Histories of forced sex and health outcomes among Southern African lesbian and bisexual women: a cross-sectional study

Healthcare worker training to improve quality of care for sexual and gender minority people in sub-Saharan Africa: learning from efforts in Uganda

INTRODUCTION

Training in care for sexual and gender minority (SGM) populations is critical for ending the HIV epidemic. SGM people, particularly men who have sex with men (MSM) and transgender women, experience disproportionate HIV infection across the globe. The objective of this commentary was to synthesize facilitators of and barriers to SGM health training efforts for healthcare workers in Uganda, in order to help inform potential priorities, strategies and next steps to advance culturally responsive HIV-related care for SGM communities across Uganda and sub-Saharan Africa.

DISCUSSION

SGM health training often includes education on: foundational concepts and language; stigma, discrimination and SGM health disparities; understanding and addressing implicit bias; sensitive and effective communication and building SGM-inclusive and welcoming healthcare environments. Clinicians' education includes sexual and gender histories, sex-positive HIV counselling, sexually transmitted infections, HIV pre-exposure prophylaxis and gender-affirming hormone therapy. SGM communities in sub-Saharan Africa have often experienced discrimination, persecution, incarceration and physical violence, and they encounter unique barriers to engagement in sexual health services and HIV prevention and treatment. SGM health training efforts in Uganda reveal challenges to and opportunities for advancing equity for SGM communities in sexual health and HIV medical care across the region. In Uganda, SGM community advocacy, as well as policies and programmes of the Ministry of Health and US President's Emergency Plan for AIDS Relief, have increased readiness and need for scaling up training and skills-sharing in SGM-focused HIV and sexual healthcare, including Ugandan-led and international initiatives.

CONCLUSIONS

Numerous challenges exist to widespread culturally responsive HIV and sexual healthcare for SGM communities in sub-Saharan Africa. Lessons learned from healthcare worker training efforts in Uganda may inform future replication, adaptation and dissemination initiatives to meet the needs of more SGM communities in the region. Evaluation of SGM health training programmes to determine the impact on HIV virological suppression and sexual health outcomes will be critical for identifying best practices and strategies that may support advancing HIV epidemic control for SGM communities in Uganda and across sub-Saharan Africa.

Mental health research in Botswana: a semi-systematic scoping review

Mental and substance use disorders are a leading cause of disability worldwide. Despite this, there is a paucity of mental health research in low- and middle-income countries, especially in sub-Saharan Africa. We carried out a semi-systematic scoping review to determine the extent of mental health research in Botswana. Using a predetermined search strategy, we searched the databases Web of Science, PubMed, and EBSCOhost (Academic Search Complete, CINAHL with Full Text, MEDLINE, MEDLINE with Full Text, MLA International Bibliography, Open Dissertations) for articles written in English from inception to June 2020. We identified 58 studies for inclusion. The most researched subject was mental health aspects of HIV/AIDS, followed by research on neurotic and stress-related disorders. Most studies were cross-sectional and the earliest published study was from 1983. The majority of the studies were carried out by researchers affiliated to the University of Botswana, followed by academic institutions in the USA. There seems to be limited mental health research in Botswana, and there is a need to increase research capacity.

Southern African Lesbian and Bisexual Women Responses to Symptoms of Sexually Transmitted Infections

Sexually transmitted infection (STI) in lesbian and bisexual women is a relatively unexplored topic, particularly for women from low- and middle-income countries. Despite perceptions that women who have sex with women (WSW) are at negligible risk of contracting STI, existing research demonstrates that WSW do become infected with STI. Given the opposition between assumptions of invulnerability and the observed risks, we explored how WSW would respond to symptoms of STI (i.e., wait until symptoms passed, see a medical doctor, and inform sexual partners). We used data collected as part of a collaboration between academic researchers and community-based LGBTQ organizations in Botswana, Namibia, South Africa, and Zimbabwe. Chi-squared tests were used to test whether participants' responses to hypothetical STI symptoms varied in relation to several intrapersonal, interpersonal, and structural factors. Multivariable logistic regression (backward) was used to assess whether these variables were independently associated with women's responses. Most women would be proactive in response to potential STI symptoms and would see a medical doctor. However, most women would not inform their sexual partner of symptoms of STI. Findings demonstrate several intrapersonal, interpersonal, and structural factors that influence WSW's health agency, and show a clustering of high-risk factors among women who would not be proactive about their health. Our findings suggest the need for improved health and health care of WSW in Southern Africa.

HIV and sexually transmitted infection knowledge among women who have sex with women in four Southern African countries

Women who have sex with women in Southern Africa, where HIV prevalence is high, are often presumed to have minimal risk for sexually transmitted infections (STI) and HIV despite research documenting female-to-female transmission. This study examined the demographic and social factors contributing to female-to-female STI/HIV transmission knowledge among Southern African women who have sex with women using an integrated model of health literacy. In collaboration with community-based organisations in Botswana, Namibia, South Africa and Zimbabwe, data were collected through anonymous surveys (N = 591). Multivariable stepwise forward logistic regression assessed independent associations between participant characteristics and high vs. low knowledge using five items. Overall, 64.4% (n = 362) of women had high knowledge; 35.6% (n = 200) had low knowledge. Higher education (adjusted odds ratio [aOR]: 2.24, 95% confidence interval [CI]: 1.48, 3.40), regular income (aOR: 2.14, 95% CI: 1.43, 3.21), residence in Botswana (aOR: 3.12, 95% CI: 1.15, 8.48) and having ever received tailored STI/HIV information (aOR: 2.17, 95% CI: 1.41, 3.32) predicted significantly higher odds of high knowledge in the final multivariable model. Results suggest opportunities for peer-led sexual health programming and expanded HIV prevention campaigns addressing women who have sex with women.

Research on alcohol and other drug (AOD) use among sexual minority women: A global scoping review

Until the 1980s, the limited research on alcohol and other drug (AOD) use among sexual minority women (SMW) focused on alcohol and used samples recruited from gay bars, resulting in inflated estimates of hazardous drinking. Over the past several decades the number of AOD studies with SMW has increased dramatically. To characterize this literature, we conducted a scoping review to answer the following questions: What do we know, and what are the gaps in research about AOD use among SMW? We searched multiple electronic databases (Medline [PubMed], CINAHL, PsycInfo, and Web of Science) for peer-reviewed research articles about AOD use among adult SMW published between January 1, 2000 and May 31, 2017. After duplicates were removed the search identified 4,204 articles. We reviewed the titles and abstracts and removed articles that did not meet inclusion criteria. We used full-text review of the remaining 229 articles to make a final determination regarding inclusion and we retained 181 articles for review. Although the quantity of AOD research with SMW has grown substantially, the great majority of studies have been conducted in the United States (US) and most focus on hazardous drinking; relatively little research has focused on other drugs. In addition, although there has been marked improvement in theories and methods used in this research, many gaps and limitations remain. Examples are the lack of longitudinal research; reliance on samples that tend to over-represent white, well-educated, and relatively young women; sparse attention to mechanisms underlying the disproportionately high rates of AOD use among SMW; and the absence of intervention research. In general, more high-quality research on SMW's use of AODs is needed, but gaps and limitations are particularly large in non-western countries. Addressing these research gaps and limitations is essential for providing information that can be used to develop more effective prevention and early intervention strategies, as well as for informing policies that can help to reduce risky drinking and drug misuse among SMW.

Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms

Evidence that gender inequalities and restrictive norms adversely affect health is extensive; however, far less research has focused on testing solutions. We first comprehensively reviewed the peer-reviewed and grey literature for rigorously evaluated programmes that aimed to reduce gender inequality and restrictive gender norms and improve health. We identified four mutually reinforcing factors underpinning change: (1) multisectoral action, (2) multilevel, multistakeholder involvement, (3) diversified programming, and (4) social participation and empowerment. Following this review, because little research has investigated the effects of national-level law and policy reforms, we conducted original quasi-experimental studies on laws and policies related to education, work, and income, all social determinants of health in which deep gender inequalities exist. We examined whether the laws and policies significantly affected health outcomes and gender norms, and whether law-induced and policy-induced changes in gender norms mediated the health effects, in areas for which longitudinal data existed. Laws and policies that made primary education tuition-free (13 intervention countries with the law and/or policy and ten control countries without) and that provided paid maternity and parental leave (seven intervention and 15 control countries) significantly improved women's and their children's health (odds ratios [OR] of 1·16-2·10, depending on health outcome) and gender equality in household decision making (OR 1·46 for tuition-free and 1·45 for paid maternity and parental leave) as a proxy indicator of gender norms. Increased equality partially mediated the positive effects on health outcomes. We conclude by discussing examples of how improved governance can support gender-equitable laws, policies, and programmes, immediate next steps, and future research needs.

Gender inequality and restrictive gender norms: framing the challenges to health

Gender is not accurately captured by the traditional male and female dichotomy of sex. Instead, it is a complex social system that structures the life experience of all human beings. This paper, the first in a Series of five papers, investigates the relationships between gender inequality, restrictive gender norms, and health and wellbeing. Building upon past work, we offer a consolidated conceptual framework that shows how individuals born biologically male or female develop into gendered beings, and how sexism and patriarchy intersect with other forms of discrimination, such as racism, classism, and homophobia, to structure pathways to poor health. We discuss the ample evidence showing the far-reaching consequences of these pathways, including how gender inequality and restrictive gender norms impact health through differential exposures, health-related behaviours and access to care, as well as how gender-biased health research and health-care systems reinforce and reproduce gender inequalities, with serious implications for health. The cumulative consequences of structured disadvantage, mediated through discriminatory laws, policies, and institutions, as well as diet, stress, substance use, and environmental toxins, have triggered important discussions about the role of social injustice in the creation and maintenance of health inequities, especially along racial and socioeconomic lines. This Series paper raises the parallel question of whether discrimination based on gender likewise becomes embodied, with negative consequences for health. For decades, advocates have worked to eliminate gender discrimination in global health, with only modest success. A new plan and new political commitment are needed if these global health aspirations and the wider Sustainable Development Goals of the UN are to be achieved.

'They will be afraid to touch you': LGBTI people and sex workers' experiences of accessing healthcare in Zimbabwe-an in-depth qualitative study

Objectives

To examine experiences of key populations (lesbian, gay, bisexual, trans and intersex (LGBTI) people, men who have sex with men (MSM) and sex workers) in Zimbabwe regarding access to, and experiences of, healthcare.

Design

Qualitative study using in-depth interviews and focus groups, with thematic analysis.

Participants

Sixty individuals from key populations in Zimbabwe.

Setting

Participants were recruited from four locations (Harare, Bulawayo, Mutare, Beitbridge/Masvingo).

Results

Participants described considerable unmet needs and barriers to accessing basic healthcare due to discrimination regarding key population status, exacerbated by the sociopolitical/legal environment. Three main themes emerged: (1) key populations' illnesses were caused by their behaviour; (2) equal access to healthcare is conditional on key populations conforming to ‘sexual norms’ and (3) perceptions that healthcare workers were ill-informed about key populations, and that professionals' personal attitudes affected care delivery. Participants felt unable to discuss their key population status with healthcare workers. Their healthcare needs were expected to be met almost entirely by their own communities.

Conclusions

This is one of very few studies of healthcare access beyond HIV for key populations in Africa. Discrimination towards key populations discourages early diagnosis, limits access to healthcare/treatment and increases risk of transmission of infectious diseases. Key populations experience unnecessary suffering from untreated conditions, exclusion from healthcare and extreme psychological distress. Education is needed to reduce stigma and enhance sensitive clinical interviewing skills. Clinical and public health implications of discrimination in healthcare must be addressed through evidence-based interventions for professionals, particularly in contexts with sociopolitical/legal barriers to equality.

Finding solid ground: law enforcement, key populations and their health and rights in South Africa

INTRODUCTION

Sex workers, people who use drugs, men who have sex with men, women who have sex with women and transgender people in South Africa frequently experience high levels of stigma, abuse and discrimination. Evidence suggests that such abuse is sometimes committed by police officers, meaning that those charged with protection are perpetrators. This reinforces cycles of violence, increases the risk of HIV infection, undermines HIV prevention and treatment interventions and violates the constitutional prescriptions that the police are mandated to protect. This paper explores how relationship building can create positive outcomes while taking into account the challenges associated with reforming police strategies in relation to key populations, and vice versa.

DISCUSSION

We argue that relationships between law enforcement agencies and key populations need to be re-examined and reconstituted to enable appropriate responses and services. The antagonistic positioning, "othering" and blame assignment frequently seen in interactions between law enforcement officials and key populations can negatively influence both, albeit for different reasons. In addressing these concerns, we argue that mediation based on consensual dialogue is required, and can be harnessed through a process that highlights points of familiarity that are often shared, but not understood, by both parties. Rather than laying blame, we argue that substantive changes need to be owned and executed by all role-players, informed by a common language that is cognisant of differing perspectives.

CONCLUSIONS

Relational approaches can be used to identify programmes that align goals that are part of law enforcement, human rights and public health despite not always being seen as such. Law enforcement champions and representatives of key populations need to be identified and supported to promote interventions that are mutually reinforcing, and address perceived differences by highlighting commonality. Creating opportunities to share experiences in mediation can be beneficial to all role-players. While training is important, it is not a primary mechanism to change behaviour and attitudes.

Making the invisible visible: a systematic review of sexual minority women's health in Southern Africa

BACKGROUND

Over the past two decades research on sexual and gender minority (lesbian, gay, bisexual and transgender; LGBT) health has highlighted substantial health disparities based on sexual orientation and gender identity in many parts of the world. We systematically reviewed the literature on sexual minority women's (SMW) health in Southern Africa, with the objective of identifying existing evidence and pointing out knowledge gaps around the health of this vulnerable group in this region.

METHODS

A systematic review of publications in English, French, Portuguese or German, indexed in PubMed or MEDLINE between the years 2000 and 2015, following PRISMA guidelines. Additional studies were identified by searching bibliographies of identified studies. Search terms included (Lesbian OR bisexual OR "women who have sex with women"), (HIV OR depression OR "substance use" OR "substance abuse" OR "mental health" OR suicide OR anxiety OR cancer), and geographical specification. All empirical studies that used quantitative or qualitative methods, which contributed to evidence for SMW's health in one, a few or all of the countries, were included. Theoretical and review articles were excluded. Data were extracted independently by 2 researchers using predefined data fields, which included a risk of bias/quality assessment.

RESULTS

Of 315 hits, 9 articles were selected for review and a further 6 were identified through bibliography searches. Most studies were conducted with small sample sizes in South Africa and focused on sexual health. SMW included in the studies were racially and socio-economically heterogeneous. Studies focused predominately on young populations, and highlighted substance use and violence as key health issues for SMW in Southern Africa.

CONCLUSIONS

Although there are large gaps in the literature, the review highlighted substantial sexual-orientation-related health disparities among women in Southern Africa. The findings have important implications for public health policy and research, highlighting the lack of population-level evidence on the one hand, and the impact of criminalizing laws around homosexuality on the other hand.