African LGBTI Civil Society and its Role in Promoting Policy and Programming Change

1. African LGBTI Civil Society and its Role in Promoting Policy and Programming Change XIX International AIDS conference July 26th 2012 Washington, dc By Nguru Karugu

2. Discussions around health concerns affecting the Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) communities in the East Africa region are recent (emerging around 2004), and have been primarily driven by the need to respond to HIV/AIDS.

3. Within this, the discussion has focused on what is now termed as Most At Risk Populations (MARPs) which often includes sex workers (SW),men who have sex with men (MSM) and IDUs. Discussion around the broader health concerns affecting the LGBTI community are just beginning and are primarily driven by new and emerging LGBTI organizations across the region

4. LGBTI health in East Africa While there has been limited research in East Africa focusing on LGBTI communities, research elsewhere suggests that LGBTI individuals face health disparities linked to societal stigma, discrimination, and denial of their human rights. Emerging research in East Africa, focusing on MSM and HIV continue to indicate significantly higher prevalence rates throughout the region.

5. Despite the broad range of public health issues affecting LGBTI persons, efforts have primarily been limited to issues of sexual health, and in the “traditional” realms of HIV/AIDS and sexually transmitted infections.

6. In East Africa the HIV/AIDS epidemic has provided a platform for the initiation of the discussion around sexual health needs of the LGBTI community with a specific focus on men who have sex with men. This discussion and focus came around as a result of a number of factors.

7. One was the reality that as the epidemic continued to ravage Africa, there were questions as to whether it was only a generalized epidemic ( affecting the majority heterosexual population) and that there might also be sub-populations not being met with the prevention, treatment and care services rolling out across the continent.

8. Additionally and very critically local LGBTI HIV activists and organizations had begun a concerted effort to advocate for services and care for their communities.

9. These efforts had varying degrees of success: • In Uganda an attempt by the local UNAIDS Director to mobilize the LGBTI community to respond to the HIV epidemic led to his expulsion from the country in 2004.

10. In Kenya, after concerted efforts, the Kenya National Strategic Plan II (2005/06 – 09/10) included a paragraph that for the first time mentioned the unique vulnerabilities of marginalized communities including sex workers and men who have sex with men.

11. From this single mention in 2005, the LGBTI community including MSM HIV activists together with health providers were able to advocate for the full recognition of the needs of MSM leading to full recognition in the new strategic plan (2009/10 – 2012/13). This included clear actionable developed indicators and inclusion in the operational plan with budgetary allocations (programing ,condoms, lube etc.).

12. Tanzania’s National Strategic Plan mentions MSM as a MARPS and goes further than any other East African country and recommends decriminalization of activities’ that put MSM and SW at risk.

13. While there has been some movement at looking at the issues affecting MSM, health care services for Lesbian, Transgender and Intersex communities are near non-existent.

14. A 2011 baseline survey of the LGBTI community in Kenya indicated clear disparities around accessing health care between MSM/gay and bisexual men and women who have sex with women (WSW)/LBT women.

15. All WSW/LBT groups across the country stated that there were no friendly competent health care sites that their members could access. Local LBT organizations including Minority Women in Action (MWA) and Artists for Recognition and Acceptance (AFRA-Kenya) have attempted to enroll individual health care providers (gynecologists) to provide services to their members.

16. It has been a slow process and only a small number have been enrolled to date. For the majority of WSW/LBT members simply do not have access to competent friendly health care services.

17. New and emerging Transgender and Intersex organizations in the East Africa region (Transgender Education Advocacy - TEA, Transgender Support Initiative Uganda -TSIU and Support Initiative for People with Atypical Sex Development - SIPID) are at the forefront in providing some care and services to transgender and intersex communities in the region.

18. Services to these communities are scant and there continues to be incredible ignorance on the needs of transgender and intersex populations by health care workers.

19. Debating strategies: Public health “vs” Human Rights approach To better understand the role LGBTI civil society can and does play in policy and programming development it is important to understand some of the contexts they operate from. In East Africa and possibly across Africa there are a range of debates around how effective public health approaches arein achieving both full health rights for LGBTI or MSM communities, and in advancing the agenda of LGBTI rights, an end to homophobia and transphobia, and more inclusive government policies.

20. This is often posed as the tension between public health approaches and human rights frameworks. Most Ministries of Health and National AIDS Control Institutions are responding to a public health concern, while many of the LGBTI/MSM organizations and individuals are engaged in advocacy for recognition of their very existence.

21. Criticisms of public health approaches rest on the argument that a public health approach focuses solely on the public health concerns of a marginalized group and does not interrogate or get involved in looking at the wider human rights violations facing that group.

22. For example, in the case of MSM, a public health approach may push for the provision of services to MSM but not advocate for the decriminalization of the laws that make MSM marginal in the first place.

23. A human rights approach, in contrast, suggests that there is need to look at the whole person and the conditions that they live and to remove all the legal and other structural oppressive mechanisms including advocating for decriminalization of adult consensual same sex activity.

24. Advocates of public health argue that this is a false argument and that public health services that use a rights-based approach do in fact challenge social inequalities by actively supporting the diverse needs of the communities in which services and public health messaging is targeted, providing quality services to marginalized populations and thereby affirming their right to health, and also contributing to opening public dialogue around the existence and needs of diverse groups in society.

25. Experience on the ground suggests that while public health approaches may not always tackle the root causes of discrimination, they have nevertheless been important in advancing elements of LGBTI/MSM health rights.

26. Firstly, activism around HIV/AIDS has created spaces to discuss sexual diversity including at government levels and with service providers. It has also succeeded in securing services- albeit limited, for LGBTI people (most significantly for MSM and GB men).

27. Experience from five East African countries indicates that in practice a combination of both public health and human rights approaches have been used to create space for discussion, advocate for services, and challenge homophobia and transphobia more broadly:

28. Burundi: The Burundian government criminalized consensual adult same sex activity for the first time in 2009. The law Article 567 penalizes consensual same-sex sexual relations by adults with up to two years in prison. Despite these laws, the main LGBTI organizations in the country focus on HIV and human rights (ANSS, Humure, Together for Women’s Rights and Rainbow Candle Light). The oldest organization formed in Burundi was HIV/AIDS focused.

29. Kenya In Kenya since (2004) there has been growing involvement of the LGBTI community in informing the public health realm, specifically around HIV/AIDS. In addition, the promulgation of the new Kenyan constitution (2010) for the first time provides for protections and avenues for the LGBTI including MSM communities to access their rights under the laws of the land.

30. The oldest LGBTI organization in Kenya, Ishtar MSM (formed 1997 and registered in 2002), is an HIV/AIDS organization and many of the new groups in the rural areas are MSM and HIV focused. Kenya has utilized a public health rights approach at the national policy level to create space for discussions of the human rights of LGBTI communities including MSM.

31. Rwanda In early 2010 as the government of Rwanda embarked on a review process of the penal code in force since August 1978, it recommended that it criminalize consensual adult same sex relations for the first time.

32. Rwandan civil society activists involving a mix of LGBTI activists and health allies mobilized to reject this article and stated that it contradicted the Rwandan Constitution, was a violation of human rights, a hindrance to the implementation of the Rwanda National Strategic Plan on HIV and AIDS 2009 – 2011, a betrayal to the Rwandan recent history and the political drive of national unity, tolerance, inclusiveness and dialogue among Rwandan citizens and residents.

33. The coalition was successful and the recommended amendments dropped. Truly a combination of a human rights and public health synergistic approach.

34. Tanzania Tanzania has progressively increased the punishment for its existing penal code criminalizing consensual adult same sex relations. While the 1954 Penal Code provided for seven years in prison for carnal knowledge against the order of nature, a 1998 amendment increased this to a term not less than twenty years.

35. A further amendment in 2002 further increased the minimum sentence to thirty years. The few MSM/ LGBTI organizations in Tanzania are at their very initial stages of formation. Significant challenges exist for these groups given the high levels of stigma and the criminalization of homosexuality. The majority of the few emerging organizations are HIV/AIDS and health focused. Despite these challenges MSM organizations recently held an HIV training with specific focus on HIV and MSM supported by TACAIDS, the governments’ AIDS organization.

36. Uganda LGBTI groups began to focus on public health in 2004. However after the expulsion of the UNAIDS Director for his alleged work of “promoting homosexuality in Uganda” the community decided to utilize a human rights approach exclusively.

37. In 2009, the draconian Anti-Homosexuality Bill, was tabled before the Ugandan National Assembly. To the offences already contained in the penal code, it proposed to add a slew of new ones including homosexuality, aggravated homosexuality, the promotion of homosexuality and failure to report homosexuals to the state.

38. The Bill was heavily criticized by a range of actors, including the broad women’s rights, human rights movements, the LGBTI rights community within Uganda, activists working on HIV/AIDS and a handful of religious leaders as well as the international community.

39. While the Bill was not debated in the last parliament it has now been re-tabled under the present one. Despite the earlier challenges of engaging in the HIV discourse at the national level, LGBTI groups continued to provide services and create awareness around the health issues affecting their communities.

40. Part of their continued efforts recently resulted in one of the prominent Ugandan LGBTI organization, Uganda Health and Press Association(UHSPA), being selected by the government to join a committee that will mainstream LGBTI issues in Uganda’s Public Health Policies. This included directly participating with the development of Uganda’s current National AIDS Strategic plan. Additionally one of the local LGBTI organizations recently opened the first LGBTI clinic in the country.

41. Role of LGBTI Civil Society in policy and programming As the illustrations above show, a public health rights approach has been used as an entry point for discussion of the rights of the LGBTI community in some of the East African countries.

42. Tanzania, Kenya, Burundi and Rwanda have included men who have sex with men into their national strategic plans. The Uganda National HIV/AIDS Strategic Plan 2007/8 – 2011/12 does not include MSM as a most-at-risk population despite research indicating the higher than national prevalence among the population.

43. The placement of MSM into these national strategic plans provided for the first time governmental documentation of a sexual minority group in each of these countries.

44. In Kenya it is from this first mention and acknowledgement in their strategic plan in 2005, that began a long process of utilizing that information for the advocacy of the rights of not only the MSM population but the LGBTI community in its in entirety by LGBTI groups and organizations.

45. This advocacy lead to the hosting of the first ever MARPS Symposium (2010) hosted by the government that had presentations made by MSM and Transgender representatives from across the country. Today MSM activists are deeply involved in any national policy development meetings pertaining to MARPS populations and are consulted constantly by the government where MSM issues are concerned.

46. In Tanzania the National Multi-Sectoral Strategic Framework on HIV and AIDS (2008 – 2012) states that there is need to acknowledge the vulnerability of sex workers and men who have sex with men and advocates for their access to HIV preventive information and services and for the decriminalization of their activities.

47. This is the only National HIV and AIDS Strategic plan in the region that mentions the need to decriminalize activities that affect service provision for MARPS. This provides for an important entry point for LGBTI and MSM HIV activists in influencing policy.

48. In Burundi, MSM/HIV activists are involved in the development of policy and programing by participating in National HIV policy development meetings through their largest HIV MSM organization, Humure. One of their successes has been getting the government to purchase and distribute lube to MSM organizations. This is the only government in the region that provides this service.

49. In Uganda, as mentioned earlier, due to consistent advocacy and engagement with governmental entities, the Uganda Health and Press Association(UHSPA),an LGBTI organization was selected by the Ministry of Health to join a committee that will mainstream LGBTI issues in Uganda’s Public Health Policies.

50. It is important to note that there limitations to the use of the public health rights approach. Firstly there can be resistance to the inclusion of sexual and gender minorities in public health discussions.