The Nexus of and HIV among People in Kenya

SUMMARY PAGE Gender norms and inequalities increase transgender people’s experiences of violence and HIV risk while limiting their service uptake. Specific gender-related beliefs (however untrue) are one cause of stigma and discrimination against transgender people and a reason that HIV programs rarely reach transgender people. Acknowledging and working to transform the gender norms most harmful to the transgender community is an important first step in developing effective programming by and for transgender people.

Harmful gender-related beliefs most relevant to transgender people • Transgender is the same as • Trans women have degraded This brief was developed to homosexual/gay. themselves by becoming women instead encourage and inform gender- • Transgender is a Western invention and of remaining men. integrated HIV prevention, care, not African. • Violence toward transgender people and treatment programming for transgender people in Kenya. It • Transgender people are confused or is deserved; transgender people bring can be used by individuals and mentally ill, and they need to be fixed or violence onto themselves. organizations that deliver services grow out of it. • The most important thing about a trans to transgender people; those woman is how she looks. • Transgender people are cursed participating in program design or possessed. and monitoring and evaluation; and decision makers and funders supporting the programs. It is one Recommendations in a series of briefs on the Nexus • Include transgender people as a • Integrate violence response of Gender and HIV among key key population in the Kenya AIDS services into HIV-related services for populations most affected by HIV: Strategic Framework. transgender people. men who have with men, sex • Train clinic staff to provide trans- • Work directly with perpetrators workers, transgender people, and competent care at strategically selected of violence, such as the police, to people who inject drugs. Information sites offering HIV services. prevent violence. relevant to individuals who are • Increase the provision of holistic care, • Explicitly discuss and challenge the members of multiple populations including the provision of gender- gender-related beliefs that put transgen- (such as transgender sex workers) affirming services, in clinical settings der people at risk for HIV and violence as can be found across the series. that offer HIV services. well as limit their uptake of services. • Provide support so that community- • Invest in community education based organizations and health care and awareness, both inside the size and inform programming for facilities that transgender people already transgender community and with transgender people. know and trust can offer HIV-related the broader community. • Employ monitoring and evaluation that information and services. • Conduct further research, in disaggregates program data for key • Invest in empowerment for transgender collaboration with the transgender populations (KPs) in a way that correctly individuals and organizations. community, to estimate population identifies transgender people. BACKGROUND partners, experience difficulty negotiating It can further identify the gender norms and condom use. Appropriately, HIV programs inequalities that cause many of the issues There are no data on HIV prevalence among respond to these realities through gender the transgender community faces and help transgender people in Kenya. Globally, integration. Gender integration has been shown identify ways to approach these long-standing transgender women are 49 times more to improve and sustain HIV programming problems by addressing gender-related root likely to be living with HIV than are adults outcomes. 2, 8, 9 causes. Finally, a gender analysis can be used in the general population,6 and research to advocate for transgender people to be demonstrates that transgender sex Systematic gender integration has not been recognized as a KP and for their needs to be workers in multiple settings have a higher widely employed in KP programming.10 understood and met in HIV programming. HIV prevalence than their male or female However, this approach is vital because gender counterparts.7 To inform HIV programming norms and inequalities negatively affect KPs, for all transgender people, the USAID- and METHODS and their effects are often amplified because PEPFAR-supported LINKAGES project they occur not only when KPs and those The gender analysis with transgender people conducted a gender analysis to examine around them conform to gender norms but also was part of a larger gender analysis conducted how gender norms and inequalities affect when KPs are perceived to be non-conforming. in Nairobi with the four KPs that are the transgender people’s HIV risk and uptake of A gender analysis is the first step in the process focus of the LINKAGES Project. The trans services across the HIV prevention, care, and of gender integration and an important tool for portion of the analysis consisted of a desk treatment cascade. achieving ambitious 90-90-90 targets. review of relevant literature and policies, a scan of trans programming in Nairobi, and 18 Why focus on gender in HIV programs for qualitative interviews with representatives In Kenya, information about the HIV-related transgender people? from transgender-led organizations (REP_ needs of transgender people is minimal, HIV HIV programmers working with the general TG), government officials (GOV), program programming is limited, and transgender population are accustomed to thinking about managers and funders (PROG_TG), and health people are not recognized as a KP. In this gender norms and inequalities as negatively context, a gender analysis can help explain why care workers (HCW_TG) in Nairobi. Many affecting women and girls in particular (see transgender people have not traditionally been respondents, in particular the government definitions below). For example, they have included in HIV programming and can describe officials, were not familiar with transgender long understood that women, who have less the impacts of stigma, discrimination, and issues or had never worked with transgender access to education and employment and violence on their HIV risk and service uptake. people. Of the 13 respondents who had worked are expected to be submissive to their male with transgender people:

DEFINITIONS

GENDER NORMS: GENDER INTEGRATION: GENDER-BASED VIOLENCE: were assigned male at birth and The expectations of what it Strategies applied in programmatic Any form of violence that is identify as female. Transgender means to be a man or woman, design, implementation, directed at an individual based on men were assigned female at birth including social and political roles, monitoring, and evaluation to take biological sex, (e.g., and identify as male. Gender non- responsibilities, rights, entitlements gender considerations into account transgender), or behaviors that are conforming people, in the context and obligations, and the power and compensate for gender-based not in line with social expectations of this gender analysis, refers to relations between men and women inequalities [Adapted from IGWG of what it means to be a man individuals who do not identify as [Adapted from HPP Gender & training materials].2 or woman, or a boy or girl (e.g., male or female. Sexual Diversity Training].1 men who have sex with men, female sex workers). It includes GENDER AFFIRMATION: physical, sexual, and psychological TRANS-COMPETENT: GENDER IDENTITY: A person’s The process by which individuals abuse; threats; coercion; arbitrary Provision of services, especially deeply felt internal and individual are affirmed in their gender deprivation of liberty; and health care services, to trans experience of gender, which may identity. Gender affirma