Sexual and Reproductive Health needs Of LGBT

Andy Mprah


The Constitution of South Africa, Act 108 of 1996 prohibits any South African to be discriminated on the grounds of sexual orientation1. Recent evidences suggest that, the risk of acquiring HIV is higher in homosexuals than in people who engage in heterosexual sex in countries like South Africa with high epidemic2. Currently, very little is known about the epidemic amongst Lesbian, gay, bisexual and transgender people (LGBT) in the country and there is little advocacy towards the group’s inclusion in HIV and STI prevention programmes3. This report focuses on the sexual and reproductive health needs of LGBT people. LGBT people are sexual minority group which includes: men who sleep with men, women who sleep with women, men or women who sleep with both sexes, as well as people who self-identify themselves as their opposite sex although their genitals show otherwise. The main sexual and reproductive health needs of LGBT in South Africa are summarised in the table below: See Table 1
The HIV/AIDS and STI National Strategic Plan (NSP) 2007-2011 is the policy that embraces the needs of LGBT in South Africa after lobbying and advocacy by LGBT sector.
Although LGBT is touched on in the broad NSP,
there are no specific and targeted programmes in place to address the needs of LGBT people4.
NGOs such as Triangle project support groups
(Cape Town), Durban gay and lesbian community as well as OUT LGBT Well-being (Gauteng) render services for LGBT in specific constituents of South Africa. Treatment Action Campaign is also an NGO which is at the forefront of HIV human rights campaigning4.
This commentary was preceded by an effective overlook of the South African 1996 Constitution; peer reviewed journal articles on LGBT, homophobic attacks in South Africa, HIV/AIDS; and policy documents on sexual and reproductive health needs of vulnerable minority groups including LGBT. In order to establish evidence of sexual and reproductive health needs of the LGBT group in South Africa, the UNAIDS Country Harmonization and Alignment Tool (CHATS), was used as the framework to assess the sexual and reproductive health needs of LGBT in South Africa. This tool was used to assess how inclusive and participatory LGBT groups are in the South African national AIDS response; how effective coordination and funding partnerships for the national AIDS response is; and how to improve partnerships to strengthen the response to AIDS by assessing the needs of LGBT. The overarching goal in this is to factor the sexual and reproductive health needs of LGBT in South African national AIDS response so as to make the national AIDS response more comprehensive to be emulated by countries of similar settings.
Assessment of needs
The assessment of the needs of LGBT, who are often categorised as sex minorities can be done using the framework of the UNAIDS Country Harmonising Assessment Tool (CHAT) below:
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Figure 1: A Framework for Assessing Evidence of Sexual and Reproductive Health needs of LGBT. Adapted from UNAIDS CHAT5.
LGBT Participation in HIV/STI Responses
The total participation and involvement of a community is paramount to the successful implementation of policies and programmes6. However, if specific stakeholders who are the target of these policies and programmes are not actively and genuinely involved, the policy risks gaps to the detriment of this target group. The constitution of South Africa is one of the most advanced in Africa and frowns upon sexual orientation discrimination. LGBT marriages were made legal in 20064. Yet, the societal attitude towards LBGT defeats the constitutional protection of the rights of LGBT4.
The HIV/AIDS and STI National Strategic Plan (NSP) 2007-2011, provided an avenue for LGBT people`s thoughts to be considered in HIV/STI responses after engagement of all stakeholders including LGBT extensively7. However, this was made possible because of the critique and lobbying by some vocal LGBT activist groups for about 6 months after the first NSP draft was released8. In South Africa, LGBT people are classified as high risk group for HIV/STI9 but that notwithstanding, they are somehow missing from all HIV/STI programmes and policies. The NSP does admit that the needs of LGBT people must be met by specific programmes tailored to suit their specific needs. Involvement of LGBT community in the implementation of NSP specific programmes development and the provision of dedicated funding for such programmes remain a challenge. A national network of LGBT people called the Joint Working Group embarked on studies to address the needs of its members at the constituency level. In 2006, activists played an instrumental role to cause the review and revision of the screening tool for blood donors of the National Blood Transfusion Services Policy10.
Mapping the epidemic and key risk factors
The direct link between LGBT and heterosexual HIV/STI transmission is unknown in South Africa.
Table 1: Indicating the Needs of LGBT People in South Africa
Participation and engagement in HIV/STI responses
 Genuine involvement in design of policies and programmes
Mapping HIV/STI epidemic, including the information on key risk factors
 HIV/STI prevalence among LGBT
 Risk behaviour information and education
Enabling environment for service provision
 Specific outreach to LGBT
 Train staff to work effectively with LGBT individuals
 Avoidance of stigma and discrimination
 Counselling and testing availability and accessibility
 Initiatives to promote prevention and care for HIV/STI LGBT people.
The Demographic and Health Survey Indicators for LGBT people verses heterosexual counterparts remain non-existent in South Africa. Information on the incidence and prevalence of HIV/STI and associated risk factors among LGBT is very limited in South Africa12. The proportion of LGBT people who engage in same sex or sex with both genders remains unknown. The stigma and discrimination characterised by HIV/AIDS has made it more challenging, characterising it among LGBT people who experience similar stigma13.
There have been several surveillances done on pregnant women attending antenatal clinics and household surveys in South Africa. However, none
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of these surveillances focussed questions on LGBT sexual activities. This could be solely because of concerns about privacy13.
Table 2: Showing Estimates of HIV Prevalence among Adults aged Between 15-49 Years in South Africa.
Adult (15-49 years)
Adult men (15-49years)
Adult women (15-49 years)
The above shows that different studies lack the specific information on the prevalence of HIV/STI among LGBT in South Africa.
Research conducted by the Triangle Project and the Centre for applied Psychology among 948 LGBT people in Cape Town16, showed that 12% of men and 1% of women are HIV positive; 15% of men and 5% of women had an STI in the previous 2 years; 23% of men and 31% of women had never tested for HIV among people aged between 16-24 years, 44% had never tested for HIV. Specific research like this targeted at LGBT people is a good step for surveillance of LGBT people. However, findings from this research cannot be generalised in South Africa and the limitation of this could be the sampling method used.
Enabling environment for service provision, funding and human resources
Although the South African constitution and political environment promote the rights of LGBT people, this has not caused a turnaround in the access to healthcare services and resources8. A state-run HIV prevention campaign was challenged by LGBT organisations in South Africa in 2005, but these challenges were ignored and no messages were directed towards the LGBT community18. Stigma and discrimination at healthcare facilities also compound the isolation of the LGBT community from programmes18. Currently, health services for LGBT people are provided by LGBT organisations whose source of funding are from foreign donors4. Information gathered by LGBT organisations suggest that most LGBT people are
asked questions bias to heterosexuality by health professionals when they go for treatment and hence delay in presenting complications like haemorrhoids, rectal bleeding and genital infections because of fear that their sexual orientation would be discovered19. Health workers in South Africa do not receive the specific additional training to meet the psychological and physical needs of LGBT people in order to show the needed compassion and acceptance of whom they are4. Nonetheless, LGBT organisations have bridged the gap in the last years. For instance, a project called the Triangle project showed satisfaction with medical practitioners among homosexuals who attended clinic in Cape Town20. However, a study like this is not a general representation of the issue in South Africa as the research participants were already members of the Triangle project support group and there may have been problems with the methodology of the research.
The Apartheid era in South Africa was noted to be a dictatorial society and strong emphasis was placed on laws regulating sexual behaviour. There was criminalisation of sex between men and pornography until 199621. There is now freedom of political association, speech and sexual preference in this post-apartheid era4. South Africa, a member of the United Nations has, like all members, aligned towards achieving the Millennium Development Goals which has 4 of its components as direct bearing on sexual and reproductive health. South Africa is therefore required to protect and respect the sexual rights of its citizens regardless of sexual orientation. LGBT issues are virtually not touched on in the South African Department of Health. There is no specific LGBT healthcare provided by government as against LGBT organisations that seem to provide the only care for this group in the country with resource limitations22. The government however focuses on the mainstream sexual and reproductive health of its citizens.
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In South Africa, HIV and STI are commonly viewed as invasion of the body by dirt which makes the blood dirty23. Sex-related issues elicit negative responses such as feeling of guilt and shame. They are thus demanded not to be discussed in public. Sexual behaviours deviating from the “normal” are severely criticized across the country4. Heterosexism is viewed in South Africa as the “normal” and is all over the media, in religious teachings, education as well as healthcare. As such, there is usually a neglect of LGBT in policy discussions such as HIV/STI policies22. Prejudice and silence on LGBT practices has thus become the order of the day. Being lesbian or gay was considered and is still considered as a “sickness” and very un-African4.
It is worthy to note that, it is not possible to compare South African LGBT people and communities to those of developed worlds like United Kingdom, Australia and the United States of America. This could be because of the diversity of culture and social backgrounds in these advanced countries. LGBT identities in South Africa differ with respect to race22. Until recently, the most vocal LGBT people were white males predominantly placed in high social class. However, the large majority of LGBT individuals are poor unemployed blacks, a true reflection of the South African community in general24. These under-resourced black LGBT are deemed in the society as the most vulnerable subsets of the community often under-researched. To date, most LGBT research is primarily focussed on rich, white and vocal people4.
Based on the findings above, I will suggest the following recommendations to the South African National AIDS Commission:
1. The LGBT community should be closely involved in the formulation of programmes and policies. Involvement will ensure that policies and programmes enacted will respect and protect the rights of the LGBT community to privacy on the grounds of their sexual orientation.
2. Sentinel surveillance should be initiated to determine the prevalence of HIV/STI among LGBT. This should also include research on the contexts and social situations of HIV/STI transmission and the appropriate HIV/STI prevention and care strategies. These researches will provide insights into barriers to care and expose funding constraints in health services as well as behaviours of health care professionals.
3. There should be a supportive programme development which should include dedicated financial and human resources, appropriate guidelines and improved access to and coverage of HIV/STI prevention, treatment and care services for LGBT. Acceptance of LGBT and safer- sex campaigns and skills training, including the use of condoms, voluntary counselling and testing as well as the promotion of lower-risk sexual practices are essential.
Conflict of Interest
I confirm that there are no conflicts of interest.
Author’s Contribution
AM carried out the literature review on LGBT in South Africa and solely wrote all the sections of this work from the introduction, assessment of needs, context and recommendations. AM read the final manuscript and approved before submission.
I wish to acknowledge Dr. Steve Pearson, module leader for the Sexual and Reproduction Health program at the University of Leeds as well as Dr. Maryam Ba-Break, a lecturer at the University of Leeds. I lastly want to thank all the technical staff at Health Policy Consult for their support and encouragement.

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