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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