World Report

Discrimination against LGBT people triggers health concerns

Several countries are introducing anti-gay laws and homophobia seems to be increasing in
nations usually thought of as liberal. What are the health consequences? Fiona Clark reports.
When the Olympic teams touch
down in Sochi, Russia, for the start
of the winter games this week, the
lesbian, gay, bisexual, and transgender
(LGBT) members among them will
apparently be making history. Just like
Neil Armstrong on the moon, these
individuals will be the rst gay people
to step foot in the Black Sea resort,
according to the citys mayor, Anatoly
Pakhomov. Its not accepted here
in the Caucasus where we live. We do
not have them in our city, he told the
BBCs Panorama programme.
But LGBT people will be welcome
in Sochi as long as they obey the
countrys laws, says the Russian
Government and, as President
Vladimir Putin says, they leave our
children alone. It is this phrase which
raises the hackles of gay and rights
activistsa deliberately targeted sting
in the tail that is designed to fan the
flames of homophobia. Absolutely
he [Putin] knew what he was saying,
says Shawn Gaylord, advocacy counsel
for Human Rights First. We see this all
the timegetting lumped in together
with paedophiles. Its very insulting
and designed to drive home fear.
And fear is one factor that was used
to push for Russias controversial
anti-propaganda bill that passed into
law last June, which eectively bans
the dissemination of information
to minors if it could be seen as
promoting non-traditional relationships.
In a nutshell, Russias Article 6.21
states that propaganda is the act
of distributing information among
minors that is aimed at encouraging
non-traditional sexual attitudes,
makes non-traditional sexual relations
attractive, equates the social value of
traditional and non-traditional sexual
relations, or creates an interest in nontraditional sexual relations.
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But critics argue the law is not only

discriminatory but also vague and
it might have devastating health
eects. According to Denis Godlevskiy,
advocacy officer for the AIDS
Healthcare Foundation in Moscow,
the law strikes at the heart of HIV
prevention. These laws definitely
make prevention more difficult
because when you try to set up an
outreach centre, if youre a community
group or an NGO [non-governmental
organisation], and you cannot say
anything about homosexualityhow
can you work? If you cant mention
any gay relations in a positive context
it makes it dicult, he says.

Were missing many of these

epidemics among young
criminalised men and its one of
the greatest injustices that
were complicit in...
And no information can only lead
to one thingan increase in HIV
rates among men who have sex
with men (MSM). Alex Kovkov is one
man who could have beneted from
information about HIV transmission
in his younger years. The 32-year-old
tested HIV positive about 5 years ago
and now actively campaigns for gay
rights and anti-discrimination laws.
He says he is shocked by the continued
level of ignorance about HIV in
Russias straight and gay communities,
especially the younger members.
People are not informed. These young
guys dont even know how the virus
is spread. The kids dont even know
what condoms are. Theres no doubt
infection rates will rise, he says.
Laws that make it more difficult
to have open discussion feed into
what Stefan Baral, the director of Key
Populations Program in the Center for

Public Health and Human Rights at

Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD, USA, says
is tantamount to a silent epidemic
and it is not conned to Russia. Were
missing many of these epidemics
among young criminalised men and its
one of the greatest injustices that were
complicit in as were accepting the
stigmas and the laws that are allowing
them to be covered up.

Around the world

According to UNAIDS, there are
78 countries globally where homosexuality is listed as a crime (gure).
Sentences for same-sex activities can
range from up to 10 years in prison in
countries like Senegal and Kenya to
death sentences in some countries like
Nigeria, Sudan, and parts of the Middle
East such as Saudi Arabia and Iran.
Uganda could soon join their ranks
if it passes its Anti-Homosexuality Bill,
which proposes life in prison for those
involved in same-sex activities. The
bill proposed the death penalty for
aggravated homosexuality, which it
denes as including homosexual acts
by a person who is HIV-positive and
for those repeatedly found to be in
same-sex relationships.
Also in the bill, which was passed by
parliament but has been put on hold by
the President, is an article stating that
anyone who knows about same-sex
activities and fails to report it within
24 hours can face nes or up to 3 years
imprisonment. This provision would
place those who provide care to MSM in
a dicult situation, as they are already
in other countries that have anti-gay
laws. In many cases, the laws have
provisions in them that are very broad
and ill-dened. They go beyond their
original purpose, which is bad enough,
but could also be applied to people who
hold meetings, host clubs, or try to give
www.thelancet.com Vol 383 February 8, 2014

health support. Its a major concern of

ours that people providing health care
and trying to access it could get swept
up in such laws, says Susan Timberlake,
chief of the Human Rights and Law
Division of UNAIDS.
Jasmine OConnor, the international
policy adviser for the UK-based gay
rights charity, Stonewall, says many
health workers are committed to
providing care but she is hearing
reports that some are being stymied
in eorts including things like being
harassed by police and having their
condoms taken away.
And as Enrique Restoy, senior adviser
on human rights at the International
HIV/AIDS Alliance explains, criminalisation increases the reluctance of
HIV providers to engage with this
populationwe have seen this among
civil society organisations in Uganda,
Nigeria, and Senegal who have become
reluctant to oer services to MSM and
the transgender community.
Baral says service coverage in Senegal
for MSM all but evaporated after nine
HIV health workers were arrested in
2008. He believes this is a tragedy
because studies show an estimated HIV
prevalence among MSM of above 20%
(and possibly as high 47%) with HIV
incidence of 16% and he believes it will
take years for services to recover.
In Cameroon, he estimates that
somewhere between 30% and 50%
of MSM may be infected with HIV and
other countries with high HIV burden
have also had challenges in providing
supportive health services. Its
interesting because we were asking
ourselves why health workers werent
doing more so we interviewed some
in Malawi and we found theywere
worried if theyd be legally liable as
aiding and abetting, so there was a real
fear about providing services, he says.
This situation is a concern for UNAIDS
because no one really knows exactly
how many services are being provided
and who they are reaching, and its hard
to push for changes in the laws without
the data to prove there is a problem.
We need systems to collect such data
www.thelancet.com Vol 383 February 8, 2014

Legal and protective laws are in place

Legal
Illegal or where lesbian, gay, bisexual,
and transgender people have been criminally
prosecuted under other laws on the basis
of their sexual orientation
Illegal and punishable by death

UNAIDS

World Report

Figure: Legal status of same-sex sexual conduct globally

because no ones doing the collection,

says Timberlake who is working on
ways to get this done. One way is to
support civil society groups where the
population is criminalised and another
is by getting the government and the
AIDS bodies to understand that there
will be an impact and put systems in
place. A third way is to send in outside
bodies to do the studies.
In addition to losing services, Restoy
says our partner organisations have
documented a number of cases of
discrimination in public health-care
settings and refusals to provide
treatment for the LGBTI [LGBT and
intersex] community. If there arent
enough resources to treat everyone,
those who are branded as criminals
are the rst to be denied treatment or
be discriminated against, he says.
Godlevskiy says the opposite is true
in Russia where MSM are favoured for
treatment over people who inject drugs.
In Russia, 56% of HIV transmission was
due to injecting drug use, according
to a report released in 2012 by health
ocials. Some 41% was attributed to
homosexual activity. Officially, there
are 617 018 people living with HIV, but
the UN and WHO estimate the gure is
probably closer to 15 million.
While the Russian Government
supplies antiretroviral drugs for the

125 000 people who are currently

receiving treatment there are
sometimes shortages, and if that is the
case, doctors have to make a dicult
decision. Clinicians are usually the
hostages of this situation. Theyd
like to treat everyone but only have a
certain amount of drugs and are under
pressure from the local departments,
Godlevskiy says. If they have a choice
between the drug user and a gay man
they will usually choose the gay man
because they are usually considered to
be people with better social status.

Fearing for their lives

But it is not only heath providers who
are under pressure in countries where
criminalisation exists: MSM are often
too afraid to seek treatment. The
existence of laws criminalising samesex [relationships] creates hostility
and stigma and that is very likely
to dissuade people from seeking
treatment or information about safe
sex, says Laura Carter, an adviser on
sexual orientation and gender identity
at Amnesty International.
Restoy adds that in countries
like Uganda or Zimbabwe, [health
providing] LGBT organisations are
often raided and condential data
then conscated or exposed in the
media, which puts their clients at
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World Report

risk. Another big problem, he says,

is adherence, as this often requires
home visits, which would increase
the visibility of MSM and, therefore,
potentially increase the risk to their
personal safety.
Baral says in many cases the men ee
their homeland. He recalls the story of
one man who was part of his cohort in
The Gambia but moved to Senegal to
escape attacks. As he wasnt a resident
there he couldnt get treatment and he
died. He escaped the violence, but he
couldnt escape the disease.
Imprisonment can also be a
death sentence, he adds, because
in some cases HIV treatment is not
available in jail. He cites the case of
Alim Mongoche, who was one of
11 men arrested in Cameroon in 2005
on sodomy charges and imprisoned
for 10 months but died just after he
was released because he was not given
treatment in prison. How many more
have died and we dont know because
they werent in the news? he asks.
In this climate, with people afraid
to come forward for testing and
treatment, plus moving around to
escape violence, he says it is almost
impossible to get a real picture of
prevalence and incidence in many
African countries and herein lies the
core problemthe epidemic were
missing because we dont know the true
gures. And in many cases, Baral says,
that absence of data is used as evidence
to back up a countrys anti-gay laws.
Restoy agrees this is not only
possible, but a reality. We know
that up until 2010 very few African
countries even considered MSM as an
at-risk population in their National
Strategic Plans. Firstly because the
size of the MSM population was
considered negligible and therefore
not a priority in generalised epidemics,
and secondly because homosexuality
was illegal and therefore the national
response couldnt legally reach this
population. This meant that the size of
the population and prevalence among
MSM and the transgender community
were not researched.
502

He says this scarcity of information is

starting to change but because of the
previous situation there are very few
reliable size and prevalence estimates
in countries which criminalise
homosexuality.
The problem isnt conned to Africa.
Central and eastern Europe also tend to
vastly underestimate. When it comes to
Ukraine, one UNAIDS report estimated
the number of MSM living with HIV was
several hundred times higher than the
gures reected in the ocial studies.
Similar discrepancies between
research and national HIV statistics
were identified in Kazakhstan. Baral
says that the ocial statistics said that
03% of MSM were HIV infected, but a
recent study using a respondent-driven
sampling study of 400 MSM showed
an HIV prevalence of nearly 20%.

Europe and the USA

But are high-income countries doing
any better? According to Stonewalls
policy ocer, Alice Ashworth, their
research in the UK shows half of
lesbians and bisexual women, and
a quarter of gay and bisexual men,
have never been tested for sexually
transmitted infections. And although
it is dicult to say if there has
been a rise in homophobic crime, a
European Union self-reported survey
of 93 000 LGBT people showed that
26% had been physically attacked but
more than 50% didnt report it. And
in the USA, according to FBI statistics
in 2011 there were 1572 hate crimes
based on sexual orientation, most of
which were anti-male homosexuality.
In 2007, the gure was 1512.
Shawn Gaylord says its interesting
because at the moment the support for
gay marriage in the USA is around 50%,
but he believes there is always a risk of
backlash and it can result in violent
incidents anywhere in the country.
Even in the US in many states, theres
still a lot of stigma attached to being
LGBT, so I could imagine it would
have an effect and people may not
feel comfortable coming forward and
identifying as LGBT in the health-care

system, which will make them less

likely to get tested or get the treatment
they need early on.
In the UK, the eect of stigma can
been seen in the consulting room,
Ashworth says. Our health research
has found that half of lesbians and
bisexual women who have accessed
health-care services in the last year
have had a negative experience,
while half are not out to their
general practitioner or health-care
professionals. Correspondingly, a third
of gay and bisexual men have had
negative experiences and a third arent
open about their sexual orientation in
the same circumstances.
We know that past experiences
of homophobia from health-care
professionals and other public services
can make gay people feel its not
safe to be open about their sexual
orientation, which in turn can have
a negative impact on the care they
receive, she adds.
Baral says in France, where stigma
and anti-gay sentiment is currently
running high, most people presenting
with HIV (53%) present late, which
means there has already been
significant opportunity for onward
HIV transmission and also increased
mortality related to the infection.
Collectively, these trends are going
to make it harder to achieve the
Millennium Development Goal of
reducing the transmission of HIV
by 50% by 2015 but rolling back
homophobia and the laws that go
with it wont be easy because it needs
a grassroots pushsomething that
is hard to develop in societies where
fear abounds. But without it, Barals
forecast for ending the epidemic is not
overly optimistic. Well end up with a
generation of men wholl be infected.
We have all these tools but are unable
to use them, which is really sad because,
unlike 10 years ago, we now know
what to do with them but either cant
provide services or allow the uptake of
services, and that has to be dealt with.

Fiona Clark
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