TLBz Sexperts! Using information and technology to get to zero HIV infections among Thai transgender people

Nada Chaiyajit

Published Online: November 15, 2014
Full Text: HTML, PDF

Abstract

Currently, access to sexual health information that serves the needs of transgender individuals is non-existent or severely limited.  With “Getting to Zero” as the official UNAIDS campaign to achieve zero new HIV infections, zero discrimination and zero AIDS-related deaths, this lack of access to information coupled with immense stigma and discrimination among transgender individuals will not allow UNAIDS nor the world to achieve such impressive goals.  This paper identifies gaps and challenges in HIV services for transgender individuals living in Thailand.  Among other recommendations, the paper recognises the need for the ‘de-coupling’ of transgender services from those serving men who have sex with men.  The paper describes an innovative communication technology project, the Thailadyboyz (TLBz) Sexperts! Program, a low-cost, transgender-led, community project offering accurate online transgender-specific sexual health information, social support and legal advice.  The paper describes how the TLBz Sexperts! Program exemplifies the power of online communities and social networking platforms in reaching transgender individuals, especially when transgender community members lead in the design, development and implementation of such resources.

Keywords: Transgender, HIV and AIDS, Getting to Zero, UNAIDS, Sexual Health Information, Thailand

Introduction

Throughout the world, there is a lack of transgender-specific sexual health information, even on the Internet where one would expect to find a lot of this information. Even more glaring, access to online transgender-specific sexual health information in native languages is particularly limited. In Thailand, a country recognised as a world-renowned medical hub for sex reassignment surgery (SRS), such information is almost non-existent (Aizura, 2010).

To date, most online resources dedicated to transgender individuals’ health and wellbeing are based in high income countries.  Examples of extemporary resources are the web site of the Center of Excellence for Transgender Health at the University of California, San Francisco; the Gender Health Resource Guide developed by The American Congress of Obstetricians and Gynaecologists; Transgender Women – Transgender Health Matters by the Terrence Higgins Trust in the UK; the Gender Centre Inc.’s online platform, which is supported by the New South Wales Department of Human Services in Australia; and TransHealth, a U.S.-based comprehensive web-based clearinghouse that has a list of organisations that provide information and resources on a variety of topics related to transgender health. All of these resources are English-language websites. Transh4ck, developed by Dr. Kortney Ziegler, is an innovative open source web-based approach to tackling the socio-economic obstacles experienced by the transgender community, including unemployment, relatively lower salaries, homelessness, and discrimination across multiple social services, including access to adequate healthcare services. Not only is the establishment of these online resources providing transgender individuals in these high income countries and other English-proficient individuals with easily accessible vital and potentially life-saving sexual health information, they also serve as a web-based platform designed to help bring the transgender and gay/MSM communities closer to achieving the UNAIDS goal of “getting to zero”, which calls for zero new HIV infections, zero AIDS-related deaths, and zero HIV-related discrimination worldwide.

Unfortunately, to date, Thailand remains on the sidelines in the promotion and implementation of technologically innovative sexual health resources for transgender people. This paper aims to highlight the stigma and discrimination faced by the transgender community in Thailand, efforts implemented by Thai-based transgender-focused community organisations to address these and other barriers to accessing healthcare, and recommendations to help Thailand not only be recognised as a medical hub for sex reassignment surgery, but also as an leader in ensuring access to quality transgender health information and championing the social, economic, and health rights of all transgender individuals.

Background

Currently there is only one location in Thailand (Pattaya) that provides comprehensive, transgender-led services for transgender people.  The services are unique in that they are tailored to meet the actual HIV prevention and care service needs of the transgender community. Sisters, an transgender led and staffed organisation, is able to accomplish their efforts by working closely with key public health officials in Pattaya and by actively promoting healthy sexual behaviours among transgender persons.  As for the rest of country, Thai community-based organisations (CBOs) have been tasked with conceptualising and implementing virtual or web-based general health support services for the transgender population.  Rainbow Sky Associate of Thailand (RSAT) in Bangkok, Mplus Foundation (Mplus) in Chiang Mai, Health and Opportunity Network (HON) in Pattaya, and Andaman Power in Phuket are four prominent CBOs that have taken on the challenge of addressing the online sexual health information needs of the transgender community.

Despite efforts made by CBOs in Thailand to offer information to transgender individuals via a stigma-free, non-discriminatory, and easily accessible online platform, most sexual health initiatives targeting the transgender community are a sub-component of programming intended to address sexual health and HIV needs of men who have sex with men (MSM). For example, The Silom Community Clinics in Bangkok and Chiang Mai offer general sexual health services to both the MSM and the transgender community. RSAT, Mplus, and Service Workers IN Group (SWING)–which provides services to sex workers in Bangkok, Pattaya, and Koh Samui–also strive to provide appropriate services to the transgender population.  The fact is the sexual health knowledge and HIV prevention needs and wants of a transgender individual differ vastly from the needs of MSM. Transgender women and men require a safe transgender-specific space to discuss the sexual practices and behaviors that are specific to their individual anatomies, and a safe place to discuss the fear and struggles that accompany preparation for, and the experiences following, sex reassignment surgery. Currently, the resources available at CBOs and clinics to offer this vital public health service to the transgender population are severely limited.

The term MSM has been employed to describe a broad range of individuals where male-to-male sex is not framed so much in terms of homosexuality versus heterosexuality, or gay versus straight, but along a spectrum of masculinities and gender variance that incorporate ideas of feminisation, gender orientation, penetrative masculinity, desire, and sexual orientation. Although the majority of male to female (MTF) transgender persons who have undergone sex reassignment surgery identify as women, they are still referred to as MSM by key public health professionals and organisations. This unequivocally exhibits a lack of sensitivity and respect towards an individual’s self-defined sex and gender identity (Walsh et al.).

Ami B. Kaplan, an accomplished psychotherapist and committee member of World Professional Association of Transgender Health (WPATH) explains that the difference between gay men, MSM, and transgender individuals is contingent on the narrow definition of one’s sexual orientation (who you are attracted to sexually) and one’s gender identity (who you know yourself to be). While transgender individuals are now often lumped in the same category as gay men under the lesbian, gay, bisexual, and transgender (LGBT) umbrella, there are specific differences between the groups that are vital to the identity and experience of the members of each group. Historically, transgender individuals have had to jump through many hoops in order to transition to their desired sex and gender. LGB individuals go through the process of “coming out”, but this does not require anatomical alteration. Transgender individuals also “come out”; however, the process is more complex. For example, many transgender individuals are required to address issues around body dysphoria as well as social acceptance. The transgender individual also employs more invasive medical processes such as hormone replacement therapy, voice alteration, facial hair removal, and other alterations (Kaplan, 2009).

In Thailand, male to female transgender individuals are legally identified as male.  Transgender people in Thailand cannot legally change their gender on their identification cards. This often results in difficulties in securing employment. Transgender individuals in Thailand report that potential employers have denied them employment due to misperceived complications with hiring transgender people. A “Thai phuying praphet song” (‘woman of a second kind’) carries a male ID card, and travels with a male passport, which she must use when she opens a bank account, applies for a job, and any number of other everyday activities (Winter, 2008). Current Thai law maintains that only the transgender person’s sex at birth can be reflected on the individuals’ passport. This practice creates confusion, forces the transgender person to “come out” in situations where he or she may not want to, and creates unnecessary scrutiny at border crossings and immigration checkpoints. Thailand also prohibits same sex marriage, meaning that when the partner of a heterosexual transgender person dies, the deceased’s family receives any and all assets, and the transgender individual is entitled to no inheritance (Armbrecht, 2008). As a result transgender individuals’ career opportunities are fettered by the discrimination they experience, often forcing them to accept stereotypical jobs such as waitress, hairdresser, make-up artist, and street vendor. This is true even if the transgender individual holds an advanced academic degree.   The alternative is often sex work.

Social, economic, and psychological discrimination experienced by the transgender community, as described above, places them at high risk for gender-based violence (GBV), HIV, and other sexually transmitted infections (STIs). Because transgender people are marginalised in Thai society, national healthcare providers and human rights groups have been slow to address acts of GBV against members of the transgender community. GBV is frequent in the transgender community and often results in devastating consequences for the victims, including physical, sexual, and mental harm and suffering (Thepsai & Walsh, 2008). This overt, and often unchallenged, abuse is not seen as a crime, but as a private family matter, leaving its victims feeling intimidated and fearful.

In an effort to address GBV experienced by the transgender community, the Health Policy Initiative, funded by the United States Agency for International Development (USAID), engaged CBOs and other health sector entities in a project aimed at screening transgender individuals for GBV in Pattaya, Thailand. The 2008 study found that 89% of transgender individuals surveyed had experienced some form of GBV (USAID, 2009). This degree of GBV combined with the transgender population fearfulness of reporting crimes to the police, their inadequate access to healthcare and HIV testing, and the economic pressures they face to simply survive in Thailand place this population at high risk, not only for repeat GBV, but also for HIV infection and the transmission of other STIs.

Effective Programming

Given the absence of opportunities and platforms to access information regarding the needs of the transgender community, transgender activists in Thailand established Thailadyboyz (TLBz.) in 2002. TLBz[1] is a 100% virtual community aiming to provide transgender individuals with an on-line community and a second home, where they can  safely communicate with each other about issues that specifically concern them. The online community is warmly referred to by members as the “Blue House” due to the website’s colour. Virtual services offered by TLBz include chat rooms for specific topics. The “Blue Sofa” chat room serves as a guest room for members who want to address general topics and welcome new members. The “Beauty Ladyboyz” chat room gives members the opportunity to share beauty secrets. The “Red Chair” chat room is a space where individuals can listen to and view audio-visual stories that are collected by the site administrator and site members. The “Beauty by Surgery” and “Taking Hormones” are the most popular chat rooms where people exchange information about their own experiences with hormone use and sex reassignment.

In 2011, amfAR supported the development and implementation of The TLBz Sexperts!, an online HIV/AIDS, human and legal rights counselling service run by transgender individuals for transgender individuals. The program continued under the oversight of Bridges Across Borders Southeast Asia Community Legal Education Initiative once funding for the program from amfAR ceased. The TLBz Sexperts! program was offered three hours a day, five days a week (Figure 1). The current adaptation of the program focuses on providing counselling services to male to female (MTF) transgender individuals across Thailand.

The implementation of The TLBz Sexperts! program did not come without its challenges. During the first month of services, only seven visitors utilised the services. However, TLBz Sexperts! have now provided counselling services to more than 1,300 transgender members through closed trans-groups on Facebook. TLBz Sexperts! offers online counselling via trained transgender counsellors.  The impact of social media and online networking influenced the way The TLBz Sexperts! program operated. The administrators realised that the majority of the transgender community were virtually connected, primarily via Facebook, so they adapted and began offering online counselling services exclusively through Facebook. The two Facebook groups created by TLBz Sexperts! are “Sao Praphet Song of Thailand” and “TLBz Sexperts!”.

TLBz Sexperts! aims to foster a safe, online community for the transgender community by employing the evidence-based popular opinion leader (POL) approach.

chaiyajit

Figure 1: TLBz Sexperts! Facebook website

By having strong, knowledgeable, and empathetic transgender leaders as readily available online counselors, TLBz Sexperts! offers members a unique opportunity to engage with individuals who understand them and are eager to share their experience. The POL’s primary responsibility is to ensure that members feel free to ask whatever questions they may have regarding their sex, gender, sexuality, sexual behaviours, and their basic human rights.

To gauge the effectiveness of offering TLBz Sexperts! services exclusively via Facebook, members were directly asked to comment on their experience. Most members stated that they felt no gap between themselves and the counsellors, even though the information disseminated by the counsellors is done virtually. Members stated that TLBz Sexperts! were instrumental in providing vital individual counselling services around issues commonly experienced by the transgender community and were effective in referring individuals to a healthcare provider to address an individual’s more clinical needs, such as screening for HIV/STIs. Below are a few comments shared by members regarding TLBz Sexperts!:

  • “I never thought that HIV would become a serious issue in my life before until I found out my HIV-positive status during an annual health check-up.  During that moment, I knew nothing about HIV/AIDS, and no one from the hospital provided me with adequate pre or post-test counselling services. I was completely lost. A friend of mine introduced me to TLBz Sexperts!, and I reached out, asking for more information about HIV/AIDS and a referral to a medical provider. TLBz Sexpert connected me to Silom Community Clinic, where I connected with other people living with HIV/AIDS like myself. I was linked to medical care, informed that the cost of my care would be covered by the social security healthcare plan in Thailand and placed on lifesaving HIV antiretroviral therapy.” – Malisa (TLBz Sexperts! member)
  • “Transgender people tend to want to communicate about their health needs with someone they know they can trust. TLBz Sexpert! is great in that I know I can communicate with a trusted leader and receive services anonymously. The fact that the TLBz Sexperts! staff remains connected to the community ensures the appropriate and timely dissemination of information. There is a need for the TLBz Sexperts! counsellors who are well versed in issues about the body and mind; individuals who are always sincere and honest in their approach. – Bombay (TLBz Sexperts! transman client)

In 2012, the TLBz Sexperts! program began recognising it was a “big thing that had a small beginning.” The TLBz Sexperts! staff pride themselves on this statement, because they aim to provide the best services available, even in an environment of no resources. An article describing the work of TLBz Sexperts! has been published under the title “Sexperts! Disrupting Injustice with Digital Community-led HIV Prevention and Legal Rights Education in Thailand” with Digital Culture & Education (DCE) and The HIVe (Chaiyajit and Walsh, 2012). Nada Chaiyajit, a TLBz Sexpert and program leader, was invited to record the podcast “Reaching the Transgender and MSM population through Social Media” by AIDStar-One, on behalf of USAID and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). TLBz Sexperts! was also named an effective model for the transgender community by Avert in an article entitled “Transgender and HIV”.

TLBz Sexperts! is committed to the idea of “Sexpertise”. “Sexpertise” promotes transgender-grown initiatives that are specific to their community and that assist transgender individuals in better addressing the barriers that exist with being transgender, including anxiety brought on by social pressure to be and act a certain way and not being able to access or enjoy certain basic human rights, such as the right to one’s own identity—a right that transgender people are often legally denied in Thailand.

Recommendations

TLBz Sexperts! is actively engaging the transgender community by providing 100% pro-bono work within a volunteer system, which is one example of a resourceful approach to engaging the transgender community online; however, there is a need for funds for capacity building TLBz Sexperts! would be a more effective online peer outreach and prevention platform if all counselors possessed the skill set to seamlessly deliver information, not only about the HIV prevention and care needs of members, but also to speak knowledgeably about issues of self-esteem, body image, sexual pleasures and gender rights.  Several approaches that key funders can take to address the issues of HIV infection, AIDS-related deaths, and stigma and discrimination faced by the transgender community in Thailand  were developed by TLBz Sexperts! specifically for the transgender community in Thailand to expand the work that has been to date:

Best Sexual Life in Practice Workshop: This is a learner-centered workshop conducted in safe and friendly spaces that aim to invite pre- and post-operation transgender individuals and individuals who have no intention of surgery. The goal of this initiative is to bring together a diverse group of transgender individuals to share their sexual experiences and discuss best sexual practices in a safe environment. Brainstorming sessions would be conducted to address issues Thai transgender persons experience in accessing sexual health and information about HIV prevention and care, as well as institutional and non-institutional barriers to sexual health and transgender health. Participants would also discuss how Thai transgender persons embody transgenderism or transgress heteronormative gender norms to better understand what these mean and to design customised, holistic sexual-health resources that are specific to Thailand and are specifically aimed at building and strengthening Thai transgender people’s self-esteem. An emphasis would be placed on discussing concerns around HIV and AIDS, STIs, and voluntary confidential counseling and testing services to identify obstacles and myths that influence Thai transgender person’s sexual practices. This would allow researchers to better understand not only the biological pathways of HIV infection, but also the psycho-sexual and social determinants specific for the transgender community in Thailand. The design, implementation and evaluation of this initiative should be guided by an elected steering committee of Thai transgender individuals.  This would bring the virtual online community efforts to a physical environment with peer educators for skills building.

Continue and Expand Design of Online Resources through Sexperts! Brand & Website: The aim of this activity is to use data collected on specific transgender health issues via the current website to develop holistic information regarding sexual education, sexual practices, and other health resources. This new and improved online platform would address misunderstandings that arise from stigma and discrimination; address short-term and long-term complications from body augmentations, surgical procedures, or hormone and silicone use; assist Thai transgender people in better understanding their personal risk for HIV (in relation to pre/post/no intention operation); help Thai transgender people engage in safer-sex negotiations; and provide referrals to transgender-friendly sexual healthcare providers who are known to other transgender people to be adequately aware of transgender anatomy and issues (e.g., neo-vagina & STIs; ) to meet Thai transgender person’s diverse sexual health needs. It would also provide referrals to transgender friendly legal services.

Develop Transgender Holistic Sexual Pleasure, HIV Prevention and Care and Legal Rights Online Resources Center: The aim of this activity is to create capacity to post “Sexpertise” content online, including articles and links to informative videos that could be easily accessed by all registered online members.

Designa Video Series, Transgender Mama Talk: The aim of this activity is to employ nominated Thai Transgender Champions, who can also be POL, to produce a web TV episode series conceptualised, written by, and starring Thai transgender individuals titled, Mama Talk: Living a Happy, Healthy, and Sexually Pleasurable Transgender Life in Thailand. This online series would cover topics such as transgender health, transgender sexual pleasure, transgender HIV prevention, how to negotiate safe sex, accessing transgender sexual health, top transgender beauty tips, hormone use, sexual reassignment surgery, transgender legal rights in Thailand, and dealing with stigma and discrimination.

Conclusion

Everyone has a fundamental human right to enjoy the highest attainable standard of physical and mental health. Yet, it is evident that the key international organisations responsible for crafting and promoting health policy to help ensure everyone has access to this right need to do more to better highlight and promote the specific sexual health needs required by the international transgender community, so transgender individuals can lead the safest, most productive lives possible. ).

In order to truly get to zero HIV infections, zero AIDS-related deaths, and zero discrimination, international and national organisations must invest in transgender-specific research, interventions, and advocacy needs. Research topics should include the effects of ART on hormone use and sexual reassignment surgery and the sexual risks for individuals with neo-vaginas; finding more epidemiological and behavioral data on transgender populations (including transmen); and linkages between human rights violations and increased HIV vulnerabilities specific to the transgender community. More information is needed around HIV treatment and other essential health issues affecting the health and well-being of the transgender community.

A successful, web-based transgender community was developed for providing healthcare information and sharing experiences through online communities in web boards and other types of social networking in online support groups. The experiences from this collective were compiled into TLBz Sexperts! and reached out to 1,300 transwomen. Unfortunately, TLBz Sexperts program suffers from funding limitations and lack of staffing of experts on the issues concerning transwomen’s health. Recommendations for further development of the program are contingent on funding.

An expanded online platform where transgender individuals can safely exchange information with members and benefit from the counseling of comprehensively trained online popular opinion leaders is a necessary weapon in the fight to stem HIV and AIDS and decrease stigma and discrimination towards transgender persons in Thailand. Key international organisations like UNAIDS are in a unique and powerful position to promote and advocate for these initiatives as well as engage local community-based organisations, national governments, donors, and research institutions, and to encourage public-private partnerships to tackle the socio-economic and psychological struggles that unequivocally make transgender individuals a key population at high risk for HIV infection.

Acknowledgements

I would like to thank Kent Klindera, Elena Kelly, Cameron Wolf and Dr Christopher S Walsh for their support in assisting her in publishing this manuscript.

References

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Biographical Statement

Nada Chaiyajit is transgender Sexperts! Consultant at Health and Opportunity Network (HON) and the project manager for TLBz Sexperts! Online Peer Outreach and Prevention program, where she is working to improve education and empowerment among transgender communities in Thailand.  She has worked as a transgender advocate since 2006 and has been with BABSEA CLE since 2009, during which time she has been a guest speaker at the 17th, 18th and 20th International AIDS Conferences.  She is also the Audience Council Secretary for LGBT and transgender rights for the Thai Public Broadcasting Service (Thai PBS).

Nada is a founding member of the ‘Thai Transgender Alliance’, a fellowship network that promotes understanding and equality for transgender people in Thai society. The Thai Transgender Alliance is using the Internet to compile a database of human and sexual rights violations against transgender people to prove to the authorities that this gender-based violence (GBV) is a violation of their human rights and a major public health issue.

Nada has lobbied individually and collectively to modernise the Thai criminal law on rape, advocating for a specific equality provision for both men and women. Drawing on funded research and her experiences as advocate for human rights, Nada has worked collaboratively with marginalised and stigmatised populations in initiatives to promote democracy, social justice and equity by strengthening their capabilities and promoting their involvement in online communities of practice.

Nada was the keynote speaker at the 2010 IADIS International Conference on E-democracy, equity and justice, and also presented her work at the AIDS 2010 Conference in Vienna. Her work also has included media advocacy and education pieces with productions.

Email: nada.chaiyajit@gmail.com



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Author: TLBz Sexperts! Using information and technology to get to zero HIV infections among Thai transgender people - Digital Culture & Education
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