 Solomon, S.S. et al. (2015). High Bhutan Not available (WHO fact sheet, 2015) HIV prevalence and incidence among MSM across 12 cities in MSM4.3% (IBBS, 2015) India India. AIDS. 29(6), pp. 723–31 Transwomen 7.2% (IBBS, 2015) 87 UNAIDS (2017). UNAIDS Data MSM, transwomen 3.8% (UNAIDS, 2012) 2017. Nepal Male/trans-gender sex workers 6.8% 88 UNAIDS (2013). HIV in Asia and (UNAIDS, 2012) the Pacific – UNAIDS Report 2013. MSM 4% (UNAIDS, 2015) Pakistan Transwomen 2% (UNAIDS, 2015) 89 UNAIDS (2017). UNAIDS Data 2017. Sri Lanka MSM 0.9% (UNAIDS, 2011) 90 Shaw et al. (2012). Factors associated with sexual violence against men who have sex 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% with men and transgendered individuals in Karnataka, India. PLOS One, 7(3), p. e31705.
Chapter 2: Regional context 43 Know Violence
2.4 Mental health among burden may be greater.95 In some 91 Miedema et al. (2017). sexual and gender studies, almost half of hijras in India 92 Sivasubramanian et al. (2011). suffer from a range of mental health Suicidality, clinical depression, minorities and anxiety disorders are highly problems, including substance prevalent in men who have sex abuse and depression.96 A study in Men who have sex with men in South with men in Mumbai, India: Nepal found that 68.5 percent of Findings from a community- Asia report high rates of mental transwomen reported heavy alcohol recruited sample. Psychology, health problems. The UN Multi- Health & Medicine, 16(4), pp. use. 450–462. country Study on Men and Violence 93 Logie et al. (2012). Adapting found that in sites across Cambodia, the minority stress model: China, Indonesia, Papua New Guinea 2.5 Research gaps Associations between gender and Sri Lanka, sexual minority men non-conformity stigma, HIV- related stigma and depression were more likely to report depression Overall, most research among among men who have sex with symptoms compared to non-sexual men who have sex with men and men in South India. Social 91 Science & Medicine, 74, pp. minority men. In one survey among transwomen in South Asia focuses on 1261–1268. men who have sex with men in India, HIV prevalence and associated risk 94 Reisner et al. (2016). Global 45 percent of the participants had factors. The specific links between health burden and needs of thought about or attempted suicide, SOGIE-based violence and its effects transgender populations: A review. Lancet, 388, pp. 412–36. 29 percent reported major depression on mental health and HIV risk are and 24 percent reported anxiety- 95 Jayadeva, C. (2017). less often explored. Further, research Understanding the mental related disorders.92 In South India, among men who have sex with men health of the Hijra women of depression was higher among men and transwomen in South Asia often India. American Journal of Psychiatry, 12(5), pp. 7–9. who have sex with men living in rural fails to disaggregate the specific 96 Kalra, G. and Shah, N. (2013). areas compared to those living in experiences of transwomen from the The cultural, psychiatric and urban areas, which suggests that category of men who have sex with sexuality aspects of Hijras in the cultural environment plays an men, particularly in the context of India. International Journal of Transgenderism, 14, pp. important role in the experiences of mental health research. However, 171–181. depression among this group.93 preliminary evidence suggests that this population faces specific risks Although, the highest proportion of that need to be taken into account. global research on health issues The present research aims to fill facing transgender populations these gaps. This study uses an focuses on mental health, there are ecological approach to identify the few studies on mental health among environmental and structural factors transgender populations in South that drive SOGIE-based violence, Asia.94 Given their gender identity, and how these experiences relate to transwomen may be more visible mental health and HIV risk. compared to men who have sex with men, and thus face unique challenges The study also fills data gaps for due to their gender identity (e.g. countries such as Bhutan and Sri employment-related discrimination). Lanka, where evidence of SOGIE- As a result, their mental health based violence among men who have
44 Chapter 2: Regional context Know Violence
sex with men and transwomen is sparse, and Afghanistan that lacks evidence of SOGIE-based violence among men with high-risk behaviour. This data will be critical for evidence- based policies and programmes to stop SOGIE-based violence before it starts, and develop effective HIV prevention strategies. The study’s cross-country approach enables comparison of the connections between violence, mental health and HIV in culturally distinct contexts. Thus, patterns can be assessed whether they are similar across the region or culturally specific.
Most programmes that reach out to men who have sex with men and transwomen focus on prevention, treatment and awareness of HIV and sexually transmitted infections. Programmes addressing SOGIE- based violence and its impact on men who have sex with men and transwomen are much less common. Yet global evidence shows that SOGIE-based violence directly impacts HIV risk, and indirectly impacts HIV risk through mental health problems. Greater understanding of these pathways in the South Asia context are critical to inform HIV and violence prevention policies and programmes.
Chapter 2: Regional context 45 Know Violence
Chapter 3: Methodology
46 Know Violence
3.1 Conceptual framework Like gender-based violence, SOGIE- based violence can take many forms 3.1.1 Gender- and SOGIE-based (Figure 3). Physical violence refers to violence the intentional use of physical force against an individual with a motivation As described in Section 2.2, gender- to harm, injure, disable or kill. based violence can include violence Emotional or psychological violence against persons based on sexual is aggressive verbal or non-verbal orientation or gender identity and communication that intends to harm expression. The term used in this someone emotionally or mentally, report to refer to this type of gender- devalue their self-worth, or control based violence is SOGIE-based their behaviours. Economic violence violence. SOGIE-based violence refers can include the threat of or actual to all kinds of acts of violence that are withholding of money, or harming related to (a) the social status of one’s the financial well-being of a person. gender identity; (b) not conforming to Sexual violence includes any forced socially accepted gender roles, and or unwanted sexual activity including (c) non-binary gender identities. sexual assault and rape. These forms
Figure 3: Types of SOGIE-based violence
Physical violence Economic violence The intentional use of physical force The threat of or actual withholding of against an individual with a motivation to money, or harming the financial wellbeing harm, injure, disable or kill of a person
Sexual violence Emotional or psychological violence Attempted or completed forced or Aggressive verbal or non-verbal unwanted sexual activity communication that intends to harm someone emotionally or mentally, devalue their self-worth, or control their behaviours
Chapter 3: Methodology 47 Know Violence
of SOGIE-based violence can be violence, including analysing its 97 Heise, L. (1998). Violence perpetrated by anyone. For example, causes, forms and impact. against women: An integrated, ecological framework. Violence a police officer may blackmail a against Women, 4, pp. 262–290. transwoman or take her earnings in This approach guided the study 98 Fulu, E. and Miedema, S. (2015). exchange for not arresting her. An team to conceptualize the various Violence against women: intimate partner may steal money risks, vulnerabilities, violations and Globalizing the integrated marginalization faced by men who ecological model. Violence from a man who have sex with men. against Women, 21(12), pp. This would also be conceptualized have sex with men and transwomen 1431–1455. as economic violence. SOGIE-based at multiple levels. For example, 99 Bronfenbrenner, U. (2005). violence occurs across the life course. at a macro-level, the existence of Ecological Systems Theory anti-sodomy laws contributes to (1992). In Bronfenbrenner, U. As will be seen in the following (Ed.), Making human beings chapters, men who have sex with men an environment where men who human. Bioecological and transwomen in South Asia face have sex with men and transwomen Perspectives on Human Development. Thousand Oaks: considerable levels of SOGIE-based cannot seek redress for SOGIE-based Sage Publications Ltd, pp. violence throughout their childhood, violence. Similarly, institutions in 106–173. adolescence and adulthood. society, such as health care, law enforcement and mass media, often fail to treat or respond to the needs 3.1.2 A socio-ecological approach of men who have sex with men and to understanding SOGIE-based transwomen. For example, past violence experiences of discrimination by a health care professional can affect The socio-ecological approach whether or not they visit a health provides a framework to understand professional after an incident of the many factors that drive SOGIE- sexual assault. based violence, and how they intersect with one another. This The model also considers how model is widely used in the field the more immediate environment of gender-based violence work, affects experiences of SOGIE-based although it has largely been applied violence. Immediate environmental to the experiences of violence faced factors can include those related to by women.97, 98 This model uses a families, schools, church or place of “person-environment perspective”99 worship, peer groups and intimate to situate the individual person within partnerships. This model is further their social context (see Figure 4). The discussed in Chapter 7, as related to socio-ecological framework shows multiple factors – at different levels of us how behaviours and outcomes the socio-ecological model – and how are a joint function of the interaction they interact across the life course to between a person and their shape men who have sex with men’s environment. The ecological paradigm and transwomen’s experiences of allows for a more comprehensive SOGIE-based violence, mental health approach to studying SOGIE-based and HIV risk.
48 Chapter 3: Methodology Know Violence
Figure 4: Socio-ecological model
Macrosystem Anti-sodomy laws Heteronormativity
Exosystem Law enforcement, legal services, neighbours, mass media, health care
SOGIE-based violence
Microsystem Family, school, workplace, intimate partner, peer socialization
LGBTI Individuals
3.2 Study design important to the research topic, rather than predetermined parameters The study used qualitative research set by the external research team. methods to capture in-depth This study specifically used focus information on perceptions and group discussions and key informant reports of SOGIE-based violence, and interviews (KIIs). the connections between violence, mental health outcomes and HIV risk 3.2.1 Focus group discussions among transwomen and men who have sex with men in seven South The focus group discussions Asian countries. Qualitative research centred around case vignettes, or is particularly well suited to this type short stories that acted as case of exploratory analysis. Qualitative studies. Case vignettes are designed research allows themes to emerge to prompt discussion among from the data. The voices, perspectives participants on a select topic by and narratives of participants thus providing a story on which they can determine what is significant and comment. As a research tool, case
Chapter 3: Methodology 49 Know Violence
vignettes help participants define providers, lawyers and representatives 100 Barter, C. and Renold, E. their situation in their own terms from national HIV programmes, a total (1999). The use of vignettes in qualitative research. Social while exploring the context along with of 49 key informant interviews were Research Update, 25. other sensitive issues and allowing conducted across the 7 countries (See the gathering of data in a less Appendix I for details). threatening manner.100 Case vignettes were first constructed based on major themes of the literature 3.3 Sample, recruitment review. The case vignettes were then and data collection further vetted and modified based on discussions with experts on issues of 3.3.1 Geographic scope sexual orientation and gender identity (See Appendix III and Appendix IV for The study was conducted in 12 sites the research tools). Case vignettes across 7 South Asian countries: covered the following thematic areas: Afghanistan, Bangladesh, Bhutan, types of SOGIE-based violence, India, Nepal, Pakistan and Sri perpetrators, the impacts on physical Lanka. Sites were selected and mental health, help-seeking based on feasibility and security, options, mitigation of violence, socio-economic and cultural health issues, recommendations for characteristics, and site-specific improving services, and strategies HIV prevalence in order to capture for decreasing violence. A total of variation in environmental, cultural 12 focus group discussions were and HIV-related conditions. The site conducted with men who have selection was finalized in consultation sex with men and 9 focus group with the Multi-country South Asia discussions with transwomen across Global Fund HIV Programme’s sub- the 7 countries (See Appendix I for recipients in each of the countries details). (See Appendix 1 for details).
3.2.2 Key informant interviews 3.3.2 Sample criteria and recruitment In-depth interviews were used to collect data from the key informants Focus group discussions and who were stakeholders from key information interviews were the sectors of health, law and conducted in all countries. The focus the community. They included group discussions were conducted representatives of community-based among two groups: self-identified organizations that work with men who transwomen (irrespective of whether have sex with men and transwomen they had had gender-affirming communities, community stakeholders surgery) and men who reported from men who have sex with men and sexual practices or behaviours transwomen communities, health care with other men. The focus group
50 Chapter 3: Methodology Know Violence
discussions in Afghanistan were with who were fluent in the local language, “men with high-risk behaviour”.101 had prior experience of working with 101 However, for convenience, when discussing all focus group Only individuals who were above 18 the study population, and had prior discussions or all participants, years of age102 and were willing to experience in conducting qualitative Afghanistan’s men with high- provide consent to participation in the research. Interviewers were trained risk behaviour are included with the group “men who have sex study were recruited. Key informants in a regional workshop for five days with men”. included people who worked on on different aspects of the study, 102 Though the study only SOGIE-related issues, particularly including background knowledge on recruited individuals of legal SOGIE-based violence. Focus group sex, sexuality, gender and violence; age who agreed to consent to participation, it should be noted discussions were not conducted study design; focus group discussion that many critical issues for with transwomen in Afghanistan and facilitation skills-building; practising transgender people arise very early in life, often as young as Bhutan due to difficulties in reaching conducting interviews; ethics and age 5 when the sense of gender this group in the two countries. safety; and review of protocols for dissonance frequently becomes data transcription, note-taking and discernible. Participants for both focus group data translation. The ethical and discussions and key informant safety training section focused on interviews were recruited using how to administer verbal informed purposive sampling through local consent, maintaining confidentiality, community-based organizations and and ethical practices around data HIV programmes. Participants for management. During the training the focus group discussions were workshop with the local interviewers, approached through sub-recipients the case vignettes were further of the Multi-Country South Asia adapted to each country context. Global Fund HIV Programme in each of the countries. The local offices of the sub-recipients identified and 3.3.4 Data collection recruited the study participants Data collection took place between through their project staff who were November 2015 and February 2016. involved in community and peer Focus group discussions took place outreach activities. Key informants in designated “safe areas” across were selected through consultations the seven study countries, which with UNDP and the local offices of the generally meant the drop-in centre of sub-recipients. the community-based organizations in the relevant site. Interviews with 3.3.3 Interviewer training key informants took place at their place of work or at a public place of The sub-recipients of the Multi- mutual convenience. Focus group Country South Asia Global Fund HIV discussions and key informant Programme assisted with identifying interviews were audio-recorded and and hiring local interviewers the research team took notes on the to collect data in each country. main themes of each interview. Preference was given to interviewers
Chapter 3: Methodology 51 Know Violence
A total of 21 focus group discussions was separately analysed to observe were conducted (10 focus group patterns unique to each population. discussions with men who have sex After the first round of preliminary with men, 2 with men with high-risk coding, data was further analysed behaviour in Afghanistan and 9 with to examine relationships across transwomen). A total sample size of codes. The conceptual framework 100 men who have sex with men (or guided the coding process, so that the men with high-risk behaviour) and research team coded experiences, 77 transwomen were recruited and sources and sites of violence across participated in the study (See Table all possible domains and levels, from 2 and 3). A total of 49 key informant the individual to the systemic. Memos interviews were conducted across were reviewed iteratively throughout the 7 study countries. Interviewed data analysis to identify common key informants included counsellors, themes across all study sites and doctors, lawyers, community leaders, across populations. representatives and staff from non-governmental and community- Multiple thematic areas that emerged based organizations and leaders out of the analysis were then further and officials from national HIV analysed to identify interconnections programmes across the seven between themes. The interconnections countries (see Appendix I for a further between various themes were further disaggregation of the particulars verified by checking coding to validate of key informants by country). All interpretation of data. Furthermore, interviews were audio-recorded. findings unique to countries and subgroups were identified. Families of codes that demonstrated relationships 3.3.5 Data analysis between various thematic areas were made to elaborate on the various Audio-recordings were transcribed in emergent relationships among the local language and then translated. themes. Visual diagrams of families of Translations were checked for codes were developed. accuracy by the original focus group discussion moderator and reviewed by ICRW data analysts for clarifications. 3.4 Ethics and safety ICRW data analysts blinded the data. measures Translated transcripts were coded based on an initial set of codes Given strong social, legal and developed in reference to the study religious sanctions against same- objectives. Data was analysed in sex behaviours and non-confirming English by ICRW data analysts. gender identities in the study countries, only verbal, informed Data for men who have sex with consent was sought for participation. men and transwomen participants
52 Chapter 3: Methodology Know Violence
Basic demographic information such and approved study procedures as age, education and occupation related to recruitment, data storage, 103 A detailed description of the study ethical review procedures, was sought from the focus group obtaining informed consent and names of the review boards and discussion participants. However, ensuring confidentiality of data.103 affiliations of experts across no names, addresses or contact the study countries is located in Appendix II. information were collected for any 3.5 Strengths and 104 WHO (2001). Putting women of the study participants. During the first: Ethical and safety focus group discussions, participants limitations recommendations for research were assigned numbers to facilitate on domestic violence against women. Geneva: WHO. discussion while they were cautioned This study had a number of strengths to refrain from sharing the contents and limitations. A major strength of the discussion elsewhere. While of the study was the cross-country the focus group discussions were comparable nature of the data. The conducted in private spaces that study collected critical information were safe for the participants such on SOGIE-based violence, and its as offices of community-based connections with mental health organizations, no staff members and HIV risk in a number of working at those community- underresearched countries (such as based organizations were allowed Afghanistan and Bhutan). Further, to observe or participate in the comparable methodology across focus group discussions. Notes and sites allowed the assessment of audiotapes from the discussions similarities and differences across were stored in password-secured study sites. A second strength is the files that were accessible only to strong ethics and safety framework the study staff. The researchers used for this study. Ethics and aimed to not collect any identifiable safety mechanisms are critical to information during data collection. As ensure robust, ethical research on a further measure, transcripts were sensitive topics, including gender- blinded and all potentially identifiable based violence.104 The emphasis on information was removed. the protection of the participants’ confidentiality, rights as research Members of APCOM South Asia subjects, and compliance to ethical Strategic Information Advisors standards all contributed to the (ASASIA) reviewed the protocol for collection of high-quality, ethical data. this study. The ICRW Institutional Review Board (IRB) reviewed the Finally, the study used qualitative study and provided ethical approval. methodology which is well-suited Additional ethical reviews were to research topics and settings conducted in each of the study where little is already known. The countries. In countries where IRBs exploratory nature of data collection were not available or accessible, an and analysis means that the findings independent expert panel reviewed directly reflect the voices and
Chapter 3: Methodology 53 Know Violence
experiences of men who have sex purposively and do not capture the 105 Outright Action International with men and transwomen around complete regional diversity and (2014). Violence through the Lens of Lesbians, Bisexual SOGIE-based violence, mental health cultural variation around SOGIE- Women and Trans People in and HIV risk in these countries. The based issues. For example, in India, Asia. New York. use of ‘case vignettes’ to facilitate data was collected in a high-HIV- discussion allowed the exploration of prevalence and a low-HIV-prevalence the breadth of experiences of SOGIE- state from West and Central India. based violence through the use of a However, the cultural environment third-person story. This prevented can vary from state to state, or region a sense of “coercing” participants to region. This variation impacts the to reveal personal information. This experiences of men who have sex method yielded rich information with men and transwomen. Given on the perspectives, opinions and the lack of evidence on SOGIE- observations of participants, their based violence to date, this type of networks, contexts regarding in-depth, exploratory qualitative experiences of violence, and help- data collection, despite these seeking behaviours. limitations, is a necessary first step to map experiences related The study also had limitations. to violence among this population, Although qualitative data is important and connections with mental health as a tool to explore a topic not outcomes and HIV risk. accurately known until now, it is not possible to ‘count’ individual A further limitation regards the study responses to represent the occurrence population. The present study sample of an experience or event. Further, the did not include transmen, thus use of a qualitative research design preventing a better understanding of limited the generalizability of the discrimination and rights violation findings. While this research attempts faced by transgender people as a to unearth experiences of SOGIE- whole. A study in the Asia region105 based violence, its consequences has documented experiences of and far-reaching implications for HIV transmen and alludes to a different vulnerability, the interpretation of set of experiences and challenges participant narratives is not clear- faced by them, which were not cut and is not generalizable to entire covered in this research. The study country contexts. There could be also recruited only those participants alternative explanations that this that were reached by community- research did not identify. based organizations and HIV programmes. Though this approach In the future, mixed-method enabled the study team to reach a approaches, with greater geographic hard-to-reach population, men who scope, are needed. The study have sex with men and transwomen data collection sites were chosen who fell outside the service net of
54 Chapter 3: Methodology Know Violence
community-based organizations and different population with a unique HIV programmes are not adequately set of experiences and challenges. 106 ‘Men with high-risk behaviour’, or ‘MHRB’, is the term used represented in the study and such Understanding these would certainly to refer to men who have sex individuals could represent a different aid in extending the reach of HIV with men in the context of population and have different kinds of programmes and decrease risk of HIV Afghanistan. vulnerabilities to violence and HIV. transmission.
Further, this research did not explore A final limitation was the little the experiences of transwomen evidence collected on intimate partner in seeking gender-affirming violence. Although issues of intimate surgeries and other forms of partner violence and experiences feminization procedures. This is an of married men who have sex with important event in the lives of many men and transwomen surfaced transwomen and presents several in this research, the study did not opportunities to study structural explicitly focus on these areas of risk. barriers and experiences in help- These issues need more in-depth seeking and interaction with health understanding for better articulating care providers. An in-depth study their impact on exposure to HIV risk could look at this issue. Factors and the needs of female and other such as the availability of transition- same-sex partners and gaps in related services at affordable prices services with regards to addressing and the availability of trained mental health and mental health needs. health and health professionals in the journey of transition are much needed areas for further research. 3.6 Sample demographics
Finally, this research has not Study participants across all the explored the specific experiences seven countries and study sites of lesbians and bisexual individuals represented varied backgrounds, and their unique needs, experiences educational qualifications and of SOGIE-based violence and help- occupations (Table 2). Among the seeking. Although a number of the participants who were men who participants could be bisexual or have sex with men, the majority engage in bisexual sexual behaviour, were young adults, with a reported they were included within the wider average age ranging from 24 years umbrella of men who have sex with in Nepal to 31 years in Bangladesh. men and/or transwomen and thus There was a broad range of their specific needs and challenges educational attainment among were not specifically analysed in this participants. Among men with high- 106 study. Further research is needed risk behaviour in Afghanistan, the to understand the vulnerabilities of average level of completed education bisexual people as they represent a was 7.4 years. Comparatively, among men who have sex with
Chapter 3: Methodology 55 Know Violence
Table 2: Participant profile: MSM and MHRB
Mean age, Study sites Education Justification for site selection years (range)
Afghanistan 28.7 7.4 years Unemployed (5) (n=15) (19–40) (0–12 years) Cook in a hotel (2) Dancing in parties (4) Casual labourer (4)
Bangladesh 31.6 12.6 years Working in full-time employment (3) (n=18) (19–45) (10–17 years) Working in a NGO (2) Casual labour (4) Hotel boy (4) Mechanic (1) Currently unemployed (2) Sex work (2)
Bhutan 26.8 13 years University students (2) (n=7) (19–35) (11–15 years) Coordinator in a NGO (1) Government employee (1) Out-of-school youth (2) Currently unemployed (1)
India 27.2 10.2 years House help (1) (n=18) (19–50) (0–15 years of Agricultural work (2) education) Full-time employed (3) Cook (3) Vegetable vendor (3) Small shop owner (2) Beautician (2) Tailor (1) Dance teacher (1)
Nepal 24.8 10.5 years Unemployed (4) (n=16) (18–32) (7–15 years) Mechanic (1) Farmer (4) Service (2) Student (3) Lab technician (1) Casual labour (1)
Pakistan 25.4 8.7 years Casual labour (3) (n=17) (18–38) (0–15 years of Driver (2) education) Teacher (1) Hotel staff (3) NGO worker (1) Unemployed (4) Student (3)
Sri Lanka 26.7 12.2 years Student (2) Note: data for (n=9) (19–35) (9–17 years) Self-employed (1) employment was Full-time employment (1) not available for 3 Currently unemployed (1) participants Accountant (1)
56 Chapter 3: Methodology Know Violence
men in Bhutan, the average level of with men, except with regards to completed education was 13 years. occupation (Table 3). The average Similarly, participants across the age of transwomen ranged from study sites were engaged in various 24 in Pakistan to 35 in Bangladesh. occupations, ranging from having Country average levels of educational full-time employment (n=17), to being attainment ranged from 8.3 years in casual labourers (n=12), dancers Bangladesh to 12.7 years in India. (n=5), or self-employed (n=13) as Across all countries, 29 transwomen vendors, tailors, or beauticians reported engaging in sex work for running small businesses. their livelihood. Eleven transwomen participants reported that they were The sample demographics among unemployed. The remainder reported transwomen were similar to the a range of occupations, from self- sample of men who have sex employment to office work.
Table 3: Participant profile: Transwomen
Mean age, Study sites Education Justification for site selection years (range)
Bangladesh 35.4 8.3 years Currently unemployed (5) (n=19) (20–38) (0–9 years) Sex work (10) Beautician (1) Office assistant (2) Helper (1)
India 29.2 12.7 years Chhalla Mangti (7) (n=16) (18–30) (0–17 years) Badhai (7) *Note: participants Sex work (5) reported more Office helper (1) than one source of Videography (1) income Farmer (1) Unemployed (1)
Nepal 28.6 10.5 years Beautician (2) (n=17) (19–30) (6–15 years) Self-employed (4) Occupation details Sex work (5) for 3 participants Currently unemployed (2) not available Office assistant (1)
Pakistan 24.3 8.4 years Sex work (7) (n=16) (18–30) (0–10 years) Office assistant (2) Beautician (3) Dancer (1) Currently unemployed (3)
Sri Lanka 27.4 10.7 years Beautician (1) (n=9) (20–28) (5–15 years) Full-time employment (2) Working in hotels, spas, massage parlours (4) Sex work (2)
Chapter 3: Methodology 57 Know Violence
Chapter 4: SOGIE-based violence: Forms, impact and coping
58 Know Violence
4.1 Types of SOGIE-based in public places, sexual assault violence by a sexual partner, and sexual harassment in the workplace. Each Participants discussed a wide of these forms of violence was range of violent experiences faced discussed in over half of all focus by men who have sex with men group discussions. and transwomen across all seven Some differences in discussions countries. Table 4 breaks down how were seen between the two groups. often different forms of violence were Transwomen tended to discuss discussed in each of the focus group sexual harassment in the workplace discussions. Although data presented more often than men who have sex in Table 4 is not representative of with men (in 8 out of 9 of the focus all the forms of violence reported group discussions). Transwomen also by the participants, it illustrates the discussed extortion or blackmail as a varied forms and intensity with which problem facing the community (in all men who have sex with men and 9 focus group discussions ). Sexual transwomen experience violence, assault by a sexual partner was more and how certain forms of violence commonly discussed by transwomen are experienced differently across (in 8 out of 9 focus group discussions) contexts. The frequency with which compared to men who have sex different types of violence were with men (in 7 out of 12 focus group discussed in focus group discussions discussions). reflects the pervasiveness of that type of violence as a known experience Another significant result of the within the community. The subtypes focus group discussions was the of violence are specifically derived variation of violence discussed by from the participant narratives both men who have sex with men themselves, thus giving voice to their and transwomen. The most common interpretations of violence facing their forms of sexual violence discussed communities. by participants included assaults, staking and rape, and gang rape. The Participants discussed various most common forms of verbal abuse forms of physical violence faced by discussed included name calling men who have sex with men and and abusive language directed at transwomen, ranging from being hit, sexual and gender minorities. These slapped and thrown out of running types of violence were mentioned in buses to being assaulted by weapons. all of the focus group discussions. The most commonly discussed Respondents reported various types forms of violence for both men who of emotional violence included have sex with men and transwomen humiliation, ridicule and mockery in were sexual harassment in college, front of others or in public places. blackmail and/or extortion, violence
Chapter 4: SOGIE-based violence: Forms, impact and coping 59 Know Violence
Table 4: Forms of SOGIE-based violence mentioned in focus group discussions
Total number Type of Subtypes of of FGDs in Afghanistan Bangladesh Bhutan India Nepal Pakistan Sri Lanka violence violence which type of violence is mentionned Assault with (4/21) a weapon Forceful (10/21) eviction from home Honour (1/21) killing Physical Violence (17/21) violence in public spaces such as at bus stands and railway stations. Sexual (6/21) assault in police custody Sexual (15/21) assault by sexual partner (including Sexual gang rape) violence Sexual (21/21) harassment in school/ college Sexual (14/21) harassment at workplace Blackmail/ (18/21) extortion Online (2/21) harassment
Emotional Forceful (6/21) violence attempts at conversion therapy
Notes: 21 FGDs (12 MSM and 9 transwomen); = MSM FGD; = Transwomen FGD.
60 Chapter 4: SOGIE-based violence: Forms, impact and coping Know Violence
Country-specific patterns emerged known to impact the community. from the focus group discussions. Comparatively, in other countries The frequency with which different with a high frequency of different types of violence were discussed in types of violence, the violence tended focus group discussions varied across to affect transwomen more so than countries. Participants in Bhutan men who have sex with men. For reported the fewest forms of SOGIE- example, in Pakistan, as noted above, based violence in their communities participants discussed a total of 23 (a total of three forms of violence different types of violence affecting across the focus group discussions). their communities. However, only Comparatively, participants in 9 of these were discussed in focus Pakistan reported the most forms group discussions with men who of SOGIE-based violence (a total of have sex with men, compared to 23 23 different forms of violence across different types of violence that faced the focus group discussions). Given transwomen. These regional patterns the minimal visibility around sexual suggest that risk of SOGIE-based and gender minorities in Bhutan, violence varies between transwomen and limited community outreach, and men who have sex with men these results are likely a result and across countries. Transwomen of underreporting due to limited may face more types of violence in knowledge of community-level some countries compared to men issues. As a transwoman activist who who have sex with men, and men served as a key informant in Bhutan who have sex with men face different noted, key national issues include the types and risks of violence across lack of “information” and “visibility” cultural contexts. Awareness of what of “transgender”, which acts as a types of SOGIE-based violence face barrier in reaching out and organizing their communities appears to be the transgender community. “Our contingent on the level of community biggest challenge is that they organization among men who have (community members) are not willing sex with men and transwomen in a to associate even when we know that given context. they are men who have sex with men or transgender.” Participants reported that the perpetrators of violence were In a similar vein, men who have overwhelmingly, but not exclusively, sex with men and transwomen male, and included: fathers, mothers, communities across countries siblings (particularly brothers), appeared to face different types of classmates and work colleagues. concurrent violence. In Afghanistan, focus group discussions with men of high-risk behaviour referenced a total of 15 different forms of violence
Chapter 4: SOGIE-based violence: Forms, impact and coping 61 Know Violence
4.2 Sources of SOGIE- 4.2.1 Police based violence The forms of violence reported by participants faced at the hands of Participants report that their police and other people who have communities face SOGIE-based been arrested ranged from arrest violence across multiple domains to humiliation and harassment. of their lives. Figure 5 breaks out A participant in a focus group the main sources of SOGIE-based discussion in Afghanistan recounted violence and discrimination discussed an incident in their community, “One in this study: legal and law-related day, one of our friends was arrested discrimination and violence; barriers by the police along the street. The to education; violence within religious police asked our friend to dance in spaces; health-care-related abuse; front of all the people and said that employment discrimination and only if you do this, we will let you go. harassment; and violence by the So, finally, he danced ... the police community. The following section instead of helping us, made fun of discusses each of these in turn.
Figure 5 – Sources of SOGIE-based discrimination based on focus group discussions in Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka
Health care providers Community Schools
Religous institutions Workplace
Police Family
First sexual partner Intimate partner
62 Chapter 4: SOGIE-based violence: Forms, impact and coping Know Violence
us.” In Sri Lanka, men who have still had to go through a lot of pain sex with men reported that police and suffering besides having to stay 107 The Rangers are a paramilitary force in some provinces of act as decoys to identify men who in custody for 21 days.” Pakistan. have sex with men. “Sometimes when the police catch gay people, Overall, across the countries, police they also pose as gay and make officers were a major source of advances towards other men. If a SOGIE-based violence. The violence man reciprocates, they alert other perpetrated by law enforcement police staff on duty and then arrest officers (among others) signals the and harass the person in all possible harm that comes from national manners.” In Pakistan, participants legislation that discriminates against reported that police have tacit or fails to protect minority groups. understandings with local gangs When sexual and gender minority or hooligans to ignore incidents groups are considered unprotected of violence against men who have by the law, violence against them can sex with men. “In the area I live be perpetrated with impunity and is in, at around midnight, no boy can often done so by those responsible roam around. Whoever does so, no for upholding justice. Further, the matter how young or beautiful, gets institutional culture of impunity for kidnapped. Hooligans take them, rob police perpetrators of SOGIE-based them and more often than not, the violence can enable other institutional police are in connivance with them. settings to perpetrate violence with They do not do anything to rescue impunity. or protect them. Help, if any, comes from the Department of Rangers.”107 4.2.2 Religious institutions Only in Nepal did study participants Religious leaders and institutions report recent reductions in violence were listed as a major source committed by the police. An advocate of SOGIE-based violence among from Nepal stated, “Compared to participants in Afghanistan, earlier times, police perceptions Bangladesh and Pakistan. For and behaviour towards the LGBTI example, in Afghanistan, participants community has changed a lot. I do discussed ‘honour killings’ as a not mean discrimination does not religiously sanctioned punishment take place at all, but it has definitely for engaging in same-sex behaviour. reduced significantly. Earlier, they just Participants feared losing their right used to pick [people] from the streets to visit the mosque if their sexual and put them in custody, harassing orientation, gender identity and/or them verbally and physically. gender expression were revealed. Recently, two transwomen were Participants in Afghanistan also convicted with a false theft case. We reported that religious leaders had fought their case and won it, but they ordered entire families to leave their
Chapter 4: SOGIE-based violence: Forms, impact and coping 63 Know Violence
village or community upon learning society organization-based HIV and 108 On 6 July 2018, the Indian that one family member engaged health services as they found health Psychiatric Society (IPS), the country’s largest body of in same-sex relations. Several providers and counsellors in these psychiatrists, psychologists key informants in Afghanistan, facilities to be more accepting and and psychiatric social Bangladesh and Pakistan also spoke friendly. workers released a ‘Position statement on homosexuality’, of the role of religious sanctions stating that homosexuality against same-sex behaviour, stating Though outright denial of services is not a psychiatric disorder. that religiously sanctioned bans on was not reported significantly, focus See: https://www.ndtv.com/ india-news/homosexuality- homosexuality were used to legitimize group discussions and key informants not-a-disorder-says-indian- actions against same-sex behaviours. across countries reported several psychiatric-society-1880806 The power of religious leaders on other barriers to men who have sex this topic was described as a major with men and transwomen accessing barrier to any legal reforms. As focus health care services. According to group discussion participants in India a key informant in India, ignorance noted, “Religious leaders claim that of issues of gender and sexuality, sex of this kind doesn’t exist. They and lack of training on the topic lie say, ‘No two men can love each other, at the heart of insensitive health nor can they marry and therefore care. The key informant noted that these are all symptoms of madness!’” although homosexuality was no By disapproving of homosexuality, longer officially pathologized in religious leaders delegitimize the India108, counselling is still given to social status of sexual and gender change one’s sexual orientation. In minorities. India, the medical curriculum itself is outdated in terms of information on gender and sexuality, with many 4.2.3 Health care providers students still using references that pathologize non-normative genders No participant from the 21 focus and sexualities. group discussions reported a positive experience from health care Apart from lack of understanding providers, except those provided on SOGIE issues and anticipated by community-based organizations stigma from health care providers, or civil society organizations. In participants reported several Bangladesh, India, Nepal and instances of harassment faced at Pakistan, participants unanimously the hands of health care providers. reported that they, and those in These instances were reported more their communities, sought help for by transwomen than men who have their health problems (particularly, sex with men. Among transwomen, sexual health problems) from 7 of 9 focus group discussions community-based organizations, and discussed facing harassment by in countries like Afghanistan, Bhutan health providers, whereas only 4 and Sri Lanka, they accessed civil out of 12 focus group discussions
64 Chapter 4: SOGIE-based violence: Forms, impact and coping Know Violence
among men who have sex with the information may even be leaked men described such experiences. out to the media.” 109 As reported from stakeholder interviews for the development Transwomen reported acts of sexual of this report and the UNDP, harassment ranging from undue and Consequently, participants admitted APTN (2017), Legal Gender inappropriate enquiries about their a general reluctance to seek medical Recognition: A Multi-Country Legal and Policy Review in Asia. sexual behaviour to cases of sexual services, particularly in instances assault. For example, a transwoman of rape and where they feared being participant in India reported how “outed” by the health provider. As transwomen experienced instances shared by a participant of a focus where the HIV counsellor and doctor group discussion of men who have repeatedly asked them to describe sex with men in Nepal, in response to in detail each sexual act with their the case vignette on sexual assault, partner/s even after providing them “[the vignette character] cannot go with all information that was needed to the hospital for treatment because to carry out a test. A transwoman again lots of questions regarding his in Pakistan reported being sexually sexual orientation will be raised for harassed by her dentist: anal injuries and he will be harassed in the hospital too.” “I had pain in my teeth, It was reported in Bangladesh that a so I went to a particular key issue is a lack of guidelines for hospital. I told the doctor medical practitioners to engage with about my symptoms and members of the hijra community. he realized what I am and Therefore, medical examinations are often performed in a degrading way. he started harassing me If hijras are not officially identified, sexually.” they are prevented from accessing government facilities specially meant Several participants reported for them.109 instances of breach of trust by a health care provider including Finally, participants discussed subtle discrimination based on their forms of service denial like deliberate sexual behaviour and involuntary delays in providing services. A health disclosure of their sexual orientation. care provider in India said, “Stigma In Sri Lanka, a transwoman in health care settings is not gone said, “Health facilities do not (in both private and government maintain confidentiality about their sectors), but is much subtler now. transgender clients. For instance, if Instead of outright denial, doctors a transgender person has to undergo defer treatment.” Similarly, men who surgery because of an accident, the have sex with men in a focus group entire hospital will come to know that discussion in India complained, “Even the client is a transgender person and today when we go to a doctor, even
Chapter 4: SOGIE-based violence: Forms, impact and coping 65 Know Violence
when we voluntarily go for an HIV test Public harassment on buses and in with full information and knowledge, public spaces. Focus group discussion we are asked why we want to get participants in several discussions tested. Rather than doing the test, cited instances of harassment in they keep asking why we want to public spaces including the use get tested.” of public services such as buses. Participants from Bangladesh, India, The range of discrimination, Nepal and Pakistan reported various harassment and abuse faced by forms of harassment while using men who have sex with men and public transport, including being transwomen in health care settings thrown out of buses, drivers refusing has critical implications for HIV to stop buses for them, being verbally risk. When health care providers abused and being handed over to the fail to treat clients with respect and police just for travelling in a crowded adequate care, or in worst case local train or bus. A transwoman scenarios, abuse clients, this can participant in Bangladesh made this create community-level distrust of telling comment: “If I go in a bus here the institution. Health care settings in [site], I often see that the moment can be a critical source of life- I sit, at least two or three people saving interventions or a venue for will get down from the bus. The bus prevention efforts. When men who conductor will use very foul language have sex with men and transwomen with me even if I don’t have change.” face discrimination, and subsequently While public transport is just one of do not access these resources, the sites of violence, transwomen they can suffer harmful health sometimes use public space as their consequences as a result. ‘workspaces’ for carrying out activities like seeking-alms for a living or dancing on occasions of childbirth or 4.2.4 Community marriage. In particular, transwomen in Bangladesh, India and Pakistan The immediate community served reported facing humiliation at traffic as another source of SOGIE- signals or when approaching a family based violence, according to study to dance for their newborn baby. participants. Major forms of violence included harassment in public Housing discrimination. Transwomen spaces and on public transportation participants from Bangladesh and difficulty renting homes. These and India noted discriminatory sources of SOGIE-based violence experiences when renting were more commonly discussed by accommodation. A transwoman in transwomen, whose gender identity Bangladesh shared, “We cannot find a is more visible in public spaces rented house, landlords make us pay compared to men who have sex extra rent and evict us without notice with men.
66 Chapter 4: SOGIE-based violence: Forms, impact and coping Know Violence
suddenly when we come from home. Legal status and barriers to Where should we go then? Sleep at education. Transwomen faced bus stations?” Another transwoman considerable difficulty accessing in India shared her difficulties in greater educational opportunities renting a house, due to barriers related to their legal status and the lack of educational “If we want to rent a room, quotas for transgender people. For nobody [rents one] to us, example, a transwoman in Nepal (in a focus group discussion) commented even if we are ready to pay on policy gaps: “We can do anything, the full rent and conform to because some of us are educated. If all their conditions. Don’t we get an opportunity, we can excel. kinnars have the right to There are quotas for females and others, but not for transwomen. We live? Are we ghosts who have the capacity and the necessary will gobble others up?” documents, but we cannot move forward because there are only These instances of violence within quotas for females and males.” the community signal the conditions Another transwoman participant in of discrimination, abuse and harm India expressed her difficulties in under which many sexual and gender enrolling at a local university, minority groups live. “I went to complete 4.2.5 School graduation. I have passed my class 12 with good School and educational settings marks, but when I went to as sources of SOGIE-based discrimination differed between seek admission for a BA transwomen and men who have after a few years, university sex with men in this study. For staff would not even look at transwomen, a critical aspect of my application form. They education-related SOGIE-based violence was the lack of legal status said, the name on the class and name change formalities as a 12 passing certificate is barrier to greater education and that of a man, but in your opportunities in their communities. form, you are insisting on For some men who have sex with men as well as transwomen, schools using a different name.” were also a site where SOGIE-based violence occurred, often early in the life course.
Chapter 4: SOGIE-based violence: Forms, impact and coping 67 Know Violence
Structural problems like not being because of their gender behaviours, 110 UNESCO (2016). OUT IN THE able to change names on certificates such as their preference to play OPEN: Education Sector Responses to Violence Based and other documents continue to act with female classmates, to play with on Sexual Orientation and as barriers to accessing education, dolls or to play ‘kanya-kanya’111 with Gender Identity/Expression. despite countries like Bangladesh, other girls in school. Teachers, in France, UNESCO. Available at: http://unesdoc.unesco.org/ India, Nepal and Pakistan recognizing addition to students, bullied and images/0024/002447/244756e. the ‘third gender’. A key informant sexually harassed participants. A man pdf activist from Bangladesh highlighted who has sex with men in Pakistan 111 Term from a focus group the gaps and problems with these described experiencing sexual abuse discussion in Nepal. Kanya- kanya is a make-believe game new policies: “A separate column as by a teacher as a child, “One of the played by girls using dolls. third gender has been created in the teachers in the school I attended They pretend to enact feminine passport form … where hijras can loved me and made me sit in his lap. I gender roles like cooking as a part of this pretend play. fit … but who will fit under this third didn’t know what was happening with column? There is no clarification of me. I only knew that he was a teacher that. If a hijra wants to fit there, the and he liked me. But how would I authority wants several papers. But have known what he was doing while the authorities who are supposed to loving me?” provide those papers do not know [about it].” The activist went on At a school level, the absence of a to describe an incident in which a redress mechanism for pressure, hijra friend had undergone gender- criticism, bullying and sexual violence affirmation surgeries and then in schools and colleges by faculty, attempted to change her legal gender students and other staff resulted in order to apply for a job. She found in additional trauma for students. a considerable lack of coordination As a respondent in a focus group between government ministries, and discussion in Afghanistan of men a lack of clarity among stakeholders with high-risk behaviour described around what qualifications were evocatively, “We are not accepted in required for hijras to be recognized school. They have special hate for legally. In these cases, even when us. No one accepts us. There is no legal recognition is a possibility, it can one to listen to our problems ... and be difficult to put into practice. if the family knows that their son is like this, there will be no place for School-based bullying and him in that family.” School policies harassment. This study confirms that do not provide options for previous research that shows schools gender-neutral bathrooms further as a major source of SOGIE-based marginalize transwomen students. violence in Asia.110 Study participants A transwoman in Nepal stated, “We across all sites spoke about violence can’t take a piss at school, we just faced in schools and colleges at the hold it. We cannot go inside a ladies’ hands of their peers and teachers. or a men’s restroom.” Classmates ridiculed transwomen
68 Chapter 4: SOGIE-based violence: Forms, impact and coping Know Violence
In Bangladesh, India and Nepal, expression seems to be an important transwomen discussed continued marker for experiencing violence, difficulties in accessing college or particularly in childhood and university-level education despite adolescence. embracing female attire and taking hormones. As summed up by a The spectrum of violence within transwoman in Nepal, the educational system, alongside barriers to accessing the education “I joined the community- system, was a major source of SOGIE-based violence discussed based organization and by participants. These formative they encouraged me to experiences have long-term continue education. I impacts. Lack of education or poor started to dress like a girl scholastic performance can later and I also started taking inhibit men who have sex with men’s and transwomen’s ability to gain hormones. When I started employment related to training or college, I used to dress as education. a man, I am identified as male on a certificate, but 4.2.6 Workplace later on, I started to go to college in a female getup, Participants faced challenges, discrimination and harassment with makeup and long both in gaining employment as hair, then other students well as in keeping a job. Again, like started staring at me. Even SOGIE-based violence experienced teachers started to look in educational settings, violence experienced in the workplace varied at me differently. Students between men who have sex with from other classes used to men and transwomen. Transwomen call me chakka and hijra, reported discrimination and so I had to leave college.” harassment due to their (visible) gender identity. Among men who have It is notable that bullying and sex with men, workplace harassment discrimination against men who have and violence were discussed often sex with men and transwomen in in reference to more feminine- educational settings were related to presenting men. femininity. Participants observed that In all nine focus group discussions harassment and violence in schools with transwomen, participants were largely due to ‘effeminate’ discussed the lack of job behaviour. Outward feminine gender opportunities and avenues for gainful
Chapter 4: SOGIE-based violence: Forms, impact and coping 69 Know Violence
and remunerative employment, Discrimination in the workplace was including issues related to masking also brought up in 8 out of 12 focus themselves in order to find and keep a group discussions with men who job. In terms of gaining employment, have sex with men. Experiences of participants discussed various forms discrimination at workplaces faced of harassment and discrimination by men who have sex with men were faced by their communities. A discussed in the context of feminine- transwoman participant in Sri presenting men who were often the Lanka said, “It is not uncommon for targets of ridicule, gossip, and in [transwomen] to be interviewed for a some cases, sexual harassment by job and be posed degrading questions colleagues. like, ‘What is your sex organ? Is it well grown? How long has it been? 4.2.7 Family Are there any surgeries?’ So, by the time they leave the interview The family emerged as a major room, everyone in the office knows source of early life adversity and about their most private details.” A trauma among men who have sex transwoman participant in Sri Lanka with men and transwomen across shared, “If I want to work in a proper all seven countries. Bother men who office, I will have to dress like a man have sex with men and transwoman and not let anyone know about me.” participants discussed that as children, they were expected to learn and follow Employment-related discrimination expectations of what it meant to be a was discussed in relation to driving man in their communities. All focus transwomen into sex work. As group discussions suggested that one transwoman participant in the first experience of violence faced Bangladesh stated, ““When I went to by men who have sex with men and Dhaka, I wanted to pull a rickshaw, transwomen was perpetrated by the but no one was ready to rent me a family due to their transgression of rickshaw, so I had to do sex work these expectations. Multiple forms of for the sake of survival.” Even those violence – emotional/psychological, participants who found work in physical and financial – began to occur, the area of their choice reported particularly as men who have sex with facing sexual harassment at the men and transwomen shift away from workplace and discrimination in paid “appropriate” appearance, dress, play, wages. Some even faced sudden body language and choice of friends. and unexplained termination of jobs. Following this, some participants Both groups of participants in all resorted to sex work, dancing in bars seven countries reported a wide or seeking charity and alms as a range in instances of discrimination means of livelihood. and violence towards non-conforming children. These ranged from subtler
70 Chapter 4: SOGIE-based violence: Forms, impact and coping Know Violence
forms of discrimination, such as enquiries, complaints or taunts neglect in food distribution, to about children who did not conform violence, including physical violence to social expectations. This pressure in the form of beating. A participant sometimes triggered further family in focus group discussions for men violence. A transwoman from who have sex with men in Pakistan Bangladesh said, “My father goes said, “my father, brother, both would to mosque for his prayer. He [faces] yell at me and sometimes beat me complaints … The people at the when they would find me playing mosque say that I talk like a girl. Or with my sisters’ dolls.” In some I dance or sing like a girl. Again, my cases, violence took on the form of mother goes to the neighbour and neglect. A transwoman in Bangladesh her friends’ places in her pastimes. reported, “when I was growing up … She is also reproached there. So, our my brother was given [the] head or parents scold us always for these larger piece of fish, or the chicken reasons.” In Afghanistan, participants leg, but I was not given a big piece. I reported that families could even face was underestimated”. eviction from the neighbourhood, which was the most extreme type A particular form of violence enacted of community pressure discussed by families was the attempt to “cure” in the study. Across the countries, a non-conforming gender identity or family members could face loss of sexual orientation through “quackery” social standing and position due to or questionable medical practices non-conforming behaviour among or treatments. A participant in focus children. group discussions for men who have sex with men in India told the story of It is notable that participants a friend, “He was educated … when remarked that “only effeminate” he tried to tell his mother about his boys faced restrictions and sanctions feelings, his family took him for black against them. As in the education magic to cure him. Then the pundit system, this signals that violence who does the puja, the ojha, suggested was a result of deviation from gender that the boy was possessed by a girl’s norms. When men who have sex with spirit and soon a story was made up men did not appear effeminate, they that the spirit was that of a girl who did not necessarily face this abuse had died recently in a village... and this and harassment. boy was quite feminine in appearance and mannerisms.” Another key form of pressure – which sometimes gave way to The larger community (including violence – was the pressure of extended family, neighbours and conforming to social expectations family friends) were a source of by marrying. This pressure was pressure for families who faced discussed as a major issue in all 12
Chapter 4: SOGIE-based violence: Forms, impact and coping 71 Know Violence
focus group discussions with men 4.2.8 First sexual encounter 112 Some respondents noted that who have sex with men. It was not a first sexual encounter could also be with girls, but this discussed in transwomen focus First sexual encounters with same- issue was not explored in any group discussions. As noted earlier, sex partners were often discussed as detail in the study, suggesting masculine-appearing men who have being forced or abusive in nature.112 that it might not be relevant or meaningful to the study sex with men may not have faced First same-sex sexual encounters population. harassment in schools or may not tended to occur during adolescence, have been penalized by parents for although participants in one focus their effeminate behaviour. However, group discussion in Bangladesh they have to deal with the pressure to for men who have sex with men marry a woman. Attempts at forcibly discussed the age as being as low as marrying them off become the next 8 years old. First sexual encounters recourse for the family to “set things were discussed as often taking place right”. This is often accompanied at home, giving participants no option with several other forms of violence to escape. Some encounters took including verbal abuse, gossip and place as a result of self-exploration community-based discrimination. of sexuality, where exploration As noted by a participant from Nepal led to the first encounter and in from the focus group discussions some instances, the first sexual for men who have sex with men, encounter was a result of a sexual “We are forced to get married to a assault, followed by repeated sexual girl at a young age. Our parents and abuse accompanied by threats and elders, on getting to know about our blackmail. sexual orientation, want us to get married. They think we will correct Participants discussed the grey areas our behaviour after marriage. They around sexual consent during first are convinced that if we do not get same-sex sexual encounters and married, then our behaviour will get the development of early sexuality. worse in the future.” A core dilemma They spoke about how consent for that seems to characterize this life acts such as hugging might progress stage of men who have sex with men to more sexual acts such as being in particular is between forming penetrated, and that at the time, intimate romantic relationships they did not know what to expect with same-sex partners and getting or how to say “no”. One participant married to a woman. The coping in focus group discussions for men strategies and consequences of this who have sex with men in Pakistan pressure are discussed in Chapters 5 recounted, “I did not know that and 6 respectively. there is something like anal sex … I just thought that I am enjoying the hugging ... just doing it for fun, but suddenly when anal sex happened, when he entered me, I felt sudden
72 Chapter 4: SOGIE-based violence: Forms, impact and coping Know Violence
shock and pain and I pushed him relationships was the economic back and told him I don’t want to do abuse faced in intimate relationships this. I started crying and I ran away where study participants reported from that park”. Across all the study meeting financial demands of countries, participants mentioned intimate partners. A transwoman that the male person they had their focus group discussion participant first sexual encounter was an older in India said, “Among hijras, there is person such as a cousin, uncle or no such thing as love. It is all about acquaintance such as a neighbour, begging and eating and taking care teacher, friends, classmates or other of the household. Even if we fall in relatives. This was an observation love, then that person will be with common to both men who have sex us for one month or a maximum six with men and transwomen. months and after that, he shows his true colours, like drinking and taking money. If the hijra does not give the 4.2.9 Intimate (male) partner money, she faces torture by having her hands burned or being beaten Although this study did not explicitly up. In fact, most of us cannot reveal investigate intimate partner our feelings to anyone because if we violence, 4 out of 12 focus group share anything with anyone they will discussions with men who have sex torture us even more.” with men and 7 out of 9 focus group discussions with transwomen talked Similarly, a transwomen focus about violence faced in intimate group discussion participant in partnerships. There appeared Nepal shared, “Whenever we see to be a connection between the a handsome guy who talks to us, extent of family violence and the we start fantasizing about our life experiences of violence during together with him and we request intimate partnerships. Common him to stay. There was a guy for forms of family violence (by parents, whom I bought so many things like siblings and female spouses) such as cell phone, bicycle and others. Then physical, verbal and sexual violence, I knew that he also had relations financial exploitation and controlling with a girl. He got calls from her and behaviour were also discussed used to lie that it was his mother. in relation to intimate same-sex Then he took 50,000 rupees from me partnerships. Although transwomen and ran away with his girl. I had no did not report issues around pressure one to report to. I could not even say to marry, the pressure to maintain to anyone that he was my partner.” intimate partnerships at all costs A common expression is “Kothis was shared by both transwomen support their parikhs for a lifetime and men who have sex with men. and in return the parikhs leave them.” One of the factors affecting intimate
Chapter 4: SOGIE-based violence: Forms, impact and coping 73 Know Violence
Chapter 5: Resilience and coping strategies
74 Know Violence
When faced with chronic violence, men. They could travel to other cities people tend to have strategies to to act out their sexual orientation, resist and cope with the impact of while maintaining a heterosexual that violence. These strategies can appearance back at home. Living a mitigate the short-, medium- and dual life, according to participants, long-term effects. Coping strategies was justified, given the alternative. can be positive or harmful. In this They suggested that this ‘duality’ study, men who have sex with men enabled them to acquire respect and and transwomen discussed four status in society, while also seeking major coping strategies: living a dual romantic and sexual fulfilment. life, coming out, self-exclusion and leaving the community, and fostering However, participants in focus group resilience, including through building discussions in several countries self-acceptance and fostering observed that for men who have community networks. sex with men, the ability to fulfil the breadwinner’s role for the family superseded even the pressure to 5.1 Living a dual life marry. Participants from these countries observed that as long as A major theme emerging from the they provide financially for their data was the option of living a dual family, they are perceived to be life. Men who have sex with men valuable, and the family does not and transwomen tended to conform pressure them as much to marry, to dominant expectations of what it even if they are effeminate. meant to be a man in their societies as a way to reduce their exposure to SOGIE-based violence. This included 5.2 Coming out conforming to more ‘masculine’ personal attributes and/or marrying A second set of participants felt a woman. Participants indicated that marriage to a woman was not that men who have sex with men something they could live with as it and transwomen often “gave in” to would put extra pressure on them societal or family pressures by “acting to maintain a relationship with their straight” and dressing in a masculine wives. They do not feel sexually way, cutting their hair short, changing attracted to women and feel that their mannerisms and getting marriage would distance them married. Participants who were men from their male intimate partners. who have sex with men elaborated It would only add to their current on various ways in which people in issues instead of solving problems. their community lived dual lives. They As observed by a participant in could pretend to have girlfriends, Pakistan, “After you marry, they but maintain secret relations with immediately want to know if you
Chapter 5: Resilience and coping strategies 75 Know Violence
have been intimate with the wife, support while dealing with when do we hear the ‘good news’ pressure to marry a woman and the (about pregnancy)? If there has been subsequent coming out process. no sexual intercourse with the wife, Parents, they said, go through a the woman is often blamed and mourning process as they lose the everybody wants her to get tested. It “image” of a son they had cherished, can be dealt with by postponing the and the expectations they had built in topic – by giving excuses, stating high terms of grandchildren. However, with expectations from the match.” support, some parents are willing to stand by the choices of their children. Participants in three focus group A psychologist in India said, “Parents discussions with men who have in Asia raise their sons with long- sex with men in Bhutan, India and term plans for their (sons’) lifetime. Nepal reported taking active steps They have already thought about how to avoid marriage. Apparently, the their son’s future life will be, their most successful strategy was to grandchildren, their retirement and disclose their sexual orientation to grandchildren being a major focus their parents and families. Disclosure of retired life. When they realize that of sexual orientation to family their son does not want to marry, members, however, was easier said all their dreams come crashing than done. Participants in focus group (down). With a lot of education and discussions for men who have sex counselling, they accept that same- with men in Nepal shared that they sex behaviour is natural, but they find needed help in breaching the topic of it most difficult to come to terms with marriage and their sexuality to their their lost cherished dreams. They family members. A participant from then feel the challenge of what to Nepal said, “My mother kept asking tell their relatives, and what should me about my plans for marriage. I they expect will happen to their son tried to tell her on several occasions in his future, like, who will care for that I am not interested in marriage, him once we are gone?” However, but she wouldn’t listen. I decided with the exception of India and Nepal, to speak to the counsellor in [site]. in no other study country did the She helped me in gaining confidence participants mention counselling for to tell my mother and offered their family members. help. Finally, I told my mother, and made her talk to the counsellor to Of all the study countries, Bhutan understand. She is still sad, but has was the only site where participants stopped asking about marriage.” remarked that parents do not pressure them to marry to a great Mental health professional key extent. They attributed this to the informants in India and Nepal overall increasing age of marriage in corroborated the need for counselling Bhutan as a result of changing gender
76 Chapter 5: Resilience and coping strategies Know Violence
norms and improved education levels. Participants revealed that when Focus group discussion participants in faced with situations of violence and Bhutan also stated they find it easy to discrimination due to their gender talk to their parents and make them identity or sexuality, individuals understand their sexuality. Despite tended to withdraw from those being unsure of the outcome of such situations as a way to mitigate the conversation, they felt that parents violence. A common demonstration would accept them. As summarized by of self-exclusion across all seven a focus group discussion participant in countries was moving out and away Bhutan, “Parents would first ask why from home, villages, towns or even they don’t want to marry. They will try the country. The explanation behind to persuade him that it is high time one’s decision to leave the family that he got married. The older family or home community varied. For members would think that it is the example, transwomen in all focus obligation of their sons to get married. group discussions listed the desire If the son tells their parent that he to live on their own terms, the wanted to marry a boy and not a girl, desire to live as a woman and the then their parents would not believe need to be with other transwomen. it and it would be like giving their Comparatively, men who have sex parents a surprise birthday party. But with men often moved away from if their son explains to their parents, their home communities to avoid they would understand. But again, marriage or to escape violence and there is also the chance of going in eviction due to the disclosure of their the wrong way [another way round sexual orientation. Notably, men who depending upon the family] in which have sex with men did not report he may get kicked out of the house or similar experiences with clans or [they would] not talk to him [again].” established communities as a new home, unlike transwomen.
5.3 Self-exclusion and However, a consequence of this leaving the community coping strategy was the loss of home-based economic opportunities Another form of coping that and support networks. Men who emerged from the data was that have sex with men and transwomen of “self-exclusion” or withdrawal, discussed challenges when migrating particularly from the family unit or to a new city or town. Given the community. The family unit is an impact of discrimination and violence important social unit in South Asian on participants’ education levels, societies. Individuals reflect one’s participants reported that finding family, and honour and status are regular employment was a major given to the individual and family challenge. Of the 77 transwomen accordingly within the community. participants, only 7 held regular or
Chapter 5: Resilience and coping strategies 77 Know Violence
salaried employment while all other community resilience, build alliances participants reported engaging in and celebrate their sexuality and low paying, irregular jobs such as gender identity. hotel staff, cooks, delivery personnel and running small shops. As 5.4.1 Self-acceptance and described in Chapter 4, they faced sexual harassment at work, such coming out as delayed wages, and harassment Participants discussed ‘self- by co-workers and employers. Key acceptance’ as a strategy that informants corroborated this trend, enabled them to build resilience. and noted that feminine-presenting At the individual level, participants men who have sex with men and reported that ‘coming out’ or transwomen struggled more to find disclosure to friends and family was work opportunities. As expressed by adopted as a strategy irrespective a transwoman activist in Pakistan, of the outcome of such disclosure. “Nobody wants to give murat a job. Participants reported that when You will not find a singlemurat voluntary, the disclosure was received working in an office job, and it’s only not with violence but with curiosity, in community-based organizations particularly from heterosexual friends that you will find men who have sex who then stood by them and provided with men and transwomen doing jobs support. Participants in focus group sitting in front of a computer.” Lack discussions for men who have sex of job security may attenuate the with men in Bhutan, India and Nepal potential positive effects of leaving reported that the support of an home as a coping strategy. organization, community or friends Participants also revealed they was crucial during the disclosure withdrew or excluded themselves to family members in the context of from social settings, such as avoiding marriage. Participants noted that family functions, withdrawing from when they identified others like socialization with peers in schools themselves and could associate and colleges, and keeping themselves themselves with “a community”, it away from those they felt threatened provided a sense of belonging. by, in order to avoid facing violence. 5.4.2 Fostering community 5.4 Resilience networks
The extent to which community Participants discussed several bonding facilitated self-acceptance positive coping mechanisms to enable varied depending on the level of them to thrive in adverse conditions, community mobilization in a country. fight back, build individual and In some contexts, like Afghanistan,
78 Chapter 5: Resilience and coping strategies Know Violence
Bhutan and Pakistan, community- being part of networks that spread based organizations facilitated beyond services provided by community bonding through their community-based organizations to drop-in centres, by delivering health networks of friends and communities and outreach services and facilitating who helped participants overcome individuals to reach out to each other difficult situations or crises. These through social media, particularly networks formed a kind of emotional where congregating was considered support, ensuring guidance from unsafe. Focus group discussion peers, in addition to material support participants in Afghanistan and such as shelter and sometimes, Bhutan discussed the lack of “visible” financial resources. networks, and therefore visits to civil society organizations for services Transwomen participants from provided the only opportunity for them countries like Bangladesh, India and to talk about their issues with others Pakistan stated that the support of like them. Participants in Bhutan the community was their biggest suggested that they had few friends resource and instrument of coping. in the community and most ‘cruising’ Often, transwomen discussed leaving took place online and through social home and joining the “family of [their] media. A participant from Afghanistan choice”, in order to fully embrace said, “I know there are others like their identities. When transwomen me who are into the same work, but I migrated to cities, they often cannot meet them. I only have my few joined transwomen communities. friends. Most of us talk to each other Participants from Bangladesh, on mobile phones.” Coming together India and Pakistan reported that the in a group could create safety and transwoman community ensured security issues. A key informant their basic needs were met, and from Afghanistan reported that civil helped them to find employment society organizations that reach out opportunities, often sex work and to men with high-risk behaviour face begging. Although these occupations, challenges in delivering services and especially sex work, further exposed have to be careful in allowing large transwomen to violence, in some groups of men to be seen together. instances transwomen participants At the same time, when visits to civil discussed their safety techniques. A society organizations were possible, major technique was to travel with they provided an opportunity for men other transwomen in small groups. to make friends in person and share Many transwomen, especially in experiences. Bangladesh and India, reported that community-based organizations and Comparatively, in countries like their transwoman leader intervened Bangladesh, India, Nepal, Pakistan in crises and advocated for them with and Sri Lanka, participants reported police with success.
Chapter 5: Resilience and coping strategies 79 Know Violence
But sometimes, communities can with their communities even when be a source of violence alongside they experience violence from their support. A transwoman in India gurus or other community members. described this experience: “If we A transwoman participant in India listen to them (gurus), that is when noted, “Kinnars are my family … they support us … if we don’t listen kinnars are my parents, siblings and to them, they beat us with a stick, everything to me … even if they beat chop off our hair … make us bald … me up, I don’t feel bad … I earn and after that, if we beg in the trains, the whatever money I get I give them and policemen also equally harass us…” make them proud and make myself However, transwomen still identify proud too.”
Figure 6: Coping strategies
Living a dual life Coming out In order to conform to dominant social Some men who have sex with men and expectations to marry and have children, transwomen took active steps to avoid men who have sex with men and marriage, and disclosed sexual orientation transwomen reported living a dual life – to parents and families in order to mitigate engaging in relationships with women, family pressure. while also seeking romantic and sexual relations with men.
Self-exclusion and leaving the community Self-acceptance Withdrawal and self-exclusion from natal Men who have sex with men and family and community was a strategy transwomen described processes of used by men who have sex with men self-acceptance, through the support of and transwomen to avoid violence and friends, family and community bonding. discrimination based on gender identity Self-acceptance facilitated their ability and sexuality. to build alliances and celebrate their sexuality and gender identity.
80 Chapter 5: Resilience and coping strategies Know Violence
Chapter 5: Resilience and coping strategies 81 Know Violence
Chapter 6: SOGIE-based violence, HIV and mental health
82 Know Violence
6.1 SOGIE-based violence Another focus group discussion participant in India said, “If a 13 or 113 A superhero character, akin and mental health to Superman, on an Indian 14-year-old commits suicide, people television show in Hindi for Lifetime exposure to violence and say he was just a kid – he must have children. discrimination, including social been playing when he put the noose exclusion and marginalization, around his neck and then got killed negatively impacts on the mental by accident, or that he must have 113 health and well-being of men who been trying to imitate Shaktiman ... have sex with men and transwomen. some people may say he failed in the According to the data, their fifth class and was in depression, but psychological issues ranged from the reality of him being tortured and poor self-esteem and self-doubt to abused remains hidden [due to his suicidal attempts and occurred due sexual orientation or gender identity]. to the gradual build-up of stress, Family members, too, even if they coupled with a lack of recourse, want to, cannot be open about the acceptance or support systems in real reason because of social shame face of discrimination or abuse. ... If the real reason gets known, tongues will start wagging.”
6.1.1 Suicide 6.1.2 Substance abuse Participants discussed attempted suicide and suicide as a serious Both men who have sex with men and consequence of SOGIE-based transwomen participants, particularly violence. A participant from focus in Bangladesh and Pakistan, and group discussions for men who have men with high-risk behaviour sex with men in India recounted a in Afghanistan, reported using story about a peer whose family tried substances to cope with the emotional to use black magic to eliminate his and psychological impacts of violence same-sex attractions: “He finished and discrimination. Particularly his school and entered college. But men with high-risk behaviour the problem continued with him. He in Afghanistan mentioned using was compelled to go for a medical cannabis and injecting drugs whereas check-up though this was not a both men who have sex with men and mental health problem. He attempted transwomen participants in Pakistan suicide twice, he even slashed reported using hashish and injecting his hands, but his family failed to drugs. Additionally, participants from understand him. Now he doesn’t stay Bangladesh reported misusing over- with them and his family also doesn’t the-counter drugs like sleeping pills. ask about him or try to look for him. Almost all transwomen focus group Now he lives elsewhere and works in discussions in India, Nepal, Pakistan an NGO as a peer.” and Sri Lanka reported alcohol use to
Chapter 6: SOGIE-based violence, HIV and mental health 83 Know Violence
cope with mental stress, tension and 6.2 SOGIE-based violence feeling low. A transwoman in Pakistan and HIV risk reported, “Drugs are to control the mental stress, it slowly becomes a Participants described a number habit.” Transwomen participants from of situations in which SOGIE-based Bangladesh, India and Pakistan also violence led to greater HIV risk. reported being coaxed into drinking Three major themes that emerged alcohol by an intimate partner. were (1) SOGIE-based violence and discrimination driving men who have 6.1.3 Stress related to dual lives sex with men and transwomen into sex work and risky sexual situations As noted in Chapter 5, participants with clients and police; (2) barriers to discussed leading dual lives – health care in cases of sexual assault; marrying women and continuing and (3) the processes of finding secret same-sex relations – as a sexual partners in contexts where strategy to avoid discrimination same-sex activities were illegal or and violence related to their gender socially unacceptable. identity or sexuality. However, participants also note that living a 6.2.1 Violence during dual life impacts the mental health transactional sex and HIV risk of married men who have sex with men. Participants reported that The violence that men who have sex married men who have sex with men with men and transwomen faced resorted to alcoholism to deal with from families and communities often the stress of demands from marriage forced them to leave home. With and maintaining a relationship with little educational or employment the same-sex partner. Men who opportunity (see Chapter 4), have sex with men also felt constant participants discussed how men who anxiety and fear around being found have sex with men and transwomen out by their families. One participant might transition into transactional sex in Sri Lanka said, “One person might work. For transwomen, the transition control himself and go for a marriage. could lead them to the care of a After marriage, he secretly continues guru or mentor in the transwomen his desires the way he wants. He is community. Transwomen also saw too stressed. He has to pay attention this transition as a shift into sex work to his wife or the family will complain as well as earning money by dancing and on the other hand if he can’t give at parties, religious occasions and time to his male partner, then that seeking alms as means to earn a is also bad. Plus, there is tension of living. Transwomen gurus often people finding out at home. Anyone encouraged and supported these can easily lose their mind.” means of earning. For men who
84 Chapter 6: SOGIE-based violence, HIV and mental health Know Violence
have sex with men, the transition give money too and drop us home was less about organized sex work … and some just take money …“ In through a guru, and more about circumstances like these, men who transactional sex as a dancer, have sex with men and transwomen or providing transactional sex in face HIV risk through the lack of or cruising spots. However, participants inability to negotiate condom use, as perceived sex work as a high HIV risk well as increased HIV transmission activity. A transwoman in Pakistan risk through open wounds, tears and noted, “Some people say that they ran abrasions. away from home, entered in guru- chela (leader-disciple) system and Participants did describe creating got freedom. I think the guru-chela strategies to protect themselves from system is itself a jail in that you have violence. These strategies included to follow various restrictions and not keeping the hijra guru informed about every guru is one who takes care of their whereabouts while engaging you. There are many who ruin your in sex work, accompanying clients life and at the same time, many who only to known places, working in are good for you. They force them into pairs within a specified geographical sex or to beg and torture them. You area and marking safer spaces come to a guru with a thought in mind for engaging in sex work. Yet, as that she will be a support for you, but described in Section 4.2.1, the she ends up forcing you to become a impunity with which perpetrators paid sex worker to make money off operate gives men who have sex with of it. So, rather than having a good men and transwomen little recourse future, you end up having sexually to justice, in cases of assault and transmitted diseases.” violence.
Participants noted that engaging When asked about help-seeking in sex work and having sex with after a sexual assault, participants unknown partners were fraught reported that they turned to friends with many dangers like blackmail, as the first line of support. When extortion and gang rape, particularly asked about seeking formal help, by clients and police. A transwoman both men who have sex with men and in Bangladesh said, “I do sex work transwomen participants said they … so there are some boys who while sought help from police, but faced negotiating sex, say that they will give further discrimination and violence. 500, 250 whatever … one person takes One transwoman participant in India us there, five, six people come … they shared, “Even if we go to complain come in a gang under the influence to the police, for example, there is a of alcohol … if we say no, they force kinnar who is alone and seeks help themselves, they tear our clothes … from the police … the person who has beat us … some people have sex and attacked them will give some money
Chapter 6: SOGIE-based violence, HIV and mental health 85 Know Violence
to the police and he will be freed … expressed fear that the media might instead, the kinnar will be put in the report and sensationalize their rape lockup and whichever police is there cases. on the night shift will have sex with the kinnar.” Stigma and discrimination by health care providers can also exacerbate general HIV risk, outside 6.2.2 Discrimination by health of direct instances of sexual assault. care providers Anticipated stigma led to low levels of health care usage, which could lead Section 4.2.3. describes the violence to mistreatment, delayed treatment experienced by men who have sex or lack of treatment for sexual with men and transwomen by health health issues. A health professional care systems. This discrimination in Bhutan said, “Access to health is can compound the HIV risk that guaranteed but people are afraid occurs in instances of sexual to go. They have equal access to assault. In addition to reporting education and health facilities like instances of sexual assaults, any other. We see cases of anal warts participants had physical injuries, coming mostly from the monastic which needed immediate medical bodies. Even discharge from their attention. Participants’ experiences genitals. But nobody is being denied in seeking health services in the any health services. Firstly, they event of sexual assaults varied. come during the late stages of any All participants reported going to symptoms. For example, if there is clinics for sexually transmitted urethral discharge from their genital infections first for treatment given areas, they will come only during the likelihood of doctors being more late stages, because of the fear of sensitized at these clinics. However, stigmatization from health workers. if these services were unavailable, So, the treatment becomes difficult. If they described feeling more anxious they come with problems in the anal about seeking treatment from other region due to anal sex, most of them health care providers, as they often are hesitant to tell us that they had face humiliation and discrimination anal sex rather than normal vaginal at other facilities. For example, intercourse.” participants in Afghanistan and Bhutan reported that at government In Afghanistan, Bhutan and Sri Lanka, clinics, they did not disclose their participants underscored that health sexual behaviour and felt that they care systems may not be sensitized had no alternative, but to tolerate to SOGIE issues and were either the pain. Participants in Sri Lanka largely unaware of or unwilling to were concerned that doctors might acknowledge the existence of sexual fail to maintain confidentiality and and gender minorities. For example,
86 Chapter 6: SOGIE-based violence, HIV and mental health Know Violence
a participant in Bhutan said, “There sex. Many times, the doctor does is an absence of organizations not even ask for patient history. So, and services where help can be it is neither the fault of the service sought. Most agencies, services, and institution nor that of the individuals.” counsellors do not even know about Discrimination or lack of training by the existence of men who have sex health care professionals, coupled with men or are not sensitive to their with the hesitation of men who needs. Mental health departments in have sex with men and transwomen hospitals, rehabilitation centres and to access health care settings, other agencies are not sensitized to contribute to inadequate prevention their issues.” of sexually transmitted infections and HIV, care, support and treatment. For participants of the focus While discrimination by health care group discussions, this lack of providers is a serious concern, acknowledgement of SOGIE issues advocacy efforts by community- is reflected in the lack of sensitive based organizations in countries like health services. For example, across Bangladesh, India and Nepal helped all focus group discussions in to offset some of this discriminatory Afghanistan, participants expressed behaviour. a sense of helplessness with regard to seeking health care, especially Participants emphasized the impact for their sexual health. Participants of community-based organizations reported that only two male health on the lives of men who have sex with clinics existed in the country where men and transwomen, speaking at they could talk to health providers length about their efforts concerning and counsellors about their health sensitization and advocacy over the and mental health issues and feel years that have resulted in building safe in doing so. alliances with friendly health providers, lawyers and even police. Very often, participants of focus A community-based organization group discussions in these study sites leader in India shared his experiences reported either not seeking health saying, “We initially met at a support services or not fully revealing their group. But we realized that there sexual history at health services were many like us and we needed to due to the fear of discrimination, reach out. With HIV knocking at our humiliation or being outed. As shared door, it became imperative to have by a participant in Bhutan, “Medical health providers on our side who services are readily available, but understood issues of the community. people do not go because they We were lucky to forge friendships hesitate. There is no restriction based with fantastic doctors who sent on gender, but they will not have the their students for internships at our courage to say that they had anal organization, and to date, we have
Chapter 6: SOGIE-based violence, HIV and mental health 87 Know Violence
health clinics that are very friendly.” they can take photos and post it on Community leaders in Bangladesh, Facebook and trap us. Once they India and Nepal shared experiences get to know us and our real identity, of working with the police and legal they can spill the beans on us in system to help community members our homes, or sneak to the police in situations of crises that included saying we are sex workers. They can initiating dialogue and sensitization of spread (the news) all over causing police and lawyers to ensure friendly devastation in our lives. Sometimes, it services. can cause legal problems for us, and at the same time, threaten to destroy our professional life by coming to 6.2.3 Risky situations and our work. Further, the lack of ability evolving networks to negotiate safety and locations where little to no help was available In countries like Bhutan and Sri heightens the risk of unsafe sex.” Lanka, the participants in focus group discussions for men who Among men who have sex with men have sex with men spoke about and transwomen participants who the changing nature of social and discussed intimate partnerships, sexual networking through the they noted that although failure to use of social media and the perils use condoms increases the risk of involved in identifying sexual partner, HIV, negotiating condom use in a given the highly stigmatizing social same-sex relationship could be a environment. Men who have sex challenge. As a participant in focus with men in Bhutan said, “Social group discussions for men who have media networking sites are a source sex with men in India said, “We are of emotional support and finding unable to negotiate condom use friends and sexual partners ... but because of lack of pleasure and to sexual partners found over these be able to retain the partner’s trust, sites, especially older ones, may be which places the individual at risk of exploitative. They may promise to getting infected.” teach the basics of sex, but refuse to use condoms.” Transwomen in Sri Lanka agreed, “It’s not safe finding partners via Facebook, because there are so many fake accounts floating around. Assume we find a person. Here, they might decide to meet up alone and yet, come along with a group of around four or five people leading to the highly risky situation of sexual abuse. Other than that,
88 Chapter 6: SOGIE-based violence, HIV and mental health Know Violence
Chapter 6: SOGIE-based violence, HIV and mental health 89 Know Violence
Chapter 7: Life course pathways between violence, mental health and HIV
90 Know Violence
In all of the countries covered in this a single life course model of how study, the perception that men who multiple sources of violence and have sex with men and transwomen discrimination can have complex transgress the dominant social and harmful consequences for paradigm that privileges heterosexual mental health and HIV risk within cisgender men within society the study populations. The life appears to be the fundamental cycle approach demonstrates the cause of the various forms of long-term consequences of early violence. Participants discussed the adolescent and youth experiences on considerable impact of this violence the life trajectories of men who have on mental health and HIV risk among sex with men and transwomen, and men who have sex with men and how constant exposure to violence transwomen. The connections are and trauma can lead to heightened complex and qualitative data lends vulnerability to HIV risk and mental itself to an exploratory approach health problems throughout to these connections. This chapter adulthood. The pathways in Figure 7 maps links between violence at the are by no means exhaustive; however, individual, family, community and they bring forth the major themes society levels with mental health and that emerged from participant HIV risk faced by men who have sex discussions. This section highlights with men and transwomen in the particular sections of Figure 7 for seven countries. Figure 7 integrates further discussion. results from Chapters 4, 5 and 6 into
Figure 7: Connections between SOGIE-based violence, HIV and mental health across the life course
Gossip within the community Pressure to marry Dual relationships
Family pressure to conform Leave home Economic insecurity
Deviance from gender norms Drop out of school Harassment & abuse
Childhood Adolescence Adulthood
Low self-esteem / lack of social support / Forced sexual initiation Substance abuse / depression & anxiety / lack of confidence transactional sex / risky sexual behaviours
Chapter 7: Life course pathways between violence, mental health and HIV 91 Know Violence
7.1 Power and status in Thus, across Figure 7, we see that society the presence of social norms against sexual and gender minorities provide A major trend across the countries a backdrop for men who have sex with was the loss of power or status men’s and transwomen’s experiences across the life course due to one’s of SOGIE-based violence. gender identity or sexuality. Often, teasing, bullying, harassment and 7.2 Family context stigma against men who have sex with men and transwomen as Early life experiences of children would lead to lower access discrimination by family members to resources, such as education or were discussed as being key sources occupational training. Leaving the of SOGIE-based violence that led to family or community might further considerable emotional distress and exacerbate economic insecurity. Not framed the life course trajectory of being able to get good jobs, men who stigma, discrimination and adversity. have sex with men and transwomen A transwoman from India recalled, might face further loss of status in “I had left home, but I went back society. Combined with continued home because I was missing my discrimination, harassment and parents and my siblings … my hair abuse as adults, these experiences was long … so, my father and uncle contributed to experiences of together chopped my hair … they mental health problems (notably said, ‘Why are you like this?’ … they depression and substance abuse) took me to the hospital and gave me and HIV risk behaviours and settings. shots … they took me everywhere In instances when men who have … I thought it would be better that I sex with men or transwomen were die than suffering here.” However, able to provide for their families other men who have sex with economically, they retained a level of men and transwomen discussed status in their families, despite their situations where they or those in sexual or gender identity. This trend the community received family demonstrates the powerful impact support, although it was attenuated of social norms around masculinity – by perceived condemnation from what men should do, how they should the community. Where families are act, who they should marry and love tolerant of a gender non-conforming and who they should have sex with. family member, the societal pressure When men who have sex with men to conform and stigma places the and transwomen deviate from these family in a difficult situation: either norms, they experience violence, reject their child or risk losing social stigma and discrimination across standing and position. A participant the life course, which can lead to a from focus group discussions for men loss of power and status in society.
92 Chapter 7: Life course pathways between violence, mental health and HIV Know Violence
who have sex with men in Pakistan entering heterosexual marriages. explained, “The family usually is fine Across the region, many sexual 114 No transwomen in the study discussed marriage to women. with us, but they are too afraid to minority men do enter heterosexual 115 Miedema et al. (2017). support us openly. Other relatives and marriages. The UN Multi-country neighbours don’t leave them alone. Study on Men and Violence in Asia- They want to know everything.” Pacific found no significant difference between sexual minority men and A mental health practitioner in India heterosexual men of whether they further corroborated the pressure had ever been married or cohabited faced by family from community with a woman.115 While on the one and extended family stating, “There hand, marrying women enables men are supportive families as well, to adapt to the social context, as we because there is no absolute support saw in Chapters 5 and 6, it can also or absolute absence of support lead to stress and fear of exposure. ... In my experience, I have seen The practice also has implications for supportive families. Many a time, HIV risk for both men who have sex the mother is accepting, the father with men, their same-sex partners, is not, something like that. Later on, and their female partners. there is partial acceptance: ‘Okay, fine, you do this but please do not Dual lives can lead to concurrent dishonour us’ or ‘please do not sexual partners. Among the bring your friends to our home.’” participants, there were differences Conditional acceptance by family in how they viewed concurrent members highlights the challenges sexual partners, or engaged in that supportive families might face sexual relations with both a wife while supporting their children. This and a male same-sex partner(s). further demonstrates the influence This perception was shaped by their of community and social-level factors internalization of social norms. In on the interactions between men who Pakistan, participants felt, “When have sex with men and transwomen in Rome, you have to be a Roman” and their families. and that once marriage takes place, family members leave them alone and they can lead a double life. 7.3 Trajectories into a In Afghanistan, a participant who dual life, or not identifies as a man with high-risk behaviour felt, “We should fulfil Discrimination, violence and family duties and be good with all harassment from family and people and leave bad behaviour community, alongside the pressure to behind.” In the context of Afghanistan, marry and fulfil social expectations, key informants agreed with this often drove men who have sex with justification of marriage, stating that men114 into considering, and possibly “homosexuality is a sin in the eyes
Chapter 7: Life course pathways between violence, mental health and HIV 93 Know Violence
of the religion and marriages are a with stress, and live in fear of others 116 Potentially a reference to the must, as these are expected things finding out about their extramarital fact that women in most parts of South Asia are expected to for a man to do.” Key informants same-sex practices. A participant in compromise and uphold the alluded to the larger social, religious focus group discussions for men who institution of marriage much and cultural contexts of countries have sex with men in Sri Lanka said, more than men. such as Afghanistan, where there “They might control themselves and 117 Choi et al. (2008). Social discrimination, concurrent are no existing role models for get married but after marriage, they sexual partnerships, and HIV men with high-risk behaviour and secretly continue with fulfilling their risk among men who have sex homosexuality is strongly condemned desires. If they are caught, they risk with men in Shanghai, China. AIDS Behavior 12, pp. S71–S77. with harsh penalties for deviance losing their family life and respect in (as documented in the previous society. There are some friends who chapters). have left their home and country due to such situations.” Studies show that Some men who have sex with men having multiple concurrent sexual faced this challenge more than partners is linked to overall higher HIV others. A focus group discussion transmission risk.117 Further, condom participant in Pakistan said, use with female partners is likely to “Masculine or male-presenting men be low, thus increasing risk of HIV who have sex with men face greater transmission to women. Married men pressure to get married as they do who have sex with men face additional not express their sexuality outwardly. pressure to have children. This results They are, however, believed to be in a lack of condom use, which can better able to work out the marriage place their female partners at greater compared to effeminate men who risk of HIV exposure. While this have sex with men, in whose case linkage has not been directly reported the onus to make the marriage work in the data, it is an interpretation falls more on the wives.”116 In such drawn from the narratives. environments, the internalization of social norms around “appropriate” behaviour may thus lead to marriage 7.4 Mental with women. health problems, substance abuse and When marriage with women takes place alongside sex outside the unprotected sex marriage with same-sex partners, the A final key area of connection connections can be traced between between SOGIE-based violence, the broader social context, the mental health and HIV was the individual sexual behaviours, and the impact of mental health problems, risk of both mental health issues and stemming from discrimination, on HIV. Participants in previous chapters risky sexual practices. As a man with describe the increased chances that high-risk behaviour in Afghanistan dual lives lead men to drink to cope noted, “Most of our men who have
94 Chapter 7: Life course pathways between violence, mental health and HIV Know Violence
sex with men suffer from mental health problems. They talk and laugh with themselves because of all these pressures and bad reactions. Some of us have left our families and live alone.” This isolation, alongside a lifetime of stigma and discrimination can lead to risky sexual behaviours. As a participant from focus group discussions for men who have sex with men in Pakistan said, “In a depressed state of mind, the individual indulges in sex with multiple sexual partners, even while telling themselves that they are not gay. Often there is a lack of safe space to have sex, leading to indiscriminate sexual encounters at different places where the use of a condom too may be rare.” Participants in Bhutan corroborated this statement, “People have anger issues, leading to their taking up substance use as a result of depression to neutralize pain, and indulge in unprotected sex.“ This pattern also appeared among focus group discussions with transwomen. A transwoman in Pakistan noted, “Use of substances like alcohol, drugs, cigarettes and sleeping pills to reduce stress is common among transwomen in Pakistan.” The mental health consequences of a lifetime of SOGIE-based violence – across multiple domains – can thus lead to the uptake of risky sexual behaviours as a coping strategy. Combined with the low levels of health care use described in Chapters 4 and 6, these links put men who have sex with men and transwomen at increased risk of HIV transmission.
Chapter 7: Life course pathways between violence, mental health and HIV 95 Know Violence
Chapter 8: Recommendations
96 Know Violence
Transwomen and men who have population. This section provides sex with men face multiple forms recommendations for multiple actors of SOGIE-based violence across and institutions across different levels Afghanistan, Bangladesh, Bhutan, of society, to address the experiences India, Nepal, Pakistan and Sri Lanka. of violence across the life courses of The results of this study demonstrate members of these groups, and the how SOGIE-based violence is long-term effects on mental health linked to mental health issues and and HIV. HIV vulnerability among the study
What can a policymaker do?
Recommendation Evidence
Repeal laws Legal discrimination towards those who engage criminalizing same-sex in same-sex behaviour creates an environment behaviour of impunity for those who are discriminatory and encourages the belief that men who have sex with men and transwomen are not equal citizens. This leads to increased violence and mental health problems. Enforcement of these laws can reduce the use of health care facilities and support networks.
Provide legal Lack of gender recognition hinders the ability of gender recognition transwomen to seek higher education. Lack of of third gender and education and the formal recognition of gender transgender people identity can be a barrier to stable work and the ability to make a living wage.
Include sexual and Men who have sex with men and transwomen face gender minorities in high levels of SOGIE-based violence, partly due laws and policies to to impunity and a lack of legal mandate against criminalize gender- these types of violence. Amendment of laws to based violence criminalize rape, sexual assault and domestic violence against sexual and gender minorities is an important step toward reducing violence and shifting norms that normalize or condone SOGIE- based violence.
Chapter 8: Recommendations 97 Know Violence
Pass anti- Protection against violence is not enough, when discrimination policies countries fail to also protect the broader rights across industries of sexual and gender minorities to live free from discrimination. Anti-discrimination laws for the workplace, housing and health care settings can help to reduce direct and indirect discrimination and abuse that men who have sex with men and transwomen experience, and mitigate the long- term effects of abuse.
Ratify the ILO Specific to the workplace, policy-makers Discrimination in countries that have yet to ratify the ILO (Employment and employment and occupation discrimination Occupation) Convention convention should advocate for its ratification in 1985 (No. 111) accordance with international legal and treaty standards.
Prohibit conversion Conversion therapy has harmful and long-term therapy effects on the mental health and well-being of those who undergo this “treatment” and constitutes a form of abuse against sexual and gender minorities.
Establish budget Funding is needed to build inclusive and allocations to design supportive policies across multiple domains, and implement including education, labour and health care. inclusive systems The allocation of resources to the development of these policies demonstrates a practical commitment to ending SOGIE-based violence.
98 Chapter 8: Recommendations Know Violence
What can the health care system do? 118 The Time Has Come package is a good example of training and sensitization material. UNDP and WHO (2013). The Time Has Recommendation Evidence Come: Enhancing HIV, STI and other sexual health services Establish formal Men who have sex with men and transwomen for MSM and transgender training and face considerable discrimination from health care people in Asia and the Pacific. sensitization providers. This discrimination and abuse stem, Bangkok, UNDP. Available at: http://www.asia-pacific.undp. mechanisms in in part, from lack of knowledge or awareness of org/content/rbap/en/home/ the curricula of the specific health needs facing these groups. library/democratic_governance/ medical and health With sensitization and education around hiv_aids/the-time-has-come/ care professionals sexual orientation and gender identity issues (including doctors, mainstreamed into curricula, more health care nurses, mental health professionals will be formally trained to respond professionals and adequately and appropriately to the health needs social workers) of men who have sex with men and transwomen.
Sensitize health care Ongoing professional training and education can providers around help to sensitize health care providers to SOGIE- SOGIE health issues related health concerns, and make them aware of biases, stigma and negative perceptions they may hold that negatively impact the quality of care for sexual and gender minorities.118
Integrate the rights Professional associations for medical and health of sexual and gender care professionals have codes of ethics that guide minority patients into behaviour. Revisions to codes of ethics to formally professional codes of declare the rights of sexual and gender minorities ethics can drive normative change in the health care system around SOGIE rights and well-being.
Create supportive A key barrier to health care access among the health care study population was the perception of stigma environments and abuse they would experience by health care providers. By demonstrating a visual understanding of SOGIE-issues (e.g., posters about population-specific health care issues), health care settings can demonstrate their commitment to improving the health of all, including sexual and gender minorities.
Chapter 8: Recommendations 99 Know Violence
Develop networks of Community-based organizations and civil society 119 UNESCO provides specific education policy guidelines community-based organizations are often the first stop for men who for the inclusion of SOGIE organizations and civil have sex with men and transwomen when they groups, for reference, see UNESCO (2016). OUT IN THE society organizations seek health care. Direct connections with health OPEN: Education Sector with the health care care institutions can facilitate the provision of Responses to Violence Based system health care to these hard-to-reach populations. on Sexual Orientation and Gender Identity/Expression. Declassify The declassification of homosexuality and gender France, UNESCO. Available at: http://unesdoc.unesco.org/ homosexuality and identity disorders from psychiatric diagnostic images/0024/002447/244756e. gender identity manuals can help to reframe the understanding pdf disorders of men who have sex with men and transgender people as normal and healthy, as opposed to deviant and pathological.
What can the educational system do?
Recommendation Evidence
Develop educational Participants of the study discussed schools as policies that prohibit a key place where they suffered SOGIE-based SOGIE-based violence violence during childhood and adolescence. This and discrimination in violence often contributed to high drop-out rates. schools Creating a safe space in schools can reduce violence during key development stages and increase the educational attainment of sexual and gender minorities.119
Build the capacity of Teachers, faculty, staff and administrators are teachers, faculty, staff often the first to hear of incidences of SOGIE- and administrators to based violence. These actors play a key role in respond to and prevent the frontline response to incidences of violence, SOGIE-based violence to reduce impunity and implement anti- discrimination school policies. Ensuring that schools have adequate information for referrals for further intervention, and friendly service providers will also help to mitigate the effects of school bullying and harassment.
100 Chapter 8: Recommendations Know Violence
Establish policies and Many study participants discussed barriers procedures to protect to higher education as a consequence of and promote the discrimination and stigma against sexual and rights of sexual and gender minorities. Implementation of formal gender minorities in policies and procedures to protect the rights admissions and testing of these populations can reduce barriers to educational attainment.
Integrate sexual Integrating the histories, cultures, experiences orientation and gender and needs of sexual and gender minority groups identity topics in school in school curricula can help to reduce stigma and curricula increase acceptance of these groups, as well as provide role models for students.
What can industries and workplaces do?
Recommendation Evidence
Implement inclusive The lack of recognition of a person’s gender policies and practices identity and sexual orientation can contribute in the workplace to a sense of hostility and discrimination in the workplace. Conversely, validation of a person’s gender identity and sexual orientation through formal policies and practices can create a supportive environment for gender and sexual minority groups. Examples include gender- neutral toilets, dress codes that do not impose specific gender identities on employees, and appropriate leave policies for HIV-positive employees.
Develop and implement Public and private sector workplaces can response mechanisms help to foster an inclusive and safe workplace against discrimination environment for sexual and gender minorities by in the public and taking active steps to implement responses to private sector incidents of discrimination or stigma.
Chapter 8: Recommendations 101 Know Violence
What can gender-based violence and sexual reproductive 120 Garcia-Moreno et al. (2015). The health-systems response to health programme teams do? violence against women. Lancet, 385, pp. 1567–79. Recommendation Evidence
Promote definitions of Gender and sexual minorities face high levels of gender-based violence discrimination, harassment and abuse. At the that include gender root of this violence are gender inequalities and and sexual minorities heterosexism. A broader framework of gender- based violence can facilitate greater attention to the experiences of these groups, and highlight the interlinkages between cisgender women’s experiences of violence and those of sexual minority women and trans and sexual minority men.
Sensitize gender- Gender-based violence and SOGIE-related based violence and issues remain largely separate from each sexual reproductive other in development work. However, there health practitioners to are considerable overlaps and commonalities the overlap between between these forms of violence. Greater gender-based violence conceptual awareness can lead to more nuanced and SOGIE-based interventions that are attuned to the overlapping violence experiences of multiple groups.
Build gender-based A systems-wide response to violence against violence response women is considered a gold standard of health services specifically care response.120 A parallel multisectoral tailored to sexual and response to SOGIE-based violence needs to be put gender minorities in place, in order to develop appropriate health systems responses to violence experienced by sexual and gender minorities. Gender-based violence programmes can help to advocate and begin planning for this type of systemic change in health care delivery.
102 Chapter 8: Recommendations Know Violence
Include sexual and Programmes to prevent gender-based violence 121 Groups like the Parents and gender minority groups – such as gender equality training in schools Friends of Lesbians and Gays in gender-based and programmes to transform harmful forms of (PFLAG) that are based in countries like the United States violence prevention and masculinity – can integrate sexual and gender of America and have also been response programmes minorities to provide more comprehensive established in Asian countries coverage, make programmes relevant to a like China and Vietnam are important support groups for broader group of participants, and prevent providing support and education overlapping forms of gender-based violence. to families of men who have sex with men. Of the seven South Link gender- The evidence presented in this study Asian countries in this research, based violence demonstrates the impact of violence on India is the only country that has initiated such a support prevention work HIV vulnerability. Greater integration and group for parents. The value with HIV prevention collaboration between agencies and organizations of this support group is best interventions working on gender-based violence prevention and highlighted by one of the family members who runs this support HIV prevention can help to respond to the specific group who said, “Many parents risk factors facing sexual and gender minority who attend our meetings feel that they are not alone and that groups. their children are not the only ones. We often discuss how Conduct formative More evidence on the specific forms of violence we all confront questions from research on the faced by sexual and gender minorities is needed extended family and neighbours specific gender- to ensure that programmes to respond and on things like ‘Why is your son not getting married?’ or based violence and prevent gender-based violence integrate and are ‘Your son seems to have very reproductive health aware of intersectional types of violence. Specific special friends’ … such sharing concerns of sexual and research is needed on the reproductive and sexual goes a long way in building the confidence of family members.” gender minorities health issues facing sexual and gender minorities.
Counselling and Participants noted the effects of their sexual support services for orientation or gender identity on their families, families and family expectations. In places where family counselling was available, this served as a bridge between the individual and their families. Gender- based violence prevention and response efforts can target greater awareness and mentorship of families, to build supportive home environments for men who have sex with men and transwomen in early childhood and adolescence.121
Chapter 8: Recommendations 103 Know Violence
122 See UNDP (2015). The Right(s) What can an HIV prevention programme team do? Evidence – Sex work, violence and HIV in Asia: A Multi-Country Qualitative Study for further recommendations specific to Recommendation Evidence sex workers. Synchronize SOGIE-based violence has considerable impact programme on HIV vulnerability. Integrating gender-based intervention design violence experts and programme staff into HIV with gender-based programmes can help to mainstream gender- violence experts based violence frameworks and response and prevention strategies into ongoing HIV programming.
Conduct capacity and Identify key gaps in knowledge around links needs assessments between SOGIE-based violence and HIV among with staff and partners programme staff and partners and build capacity development materials to increase awareness.
Work with police Study participants described violence by police officers and law and law enforcement officers. In addition, they enforcement to reduce did not have confidence that police officers would SOGIE-based violence respond appropriately to their experiences of and improve formal violence. This was particularly pronounced for responses sex worker communities. Increased education and sensitization, and building collaboration with police stations and law enforcement departments can create an environment in which violence is not perpetrated with impunity.122
Support community- For many men who have sex with men and based organizations transwomen, community-based organizations and and civil society civil society organizations provide critical health organizations, a and services and community support. Community- build networks based organizations and civil society organizations also serve as key advocates for the rights of men who have sex with men and transwomen, and build alliances with stakeholders such as doctors, mental health professionals, lawyers and police officers. These services are important to mitigate the effects of SOGIE-based violence. More networking and collaborations across the region can facilitate cross-national learning and build a collaborative movement to promote SOGIE rights and well-being.
104 Chapter 8: Recommendations Know Violence
What can researchers do?
Recommendation Evidence
Conduct research on More evidence is needed on country-specific links between SOGIE- patterns of interlinkages between SOGIE-based based violence, HIV and violence, HIV vulnerability and mental health and mental health other health outcomes
Conduct research Sexual minority women face a unique combination among sexual minority of gender-based violence due to their status women as women (at some period of the life course) and SOGIE-based violence due to their sexual orientation or gender identity. These experiences warrant further research, as little is known about this population in the Asia-Pacific region.
Chapter 8: Recommendations 105 Know Violence
Bibliography
106 Know Violence
Andersson, N., Cockroft, A. and Shea, B. (2008). FHI 360 (2013). Exploring gender-based violence Gender-based violence and HIV: Relevance for among men who have sex with men, male HIV prevention in hyperendemic countries of sex worker and transgender communities in southern Africa, AIDS, 22 Suppl 4 Bangladesh and Papua New Guinea. Available at: http://www.fhi360.org/sites/default/files/media/ Asia Pacific Forum of National Human documents/GBV%20Study%20report_Final.pdf Rights Institutions (2009). Conclusions of the Workshop on the Role of National Human Fulu et al. (2013). Why do some men use Rights Institutions in the Promotion and violence against women and how can we prevent Implementation of the Yogyakarta Principles. it? Quantitative findings from the United Nations Asia Pacific Forum of National Human Multi-country Study on Men and Violence in Asia Rights Institutions. Available at: https:// and the Pacific. UNDP, UNFPA, UN Women and www.outrightinternational.org/sites/default/ UN Volunteers: Bangkok. files/316-1.pdf Fulu, E. and Miedema, S. (2015). Violence against Barter, C. and Renold, E. (1999). The use women: Globalizing the integrated ecological of vignettes in qualitative research. Social model. Violence against Women, 21(12), pp. Research Update, 25. 1431–1455.
BBC (2016). Pakistan’s Transgender Community Global Commission on HIV and the Law (2012). Cautiously Welcomes Marriage Fatwa, 28 June HIV and the Law: Risks, Rights and Health. 2016. Available at: http://www.bbc.com/news/ UNDP. world-asia-36648141 Hagan, J. (2016). Sexual orientation and gender Beyrer, C. et al. (2012). Global epidemiology of identity as part of the Women, Peace and HIV infection in men who have sex with men. Security Project. Available at: http://blogs.lse. Lancet, 380 ac.uk/wps/2017/01/10/sexual-orientation-and- gender-identity-as-part-of-the-wps-project/ Carroll, A. and Mendos, L.R. (2017). State- sanctioned Homophobia (12th ed.). Geneva: Health Issues India (2013). Supreme Court International Lesbian, Gay, Bisexual, Trans and Verdict on IPC Section 377 Impedes Fight Intersex Association. Against HIV/AIDS. Available at: http://www. healthissuesindia.com/2013/12/17/supreme- Chakrapani, V., Newman, P.A., Shunmugam, M., court-verdict-ipc-section-377-impedes-fight- McLuckie, A. and Melwin, F. (2007). Structural hivaids/ violence against Kothi-identified men who have sex with men in Chennai, India: a qualitative Heise, L. (1998). Violence against women: An investigation. AIDS Education and Prevention, integrated, ecological framework. Violence 19(4). against Women, 4.
Choi et al. (2008). Social discrimination, Human Rights Campaign (2015). In a Historic concurrent sexual partnerships, and HIV risk Step, Nepal Ratifies New Constitution That among men who have sex with men in Shanghai, Includes LGBT Protections Available at: http:// China. AIDS Behavior, 12. www.hrc.org/blog/in-a-historic-step-nepal- ratifies-new-constitution-that-includes-lgbt- Council of Europe. (2007). Chapter 2: Gender- prote based Violence. Gender Matters: A manual on addressing gender-based violence affecting International AIDS Society (2014). Key Affected young people. Available at: http://www.eycb.coe. Populations – Men Who Have Sex with Men – int/gendermatters/chapter_2/1.html Factsheet, March 2014.
Firstpost (2013). Transgenders Officially a Jayadeva, C. (2017). Understanding the mental ‘Third Gender’ in Bangladesh, 14 November. health of the Hijra women of India. American Available at: http://www.firstpost.com/world/ Journal of Psychiatry, 12(5). transgenders-officially-a-third-gender-in- bangladesh-1229221.html
Bibliography 107 Know Violence
Kalra, G. and Shah, N. (2013). The cultural, OHCHR (2011). Discriminatory Laws and psychiatric and sexuality aspects of Hijras in Practices and Acts of Violence against India. International Journal of Transgenderism, Individuals based on their Sexual Orientation 14. and Gender Identity. OHCHR. Available at: http://www.ohchr.org/Documents/HRBodies/ Khan et al. (2005). Men who have sex with men’s HRCouncil/RegularSession/Session19/A- sexual relations with women in Bangladesh. HRC-19-41_en.pdf Culture, Health & Sexuality, 7(2). Orinam (2015). Telangana Hijra Intersex Khan F.A. (2016). Khwaja Sira Activism – The Transgender Samithi Responds to MSJE Politics of Gender Ambiguity in Pakistan, Transgender Rights Bill. Available at: http:// Transgender Studies Quarterly, Volume 3, No. orinam.net/telangana-samiti-response-msje- 1–2, Duke University Press. trans-rights-bill
Lawyers Collective (2016). Supreme Court Outright Action International (2014). Violence Recognizes the Right to Determine and Express through the Lens of Lesbians, Bisexual Women One’s Gender; Grants Legal Status to ‘Third and Trans People in Asia. New York. Gender’. People’s Union for Civil Liberties (2003). Human Lawyers Collective (2016). Supreme Court Sets Rights Violations Against the Transgender Aside the High Court Decision on Anti-Sodomy Community: A PUCL Report. A study of Kothi and Law: Huge Setback for LGBT Rights, Activists Hijra Sex Workers in Bangalore. Vow to Continue the Fight. Reisner et al. (2016). Global health burden and Logie et al. (2012). Adapting the minority stress needs of transgender populations: A review. model: Associations between gender non- Lancet, 388. conformity stigma, HIV-related stigma and depression among men who have sex with men Sivasubramanian et al. (2011). Suicidality, in South India. Social Science & Medicine, 74. clinical depression, and anxiety disorders are highly prevalent in men who have sex with men Mago, A. (2012). South Asia Roundtable in Mumbai, India: Findings from a community- Dialogue: Legal and Policy Barriers to the HIV recruited sample. Psychology, Health & Response, IDLO. Medicine, 16(4).
Miedema, S. et al. (2017). Integrating male Safren et al. (2009). Depressive symptoms and sexual diversity into violence prevention efforts human immunodeficiency virus risk behaviors with men and boys: evidence from the Asia- among men who have sex with men in Chennai, Pacific Region.Culture, Health & Sexuality, India. Psychology, Health & Medicine, 14(6). 19(2). Sarkar, A. and Nath, P. (2013). Preparing for Mills, E. (2015). Gender, Sexuality and the Section 377 Verdict, ‘Varta’, December. Available SDGs: An Evidence-base for Action, Institute of at: http://varta2013.blogspot.in/2013/12/ Development Studies. Available at: http://www. preparing-for-section-377-verdict.html. ids.ac.uk/opinion/gender-sexuality-and-the- sdgs-an-evidence-base-for-action Shaw et al. (2012). Factors associated with sexual violence against men who have sex Ministry of Health and Population (2015). Nepal with men and transgendered individuals in Country Progress Report on HIV/AIDS Response Karnataka, India. PLOS One, 7(3). 2014. Solomon, S.S. et al. (2015). High HIV prevalence National AIDS Control Programme of and incidence among MSM across 12 cities in Afghanistan and Johns Hopkins University India. AIDS, 29(6). (2012). Integrated Behavioural and Biological Surveillance in Afghanistan. Kabul, Afghanistan.
108 Bibliography Know Violence
Sustainable Development Knowledge UNDP, IDLO (2013). Regional Report: The Platform. (2015). Transforming Our World: The Capacity of National Human Rights Institutions 2030 Agenda for Sustainable Development, to Address Human Rights in Relation to Sexual United Nations. Available at: https:// Orientation, Gender Identity and HIV. Bangkok, sustainabledevelopment.un.org/post2015/ UNDP. transformingourworld UNDP, APF (2016). Promoting and Protecting The Hindu (2017). All you need to know about the Human Rights in relation to Sexual Orientation, Transgender Persons Bill, 2016. 30 November. Gender Identity and Sex Characteristics: A Available at: http://www.thehindu.com/news/ Manual for National Human Rights Institutions. national/all-you-need-to-know-about-the- Available at: http://www.asia-pacific.undp.org/ transgender-persons-bill-2016/article21226710. content/rbap/en/home/library/democratic_ ece governance/hiv_aids/promoting-and-protecting- human-rights-in-relation-to-sexual-orie.html Times of India (2016). Govt. agrees to remove ‘eunuch’ from Police Act. UNDP, APTN (2017), Legal Gender Recognition: Available at: http://timesofindia. A Multi-Country Legal and Policy Review in Asia. indiatimes.com/articleshow/50556225. Available at: http://www.asia-pacific.undp.org/ cms?utm_source=contentofinterest&utm_ content/rbap/en/home/library/democratic_ medium=text&utm_campaign=cppst governance/hiv_aids/legal-gender-recognition-- a-multi-country-legal-and-policy-revie.html Times of India (2018). Supreme Court to review Section 377 which criminalises gay sex, 8 UNDP, SAARCLAW (2014). South Asia Regional January. Available at: https://timesofindia. Advocacy Framework and Resource Guide: indiatimes.com/india/supreme-court-to- HIV, Human Rights and Sexual Orientation and review-article-377-which-criminalises-gay-sex/ Gender Identity, UNDP. articleshow/62412768.cms UNESCO (2016). OUT IN THE OPEN: Education UNDP (2012). Country Snapshots: Bangladesh, Sector Responses to Violence Based on Sexual India, Nepal, Pakistan and Sri Lanka. Available Orientation and Gender Identity/Expression. at: http://asia-pacific.undp.org/practices/ France, UNESCO. Available at: http://unesdoc. hivaids/ unesco.org/images/0024/002447/244756e.pdf
UNAIDS (2013). HIV in Asia and the Pacific Van Griensven, F. and de Lind van Wijngaarden, – UNAIDS Report 2013. Available at: http:// J.W. (2010). A review of the epidemiology of HIV www.unaids.org/sites/default/files/media_ infection and prevention responses among men asset/2013_HIV-Asia-Pacific_en_0.pdf who have sex with men in Asia. AIDS, 24 Suppl 3.
UNAIDS (2016). Sri Lanka’s Supreme Court WHO (2001). Putting women first: Ethical Makes Landmark Decision Prohibiting HIV and safety recommendations for research on Discrimination, 4 June 2016. Available at: http:// domestic violence against women. Geneva: WHO. www.unaids.org/en/resources/presscentre/ featurestories/2016/may/20160502_Srilanka_ nodiscrimination
UNAIDS (2016). Global AIDS Update 2016. Available at: http://www.who.int/hiv/pub/arv/ global-AIDS-update-2016_en.pdf?ua=1
UN Habitat and UNAIDS (2015). Ending the AIDS epidemic: the advantage of cities. United Nations Human Settlements Programme. Nairobi; UNAIDS (2017).
Bibliography 109 Know Violence
Appendices
110 Know Violence
Appendix I: Rationale for site selection at each study site
Number of sites for Focus Groups Country Discussions (FGDs) FGDs and KIIs per site Justification for site selection and Key Information Interviews (KIIs)
Afghanistan Kabul 2 FGDs with men with Recruitment was feasible in Kabul. high-risk behaviour
5 KIIs (2 officials from the National AIDS Program, 1 head of a CBO, 1 medical doctor at a CBO and 1 counsellor)
Bangladesh Dhaka and Sylhet 4 FGDs, 2 per site Dhaka has the oldest CBO and reaches a diverse population. 9 KIIs (3 heads of CBOs/ activists, 1 lawyer, Sylhet is Hindu-dominated and offered diverse data. 3 counsellors and 2 doctors)
Bhutan Thimphu 1 FGD per site (MSM) Recruitment of men who have sex with men was feasible only in the capital city. 5 KIIs (1 NACP official, 1 Health Ministry official, 2 community activists and 1 doctor)
India Maharashtra and 4 FGDs, 2 per site Maharashtra and Chhattisgarh were selected as there Chhattisgarh is little information on the situation of violence faced 9 KIIs (2 lawyers, 2 by men who have sex with men in these states. States transgender community were selected to represent a mix of high and low HIV leaders, 2 counsellors, prevalence states. Maharashtra is a high prevalence state 1 doctor and 2 MSM with good penetration of HIV programmes and men who community activists) have sex with men and transwomen have relatively more access to resources, whereas a low prevalence state like Chhattisgarh has very little information available to men who have sex with men and transwomen as the HIV programmes are new and men who have sex with men and transwomen are likely to have less access to services. Thus, a diversity in responses can be expected.
Appendices 111 Know Violence
Appendix I: Rationale for site selection at each study site
Number of sites for Focus Groups Country Discussions (FGDs) FGDs and KIIs per site Justification for site selection and Key Information Interviews (KIIs)
Nepal Kathmandu and Virat 4 FGDs (2 FGDs in Virat Sites were chosen to represent different regions and Nagar Nagar and 2 FGDs in capture data from varied subgroups of men who have sex Kathmandu) with men and transwomen.
8 KIIs (2 counsellors, 1 transgender community activist, 2 CBO heads, 1 lawyer and 2 National HIV Program officials)
Pakistan 2 sites – Lahore and 4 FGDs – 2 FGDs per site Lahore and Karachi have operational programme sites Karachi and are relatively safer than alternative sites in North- 5 KIIs (1 counsellor, 1 western Pakistan. MSM community activist, 2 heads of CBO/activists and 1 transgender community activist)
Sri Lanka 1 site –Colombo 2 FGDs in Colombo Most participants lived in Colombo.
8 KIIs (2 transgender activists, 1 National HIV Programme official, 1 NGO head and 4 MSM community activists)
112 Appendices Know Violence
Appendix II: Ethical review procedures across study countries
Country Ethical review process Name of the approval body / Organization / Affiliations of expert committee
Afghanistan Institutional Review Board Ministry of Public Health, Afghanistan
Bangladesh Expert Committee ICDDRB (in voluntary capacity)
Responsive to Integrated Development Services (RIDS)
Asia Pacific Network of Sex Workers (APNSW)
Bhutan Research Ethics Board Ministry of Health, Bhutan
India Institutional Review Board ICRW, Institutional Review Board, Washington DC
Sigma-IRB, India
Nepal Expert Committee Climate Change Hazards Project supported by World Bank
Independent consultant
Pakistan Expert Committee London School of Hygiene and Tropical Medicine
Rozan
Independent Consultant
Sri Lanka Expert Committee Women and Media Collective
University of Colombo
Samutthana: The King’s College London Resource Centre for Trauma, Displacement and Mental Health
Appendices 113 Know Violence
Appendix III: Focus group No names are to be used by the discussion guidelines for respondents while sharing any experiences. Encourage respondents men who have sex with to share observations, concerns men and opinions about their community rather than personal experiences. Instructions to the Facilitator: The focus group discussion should be conducted by at least two people. A field guide is a guidance document. There should be a moderator and Though efforts should be made to a note-taker. Please ensure that follow the guide, skilled facilitators everybody gets a chance to speak. may change the sequencing of The discussion should be held with questions as per the flow of the the consent of each participant in the discussion. Each of the topic areas group. should be covered during the discussion. The questions indicated Note to facilitator: Speak about are just examples. This is the type the background of the study and of information we are interested in, confidentiality; reiterate the need to but how the question is asked will maintain confidentiality about what depend entirely on how the discussion gets shared in the group. Take a is going. You are requested to use five-minute break after each vignette. these pointers only as a guide to Make sure that refreshments are start off a discussion. Please allow served during the focus group your group to discuss; listen to them discussion. carefully. Make them feel that their opinions are very important to you and to the project. If you think that GUIDELINES the discussion is getting unfocused, Today, we will be discussing issues please do not cut them off rudely. around the lives of men who have Use your moderation skills to get sex with men in your country. We do back to the issue. The questions are not expect you to share any kind of not meant to limit the discussion, but personal information but you can rather to keep it on track. speak about ideas of the community Remember there are no right or in general. wrong answers! Let’s begin. I will read out a vignette, a small story of an individual. Please Begin the discussion by explaining listen to the story carefully. I will the study, its goal and objectives, then ask you questions about the and how the current discussion story that will help us understand fits into the overall goal. Reiterate issues faced by men who have sex that the discussion is confidential. with men in your country.
114 Appendices Know Violence
Vignette 1 Could you describe the social life of Anil? Anil is an 18-year-old boy. Anil’s friends have girlfriends; they talk Probes: about girls in a sexual way and —— Who does he make friends with? fantasize about them. Anil does (check for loneliness/isolation/ not enjoy such talks and cannot feelings of alienation) participate in them. He too has girls —— How does he express his sexual as friends but does not feel attracted feelings towards other men? towards them like his friends do. On the contrary, Anil notices that —— Does he find friends who don’t when he sees some men he feels react negatively to him? sexual attraction towards them. Anil remembers having similar feelings What are some of the places and since he was 12 years old. He feels organizations that Anil can go to there is something different in him for help (The facilitator should list and he is the only person who has suggestions)? such feelings. Even the other boys have noticed that he is not like them Now, moving on, let us think about in many ways. Anil further:
What do you think happens to boys Could you describe the typical like Anil in our society? situations in which Anil is likely to have his first sexual encounter? Probes: Who would the first sexual encounter —— What reactions do they face from likely to be with? A boy or girl? family, school, religious leaders Either? (The facilitator should let the and society in general? How do group share their responses before they deal with them? asking the next probe) —— What is the effect (physical and emotional) of these reactions —— Is this encounter with someone on Anil? older or with boys or girls of —— How do people like Anil cope with same age? being “different” – how do they —— What type of sexual activities deal with negative reactions from might they be? others?
Appendices 115 Know Violence
How likely is this first sexual Does Anil’s same-sex sexual encounter to be at a boy’s own will? orientation get revealed to his family (The facilitator can ask this as a and friends? How? percentage) Probe: Is he likely to be forced to have sex by —— Is the disclosure voluntary or others? By whom? involuntary (probe for both)?
What are the likely places where Anil —— What are the typical reactions in is likely to meet other male sexual case of disclosure: how do family, partners and have sex? What are friends react? examples of some places? What help do you think people like What are the circumstances in which Anil need? How can he be helped? sex happens between two men? (Facilitator should list strategies and ask the group to prioritize the three Which of these situations may most important) compel men who have sex with men to engage in activities that harm Do you think Anil can approach their lives? (e.g., high-risk sexual someone or some organization for behaviours or being forced into help? (Facilitator should note down sex work as a vocation) (Explore the services listed) differences if any as per the identity of young men) Now, let’s read the second story and continue the discussion. Please feel Probe: free to ask for any clarifications.
—— Lack of safe space and privacy —— Lack of access to condoms —— Physical environs like bushes/ jungles/abandoned buildings
Are there any sources of help available in the community for young men like him?
116 Appendices Know Violence
Vignette 2 —— Do you think these reactions are different for young men who are Akash is 30 years old, and works effeminate and those who are not hard to support his parents. His effeminate? How? Why? family is happy with him and feels —— What is the effect of these that he is a responsible son. They reactions on the physical and expect that he should get married to mental health of the man? Is the a woman. Akash’s family has a lot of effect different for effeminate and expectations from him and force him masculine men, older men who to consider marriage proposals. On have sex with men, younger men several occasions, Akash has tried who have sex with men? to escape marriage by giving various —— How do men who have sex with reasons, but in vain. Akash is well men deal with these reactions? aware of his attraction to other men and in fact has a regular male partner –– What strategies do they use to who lives in the same community. protect themselves? Akash feels that he should run away –– Do they use any strategies that from home to escape marriage on harm them? e.g. risky sexual one hand, but also feels that he has behaviours, substance use, to fulfil his duties towards his parents sex work. on the other. He is wary of leading a double life and lives in constant Do people like Akash leave their fear of being “found out”. He is village and migrate to other places? contemplating leaving his hometown to go to some other place … but is What would you advise Akash to do in unable to decide this situation?
Do such situations occur with people —— Are there any services Akash can in your country too? How different seek? (List services mentioned). If are these situations than the one he lived in your community, where described above? could he go for services? —— What kind of experience would How does the family respond in Akash have with various health situations like the one just discussed? providers (counsellors, lawyers)? (Explore physical, sexual, emotional, economic violence) What kinds of services are needed for men like Akash? (Facilitator should How do people in the neighbourhood list strategies and ask the group to treat people like Akash? How do prioritize the three most important) families treat family members like Akash? (Explore physical, sexual, emotional, economic violence)
Appendices 117 Know Violence
Vignette 3 Which types of subgroups of men who have sex with men are more likely to Ramesh, 25, is sexually attracted to face violence? other men. He used to have sex with his friends in his neighbourhood. Over —— Probe: Effeminate versus a period of time, he started meeting masculine men, people with men from outside his neighbourhood strong social networks versus and got to know about places where weak social networks, old versus men can find other men for sex. young men, sex workers Ramesh frequently visits cruising sites while returning from work. One What are the impacts of violence on such evening while returning from sexual health? work, he visits the public cruising site and finds an attractive man. They —— Would condoms be used when interact with each other and agree to sexual abuse takes place? go to a park nearby to have sex. In the —— Physical problems such as midst of having sex in the park, they anal tearing, bleeding and are surrounded by men who catch uncomfortable sex acts hold of Ramesh and beat him and take —— Gang rape away his valuables and money. One of them also forces Ramesh to have In case of unprotected sexual sex with him. While this is happening, violence, are there places where the other man runs away from the Ramesh can go and seek medical situation. help?
Are you familiar with similar —— Probe: medical check-ups, post- scenarios in your context? Could you exposure prophylaxis. describe a few? How do you think Ramesh will be What are the different forms of treated by health providers? violence that happen to men who have sex with men in your community? What are the impacts of violence on mental health? —— Probe for physical, sexual, verbal and mental forms of violence —— Probes: Trauma, depression, suicidal ideation. Who are the different people who commit violence on men who have sex with men?
—— Probe: policemen, local goons, family, partner, friends
118 Appendices Know Violence
What do people like Ramesh do when Thank you for an enriching they are faced with such kinds of discussion. Is there anything that you problems? would like to add?
—— Probe: Do they seek help or refuse Note: Names used in the vignettes to seek help from others? were changed according to various study sites. How do you think Ramesh will be treated by a counsellor? Are there friendly counsellors?
How likely is Ramesh to go to the police with his complaint? If he goes, how would he be treated by the police?
Do people in situations like Ramesh seek legal aid? What are their experiences in seeking legal aid?
Are there are any organizations that Ramesh can approach with this problem to seek help?
—— Probe: Mental health counselling, legal counselling.
Are there any other local informal groups that can help Ramesh in dealing with this crisis situation?
What else do you think needs to be done to reduce the rates of violence against men who have sex with men
—— Probe: Advocacy and sensitization programmes?
Appendices 119 Know Violence
Appendix IV: Focus group respondents while sharing any discussion guidelines for experiences. Encourage respondents to share observations, concerns transwomen and opinions about their community rather than personal experiences. Instructions to the Facilitator: The focus group discussion should be conducted by at least two people. A field guide is a guidance document. There should be a moderator and Though efforts should be made to a note-taker. Please ensure that follow the guide, skilled facilitators everybody gets a chance to speak. may change the sequencing of The discussion should be held with questions as per the flow of the the consent of each participant in the discussion. Each of the topic areas group. should be covered during the discussion. The questions indicated Note to facilitator: Speak about are just examples. This is the type the background of the study and of information we are interested in, confidentiality; reiterate the need to but how the question is asked will maintain confidentiality about what depend entirely on how the discussion gets shared in the group. Take a is going. You are requested to use five-minute break after each vignette. these pointers only as a guide to Make sure that refreshments are start off a discussion. Please allow served during the focus group your group to discuss; listen to them discussion. carefully. Make them feel that their opinions are very important to you and to the project. If you think that GUIDELINES the discussion is getting unfocused, please do not cut them off rudely. Today, we will be discussing issues Use your moderation skills to get around the lives of transwomen back to the issue. The questions are in your country. We do not expect not meant to limit the discussion, but you to share any kind of personal rather to keep it on track. information but you can speak about ideas of the community in general. Remember there are no right or wrong answers! Let us begin. I will read out a vignette, a small story about an Begin the discussion by explaining individual. Please listen to the story the study, its goal and objectives, carefully. I will then ask you a few and how the current discussion questions about the story that will fits into the overall goal. Reiterate help us understand issues faced by that the discussion is confidential. the transgender community in your No names are to be used by the country.
120 Appendices Know Violence
Vignette 1 What do you think are the different places that her parents might have Manju, age 35, has since childhood taken her to change her behaviour? felt that she is a woman trapped in a man’s body. From childhood, —— Probe: quacks, religious places, she used to wear female dress and psychiatrists behave like a female. Her parents and siblings always scolded her to What do you think about her leaving change her behaviour. One day, she home? was caught wearing her sister’s dress and ornaments. Her parents took —— Probe: Is it common and why her to different places to change her do people prefer to leave their behaviour. Manju was distressed and birthplaces and migrate to another eventually decided to run away from location? home. She moved to another city and found people who were like her and What might be the support systems started staying with them. She liked available for Manju when she is in a staying with these people as she different city? could live as a woman; however, she —— Probe: Peers from transgender/ had to beg and engage in sex work to Hijra community, gharanas, dera, make enough money to survive. CBOs How do you think people like Manju are treated in society? What role does the transgender/Hijra community play in the lives of people What would have been Manju’s feeling like Manju? when she realized that she was a woman trapped in a man’s body? —— Probe: Shelter, source of livelihood, support for health —— Probe about confusion, seeking acceptance, other feelings What are the different livelihood What could be the reasons that Manju options available for transwomen? was not accepted by her parents and siblings? —— Probe: Begging, sex work, dancing, working in NGO/CBOs —— Probe about gender roles, shame for family, societal reasons
Appendices 121 Know Violence
What are the problems faced by In general, what do you think about transwomen like Manju in these condom usage within the transgender livelihoods? community?
—— Probe: Violence across all the —— Probe: Do transwomen use livelihood options; how do people condoms all the time (on a scale of react to a transwoman begging? 1 to 10, how often do transwomen Are transwomen involved in use condoms? any religious rituals? How are —— Probe: Do transwomen use they treated in these rituals like condoms with all sexual partners welcoming a newborn? What or only a few (check whether applies to your country? people use condoms with clients, —— Probe: Where does sex work take casual partners and regular place? Who are the clients? Are partners/intimate partners)? there regular partner/s? What problems arise during sex work: How do people like Manju cope with police interference, blackmail, the various challenges in their lives? extortion, rape, forced sex. What about condom usage? —— Probe: On a scale of 1 to 10, how many people like Manju will What do you think about Manju’s sex use alcohol, tobacco or other life? Do you think the difficulties and substances? Any steps taken to risks among transwomen are also reduce substance use? related to their intimate relationships —— Probe: Support from community in with other male partners and dealing with adverse experiences relationships between a transwoman —— Probe: Community rituals such as and her giriya or panthi? celebrations that foster a sense of “belonging” —— Probe: Regular partners, type of relationship with intimate What is the effect of her life partners? Do they live with them experiences on Manju’s mental or are they clients? health? —— Probe: Violence in intimate relationships with regular —— Probe: Do some transwomen partners (extortion, blackmail, attempt suicide? other forms of violence, etc.) —— Probe: What are other signs of tension and stress? How do they seek relief? Do they go to professional counsellors/mental health professionals? Experiences with mental health providers?
122 Appendices Know Violence
Vignette 2 What kind of help does Kiran need in the situation described above? Kiran is a 30-year-old transgender woman who lives in a small town with —— Probe: Psychosocial support, other members of the transgender medical support, legal support, community. Like many other friends HIV testing, financial support, any in her community, Kiran begs and other support? does sex work for a living. One day, Kiran was waiting at her usual spot What do you think Kiran or similar on the highway to look for clients. members of the community will do Kiran was approached by a man when faced with situations like the who showed an interest in her. Kiran one described above and the other responded to him and expressed similar situations described by you? interest; however, as they got closer the man suddenly withdrew and —— Probe: Who do they typically go to began hitting Kiran and calling her (community/friends/CBOs/police/ bad names. He accused her of doing doctors/lawyers)? “dirty work” and threatened to take —— Probe: What kind of experiences her to the police. He let go of Kiran do they have with each kind of only after taking all her money away source (community/friends/CBOs/ and leaving her injured. police/doctors/lawyers)? —— Probe: What kinds of services are What do you think about the situation needed to help people like Kiran? faced by Kiran? Do other transwomen face similar situations? Could you What are some of the strategies that elaborate on some? transwomen community members can use to protect themselves while What do you think happened in this doing sex work, or even begging, situation? so as to avoid situations like Kiran faced? —— Probe: Who are people like the male client in the story? What other —— Probe: Strategies followed at an things happen to people like Kiran individual level, e.g. negotiating in similar situations? What kind of safety, developing friendships with violence could Kiran have faced? gatekeepers at sex spots, going out in small groups/pairs, avoiding What impact do you think this certain places, etc. situation will have on Kiran? —— Probe: Strategies followed at a —— Probe: Physical, emotional, sexual community level, e.g. negotiating health. Risk of exposure to HIV safety with gatekeepers at sex infection. spots (paying a part of their earnings to gatekeepers, scouting
Appendices 123 Know Violence
for “safe spaces”, building —— Probes: What are their alliances with truck drivers, etc. experiences? How do they Check for any innovative ideas.) surmount difficulties in access? —— Probe: Strategies followed by —— Probe: Who helps and who does CBOs working for transgender not? What works and what does communities (sensitization not? programmes with police, health providers, availability of friendly What could be done to help services etc.) transwomen access services? (Facilitator should write down the Where and who do transwomen strategies and ask participants to go to get treatment for any illness prioritize the three most important (including HIV)? What are their ones). general experiences? —— Probe: What needs to happen? How would you like to help people like (Change law, sensitize society and Kiran? service providers, etc.)
—— Probe: What do you think can be Thank you for an enriching done to help transwomen? (The discussion, is there anything that you facilitator should write down the would like to add? strategies and ask participants to prioritize the three most important Note: The names used in the ones.) vignettes were changed according to the various study sites. Let’s talk a bit about the experience of transwomen in health and other services in your society.
Is the social environment conducive or non-conducive for transwomen to get equal opportunities as compared to other people? How?
—— Probe: What are the reasons for equality or inequality? Who are involved in fostering inequality? —— Probe: How does inequality impact the lives of transwomen?
Are transwomen able to access different public and health services?
124 Appendices Know Violence
Appendix V: Key sex with men and transwomen Informant Interview participants cope with violence and what roles do various stakeholders guidelines play in mitigating violence and its effect. Also, we would like to know SOGIE-based violence against what various stakeholders feel about men who have sex with men and the situation of men who have sex transwomen in South Asia with men and transwomen in your country. I would like to discuss with How many years have you been you briefly about various issues working on issues of HIV and sexual that affect the sexual minority minorities? communities in your country. Designation: 1. How would you describe the overall Qualifications: environment for men who have sex with men and transwomen in your As a service provider, who do you country? provide services to? Men who have sex with men only/ transwomen only/ Probes: both men who have sex with men and —— Social: family, general community transwomen norms around sexuality —— Religious: religious sanctions, any Thank you for agreeing to participate religious penalties/diktats etc. in this discussion. To tell you briefly about this research study, we are 2. How would you describe the overall undertaking a study entitled, Know legal context for men who have sex Violence: Exploring the links between with men and transwomen in your violence, mental health and HIV country? risk among men who have sex with men and transwomen in South Asia. Probes: Under this study, we are conducting research with men who have sex with —— Legal status of same-sex men and transwomen to understand behaviour, gender-affirmation their experiences of SOGIE-based surgery violence, causes, manifestations and —— Activism against sodomy laws, etc. consequences of violence and how —— Hate crimes against sexual violence makes men who have sex minority individuals with men and transwomen vulnerable to HIV. 3. Thank you for discussing with me about the overall social and legal An important piece of this research environment for men who have sex is to understand how men who have with men and transwomen. I would
Appendices 125 Know Violence
like to know a little more about the 6. Does stigma and discrimination communities of men who have sex for transgender people differ from with men and transwomen? Could the situation you just mentioned and you tell me what are the various ways how? in which sexual minorities in your country congregate to meet with each 7. In the face of stigma, other to develop their sexual and discrimination and social isolation, social networks? where do sexual minority groups seek help and support? Probes: Probe: —— Public spaces —— Explore – networking using —— CBOs/NGOs/government technology – like chat rooms, cell- institutions? phones —— Community/informal networks —— Cruising spots like bars, parks, 8. Let’s talk a little more about public spaces, etc. health care, how easy or difficult —— Use of drop-in centres in CBOs do transwomen and men who have sex with men find it to access 4. How well are members of sexual health care? What are some of their minority groups accepted by their experiences? families? Probe: Probes: —— Do these experiences differ —— Explore pressure for marriage between men who have sex with —— Are effeminate men and men and transwomen? Why? transwomen treated differently than masculine men who have sex 9. Do transwomen and men who with men? have sex with men face barriers in —— How do men who have sex with seeking redress for abuse, assault men deal with family pressures? and crimes? Who helps them with such issues? 5. What is the status of stigma and discrimination faced by men who have Probes: sex with men in your country? —— Legal redress in the case of violence or denial of rights Probe: —— Grievance against hate crimes —— School/educational settings —— Explore existence of friendly —— Workplace lawyers, police and religious —— Health care leaders —— Other services
126 Appendices Know Violence
10. In the context of HIV, what are 13. Given that despite the hostile the major HIV prevention needs atmosphere, there are still friendly of men who have sex with men service providers like yourself that and transwomen in your country? provide services to sexual and gender To what extent are the current minorities, what strategies do you use HIV programmes able to address to overcome some of the barriers that these needs? we just discussed?
11. In your opinion, what needs to Probes: be done differently to reduce the —— Check how people interpret HIV-related risks and vulnerabilities relevant laws of men who have sex with men and transwomen? —— Did people seek information to fill in their knowledge gaps about the Probes: community? —— How did they come to engage with —— Advocacy needs the community? —— Programme restructuring —— Making the larger social and legal 14. As a friendly service provider, context more conducive how do you negotiate with the larger society to improve the rights of 12. It is documented that in several men who have sex with men and countries men who have sex with transwomen individuals who seek men and transwomen often face your assistance? Could you give me stigma while seeking various services examples from your work as to how like health, law enforcement etc. you handled sensitive situations? What are some barriers that various service providers face while providing Probes: services? —— In the case of lawyers – explore situations where legal redress Probe: was achieved or attempted and —— Knowledge gaps what helped them to assist men —— Need for training who have sex with men and —— Lack of exposure transwomen —— Fear of legal and social —— In the case of doctors – explore ramifications situations where giving health care required them to confront —— Homophobia their own attitudes in associating —— Existing laws that criminalize themselves with certain CBOs same-sex behaviours or even being seen talking to transwomen and men who have sex with men by others
Appendices 127 Know Violence
—— In the case of police – explore men who have sex with men and situations when they negotiated transwomen? safety for transwomen and men who have sex with men b. What are the challenges faced —— In the case of CBO leaders – by CBOs in reaching out to sexual explore situations in which and gender minority groups? they run programmes in an Probes: environment of fear. —— Unwillingness of the groups to 15. Do others in your community, associate with the CBO friends or family know that —— Hostile social and legal you provide friendly services to environment transwomen and men who have sex with men? Do people know that you c. What do you think could be interact with men who have sex with done to increase the participation men and transwomen? of sexual and minority groups (men who have sex with men and Probes: transwomen) in CBO activities? —— Check for disclosure and consequences of disclosure Thank you for an enriching —— Check for fear or threats perceived discussion. Is there anything that you by Key Informants in being openly would like to add? associated with transwomen and men who have sex with men —— Explore instances of rejection, ridicule or stigma from others experienced by the Key Informant for providing services to men who have sex with men and transwomen
16. What could be done to make service providers more responsive to the needs of men who have sex with men and transwomen?
If you are interviewing CBO staff, only ask the following three questions:
a. Could you elaborate a bit on the role of the CBOs in the lives of
128 Appendices
United Nations Development Programme Bangkok Regional Hub 3rd Floor United Nations Service Building Rajdamnern Nok Avenue Bangkok 10200, Thailand Tel: +66 2 304-9100 Fax: +66 2 280-2700 Email: [email protected] Website: http://www.asia-pacific.undp.org/