2. The Asia Pacific Coalition on Male Sexual Health (APCOM) in
partnershipwiththeAustralianFederationofAIDSOrganisations
(AFAO) is implementing an Australian Department of Foreign
Affairs and Trade (DFAT) funded programme for men who
have sex with men (MSM) and transgender people in the Asia
and Pacific region, under DFAT’s larger HIV Regional Capacity
Building Programme.
Through this programme, the Myanmar MSM Network
(MMN) received technical support from APCOM and AFAO to
spearhead the city-based projects in Yangon. The aim of the
city-based projects is to pilot small community-led responses
to HIV and to build the capacity of community organisations
to engage in the HIV response at a city level. Through the
city-based project in Yangon, a consultation on the issues and
barriers facing transgender people in accessing HIV and other
services was carried out in June 2014, with input from 30
transgender community representatives, community organi-
sations, United Nations (UN) agencies, AFAO, APCOM and
various international non-government organisations (NGOs).
2
3. Transgender people across the world suffer from stigma and discrimination in
multiple contexts – in family life, education, employment, health and the law. UN
agencies and a range of other international organisations have been consistent
in calling for the removal of laws that marginalise transgender people and the
creation of legal environments conducive to their well-being and protection1
.
This is grounded in a commitment to the human rights standards and principles
recognised under international law. However, despite international human rights
obligations, very few countries in the Asia and Pacific Region have domestic laws
protecting transgender people from discrimination based on their gender identity.
To translate the laudable international principles into improvements on the
ground, it is essential to address the issues and challenges facing the transgender
community at a more local level.
However, there is a lack of data on virtually all aspects of transgender life in the
region. A 2012 report by the United Nations Development Programme (UNDP)
and the Asia Pacific Transgender Network (APTN)2
estimated that there are
between 9 and 9.5 million transgender people in Asia and the Pacific, based on a
global estimate of transgender individuals making up 0.3% of the population, but
most countries lack a national population size estimate. Reasons for this include
varying definitions, inconsistent methods of instrumentation and categorisation of
gender identity, inability to engage with transgender communities, a governmental
lack of cooperation with local nongovernmental organisations in national and
routine surveillance activities and, most importantly, not distinguishing
transgender people from MSM categories3
.
“We see a pattern of violence and discrimination directed at people just
because they are gay, lesbian, bisexual or transgender. There is wide-
spread bias at jobs, schools and hospitals, and appalling violent attacks,
including sexual assault. People have been imprisoned, tortured, even
killed. This is a monumental tragedy for those affected – and a stain on
our collective conscience. It is also a violation of international law.” Ban
Ki-Moon United Nations Secretary General Geneva, 7 March 2012.
Transgender people are individuals whose gender identity and/or
expression of their gender differs from the social norms related to their
gender of birth. Transgender populations include transgender women,
transgender men, and other genders. The term describes a wide range of
identities, roles and experiences which can vary considerably from one
culture to another.
1
Global Commission on
HIV and the Law. HIV and
the Law: Risks, Rights and
Health, 2012. See www.
hivlawcommission.org;
UNDP Discussion Paper:
Transgender Health and
Human Rights, 2013. See
www.undp.org; UNAIDS
The Gap Report 2014 –
Transgender People. See
http://www.unaids.org/
sites/default/files/media_
asset/08_Transgender-
people.pdf.
2
Winter S. Lost in Transi-
tion: Transgender People,
Rights and HIV Vulnera-
bility in the Asia-Pacific
Region. Bangkok, United
Nations Development
Programme, 2012 (http://
www.undp.org/content/
undp/en/home/librarypage/
hiv-aids/lost-in-transition
-transgender-people-
-rights-and-hiv-vulnera-
bi/).
3
Page 4, Regional assess-
ment of HIV, STI and other
health needs of TG people
in Asia and the pacific.
WHO 2013
BACKGROUND
TERMINOLOGY
3
4. Data on the health needs of transgender people in the Asia and Pacific Region is
limited, and that which does exist focuses mainly on HIV and sexually transmissible
infections (STIs). One of the few global studies4
of HIV and transgender women found
consistently high levels of HIV across the countries in the study (which included
the USA, six Asia-Pacific countries, five in Latin America, and three in Europe). HIV
prevalence among the 11,066 transgender women surveyed worldwide was 19.1%
(2013). In selected Asian locations including Bangkok, Jakarta, Cambodia, Lao People’s
Democratic Republic and Myanmar, HIV prevalence was reported to be highest among
transgender women, with prevalence rates ranging from 4% to 34%.
While data on HIV in transgender populations is incomplete, data on the broader
health needs of transgender people is even scarcer. These are often neglected,
especially needs around access to sex re-assignment surgery and medical transition,
hormone use, and mental health. Transgender people face multiple obstacles to
securing health care generally, as well as a lack of access to accurate health
information. A systematic review of the literature by WHO in 2013 found that few
studies had been conducted among transgender people in the Asia and Pacific region,
with studies on HIV/STIs/sexual health mostly centred on MSM, and studies of
hormone use and surgery focusing on operative procedures on mostly transgender
men5
. Research studies therefore do not reflect the current realities in many
developing countries of Asia and the Pacific, where hormone use in transgender
women may involve self-medication, and surgery may be performed by non-licensed,
non-professional providers in non-traditional healthcare settings. Silicone injections
and other procedures are often carried out by non-professional providers, including
soft tissue body fillers that are often not human-grade silicone.
It is clear even from the limited evidence and data available that the transgender
population faces a wide range of negative health outcomes, many of which may
beginwithdiscriminationandmarginalisation.Marginalisationcanleadtopsychosocial
stress, suicide attempts, substance use, sex work, violence, and social isolation. These
outcomes have been correlated with transgender women’s lack of access to general
social services and health care services, as well as sexual risk behaviour and HIV
infection6
. The structural risks for HIV infection such as social exclusion, economic
marginalisation and unmet healthcare needs transcend the level of the individual and
help to explain why HIV rates are so high in transgender women. Stigma, social
discrimination, and discrimination in health-care settings all contribute to exclusion
from HIV prevention and treatment services, as well as other health services. Few
health-care workers have received training on addressing the specific health needs of
transgender people, and consequently consistent access to competent clinical
prevention, treatment or care services is rare. Physical and social violence targeted
towards transgender women is common, and many transgender women engage in sex
work and transactional sex because of employment discrimination and a lack of other
income opportunities, which carries its own health risks.
4
5. “Together the research identifies a slope from stigma to sickness. In many countries
the daily experience of social stigma and prejudice, as well as associated
discriminatory, harassing and abusive practices, is so consistent and marked as
to nudge many trans* people towards the social, economic and legal margins of
society, and damage their psychological health and well-being. In many cases the
forces marginalising trans* people intersect with those that marginalize ethnic
minorities, foreign and rural migrants, the poor, the poorly educated and women, so
that trans* people belonging to one or more of these other groups encounter even
greater challenges leading a life of respect, equality and dignity. Some, despite all
the hurdles, lead fulfilled lives. Many others however are tilted towards situations
and behaviour patterns (including sexual) that leave them open to many risks,
including to HIV infection. Worse, on the way along that slope they often encounter
poor healthcare (for transition-related, sexual or general health). Poverty,
involvement in sex work and HIV infection can all add to the stigma they face.’7
One further consideration relating to access of transgender communities to HIV
and other health services is the common conflation of transgender and MSM in
programme design, service delivery and data collection. Although many of the same
basic HIV and sexually transmissible infection (STI) prevention interventions are
relevant to both communities, transgender people have specific needs and barriers
which need to be addressed. This conflation often means the needs of specific
transgender sub-groups are ignored; for example, rural transgender people, elderly
transgender people or transgender men.
4
Lancet Inf Dis vol. 13 2013. Worldwide
burden of HIV in transgender women:
a systematic review and meta-analysis
Stefan D Baral, Tonia Poteat, Susanne
Strömdahl, Andrea L Wirtz, Thomas E Gua-
damuz, Chris Beyrer
5
Page viii, Regional assessment of HIV, STI
and other health needs of TG people in Asia
and the pacific. WHO 2013
6
For example Garofalo, 2006; Lobato et
al, 2007; Wilson, 2009; Guadamuz, 2011;
Winter 2012
7
UNDP HIV TG Lost in Transition Report
May 2012
5
6. MYANMAR
Recognition of the rights of transgender people and efforts to address their health
needs varies across the Asia and Pacific region. Each country has its own political,
social and cultural structures which can both enable and restrict transgender
individuals and communities from seeking health information and services.
In Myanmar, stigma and discrimination towards transgender people are high, based
on social norms and expectations regarding gender and masculinity. Myanmar’s
Penal Code (1877) retains the colonial legacy of an ‘unnatural acts’/sodomy law
under Section 377, which contributes to an environment of limited social
acceptance for MSM and transgender people, stating that the ‘unnatural offence
of carnal intercourse against the order of nature’ is liable to be punished with
‘transportation for life’, or with imprisonment for ten years to life as well as a fine.
The law is rarely directly enforced; however, it has been reported that police use
the threat of prosecution to extort bribes.
Section 35(c) of Myanmar’s Police Act (1945) criminalises wearing a disguise
or covering one’s face between sunset and sunrise, and has been used to target
transgender people. In July 2013, twelve transgender and gay people in Mandalay
werechargedundersection35(c)afterallegedlybeingharassedbypolice.Thepolice
reportedly abused the twelve detainees verbally and physically while in custody
and denied an HIV-positive transgender woman access to antiretroviral therapy.
Police officers claimed they were targeting anyone who was ‘bothering’ the public.
The story featured prominently in international media in 20138
, and LGBTI
activistsreportedotherexamplesofharassmentbypolice,includingarbitraryarrest
(for example for loitering), detention, and in some cases rape by security forces.
There have been reports of discrimination based on sexual orientation and gender
identity in employment, including limited job opportunities, the denial of
promotions, and firing of transgender persons. Generally, the environment in
Myanmar is one characterised by a lack of support from society as a whole, as well
as by widespread societal and familial discrimination.
6
7. YANGON
Why take a city focus?The 2010 report on the MSM and Transgender Multi-City
HIV Initiative9
stated that a city approach is particularly relevant in HIV as
cities are where large numbers of people move to for work and education,
and where anonymity enables a more open expression of sexuality and
gender identity. The mounting epidemics of HIV among MSM and transgender
people in Asia are most acute in urban settings. In countries where cross-sectional
studies of HIV prevalence amongst MSM have been conducted in multiple
locations, HIV prevalence has generally been found to be higher in the largest cities.
This demonstrates that there is no single HIV epidemic among MSM across the
region, but rather a number of localised epidemics which are likely to be linked.
Increased mobility within countries may result in HIV transmission spreading
between MSM communities in different cities. While such detailed studies have not
been carried out with the transgender community in Myanmar, it can be assumed
that similar patterns would be found among transgender people, who are subject to
many of the impacts of stigma and social exclusion faced by MSM. In addition, cities
have specific needs and often the authority to plan and fund localised responses,
providing opportunities for innovative approaches. The 2010 report quoted data
from the 2009 HSS showing an HIV prevalence of 12.5% among MSM in Yangon.
There was no separate data set for transgender people.
In Yangon, transgender people are generally included in HIV programmes
targeting MSM for prevention, treatment and care, and there is little data
specifically on transgender people at a national or city level. The consultation
carried out under this project was necessary to open discussions on the political,
legal and social barriers which contribute to the social exclusion of transgender
people; to identify the unmet needs of transgender people regarding HIV, health,
and human rights; to share experiences of addressing stigma and discrimination
against transgender people; to achieve dialogue between community members,
policy makers, donors, UN agencies, NGOs and government officials; to identify
opportunities and constraints to achieve quality services from public and private
sector health care providers; and to identify next steps for transgender
communities and other stakeholders in Yangon. Key transgender community stake-
holders contributing to the consultation included Myanmar MSM Network (MMN),
Myanmar Positive Group (MPG), Myanmar Youth Stars and the LGBT Rights
Network.
The areas of discussion in the consultation were: health-seeking behaviour and
access to health services (including HIV programmes and services, and quality
of services from the public and private sector); social and legal barriers; and
discrimination, abuse and violence. The key issues and needs of transgender
people in Yangon identified in the consultation are outlined below, followed by
recommendations.
9
http://www.healthpolicyinitiative.com/
Publications/Documents/1453_1_Action_
Planning_Meeting_Report_FINAL.pdf 7
8. CONSULTATION FINDINGS
A) Health seeking behaviour, access to HIV
and health services and health needs
of transgender people in YANGON
The consultation identified that although there was HIV awareness in the
transgender community, there were low levels of condom use specifically
with (i) co-habiting partners and (ii) handsome partners. Carrying condoms
was seen as a risk as they could be used as evidence of sex work if the person
carrying them was stopped by police. Certain brands of condom were also
found to be unpopular due to their strong smell, including the Aphaw brand
from PSI in strawberry and banana flavour, as subsequent partners could
detect the smell. Low levels of condom use show the need for urgent focused
HIV and STI prevention interventions. HIV prevention services are often not
tailored to the needs and interests of transgender people, and it is important
to ensure that there is not ‘message fatigue’ and that transgender people
stay engaged with the HIV response.
The Multi-City HIV Initiative found that most behaviour change com-
munication work in the region is restricted to small group or one-to-one
peer education and generally targets more visible MSM and transgender
people. Reducing HIV transmission among MSM and transgender
populations requires reaching far greater numbers than these methods
allow, and will require use of mass and targeted media to reach a broader
range of transgender groups, including TV, radio, internet and mobile phone
technology.
Unfriendly and technically inadequate healthcare services also prevent
transgender people from accessing prevention, treatment and support.
Preventioninterventionsneedtofocusonreducingriskbehaviour,improving
the availability of appropriate health services, and improving health-seeking
behaviour. Transgender people will continue to underuse health services if they
do not feel safe because of concerns over confidentiality or stigma and
discrimination. In addition to the urgent prevention work that needs to
take place, discrimination in health care settings therefore also needs to be
tackled.
If transgender people do become ill, they generally choose to visit an NGO
clinic rather than a public or private hospital (particularly for STI treatment
and VCCT). The doctors and healthcare workers at the NGO clinics were
generally perceived to be good:
“I am very reluctant to see the doctors in the beginning, especially
with STI symptoms, I am too shy to show to doctors but most of
doctors (at the NGO clinic) are well trained and very professional.
Most of the service providers are very welcoming and kind.”
8
9. AnotherkeyhealthissuearisingfromtheYangonconsultationwastheuseof
hormones. When transgender people use hormones, they tend to buy them
from sellers recommended by their peers (for example the ‘Su Po Po’ shop
where hormones are sold by an older transgender woman). Generally they
do not know the names or side effects of the hormones, and that is highly
risky in terms of health and quality control. There was also little knowledge
on the interaction between hormones and ART.
In terms of targeting outreach support, it was clear from the consultation
that there are distinct areas of the city where the transgender community
congregates – the consultation showed 12 key areas10
. This kind of informal
mapping is vital if the impact and efficiency of support is to be maximised.
Reaching transgender people in the areas where they frequent socially will
ensure access to services and also more efficient use of resources.
However one transgender representative did share a negative experience:
“I visited the MDM for follow-up with doctors and nurse. On that
day, MDM was conducting shows and events. When I went there
to get medicine, a nurse shouted at me “Why did you come now,
I cannot give you medicine today so go-go-go”. At that time I was
so angry at her. She could treat me nicely but I think that’s kind of
insulting.”
10
In terms of reaching transgender
with outreach and mobile health
support, common places to search
for sexual partners include: at the
corner of Sedona Hotel, under
Mingalar Bazaar Clubs, Kandaw-
gyi Lake, Inya Lake, North Okkala
circle, Kantharyar Junction,
Mingalardone, Kyan Khin Su,
Hlaing Thar Yar BOC circle, Bo
Tataung Harbor, Sayarsan Road,
the corner of Phoe Sein Road (near
K-Paradise KTV).
9
10. B) Social and legal barriers for transgender people
in YANGON
Nationally, there is no legal gender recognition for transgender people in
Myanmar, leading to challenges in terms of identification, paperwork for
employment etc. They are not recognised as legal citizens in the sex to which
they have transitioned, and are denied their basic identity.
Transgender people in Yangon also face barriers to employment, and are
discriminated against through employers refusing to hire, promote or
properly pay transgender employees. Generally the consultation found
that transgender people are happier to stay within the ‘transgender world’
wherethereislessdiscriminationandmoremutualsupport.However,ifthey
want to work, they face real challenges in trying to break out of what are
traditionally seen as transgender roles.
“People think that we TG are supposed to work only as Nat Ka Daw
(Spirit Medium) and makeup artists. But we are not interested in
those jobs and we want to do other jobs like a staff in private
sectors, NGOs or UNs like others. But we did not have a chance.”
Many transgender sex workers want to change their job but have very few
options as they do not have savings, skills or job opportunities. For those for
whom sex work is the only option, this exacerbates their marginalisation
and vulnerability, and has links to health risks including self-harm, suicide,
depression, and infection with HIV and other STIs. The combination of
familial stigma and discrimination, violence and poverty which forces
transgender people into sex work can be seen in the stories outlined below.
10
11. ‘One transgender from Mawlamyaing whose father and brother didn’t
like her to be a transgender mistreated her. So she fled to Yangon with
the assistance of her mother. Her mother advised her to come back
only as a male, not as a transgender. She worked at a beauty parlour,
but when the owner died a few months later she lost his job and she
had to become a sex worker around Kandawgyi Lake’.
‘There is a transgender from Bagan, now living in Sinpone village. She
is 19 years old. Her mother died when she was 6 years old. Her father
didn’t like her, she is the youngest of 7 siblings. Her father thinks if
she becomes a transgender she will have HIV. Sometimes when she
wanted to go to a meeting at PSI, her father told her not to go there
as the people are transgender and MSM and they are HIV positive.
She explained that there is training and she can get help with health
matters. She goes there secretly without telling her father. When she
took gifts including condoms from PSI, her father saw these and threw
them out. Her siblings came and beat her and asked her why she has
condoms, and whether she was HIV positive, using the condoms as
indication. She was thrown out of the house, and has since become
a sex worker. She has no money and when she was thrown out of the
house didn’t have time to take anything. She also dances at several
transgender performances, but doesn’t make enough money, so she
had to become a sex worker. Now she is facing police raids and
prosecutions. When trying to find customers, she has been hit by a
motorbike, is sometimes taken to the police station, and has been hit
and stabbed. She dreams of earning enough money to give her father,
so the family will accept her, but instead what she experienced is a lot
of stigma and discrimination.’
During the Yangon transgender consultation, Dr Win Mar from
the United Nations Development Programme (UNDP) shared the
findings of a four country report on sex workers – it found that 1
in 3 sex workers are MSM and transgender. The National Working
Group for the project included the Ministry of Health, Ministry of
Home Affairs, Supreme Court and Ministry of Social Affairs, and
when this report is launched, it will provide useful data and
information.
11
12. C) Social discrimination, violence and abuse
Abuse of transgender people by police is a major issue in Yangon;
transgender people described being abused more by the police than by
anyone else. The consultation showed that police use sections 30 and 35 of
the Police Act 1945 and equivalent sections of the Rangoon Police Act to
detain, abuse, and extort money from gay and transgender people merely
on the grounds that they are out after dark, or have their faces covered after
dark. Police were accused of assuming that all transgender women are sex
workers, and of using loitering and sex work laws against them. Possession
of condoms is often used by police as proof of sex work, particularly when
found on transgender people. When arrested, transgender people reported
human rights violations including use of electric shocks, having ice-cold
water thrown over them, or being made to ‘walk’ for police, and not being
permitted to contact their family. Rape by police is also frequently reported.
Transgender people frequently reported arrests in various locations in
Yangon where transgender people meet.
The consultation found that transgender people are generally scared to
report or share stories of police abuse in case of revenge by police. They
reportedfacingpressureandthreatsfrompolicewhenarrested,forexample,
through being encouraged to confess to a specific crime (usually sex work)
in order to receive a shorter one month sentence rather than the threat of a
longer sentence.
“For example, you have to confess in front of the judge. If you
confess, you will not get much punishment. But if you don’t
confess, it will be worse.”
If detained, transgender people may be refused access to health services or
required treatment such as ART.
The consultation showed that many transgender people feel they are
detained if police need to meet their arrest quotas. They report that police
ask trishaw drivers for assistance in ‘catching’ transgender people, creating
a climate of fear. Some of the transgender people participating in the
consultation did not know that there are organisations that can provide
them with legal support. However, even those that knew about the
organisations were afraid to contact them in case the police subsequently
targeted them. Most had limited knowledge of the Police Act 1945 and the
Rangoon Police Act, and were not aware of other laws that could be applied
to them. Just a few of the many stories about police brutality shared at the
consultation are described in the boxes below.
12
13. ‘My friend was treated badly in front of me. She was arrested at 9:00 pm on the street. Then, she was
forced to bend on her toe for two hours. She tried not to fall down as she was afraid they might torture
her more. When they saw that she did not fall down, they shaved her head with a blade. It was so fast
that skin on the head fall off. Then, the police put turmeric powder and MSG powders on her head and
released her. It happened at North Okklapa Police station. Right now, that TG has become insane.’
‘I was arrested on the bank of Kandawgyi around 9:30pm. My friends escaped as they
were running fast. But I wasn’t. The police who arrested me was in civilian clothes. Another
police officer was waiting and kicked my head with his shoes and they detained me without
clothes for one day. I asked them to call my house but they just took my money without
calling my home. The judge sentenced me to 8 months imprisonment’.
‘Around 8pm one evening there was a police raid, and 8 transgenders were caught. Their clothes
were ripped and their hair cut. The police demanded if they were guilty but they said they were
innocent. The police demanded 100,000 kyat for them to be freed and told they would be
sentenced if they didn’t pay the money. One of them was sentenced to 3 months in prison. After
her release she went to live together with her friend. On the day of her release she returned to work
as a sex worker, but one customer brought her to the police station. The police stripped her naked
and she was forced to run around the station without clothes, and was beaten again and again.
They beat her pelvis with a small stick. They also forced her to act as a man. She was caught on
Saturday night, and hoped to be released on Monday. However she was sent to court, and was told
if she confesses to be a sex worker, she will have a shorter sentence. She confessed and had to go
back to prison for one month. 5 months later she went to a pagoda festival and found a customer,
but that person took her to a park and nearly 7 persons took her money (only 3000 kyats and
medicine) and had sexual intercourse with her without paying any money. After that she was
afraid her customers would send her to the police or be violent, so she asked customers for money
in advance. In one instance after receiving money from a customer she went with her but then
was robbed of her money and gold ring. She is taking ART and was told to contact the doctors for
medical advice, but sometimes when in prison she cannot take ART.’
13
14. According to the experience of one transgender: “My father does not like me
dressing like a woman. That’s why he forced me to get married with a girl. When
I said that I cannot marry, he kicked me out from the house. Until now sometimes
I miss my father and I call him, he asked, “My son, have you changed your mind?”
And then I answer, “No, I will stay like this”. Then, he hangs up. My father is now
over 70 and I really want to go home and stay with him. If he asks me not to wear
like a woman, I will not and I will stay like hidden MSM (an Apone). But I do not
want to marry a woman.”
Transgender people report facing violence and abuse from relatives and
neighbours at a very young age (starting between 10 and 16 years old).
Transgender women also face violence and sexual harassment from peers
due to their appearance as women. Transgender adults reported many cases
of abuse by straight men, and if the transgender person refused sex, they
would face physical violence, or have belongings stolen from them.
Family discrimination and abuse is also a big problem for transgender people in
Yangon. Socially, most people consider a mother who only delivers sons a great
mother, and it therefore brings shame to a family if a son becomes transgender.
Many families try to forbid their transgender relatives from dressing as women,
and beat them or force them out of the family. Some families are willing to pay
bribes to ensure they are released when arrested but generally transgender
people face a lack of psychosocial and emotional support from their families.
While the Myanmar National Strategic Plan on HIV and AIDS 2011-2015
does not specifically acknowledge transgender people or their particular
HIV issues and needs, the National Strategic Plan recognises the importance
of PLHIV groups, and self-help groups for female sex workers, MSM, and
people who use drugs. As another key affected population, transgender
people also need psychosocial and peer support, knowledge about HIV
prevention and treatment, and access to clinical and welfare services.
Notwithstanding their invisibility in the National Strategic Plan, transgender
people have formed eight self-help groups in Yangon, and these groups
can play an important role in peer support and counselling, access to
information, and referral to appropriate HIV and sexual health services.
14
15. A) Capacity building of transgender organisations
If transgender civil society groups are to make the voices of transgender men
and women in Yangon heard, their capacity needs to be built. As stated in
Agenda in Transition: Advancing Actions to Secure the Health and Rights of
Transgender People in Asia and the Pacific (February 2014):
‘The United Nations has been consistent in calling for removal of laws that
marginalize transgender people and for creating legal environments that are
conducive to their well-being and protection. To make progress, in addition
to support from UN and other agencies, it is essential to build up the
capacity of transgender community-based organizations and networks in
order to address the pressing issues facing the transgender community.’
This should include capacity building in leadership, organisational develop-
ment, community mobilisation, peer and community-based service delivery,
advocacy, and the use of transgender-sensitive language. National and
international organisations should be encouraged to provide opportunities
and support for organisational development for transgender organisations
and groups. The capacity of transgender groups to access and analyse
existing resources also needs to be built - there are many useful and relevant
resources already available which could contribute to effective advocacy
and programming work (see footnote for some relevant examples).11
It is clear that there are huge challenges to be overcome if the
health and wellbeing of transgender people in Yangon are to be
improved. The Yangon city consultation highlighted a number
of factors which impact adversely on the health, wellbeing, and
human rights of transgenderpeople in Yangon,and in particular
their vulnerability to HIV and AIDS. These factors should be
incorporated into civil society action plans in the city, and steps
takentoaddressthemincollaborationwithexistingtransgender
groups, other civil society allies, and city officials.
11
Legal environments, human rights and HIV
responses among men who have sex with
men and transgender people in Asia and
the Pacific: An agenda for action, detailing
how punitive laws, policies and practices
negatively impact on comprehensive HIV
responses (UNDP, 2010), and HIV/AIDS
among men who have sex
RECOMMENDATIONS
15
16. Civil society groups working with transgender people need to continue to promote condom use,
focusing particularly on increasing consistent condom use with all partners, both paying and
non-paying. Consistent messages should be distributed through peer discussions and outreach,
but also through methods that will reach greater numbers, for example, social media sites and
social networks. Older forms of mass media such as television, radio and billboards also provide
an effective means of disseminating health promotion messages, but may pose particular
challengesinthecurrentenvironmentinYangon.However,theevidenceoftheireffectiveuseinother
countries provides a compelling reason to keep these means of communication on the advocacy
and health promotion agendas of transgender groups in Yangon, whether in the short or
longer term.
Transgender groups should also use the findings of this consultation to advocate to international
organisations working in Yangon to carry out further in-depth discussions about condoms and
transgender people’s needs (one example given during the consultation was a brand commonly
distributed by an international NGO – it was reported that its strong scent put people off using it).
B) Availability and use of condoms
It is vital that the eight transgender self-help groups in Yangon work together to share information,
support each other, and coordinate their work. They also need to work in partnership with
other national and international bodies. Civil society organisations representing transgender
people need to prioritise networking and making connections with both allies and decision-makers,
and becoming the professional face and voice of the transgender population. The transgender
groups in Yangon should also discuss the formation of a Yangon Transgender Network, learning
from the experiences of the development of the Myanmar National MSM Network.
Transgender groups should foster links with civil society groups which have a broad human rights
and gender focus (for example Equality Myanmar), and participate in city-wide events. They should
strengthen links in the Asia and Pacific region, and work with transgender activists across the
region through networking, social media, and advocacy. These links can then be used to gain
regional support for issues facing the transgender community in Yangon. This will include building
closer working relationships with APCOM, Asia Pacific Network of People Living With HIV (APN+)
and the Asia Pacific Transgender Network (APTN).
16
17. C) Provision of appropriate HIV and sexual
health services
D) Access to appropriate HIV and sexual
health services
Civil society groups working with the transgender community need to
advocate for the provision of appropriate health services. There are existing
resources that could be used to support this work, for example, the WHO’s
guidance on Priority HIV and Sexual Health Interventions in the Health
Sector for Men who have Sex with Men and Transgender People in the
Asia-Pacific Region (2010)12
. Lessons should also be learned from existing
HIV projects, for example, the PSI TOP project on integrated HIV prevention,
treatment, care and support for MSM and transgender people.
Civil society organisations working with transgender populations in Yangon
need to work together to improve the accessibility of health services. This
may include:
a. Documenting the lessons that can be taken from existing ‘transgender-
friendly’ NGO clinics and use these lessons in private and public clinics,
relating to respectful provision of quality services;
b. Creation of transgender-friendly service guidelines for training healthcare
workers;
c. Advocacy with City Government and health boards to ensure transgender
rights to health are included in all city health frameworks (including specific
reference to the needs of transgender men and transgender women);
d. Collaboration between all the groups representing transgender people
in Yangon to develop a map of transgender-friendly health services for
distribution across the community.
12
Available at http://www.wpro.who.
int/publications/docs/PriorityHIVand-
SHinterventionsFinal050710.pdf.
Accessed 23 June 2015.
17
18. E) Access to hormone therapy
F) Create an enabling environment
for transgender health and wellbeing
Transgender self-help groups and networks need to work together to
source funding for a project targeting hormone providers in Yangon city.
The providers should be trained on the risks of using hormones, their side
effects, interaction between ART and hormones, and safer hormone therapy.
The project could create a network of project-endorsed providers of safer
hormone therapy which also provide follow-up services to their clients.
APTN has already developed a set of hormone therapy guidelines which
could be adapted and translated for the Yangon environment. Safe hormone
use should also be integrated into information provided by peer outreach and
self-help/support groups in addition to information on sexually transmitted
infections and safe sex.
As the consultation showed, improving the quality of health services is not
enough in itself to promote transgender health and wellbeing - the environ-
ment in which services are provided needs to be improved if transgender
people are to access the services they need. The report from the MSM and
Transgender Multi-City HIV Initiative stated that:
‘[P]rogress in the HIV response among MSM and transgender people is routinely
hampered by the existence of restrictive legal environments and policies,
selective enforcement practices and the lack of communication or coordination
between local health and law enforcement officials. Collectively these challenges
serve as barriers to innovation and hamper scale up of HIV prevention and care
efforts13
.’
(i) More positive police practices
Examples of ways to reduce barriers to services for transgender people in
Yangon include negotiating locally for a ‘hands-off’ approach by police, to
ensure that outreach programmes can reach their targets, and to ensure
support from local police for mobile clinics or rapid testing services operating
in places which are most accessible to transgender people.
Useful information came out of the consultation regarding the geographical
mapping of important areas for transgender people in Yangon. A more
in-depth follow-up mapping exercise would be extremely helpful to identify
the ‘problem areas’ with police across the city. Police and other authorities in
these areas could be targeted with transgender health and rights education
to ensure that heavy-handed treatment does not drive transgender commu-
nities underground, making them harder to reach with services. However,
this information needs to be treated carefully as it may lead to police
concentrating on these areas to make arrests or harass transgender people.
13
http://www.health-
policyinitiative.com/
Publications/Docu -
ments/1453_1_Action_
Planning_Meeting_Re-
port_FINAL.pdf, page vi
18
19. Civil society groups need to work with the police to protect transgender rights at the grassroots
and local police station level, for example, through promoting the public health benefits of carrying
condoms. Efforts should be made to encourage the police to play an enabling role in public health
interventions. Transgender civil society groups should also map out what is already being done.
For example, the Myanmar Business Coalition on AIDS is carrying out advocacy at district police
stations along with other international organisations. 40 police stations have already attended
advocacy training. Instead of replicating this training, transgender organisations should talk to
the MBCA about their experiences and to see how transgender populations can be included in the
discussions. Medicins du Monde also has a Police Force Engagement Project, which may provide
further opportunities for the meaningful engagement of transgender people in programs and
services affecting them.
Advocacy at the Ministry level should focus on trying to harmonise police procedures to public
health policies encouraging condom use, outlining the public health advantages to the nation. The
Government should be encouraged to set legal and administrative procedures that help police
understand that their job is to protect all citizens equally, including transgender people. As part
of this work, transgender groups could develop a briefing about what is stigmatising and what is
an acceptable language, which could be distributed throughout Government ministries as well as
through the media.
Strong collaboration between different civil society groups representing transgender populations,
international NGOs, and UN agencies should also be encouraged here. Information on new
initiatives should be shared widely. For example, at the time of the consultation the Myanmar
police were visiting the Indonesian police in a learning exchange – what were the outcomes of the
visit? What relevant lessons were there that we can use in our advocacy work? It is also important
to keep an eye on what other international organisations and agencies are doing. For example,
the recent UNDP National Legal Review only included MSM (and not transgender people) but the
report will be disseminated to ministries and parliament and could be useful.
(ii) Reduction in employment discrimination
Civil society representing transgender people needs to advocate at a ministry level for the
development of an anti-discrimination in the workplace law or policy, and for transgender
representatives to be part of any related discussions at a city or national level. The goal should be
for policy makers to recognise that fair labour practices apply equally to all citizens, regardless of
gender identity or sexual orientation. Civil society also needs to work directly with transgender
people to improve their employment options, and not only for ‘traditional’ transgender
occupations. Training should be provided in a variety of work, and transgender self-help/support
groups should encourage individuals to group together to work in small businesses, with advice
given on microloans etc. Business sector trainings could be provided, and any training could be
combined with a general life skills training.
(iii) Integration into the school curriculum
Civil society representing transgender communities should work with broader human rights
organisations to encourage the inclusion of anti-discrimination lessons in the national school
curriculum. International agencies such as UNICEF and UNESCO are potential partners in this, and
universities could also be targeted. While this would help reduce discrimination in the longer-term,
it would also be a way to reach out to students struggling with their gender identity.
19
20. (iv) Participation in policy-making processes
Civil society should advocate for transgender groups to be represented on national working
groups separately from MSM, as well as being budgeted for separately in the national HIV budget.
The absence of any recognition of transgender people as a key affected population in the National
HIV and AIDS Strategic Plan points to the invisibility of transgender people both in policy-making
processes and their outcomes. Transgender groups need to advocate for representation on the
national Human Rights and Gender for HIV Working Group. Myanmar MSM Network is already a
member, and it could take these consultation findings to the working group meeting and push for
the separate representation of transgender people, and the issues they face to be included in all
discussions.
(v) Legal recognition of transgender identity
Civil society networks and organisations representing transgender people need to advocate to the
Government for legal gender recognition for transgender people, using positive case studies from
elsewhere in the Asia and Pacific Region. Transgender groups and networks need to demonstrate
the human, social and economic costs of the lack of legal gender recognition in Myanmar, and could
work with regional transgender networks to document lessons from countries where a third
gender is an option (India, Bangladesh, Pakistan, Nepal), or where identity-related and other legal
documents can be amended to recognise a person as the gender to which they have transitioned.
The aims of this would include repealing laws that criminalise transgender identity, sexual
alignment procedures, or associated behaviours like cross-dressing.
(vi) Access to legal information and services
Civil society has an important role to play in developing and implementing programmes that
increase access to justice for transgender people, such as legal literacy campaigns and provision
of legal services, which are critical in addressing structural discrimination and empower
ingtransgender people to know and claim their rights. As a lawyer at the consultation said:
‘[T]hereare400lawsinMyanmarandthisisgrowing–youneedtoknowwhichcouldbeusedagainstyou.’
Resources already exist to support this work, for example, those outlining relevant laws and rights
in Myanmar, as well as the role of the police, and transgender support groups can disseminate these
within their community networks. The LGBTI Rights Network has a senior lawyer who can provide
advice and support, and transgender groups should use this connection.
Civil society also needs to promote organisations that provide legal support to transgender people
and work with these organisations to ensure support for people trying to fight false charges.
Collaboration with wider civil society is important here. For example, Phyo Pin is currently carrying
out community training in human rights, and is implementing a legal aid project with a focus on
violations of human rights. The Myanmar Lawyers Network consists of 19 firms with lawyers who
will provide legal training through the NGO Equality Myanmar. Equality Myanmar is also
supporting lawyers to draft an amendment to Section 377 and is happy for transgender
communities to input into that process, as well as supporting several transgender individuals with
legal support.
20
21. (vii) Document human rights violations
Civil society organisations working with transgender people in Yangon should work together to
develop a mechanism for capturing stories of police brutality and abuse of transgender people,
and use this information in their advocacy work. A quarterly update of the issues experienced by
transgender people in Yangon would indicate the nature and extent of the challenges they face, and
would encourage the local government to act. In addition, the process of storytelling is not only a
form of documentation but also a form of resolution for those suffering from abuse. Discussions
with legal and human rights organisations should be held to identify appropriate documentation
methods, as well as discussions with donors regarding funding of this important initiative.
(viii) Develop and use strategic information
To ensure that any advocacy work is based on strong data and information, and that programmes
are evidence-based and effective, transgender groups need to work together to source funding
for the development of strategic information, including a city-wide and national population size
estimate of both transgender men and transgender women. This was also one of the findings from
the Multi-City HIV Initiative. This work will need funding and transgender groups in Yangon should
collaborate to develop a proposal which can be submitted to donors and international NGOs.
(xi) Work with city officials
Civil society representing transgender groups needs to be more visible in Yangon in reaching out to
the local government. The relationship between the government and civil society needs to be seen
as collaborative, with each learning from the other. This can be facilitated by creating a friendly
environment between the Yangon city government and civil society, based on respect and
interaction, rather than always taking an adversarial approach.
In addition to working with the police, civil society has an important role to play in advocating for
transgender rights to be included as part of officer training for city administrative officers. They
might then be able to support more general educational campaigns which could help educate the
general public on transgender people and their rights, ideally combined with the legal prohibition
of discrimination.
(x) Discrimination by the families and friends of transgender people
Self-help group leaders should be trained in family liaison to help support transgender people in
dealing with their families and in turn support and provide information to family members. They
should encourage parents to connect and support each other in a parents group. Transgender
people themselves should also be supported to deal with double or triple stigma (for example
through being a transgender woman who is HIV positive and working as a sex worker) through
counselling and support.
21
22. Civil society organisations representing transgender people in Myanmar
need to ensure visibility and collaboration at the national and regional
level. Transgender representatives should be active members of regional
networks and advocate for laws at all levels to include protection of
transgender people. They need to ensure the voices of transgender people
are heard at national and regional levels so that the challenges they face are
better understood and addressed.
The final point to make is that most of these recommendations require
funding. Transgender groups and organisations need to develop effective
resource mobilisation strategies, and ensure that their organisational
capacity is sufficient to receive, effectively use, and account for donations
and grants from international donors and the Government of Myanmar at all
levels. Resources available to transgender organisations, and for services for
transgender people, should be proportionate to the health and human rights
challenges they currently face in Yangon and elsewhere in Myanmar.
G) Participate in regional forums
H) Mobilise resources
22
23. CONCLUSION
Yangon is home to much of Myanmar’s transgender population. However,
transgender people living in the city still face stigma and discrimination at multiple
levels – within the health and education systems; in employment; in attainment of
their rights around legal representation; and in day-to-day life by family members,
friends, members of the public and peers. The needs of transgender people are
not being met because of these barriers and challenges. This has a serious impact
on their health, particularly in high rates of HIV and other STIs, and transgender-
specific health issues around hormone use, as well as general physical and mental
health challenges resulting from a lack of access to health and support services, and
broader social exclusion. Levels of violence and abuse against transgender people,
both from members of the public and from those in positions of official power, are
disturbingly high. There is a long way to go before transgender people in Yangon
can be fully integrated members of the city population – freely attending work or
school, meeting with peers, accessing health and social services, and being able to
walk the streets without fear of abuse. Civil society groups and networks
representing the transgender community in Yangon clearly have an extremely
important role to play in the journey to get to that point.
There are a number of key issues identified in this consultation which civil society
can help to tackle:
• Civil society groups need to be strengthened so that they can coordinate
and represent a unified voice for transgender people across the city.
• Civil society needs to recognise and document the health challenges
and needs of transgender people by collecting transgender-specific
dataandinformationtobuildanevidencebase,includingacityandnational
population size estimate.
• Civil society groups need to present clear evidence-based advocacy
messages targeting government, health professionals, education
professionals,anddonors,pushingfortheirrightstohealthcare,education,
family life, legal representation and legal acceptance of their gender. They
need to develop collaborative working relationships with key stakeholders
including other city-based, national and regional transgender groups and
networks, wider LGBT and human rights organisations, government
bodies, and international agencies and donors.
• Transgender groups and networks working in Yangon need to share their
experiences with national and regional networks, and contribute to the
wider regional level debates about the rights of transgender people across
the Asia and Pacific region.
• Civil society groups representing transgender people in Yangon need to
recognise that this is a long-term process – advocating for changes to laws
or policies is only the first step in the process of change. Once these things
have been achieved, transgender people will then have to commit to
the long-term push for implementation of these changes on the ground.
23
24.
25. The Asia Pacific Coalition on Male Sexual Health
Established in 2007 by men who have sex with men, APCOM brings together
representatives from our communities, government, development partners and
technical experts.
• We are a coalition of members from Asia and the Pacific representing a diverse
range of interests but working towards common goals.
• We are united in our courage to advocate issues that affect the lives of men who
have sex with men and transgender people including rights, health and wellbeing.
• Together, we’re sharing knowledge and real-life stories that are focused on
supporting and ultimately promoting the sexual orientation and gender identity
rights of these individuals and their communities.
China
China Male Tongzhi
Health Forum(CMTHF)
India
India Network for Sexual
Minorities (INFOSEM)
South Asia
South Asia MSMand AIDS
Network (SAMAN)
Youth
Youth Voices Count (YVC)
PLHIV
APN+MSM Working Group
Australasia
AustralianFederation of AIDS Organizations (AFAO)
and New Zealand AIDSFoundation (NZAF)
Greater Mekong
Purple Sky Network (PSN)
Insular Southeast Asia
Insular Southeast Asia Network (ISEAN)
Developed Asia
Develop Asia Network (DAN)
26. We are united in our courage to
advocate issues that affect the lives
of men who have sex with men and
transgender people, including HIV,
rights, health and well being.
EQUITY. DIGNITY. SOCIAL JUSTICE.
ASIA PACIFIC COALITION ON MALE SEXUAL HEALTH
APCOM SECRETARIAT, 66/1 | SUKHUMVIT 2 |
KLONGTOEY | BANGKOK | 10110 | THAILAND
+66 2255 4410 | APCOM@APCOM.ORG
