Increasing access to health services for lesbian, gay, bisexual, transgender and intersex (LGBTI) persons: by Department of Health; Protection against violence for LGBTI persons: by Department of Justice

Meeting report

The Chair noted that the meeting is part of the monthly meetings that takes place for the Multi-Party Women's Caucus. She mentioned that she sits on the Southern African Development Community Parliamentary Forum (SADC-PF), for which there will be a workshop at the end of March in Johannesburg. Some of the agenda items for today's Caucus meeting was determined by the upcoming SADC-PF meeting.

Department of Health (DOH) response to the identified needs of the LGBTI community
Dr Yogan Pillay, DOH Deputy Director-General: HIV, TB and Maternal, Child and Women's Health Programmes, presented on behalf of the Minister of Health. He noted that the constitutional and legal provisions would be covered by the Department of Justice. However, Dr Pillay did highlight three provisions in the Constitution, particularly Chapter Two, the Bill of Rights.

The South African National Aids Council (SANAC) has 19 sectors represented, one of these is the LGBTI community. This sector has participated fully in the structure and processes of SANAC over the last three years. The LGBTI sector is also seen as a key population along with other key populations such as injecting drug users and sex workers. In the context of SANAC these groupings are considered vulnerable to HIV acquisition. The concept of key populations is defined by the United Nations agency on HIV and AIDS because of their vulnerability to HIV acquisition and increased stigmatisation. This is not a concept that South Africa has come up with, it is a globally accepted concept. The National Strategic Plan for HIV and Aids, TB and Sexually Transmitted Infections (STIs) (NSP) 2012 – 2016, acknowledges and provides for key populations. Engagement with these key populations is crucial for a successful HIV response.

Dr Pillay provided an explanation for sero-negative partners, which means that in a couple one partner is HIV-positive and the other one is HIV-negative. Sero-discordant is similar, however this is in long standing couples, where one partner is HIV-positive and the other partner is HIV-negative. Dr Pillay shared that the HIV epidemic in South Africa is a generalised epidemic, meaning that everyone has the risk of acquiring the virus. Within that there are a certain groups that are more at risk, one of whom is the LGBTI community.

Dr Pillay moved on to share the Department's services and prevention strategies for HIV acquisition. The presentation provides information on services provided for in 2014/15. On the prevention side as a Department, we know that consistent use of male and female condoms protects the user from HIV acquisition and transmission. During this financial year 2014/15, the DOH has distributed 800 million male condoms and 14 million female condoms, free of charge, this includes to the LGBTI community. Dr Pillay said one might ask why there is a difference in the distribution of male and female condoms. He pointed to the difference in cost. Male condoms cost 38 cents each to manufacture, while female condoms on average cost R8 each. DOH has not been able to scale up the distribution of female condoms to the level of male condoms for this reason, however, there has been an increase in the distribution of female condoms from six million to 14 million.

The LGBTI community also requested an increase in the distribution of lubricants in addition to condom distribution. The DOH has been able to respond to this through a donation from the United Nations Population Fund. Five million tubes of lubricant were distributed in 2014, and the DOH has increased that to 20 million tubes in 2015.

With respect to health care workers, there has been an extensive sensitisation programme and training provided on the services and requirements of the LGBTI community. The DOH developed a training manual for health care workers in 2013 which focuses on the health care issues of men who have sex with men, sex workers and people who use drugs. With the support of funding accessed from the US President’s Emergency Fund for HIV /Aids Relief (PEPFAR), DOH has established three gay men clinics in Cape Town, Johannesburg and Durban. These clinics provided specific support and health care services to men who have sex with men. There are no similar clinics for other members of the LGBTI community.

DOH's HIV prevention policy was explained. Dr Pillay mentioned that there are three intervention areas: biomedical, socio-behavioural and structural. The DOH has been focusing mainly on the biomedical and socio-behavioural interventions.

Based on a series of meetings with leaders from the LGBTI community, some issues were raised which the LGBTI community wants the DOH to respond to. These were 1) Defining the primary health package of services rendered at community health care centres and clinics; 2) The number of people who have tested for HIV/Aids is not disaggregated to how many people from the LGBTI community have tested; 3) Need to revise the post-exposure prophylaxis (PEP) guidelines, this is a process that DOH has been doing in any case for everyone. The LGBTI community has been encouraged to engage in the process. Dr Pillay mentioned that the Chair may be aware that the deputy president of SANAC is a representative from the LGBTI community, this indicates that there is a representative involved in the discussions of SANAC.

Dr Pillay explained the acronyms used in his presentation: MSM – men who has sex with mentioned;
SW – sex workers; PWID – person who injects drugs.

The LGBTI community has also requested that the key populations (SW and PWID included) have an extended country wide dialogue with government and civil society on their needs. This would be extended to more than just health care needs. The LGBTI community also wanted a greater voice on SANAC, and have its sector specific needs and issues included in the current funding request that is being developed for the Global Fund funding proposal. This will provide financial support to the activities of this sector on HIV and TB related challenges that they face as a community.

In conclusion, Dr Pillay said that one can say that the rights of LGBTI people are recognised by the Constitution, DOH and SANAC. The LGBTI sector is fully represented with regards to HIV/Aids, TB and sexually transmitted infections (STIs) via SANAC. DOH has had meetings with the LGBTI community, these have always been cordial and fruitful. As a Department, we are committed to ensure that the health care needs of the LGBTI community are met and are in line with the legal provisions.

Discussion
Ms B Ngcobo (ANC) asked for a progress report from DOH with regards to funding and the strategy that will be used to deal with this funding.

An ANC Caucus member asked for clarity on why LGBTI people want more inclusion, when it is stated in the presentation that they are active members of SANAC. Why do they want inclusion when they are already included? The Member did not understand why they need to have special requests when they are part of the proceedings. On gay men clinics, she asked about the others in the LGBTI community such as lesbian women, will they not also request this? The community should accept them and gay men and other LGBTI people and they should be included in the community health services. They have to retain their dignity and equality as human beings, and all the rights that we have been fighting for as civil society will be undermined by having separate facilities. What makes female condoms expensive, is due to men. It is one part of society that determines the price, it is not the women. However, women are the ones who are affected. They do not have the power to take decisions when having sex. Women should be able to make these decisions. Patriarchy is depriving half the population from preventing the contraction of this disease. Why should women have to bear the brunt? She did not understand the excuse by DOH on the high cost of female condoms. Why do we not manufacture the condoms ourselves? If we want to reduce the infection rate, and we are concerned about the high infection rate in women, what is stopping us from making the condoms ourselves? DOH must really think about this. South Africa should manufacture the female condom to defend our women.

Ms S Nkomo (IFP) mentioned that the femidom is a serious matter. If one looks at the 14 million female condoms that are distributed, where does the budget come from, and why is it not increased? More condoms need to be given to women. It is important for women to have access to the female condom. Secondly, we need to address health education about male and female condoms. Is one of the reasons for the lower production of female condoms due to most males being reluctant about women using the femidom? Is there another reason apart from the lack of budget? Is it a matter of health education? What should be done?

She was glad that her colleague had asked about the gay clinics. She was going to ask a similar question from a different angle. We are well into fighting the epidemic, for about 35 to 40 years, however it seems as though we have not adequately educating our communities on the matter. Are we not furthering discrimination towards the LGBTI population, if we have different structures and clinics for them? Ms Nkomo's final question was on the government's STI campaign. Where does the campaign start? Ms Nkomo felt that it should begin with our children around sexuality and abstinence programmes. Also providing youth who may be sexually active with prophylaxis, and possibly even educating young girls on secondary virginity.

Ms T Memela (ANC) thanked the presenter for the information provided. She raised concern around children who are finding out about their HIV status only through the circumcision programme happening at the schools. These young people are being told that their HIV was contracted through mother-to-child transmission. They have gone through various health clinic programmes but nothing has been picked up. How are we going to improve this? What is happening in the clinics to monitor the care that is given. These children are finding out about their HIV status only in matric and they could have been treated at birth.

Ms M Khawula (EFF) said there are people who still continue to tell others to pray to be cured of HIV/AIDS. The person might have already started treatment and stops taking it, relying on prayer only. What is being done with those people because they were stopping others from taking their treatments. There was also a problem where couples, both HIV positive and having sex without a condom, they would then have a child that was HIV negative – how did that happen?

There were no clinics in rural areas, and when there were clinics they were too far and people would need money to travel to them. In these instances, what could be done so that these people could be visited and tested? Also, people who were on treatments would just stop taking their treatments even though government spent a lot of money for the treatment. There were those that had a CD4 count that was below 200 and received no grants so that they could buy food to take with the medication. There were no healthcare facilities in rural areas, why was it that this was not looked into in order to increase access to healthcare for those communities.

The Chair requested the member to keep her question short, and urged members to keep their input strictly to the agenda item. This briefing is about services for LGBTI people and not HIV generally.

Response from DOH
Dr Pillay supported the Chair's suggestion for a longer meeting on HIV generally. On the funding issue, the Global Fund provides funding to South Africa for HIV/Aids and TB programmes. The DOH is currently in the process of putting together their proposal for further funding. The LGBTI community asked that the Global Fund proposal include specific funding requests for LGBTI needs. This is in line with the requirements of the Global Fund. The DOH does not have any dedicated funding for this sector, apart from specific sensitisation training and manual development. On the engagement of the LGBTI community at SANAC, he said that there may be fears of exclusion in the larger plenary, and that they may not be equally heard. As SANAC is a large forum with 19 sectors represented, it does happen that there is a conflict of interests and ideas.

Dr Pillay was glad that Members raised the issue about gay clinics as it is something that the Department has also been grappling with. The gay community approached the American donor, PEPFAR, for funds to establish the clinics, in three sites. No government money was used in setting up these clinics, although they are based at DOH facilities, PEPFAR money was used. Dr Pillay is personally in agreement with the thinking of some of the Members about mainstreaming the services to the LGBTI community. However, there are still some people from the LGBTI community who want a dedicated clinic. It is useful to hear the thinking of the Members on this issue. The DOH is currently mainstreaming services, including services around HIV in order to normalise the disease, and in the same way normalise thinking about people's sexual orientation so that it does not attract additional stigma.

Dr Pillay mentioned that he was worried about the condom issue. The key question is what do we do about this? There has been an increase in the distribution of female condoms and the DOH is committed to increasing this number. It was noted that it is crucial to protect men and women, more specifically women from contracting HIV. For this reason the DOH is keen to investigate the use of microbicides and preventative methods that can be used by women before having sex. It is clear that we need to empower women because of structural issues in society, being a patriarchal society, and this needs to be done in all spheres of society. This is a larger issue which needs to be addressed. The DOH can provide biomedical approaches.

On the production of condoms, the DOH does not manufacture condoms. It is up to society and other departments to set up plants to be able manufacture condoms. The main product in condoms is latex, which comes from the rubber tree, however there are no natural resources in South Africa. The bulk of the cost associated with condoms is the importing of latex. There is a synthetic product which is being looked into, however in the past polyurethane was used but this got negative feedback. There is a new material but this is more expensive.

With respect to education, research has shown that for there to be effective education campaigns this needs to be run in parallel to service provision. The DOH has a tender out for a large communication campaign on not only HIV, but TB, maternal health and healthy lifestyles.

The DOH is working closing with the Department of Basic Education on HIV testing in schools. There has however been some concerns raised by school governing bodies on the roll-out of HIV testing. This is largely due to the presumption made about how one contracts HIV and its relation to being sexually active. This message needs to be changed. There are 400 school health teams that go to schools nationally. There are various health screenings that take place across the grades and the health education is done in an age appropriate manner.

With regards to the post-partum transmission, Dr Pillay shared that DOH does have figures on this occurrence as research has been done in partnership with the Medical Research Council. Some findings show that there has been a decrease in mother-to-child transmission from 8% in 2008 to 2.6% in 2012. The aim is to move towards zero transmission and various steps have been put in place, such as testing the mother before birth, another is providing HIV positive mothers with a lifelong supply of anti-retrovirals, this was initiated in 2014.

Dr Pillay responded to the question on rural health. He mentioned that DOH has built a number of rural health facilities, and where there is not a permanent structure, mobile clinics are used in that particular area. He did note that more needs to be done around rural health, as some people are unable to access health care services due to the terrain, even if the facility is within a five kilometre radius of their home.

The Chair suggested an extension of the meeting until 16:00 as there seemed to be many questions from the Members. This suggestion was declined by the Members. The Chair indicated that more time is needed for these briefings and that perhaps for the next meeting agenda only one Department should be requested to present.

A final question was posed by the Chair. She said that in the presentation there was mention of female and male services but what about bisexual and people who are transgendered, where do they fit in? Are they comfortable with using a binary system. Where does DOH locate them?

Dr Pillay explained that bisexual refers to one’s sexual orientation or preference and that the person is still biologically a female or male, so would access the respective services.

The Chair stated that she would like to further engage in the practicality around this and transgender health. She thanked Dr Pillay for his presentation and mentioned that they will be inviting DOH back to present to the Caucus. She said if Members have more questions they should send them to the Caucus secretary.

A final request was made from a Member that when DOH completes the Global Fund proposal an inclusion should be made for funds for female condoms.

The Chairperson asked that Members who still had questions should write them down and give them to the Secretary.

The Chairperson handed over to the Department of Justice to make their presentation; she added that it was not only women being killed because of their sexual orientation.

DOJ briefing on protection of LGBTI persons against violence and other human rights violations
Ms Busi Dlamini, National Co-ordinator for the LGBTI Programme, Department of Justice and Constitutional Development (DOJ) mentioned that they were only informed the day before that the briefing was to be given. It was fortuitous that they happened to be in Cape Town for a meeting with the provincial LGBTI committee.

Ms Dlamini referred to Section 9 of the Constitution, the Equality Clause, and stated that South Africa was the first country in the world to prohibit discrimination based on sexual orientation. South Africa has progressive laws and protections and is seen to be way ahead of other countries when it comes to LGBTI rights. However, there is no legislation that addresses hate crimes. The DOJ has introduced a policy framework, and she referred Members to page 8 and 9 of the presentation.

The National Task Team (NTT) is comprised of the South African Police Service, the National Prosecuting Authority, the Department of Cooperative Governance and Traditional Affairs, the Department of Correctional Services, Department of Basic Education, civil society organisations (CSOs) and Chapter 9 Institutions. The DOH has recently also joined the NTT. This was on request from civil society organisations that are part of the NTT, as it was felt that health issues and the response of DOH is crucial, especially for the LGBTI community. The Rapid Response Team (RRT) focuses specifically on hate crime cases and does follow ups on these cases.

The Chair interjected and requested that Ms Dlamini move straight to the lessons learnt (pg 18) in the interest of time. It was mentioned that all Members have a copy of the presentation.

Ms Dlamini mentioned that Deputy Minister John Jeffrey is a champion of the LGBTI justice issues and is also the Chairperson of the NTT. She said that many CSOs do not have an understanding of how the justice system works, so an action plan has been devised to inform them of the processes around the justice system. CSO members have also been informed that there should be no conflicting messages around hate crimes by members of the NTT. Should a hate crime be reported in the media, the Justice Minister will be the spokesperson for the NTT. CSOs are able to share their views as an organisation, but should not speak on behalf of the NTT.

In closing Ms Dlamini informed the Caucus that the Department is looking for funding to support the multi-sectoral collaborations on LGBTI that need to be established, as well as to fully implement the National Intervention Strategy.

Discussion
The Chair noted that there were some slides remaining on the presentation, however questions will be taken on what was presented.

Ms C Pilane-Majake (ANC) welcomed the presentation. She noted the lessons learnt and the AU Roadmap that is our guide as countries. The Mozambique 2005 conference on Gender Equality was raised and Ms Pilane-Majake shared her concern that this process has been neglected, so she is happy to see DOJ here and raising these issues. She commented that regional and continental initiatives need to be resuscitated.

The Chair asked what the religious fraternity is saying about the Department's LGBTI work. Can you explain to us what reactions you get from the religious fraternity and how you deal with those as a Department?

Ms T Memela (ANC) raised a concern about training of the police, as that is where the problem starts. It would be beneficial is the police could be trained properly to understand the schedules used to sentence perpetrators as that will make a difference. Police need to be trained as it is the path to charging criminals.

The Chair mentioned that she will allow a few more questions however there is a time restriction of one minute per contribution.

Ms P Chueu (ANC) said that we should not use the word ‘corrective’ rape as this terminology endorses what the perpetrators are doing – what are they correcting? If we want to address the issue effectively and remove the stereotype we need to remove the reference to what the perpetrators are calling it. It is rape! Ms Chueu thought that the Department was also going to touch on child marriages in South Africa. She noted that in a meeting that took place on Tuesday 24 March the practice and concept of ukuthwala was being wrongly articulated by the Department publicly and in their documents. Ms Chueu asked the Chair to see how best this question can be responded to.

A member asked for clarity on the roadshows around hate crimes and when they will start being held. The member noted that when we talk about hate crimes most of the people who are becoming victims are young women. Her second question is where does the Moral Regeneration Movement (MRM) feature in this? The DOJ mentioned that there is the angle of social cohesion, which the MRM works with, You could ask them for advice on relational behaviour. Please let us know about your relationship with the MRM.

Ms Khawula asked about the cases when someone was raped and there was evidence, but you hear that the person is told that the investigation is ongoing. The rapist would be back out in the community and the person whose child was raped was never informed. Secondly, what happened when a woman was married into a family and their husband passed away and then woman would be forced to sleep with the late husband’s brother? The woman could not say no, because her late husband’s family would take all the possession she had. Lastly, in Durban there was a problem with people who sold children – most culprits were foreigners from countries like Nigeria – but there were never cases where they were prosecuted and jailed.

Response from DOJ
Ms Dlamini mentioned that the religious fraternity is giving the Department and LGBTI committee a lot of support. In the NTT there are pastors who are lesbian and gay. Faith based organisations (FBOs) are also represented at the various task team meetings. The message that the Department keeps on hearing from the FBOs is that the Bible says we should not judge, and that we should love our neighbour. FBOs have also been identified as a target audience for the communication plan.

With regards to police, as mentioned the national intervention strategy has four areas, the DOJ is currently looking at two. The Department has appointed a service provider to complete an environment scan that will identify existing initiatives on LGBTI, this is scheduled to start in April 2015. Once the scan has been completed, standardised training and awareness material will be developed which will be used within the criminal justice system. The Department has developed a guide for service providers on how to identify and handle a LGBTI case.

Ms Dlamini agreed that the word ‘corrective’ rape is not appropriate, and that rape is rape. She mentioned that you will not find the word ‘corrective’ rape in DOJ documents. Ms Dlamini mentioned that the issue of ukuthwala is covered by the Chief Directorate on Vulnerable Groups in DOJ, and that she will forward the concerns raised to them.

On the hate crimes policy debate, the Justice Deputy Minister has been having discussions with the Chapter 9 Institutions and the Legal Review Committee on which structures and entities are best placed to lead the debate. There is no time frame currently for the debate. Ms Dlamini shared that the MRM is not on the NTT, however, they do play a part on the National Plan on xenophobia and intolerance. We will take your advice to the NTT, the CSOs have been the ones identifying which stakeholders should be represented, however the Department can also make suggestions. Thank you for suggesting the MRM.

As mentioned, DOJ has noted that there needs to be sensitisation training within the criminal justice system, and that victims and their families are kept up to date on the process of their case.

The Chair expressed thanks to the Departments for their presentations.

The Chairperson said that on the agenda was a discussion on the Southern African Development Community Parliamentary Forum (SADC PF) report on Ukuthwala. She proposed that this discussion be moved to the next meeting. It should be omitted for now because, based on the presentation by the Department of International Relations and Cooperation on 24 March 2015 to the steering Committee – all members were not satisfied [see report from 24 March 2015]. What was presented was not the Ukuthwala that members knew and the Department was asked to review the presentation. The Committee would have the discussion in the next meeting, it was essential for everyone to give their opinion. Members were clear on what Ukuthwala was and needed to correct any potential distortion of the facts.
The Committee agreed that the discussion should be held at the next meeting.

The Chairperson thanked everyone for their participation and support.

The meeting was adjourned.

[The the start of the meeting, apologies from members not attending the meeting were given. A member of the Caucus requested that the apologies that were written should be accepted and verbal apologies merely be noted. The Chair said that she appreciated the written apologies received from members prior to the meeting as it shows their concern for the Caucus meeting and the issues to be discussed].