South Africa’s first plan to fight HIV, sexually transmitted infections (STIs) and tuberculosis in lesbian, gay, bisexual, transgender and intersex (LGBTI) communities was recently launched during the national Aids conference in Durban. The plan aims to reduce new HIV infections in these communities by 63% in five years.
But activists say the framework fails to acknowledge the specific health needs of transgender men — those who identify as male but were born with female genitalia — and particularly those who have sex with men.
At least three public hospitals offer transgender men testosterone as part of hormone replacement therapy: Groote Schuur in Cape Town, Steve Biko Memorial in Pretoria and Johannesburg’s Chris Hani Baragwanath.
Testosterone use has been shown to contribute to the thinning of the vaginal wall as well as drying and inflammation — which can increase a transgender man’s risk of contracting HIV. A 2017 report published by the Centre of Excellence for Transgender Health found vaginal dryness to be one of the effects of masculinising hormone therapy.
Dr Elma de Vries, who does training for Gender DynamiX, says: “Vaginal atrophy increases the risk of tears in the lining of the vagina [during sex], which increases the risk of HIV infection.”
Zachary Shimange, the community mobilisation officer at trans rights organisation Gender DynamiX, says that anecdotal evidence suggested that, because trans men on hormone replacement therapy also have to inject themselves with testosterone — and some some may share needles — it puts them at further risk of being infected with not only HIV but also hepatitis B and C.
Although welcoming the LGBTI HIV prevention plan as “long overdue”, Shimange says it fails to address these specific HIV prevention needs among trans men.
Transgender rights activist Estian Smit says the plan assumes, as do many health workers, that transgender men only have sex with women. But this is false, with one report — by trans organisation Transgender and Intersex Africa — saying more than half of trans men surveyed (55%) have had sexual contact with men.
According to the website Avert.org, although vagina-to-vagina sex does pose some risk of HIV infection, “the risk is lower than sex involving a man because less bodily fluids are exchanged between women”.
Assumptions that transgender men only engage in heterosexual sex may mean healthcare workers are not counselling trans men who have sex with men about the higher HIV infection risk they face.
“There is a perception among healthcare providers and the general public that trans men are heterosexual and wouldn’t engage in certain kinds of sex. But the idea that trans men don’t engage in receptive penetrative sex is inaccurate,” Smit says.
“These are matters that need to be addressed,” Shimange added.
“Transgender persons have different concerns about HIV and STIs, depending on the sexual practices they engage in. Sexual orientation is a completely different issue to that of gender identity,” he said.
“Transgender people can identify with any of the different sexual orientations, which includes heterosexuality, homosexuality, bisexuality, pansexuality and asexuality.”
It was important to not make any assumptions about people’s sexual practices, Shimange said.
The report by Transgender and Intersex Africa found that most HIV prevention programmes in the LGBTI community focused on men who had sex with men and paid little attention to the specific needs of transgender people, especially transgender men.
Trans men are less likely to access healthcare because of stigma and discrimination, says Smit. Many healthcare workers are also not knowledgeable enough to counsel them effectively.
One of the new HIV prevention plan’s aims is to “ensure that all healthcare workers are appropriately trained on LGBTI issues and specific health needs”. It also seeks to develop mechanisms to deal with human rights abuses.
The framework’s lack of targeted HIV prevention services for trans men is also mirrored in its language, says Smit.
“Trans men and transmasculine persons are, for instance, not explicitly mentioned under MSM [men who have sex with men]. Instead, trans women are mentioned in passing under MSM, but they do not identify as men.
“The plan’s understanding of sex and gender still tends to be largely normative and binary, not sufficiently recognising the range and complexity of intersecting gender identities, gender expressions, sex characteristics and sexual orientations.”
But Anova Health’s Bruce Little believes HIV-prevention initiatives aimed specifically at trans men are not a priority “at this stage”
Anova Health runs specialised clinics for men who have sex with men in Cape Town and Johannesburg. The nonprofit organisation is developing Health4Trans training manuals for healthcare workers, but these guides do not cover trans men specifically, but many trans and non-binary healthcare needs as well.
“Trans men, trans women and nonbinary people all have their own challenges and vulnerabilities regarding HIV and STIs, and all of them require the same urgent attention,” says Little.
But “there is still so much transphobia and ignorance in this country that we still need to focus on all constituents of the trans and nonbinary community first, before we can begin to focus on one faction”.
Conceding the plan is “not perfect”, Steve Letsike, co-chairperson of the South African National Aids Council, says the shortage of local data on transgender men and HIV makes it difficult to advocate for specific programmes for the group.
“We are currently using international data to inform our programming. It is not easy to have a comprehensive plan without data or evidence. But that is one of our main aims with the plan: the collection of such data.”
Letsike has urged LGBTI people to interrogate the plan to identify gaps, adding that the council has asked the health department to engage with trans communities about their specific health needs.
“It is important for LGBTI communities to take this plan in their hands to really try and bridge the gaps in service provision.”
Ronald Addinall, a sexologist and clinical psychologist at the University of Cape Town, says transgender men continue to be overlooked in public policies. “This is definitely an area that is significantly neglected when it comes to HIV prevention programmes. There is an absolute blind spot when it comes to trans men.”
Carl Collison is the Other Foundation’s Rainbow Fellow at the Mail & Guardian