Transgenders in Asia: sexual health

Acknowledgements

Family Health International: Philippe Girault, Elizabeth Pisani

Ministries of Health: Bangladesh, Cambodia, China, East Timor, India, Indonesia, Thailand, Viet Nam and CDC, USA

Implementing Partners: Bandhu Social Welfare Society, Humsafar Trust, Yayasan Srikandi Sejati, Yayasan Pelangi Kasih Nusantara, Save the Children in Papua New Guinea

Images: Simon’s Cabaret, Time, Nong Tum

Sexual Health Issues –Transgenders

Feminization

STIs including HIVAno-rectal conditionsSexualityRelationshipsChildrenDrug useDepressionSex workLegalDisclosure acceptance Aging

• TGs marginalized

• High risk of HIV & other STIs

• Few data – especially STIs

• Role as “bridge populations”

• Fragmented identities & communities

• Criminalization, stigma &

discrimination

Background

No Problem

=

No Prevention Program

No Prevention Program

=

No Data

No Data = No Problem

Years of Neglect Leads To …

Multiple partners

High rates of unprotected anal sex

Poor access to commodities and services

Challenges in Programming

Challenges in Programming

Challenges in Service Delivery

• Poverty

• Needs assessments in priority areas –

identifying barriers to access

• Access to HIV clinical care, treatment &

support

• Payment

• Guidelines

• Outreach activities

• Research & surveillance

• Human rights concerns

Sexually Transmitted Infections

Outline

Ano-rectal STIs: Issues

Rectal gonorrhea and chlamydia prevalence, MSM

and TGs in Asia, 2000-8

0.2

16

12

4

29

1

8

1

12

7

13

21

8

1

15

21

2

18

9

15

5 5 4 4

10

4

9

0

5

10

15

20

25

30

35

Phno

m Pen

h 20

00

Dili M

SM 200

3

Kathm

andu

200

4 M

SW

Kathm

andu

200

4 M

SM

Pakista

n TG

s 20

05

Ban

gkok

200

5

Man

ila 200

5

Cam

bodia 20

05Han

oi 200

6

HCM

C 200

6

Mum

bai, 20

06-7

Pakista

n TG

s 20

07

Kathm

andu

MSM

200

7

Ban

gkok

MSM

200

6-8

Prevalence (%)

Re GC

Re CT

STI prevalence, MSWs and TGs, Pakistan, 2005

35.6

11.5

3 3.3 4

17.5

29.4

01.2 0 1.5 1.5

10.4

4.11.5 0 0.5

60.2

5.75.8

18.3

0

10

20

30

40

50

60

70

Karachi

MSW

(n=401)

Karachi TG

(n=197)

Lahore

MSW

(n=400)

Lahore TG

(n=198)

Prevalence (%

)

Syphilis

Urethral Gonorrhea

Rectal Gonorrhea

Urethral Chlamydia

Rectal Chlamydia

HIV

STI prevalence among MSM, Cambodia, 2005

0.4 0.4

1.3 1.1

2.9

1.41.2

2

7.9

1.4

0.8

9.1

0

2

4

6

8

10

MSM TG

Prevalence (%

)

Syphilis

Urethral Gonorrhea

Rectal Gonorrhea

Urethral Chlamydia

Rectal Chlamydia

HIV

Three sites: Phnom Penh (n=300); Battambang (n=124); and Siem Reap (n=124).

0.5

74.5 4.6 5.1

0.4 0.40

14

9.68

3.7

0.57 0

2.8

54

45

20.8

10.4

0 0

0

10

20

30

40

50

60

HIV HSV-2 Active

syphilis

Rectal

GC

Rectal

CT

Urine

GC

Urine

CT

Prevalence (%

)

Bantha

Khotki

Khusra

STI Prevalence among MSWs, Rawalpindi

and Abbotabad, Pakistan, 2007

Source: Hawkes S et al. WHO STI Meeting, Geneva, 2008.

HIV prevalence among MSM and TGs in Asia

Van Griensven. Sources: NBC, 2006; UNAIDS, 2006b, 2006b; FHI, 2006a, 2006b; Choi, 2003; MAP, 2005; van Griensven, 2005; MMWR, 2006; Ma, 2006, NCHADS, 2006.

17.6 TG

11.4 MSW

15.3 MSM

11.9 TG14.4 MSW

5.5 MSM10.5 MSW

6.7 MSW

11.5 TG20 MSW

28.3

MSM 17.3

0.8 0.8

8.7 MSM

MSM 14.0

36.7 TG

5.8 8.0 5.3 MSM

Thailand

Chiang Mai 2005

Bangkok2003-5

Pattaya 2005

Phuket 2005

Had Yai 2005

Ho Chi Minh 2002-4

Phnom Penh2000-5

Battambang 2005

Siam Reap 2005

Beijing 2001-6Shiang Hai 2004-5

0.8, 3.1, 3.1, 4.6, 5.8 MSM 1.5 MSM

5.0 MSW

Shenzen 2005

Hangzhou 2004

3.0 MSM

2225.3

MSM 2006-7

MSM 2000-3

MSW

TG

MSM 2004-5

Hanoi 20069.4 MSM

22.0 TG

Jakarta2002

3.6 MSW2.5 MSM

31.0

33.0

Mandalay

19962006

Yangon

Syphilis* prevalence, MSM and TGs in Asia

IndiaIndiaIndiaIndia

PakistanPakistanPakistanPakistan

BangladeshBangladeshBangladeshBangladesh

NepalNepalNepalNepal

7.3 MSM

14.0 MSWKathmandu 2005

Karachi 200660.2 TG

After van Griensven - Sources: NCAP, 2006, CREPHA, FHI, 2005, NAP, 2006.

3.8 MSM 5.2 TG

Dhaka 2004-5Lahore 2006

11.5 TG

36.8 MSW

5.7 MSW

* lifetime or current syphilis

Syphilis prevalence among MSM and TGs in Asia

6.8 5.5

7.0

Thailand

CambodiaBangkok 2005

Ho Chi Minh 2000

Phnom Penh2000

Shiang Hai 2004-5

13.5

Hangzhou 2004

7.8

Jiangsu2003

6.9

19.3 TG

Jakarta2002

2.0 MSW1.1 MSM

12.4

4.59.9

Beijing, 2004-5-6

Manila2005

5.0

After van Griensven. Sources: Girault, 2004, FHI, 2002, 2004, 2005; Pisani, 2004; Jiang, 2006; Lui, 2006; van Griensven, 2007; Ma, 2007; Ruan, 2007.

MSM Clinical Guidelines

Guidelines: www.iusti.org/sti-information/

Curriculum: www.go2itech.org/itech?page=co-09-01

Summary

Feminization

Anarchy in Asia

Need for guidance for clinicians

Need for community acceptance of standards

Feminization – Hormone Therapy

Physical changes

Reversibility

Bones, height

Handouts

Consent form

Hormone Therapy – Risks & Effects

Hormone Therapy – Contraindications

1. Known or suspected cancer of the breast2. Known or suspected oestrogen-dependent neoplasia3. Undiagnosed abnormal genital bleeding4. Active thrombophlebitis or thromboembolic disorders5. Past history of thrombophlebitis, thrombosis, or

thromboembolic disorders associated with previous oestrogen use

Hormone Therapy – Goals

1. Stimulate feminisation of secondary sex characteristics with oestrogen

2. Reduce androgen (male hormone) effects with spironolactone

3. Augment breast development with progesterone (controversial)

4. Doses and optimal regimens not yet established

Hormone Therapy

How Choices Are Made

1. Availability (local regulations, pharmaceutical marketing)

2. Local traditions3. Side effects4. Preferred route of administration5. Costs6. Patient and peer group beliefs

Hormone Therapy – Oestrogens

Expected effects in biological males

1. Breast growth2. Re-distribution of body fat to female form3. Loss of upper body strength4. Softening of the skin5. Decrease in body hair & slowing or stopping of loss of

scalp hair6. Decreased fertility & testicular size7. Less frequent, less firm erections8. Sense of well-being & of emotional sensitivity9. Changes mostly reversible, but breast enlargement

will not completely disappear if treatment is stopped

Hormone Therapy – Typical Costs

Costs calculated as US$1 = 42.1 Thai Baht or 58.6 Bangladeshi Taka.

$7$10Medroxyprogesterone (Provera )

$18$5 $8Spironolactone (Aldactone )

Not availableNot availableEstradiol valerate (Progynon , Estrofem )

$22 $41$7 $18Conjugated estrogens (Premarin )

$14 $60$21Estradiol (Estrace , Estrofem , Estriol , Proginova )

ThailandBangladeshMedication

Gender Re-assignment Surgery

NOT experimental

NOT investigational

NOT elective

NOT cosmetic

NOT optional

Source:

Bangkok Post, July 2008

Gender Re-assignment Surgery

Approximate external appearance of female genitals

Create a skin-lined vaginal canal (neo-vagina)

Provide normal urinary function

Permit sexual sensations.

Gender Re-assignment Surgery

Expected Outcomes

Typically includes all of:

Orchidectomy removal of testicles

Penectomy removal of penis

Vaginoplasty construction of a new vagina

Clitoroplasty construction of a new clitoris

Labioplasty construction of new labia

Gender Re-assignment Surgery

Surgical Procedures

Gender Re-assignment Surgery

Additional Issues