“…it’s not that you don’t want to live openly–to be who you are deep inside–because this is something you carry inside of you that needs to be released, but many factors do not allow you to do so. What would it be like to see yourself, who you really are?”
This testimony captured my attention while I was reviewing qualitative data from an assessment conducted by the Advancing Partners and Communities project to explore the social and health needs of trans women and the access barriers they face in the Dominican Republic. It highlights something many of us take for granted: the ability to construct and express who you are and still be included in society. Throughout the world, many sexual minorities are denied the opportunity to live openly without the fear of violence and social exclusion.
The lack of accurate information about sexuality and prevailing social taboos produce stigmatizing attitudes and discriminatory practices that have a negative impact on the construction and expression of identities that do not conform to the dominant heterosexist gender binary. The repression of sexually diverse identities contributes to the psychological, social, and epidemiological vulnerability of individuals and communities. Although available data from Latin America indicate that HIV prevalence rates among transgender women are as high as 45 percent, the transgender community continues to receive inadequate healthcare supportA few years ago I was walking down a busy street with the director of a trans organization in Central America. The street vendors and pedestrians would stop what they were doing to blatantly stare at her–several people yelled extremely rude comments. She continued walking with her head up, with great effort attempting to tune out all the negative attention.
I tried to imagine what it would be like to endure this every day—the fear, the insecurity, the imminent threat of violence. Under these circumstances, many of us would be reluctant to leave the house to catch a bus or taxi to take us to a clinic, despite feeling sick and needing medical care; so much could happen during that 30 minute trek. Imagine you’ve worked up enough bravery to (or are so ill that you’ve had to) go to the clinic: upon arrival the security guard insults you, the people in the waiting area cover their children and intentionally move away from where you are sitting, the nurse calls you the wrong name, and the doctor spends most of the consult lecturing you about your appearance and “lifestyle.” Would you go back to that clinic?
When you are repeatedly told that you are a “freak,” an “abomination,” a “sinner,”–not to mention other vulgar insults that I cannot print here–your self-esteem takes a beating, as does your belief that you are capable of accomplishing anything, or exerting agency over your own health and well-being. Imagine, after graduating with top honors from nursing school, you still cannot find employment because your documents state that you are male, but you are living as a woman because that’s who you are. I know a nurse for who this is the case; the only opportunities offered to her are as an unpaid volunteer when public clinics in her city have a national HIV testing day. She counted herself among the fortunate few who managed to complete school despite having been shunned by her family and socially rejected by her classmates and teachers. The last time I saw her she had given up applying for nursing jobs and was making a living as a sex worker.
The need to be accepted and loved can also have a profound effect on the choices people make in relationships and the behaviors they are willing to engage in to keep a partner happy. For many sexual minorities who cannot live openly, this can often mean being coerced into having unprotected sex, having multiple partners, and/or having sex while under the influence of alcohol or other substances. These behaviors significantly increase the risk for acquiring HIV and other STIs. For many trans women, the pressing need to affirm their femininity drives them to adopt traditional and stereotyped gender roles that interfere with their ability to negotiate safe sex. Tina, one of the study participants, commented “ In my relationship I am passive. For the simple reason that I identify as a biological woman.” The belief that to be a “real woman” you have to be submissive, that assertiveness is not feminine, is not only inaccurate, it’s dangerous.
As we work towards the fulfillment of UNAID’s 90-90-90 goaland focus our efforts on reaching key populations with testing and treatment services, let’s bear in mind that achieving an AIDS-free generation is impossible without promoting respect and recognition of sexual diversity, supporting the expansion of narrow notions of gender identities, roles, and expressions, and upholding human rights for everybody.
** You can read more about the Advancing Partners and Communities work strengthening community-based organizations and the Trans community in the Dominican Republic in a case study, “Inclusion Not Exclusion,” which won fan favorite in USAID Learning Lab’s 2015 CLA case competition.
 International HIV/AIDS Alliance, The Hidden Epidemic, Fact Sheet: Transgender People and HIV, August 2008
 90% of people living with HIV (PLWH) know their status, 90% of people diagnosed with HIV are on antiretroviral treatment, and 90% of PLWH are virally suppressed (UNAIDS Treatment Target, 2014)