LGBT: the vital fight for the right to health
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2019)

In this issue of The Lancet Public Health, Annick Bórquez and colleagues present findings from a study of HIV prevention among transgender women sex workers in Lima, Peru. The study follows a 2014 policy initiative aimed to introduce HIV prevention strategies for key at-risk populations. The authors report that implementation of test and offer, tailored condom promotion, and pre-exposure prophylaxis could avert nearly 50% of new infections over 10 years. The findings are a part of a larger mixed-methods study that has already informed development of a comprehensive HIV care and prevention plan specifically designed for transgender women in Peru. Studies such as this provide a much-needed foundation of evidence to inform targeted policies, which are essential for ending HIV transmission. But for such policies to be successful, governments and policy makers must be committed to supporting vulnerable and high-risk populations. In a Comment, Giota Panopoulou and Eduardo Gonzalez-Pier highlight some of the challenges to prevention and treatment of HIV in hard-to-reach populations. Barriers are, in part, the result of criminalisation and stigmatisation of the same activities that place these populations most at risk. Faced with violence, stigma, and discrimination, people are excluded or exclude themselves from essential health services, including those for HIV. Privacy and confidentiality of criminalised or stigmatised groups who access HIV care can also be an issue. As Matthew Kavanagh and colleagues explained in The Lancet HIV, there have been clinics for sex workers, people who inject drugs, and men who have sex with men that have been raided by police to gather information about people labelled as criminals, and cases of patient records made public. In many parts of the world, prosecutions for same-sex relations between consenting adults continue. Institutionalised homophobia and violence against lesbian, gay, bisexual, transgender (LGBT) people has profound and measurable impacts on their wellbeing and on public health practice and policy. According to Human Rights Watch (HRW), in January, in Chechnya, 40 people were detained and two people killed in what has been described as a purging of the LGBT community. This attack follows on the heels of actions of the Chechen Government in 2017, when hundreds of gay men were imprisoned and tortured—a move that sparked international condemnation and sanctions. Yet, the recent arrests and tortures have received scant coverage in global media outlets. Last month, HRW reported that a 22-year-old Tunisian man was forced to undergo anal examination and was subsequently imprisoned for sodomy after going to local police to report that he had been raped. Shocking, yet this appalling miscarriage of justice is far from an isolated incident. In Tunisia, same-sex relationships are a criminal offence and conviction can result in up to 3 years in prison. Individuals suspected of homosexuality might be forced to undergo conversion therapy—a pseudoscientific method that uses elements of psychotherapy, and in some cases prayer, to change one's sexual orientation. Conversion therapy has been widely condemned by the medical community as harmful, with high rates of depression, substance use, and suicidal ideation among survivors. In some countries, continued enforcement of anti-sodomy laws is rationalised on the basis of curbing HIV transmission; that by outlawing particular sexual practices, the risk of HIV transmission will be reduced. This antiquated and unjustifiable position is ineffective, counterproductive to public health efforts, and unnecessarily penalises men who have sex with men and transgender women. Chris Beyrer, from the Bloomberg School of Public Health at Johns Hopkins University, Baltimore, USA, says “you cannot punish someone for their sexual orientation or gender identity—these are an inherent part of the self.” In 2015, UN entities called on member states to end violence and discrimination against LGBT people. Indeed, the WHO Constitution, adopted more than 50 years ago, was the first international declaration of health as fundamental human right. A right that should be exercised without discrimination of any kind. International funding to end the HIV epidemic represents the largest financial investment in global health, but funding to support LGBT human rights is woefully lacking. Without recognition and upholding human rights, public health efforts to end HIV transmission will continue to be hampered. For the HRW report on Tunisia see https://www.hrw.org/news/2019/02/09/rape-victim-lands-behind-bars-tunisia For the HRW report on Tunisia see https://www.hrw.org/news/2019/02/09/rape-victim-lands-behind-bars-tunisia Subgroup-specific services or universal health coverage in LGBTQ+ health care?Designing public services for excluded groups comes with a crucial question: is it better to create group-specific and consequently segregated services catering to the unique needs of population subgroups? Or should the inclusivity and intersectionality of existing services be increased instead by opening the care offers to all members of the community—the very idea of universal health coverage? This question is especially relevant in the care of people in the lesbian, gay, bisexual, trans, queer (LGBTQ+) community. Full-Text PDF Open Access