34245 Africa Region Working Paper Series No. 84 Sexual Minorities, Violence and AIDS in Africa Chukwuemeka Anyamele Ronald Lwabaayi, Tuu-Van Nguyen and Hans Binswanger July 2005 Sexual Minorities, Violence and AIDS in Africa Africa Region Working Paper Series No.84 July 2005 Abstract Sex between people of the same gender occurs in all societies. In Africa such behavior is most often not associated with a homosexual identity, but men having sex with men usually have sex with women as well, get married, and have children. In most countries of Africa sex between people of the same gender is still prohibited under sodomy laws which were introduced by the colonial powers. Great stigma and discrimination occurs against those people who are either unable or unwilling to hide the fact that they have sex with partners of the same sex. The adverse consequences documented in this paper include eviction from families and neighborhood, loss of jobs and housing, discrimination in the health services, and a high level of violence, including from the police. As a consequence many sexual minority members are among the poorest and most marginalized members of society, and have no social safety net. They are at a high risk of engaging in transactional sex. Since anal sex is one of the most efficeint ways of transmitting HIV, men having sex with men are heavily affected by the epidemic. There are virtually no programs in Africa focusing on prevention among men having sex with men, and most of them have unprotected sex with both their male and female partners. There is therefore an important bridge between the epidemic among men having sex with men and their women and children. It is urgent that the twin epidemics of HIV/AIDS and violence be tackled as part of HIV/AIDS and poverty reduction programs. Approaches to combat HIV/AIDS among men having sex with men are well developed, and include epidemiological approaches focusing on the sexual behaviors, cultural-anthropological approaches focusing on the meaning of these relationships, and empowerment approaches fostering on capacity building of the sexual minorities themselves, so that they can take the lead in combating HIV/AIDS among themselves, cobat violence, and fight for their human rights. The reason for inaction on these issues are not lack of tolerance, but lack of political will. The Africa Region Working Paper Series expedites dissemination of applied research and policy studies with potential for improving economic performance and social conditions in Sub-Saharan Africa. The series publishes papers at preliminary stages to stimulate timely discussions within the Region and among client countries, donors, and the policy research community. The editorial board for the series consists of representatives from professional families appointed by the Region's Sector Directors. For additional information, please contact Momar Gueye, (82220), Email: mgueye@worldbank.org or visit the Web Site: http://www.worldbank.org/afr/wps/index.htm. The findings, interpretations, and conclusions in this paper are those of the authors. They do not necessarily represent the views of the World Bank, its Executive Directors, or the countries that they represent and should not be attributed to them. Authors' Affiliation and Sponsorship Chukwuemeka Anyamele 1 Tuu-Van Nguyen, and Hans Binswanger@worldbank.org Ronald Lwabaayi Acknowledgement This work was funded by the World Bank and by the DFID Regional Trade Facilitation Project administered by Imani Development. The authors are grateful for the cooperation and assistance of the TIFI unit at the SADC Secretariat and of private and public sector stakeholders in the SADC Member States who provided data, documents and valuable time to discuss the issues raised here. The views expressed are those of the authors only and should not in any way be attributed to the organisations for which they work. Momar Gueye provided logistical support." Chukwuemeka Anyamele is a medical doctor in Nigeria working as HIV/AIDS Program Manager for the Research Triangle Institute. Ronald Lwabayii is a co-founder of the NGO Livelihood Development International in Uganda; When this paper was written, Tuu-Van Nguyen is a junior professional at the World Bank; and Hans Binswanger was the senior advisor for Africa at the World Bank. The opinions expressed in this paper are those of the authors and do not necessarily reflect the views of the World Bank. i Definitions and Abbreviations Homosexuality: Preference for same gender sexual relationships. The term is restrictive as it excludes bisexuality and other possible gender identities of sexual minorities ILO: International Labor Organization IGLHRC: International Gay and Lesbian Human Rights Commission LDI: Livelihood Development International LGBT people: Lesbian, Gay, Bisexual and Transgender People: An inclusive definition of self identified sexual minorities preferred by them. MSM: Men having sex with men: Includes all males who engage in same gender sexual relationships, including boys and adolescents NGO: Non governmental organization PLWHA: People living with HIV/AIDS Sexual minorities: An umbrella term including all MSM, WSW and LGBT persons. UCC: UNAIDS Country Coordinator UNAIDS: United Nations AIDS UNDCP: United Nations Drug Control Programme UNDP: United Nations Development Programme UNFPA: United Nations Population Fund UNICEF: United Nations Children's Fund UNESCO: United Nations Educational, Scientific and Cultural Organization WHO: World Health Organization WSW: Women having sex with women: Includes all females who engage in same gender sexual relationships, including girls and adolescents ii Table of Contents 1. Introduction 1 2. Gender Identity and Sexual Behavior in Low Income Countries 2 3. The Legal Situation 3 4. Violence 7 5. Other Social Risks 9 6. HIV/AIDS 12 7. Towards an Inclusive Strategy Against Violence and AIDS 17 Why Should Policy Makers Care: 17 Existing Recommendations: From HIV/AIDS Prevention to Human Rights 19 Recommendations from UNAIDS on prevention, care and support 19 Prevention: Three Basic Models 20 A Political and Human Rights Approach: 21 Recommendations of the African Lesbian and Gay Groups at the All-Africa Rights Initiative (2004) 22 Additional Recommendations 23 Why GLBT Organizations Are Needed 23 Where Are LGBT Groups in their Efforts to Organize: 24 Embedding LGBT Issues into Broader Issues 25 Opportunities 26 Key Actors and Their Roles 28 Building Implementation Capacities 29 Recommendations for UNAIDS and its Co-Sponsors, including the World Bank: 29 Annex 1: LGBT Risk Assessment for Selected African Countries 31 Annex 2: Fact-Finding Mission To Eastern, Central and Southern Africa 34 Bibliography 35 · Altman, Dennis, 2004), "Rights Matter: structural interventions and vulnerable communities," 35 · Bangkok: International AIDS Conference: Jonathan Mann Memorial Lecture, 14, 2004 35 Jenkins, Carol, 2004), HIV/AIDS and Culture: Implications for Policy," Bangkok, Thailand, International AIDS Conference, Preconference symposium on Sexual Minorities, Violence, and AIDS, July 35 iii List of Boxes Box 1: Terminology 7 Box 2: International Law 8 Box 3. A Transgender Person in Uganda 10 Box 4: Rejection and Violence against MSM in Dakar 11 Box 5: A Traditional System for Integrating Sexual Minority Persons 13 Box 6: Repression of Free Speech About Sexual Diversity in Uganda 15 Box 7. The Sexual Behavior of MSM in Dakar 17 Box 8: Selected Facts About Anal Intercourse in Africa 18 Box 9: Boys are at risk of sexual abuse 22 Box 10. Secrecy Surrounding Same­gender Relationships 24 Box 11. A Charter for Social Justice 27 List of Figures Figure 1: Typology of Men Having Sex with Men 6 Figure 2: The Legal Situation of Homosexuality in Africa 9 Figure 3: The HIV Bridges Between MSM Groups and the General Population 16 Figure 4: Mainstreaming the Problem of Sexual Minorities into Broader Agendas, Policies and Programs 30 Figure 5: Key actors to improve the conditions of sexual minorities 32 List of Tables Table 1: Discrimination and Violence in Southern and Eastern Africa 12 Table 2. Key Social Risks in Eastern and Southern Africa 14 Table 3: HIV/AIDS in Sexual Minorities in Eastern and Southern Africa 19 Table 4: Total Risk Scores for LGBT populations in selected African Countries 20 Table 5: Opportunities for LGBT people to Socialize and Meet in Selected African Countries 29 iv 1. Introduction Sex between men and between women has occurred and does occurs in all societies, including in Africa (Murray, 2000, Murray and Rosco, 2004). Many traditional societies had ways to accommodate sex between men in one way or another, (see box 5 for an example from Africa). Widespread homophobia has been largely introduced by the colonial powers and the Christian Church (Seabrook, 2004). Today in many low-income countries, especially in Africa, the existence of same sex behavior is usually ignored or denied by public opinion, governments, and the international community. This has led to systematic violations of the human rights of sexual minorities, a high level of violence against them, and the systematic neglect of the spread of HIV/AIDS among men who have sex with men (MSM) and women who have sex with women (WSW). This situation is not unique to Africa, but common to many other low and middle income countries, and in the high income countries it progress in human rights for sexual minorities is a recent phenomenon as well. Sections 2 and 3 of the paper survey recent literature on sexual behavior, violence and AIDS in low income countries, with special reference to Africa. Sections 4, 5 and 6 then examine the individual issues of violence, other social risks and HIV/AIDS among MSM and WSW in sub-Saharan Africa. Throughout these sections will be presented the findings of a recent assessment undertaken during the All Africa Symposium on HIV/AIDS and Human Rights on the extreme marginalization of Lesbian, Gay, bisexual and Transgender (LGBT) people in Africa and their organizational efforts. Finally, section 7 reviews existing recommendations for addressing these problems and makes additional ones based on the findings summarized in the paper. The paper is addressed to three main audiences: (i) institutions involved in the preparation and implementation of HIV/AIDS programs, including specialized agencies and donors such as the World Bank, UNAIDS and its co-sponsors, and National AIDS Councils and their implementing partners in the public sector and civil society; and (ii) international, national and local associations of MSM/WSW involved in HIV/AIDS prevention, care and treatment; and (iii) all individuals and organizations involved in the fight for human rights. The social and economic costs of the spread of HIV/AIDS and of violence against sexual minorities are high, not just to individuals and families, but to whole communities and nations. Working for the protection of sexual minorities and against the spread of HIV/AIDS among sexual minorities is a preventative measure aimed at alleviating these costs, and, therefore, reducing poverty. 2. Gender Identity and Sexual Behavior in Low Income Countries Western ideas about sex and sexuality are not directly exportable to other cultures and countries. In low-income countries in general, and in Africa in particular, few people who have sexual relationships with members of the same gender openly identify as lesbian or gay. One recent study by James Robertson from the Harvard School of Public Health shows that MSM and WSW are in fact a highly heterogeneous population (Robertson, 2003, Altman, 2004, Jenkins, 2004). The terms "gay men" and "men who have sex with men" are not interchangeable as gay men are merely a subset of men who have sex with men. Most men who have sex with men are precisely and only that: men who have sex with men. Figure1: Typology of Men Having Sex With Men MSM Typology MSM LGBT Special Population Groups WSW Risk of being subject to violence WSW: Women having sex with women due to personal sexual orientation MSM: Men who have Sex with Men Non-existent LGBT: Lesbian, Gay, Bisexual and Transgender people Special Groups: Inmates in correctional institutions, Medium street boys, etc. High Very High A distinction can therefore be made between gay/lesbian-identified MSM/WSW and non-gay/lesbian-identified MSM/WSW. Among MSM/WSW who do not consider themselves as gay or lesbian, two further categories can be distinguished. The first are MSM and WSW who do not think of themselves as GLBT but nevertheless engage in sexual relationships with GLBT identified persons and socialize with them. These constitute a significant portion of the MSM/WSW population. The second are MSM and WSW who do not consider themselves as gay, and in addition do not socialize or come into contact with the GLBT identified population. These include, among others, students 2 in boarding schools, migrant workers, men in worker camps (e.g. miners), men enrolled in military service, soldiers at war, street boys who explore their sexuality amongst themselves while they are growing up, and the inmates of correctional institutions. For the purpose of this paper and despite its heterogeneity, we will refer to this second category as "special groups". Box 1: Terminology In view of the complex differentiations among sexual minorities, the paper will use different designations of people and groups according to the context. (1) When talking about all of the different groups involved and about their rights, the paper will use the term "sexual minorities". (2) When reviewing sexual behavior and HIV/AIDS prevention, it will talk mostly about MSM and WSW, although in legal texts and political discussions the term "homosexuals" is also frequently used. (We note in passing that adolescents have same gender sex among each other, and sexual abuse of boys and adolescents by men and of boys by adolescents is fairly common. It would therefore be more appropriate to interpret MSM and WSW as sex between males rather than between men, and sex between females, rather than sex between women). (3) When talking about their organizational efforts, activism, and programs, we will use the term LGBT groups, because only LGBT identified people attempt to organize. James Robertson's study (2003) shows how same-sex sexual behavior among special groups has been heavily influenced by a number of structural vulnerabilities that are unique to Sub-Saharan Africa. These include war, poverty, urbanization, and a colonial tradition that encourages or forces men to migrate for work unaccompanied by their wives. Such factors have led to the high occurrence of single sex environments where non-gay identified, same-gender sexual relationships are common. 3. The Legal Situation Articles 1 and 2 of the Universal Declaration of Human Rights guarantee full and equal human rights for all, including the right of every person to protection against discrimination. Existing international human rights law, however, does not extend protection to all victims against systematic discrimination, including sexual minorities. As box 2 shows, the United Nations Human Rights Committee has nevertheless interpreted the International Convention on Civil and Political Rights to include the protection of the rights of sexual minorities to equality and non-discrimination before the law. Several other UN commissions have commented on the special vulnerabilities of sexual minorities, and on the adverse impact on them of laws that criminalize same- gender behavior. However, these interpretations are not authoritative in international law and cannot be enforced. 3 Box 2: International Law Relationship between sodomy laws, stigma and violence: UN Special Rapporteur on Extrajudicial, Summary or Arbitrary Executions · ...criminalizing matters of sexual orientation increases the social stigmatization of members of sexual minorities, which in turn makes them more vulnerable to human rights abuses , including violations of the right to life. · ...violent acts against persons belonging to sexual minorities are also more likely to be committed in a climate of impunity Arbitrary Detention: The UN Working Group on Arbitrary Detention has affirmed that the detention of people solely on the basis of their sexual orientation violates fundamental human rights Freedom From Torture: The UN Special Rapporteur on Torture to the General Assembly reports: · ...it appears that members of sexual minorities are disproportionately subjected to torture and other forms of ill treatment, because they fail to conform to socially constructed gender expectations · ...have been subjected, inter alia, to harassment, humiliation and verbal abuse ...and physical abuse including rape and sexual assault · ...have been subjected to further victimization by the police, including verbal, physical, and sexual assault, including rape The Declaration of Universal Human Rights and The International Covenant on Civil and Political Rights (ICCPR): · Guarantee rights "without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. All are equal before the law and are entitled without any discrimination to equal protection of the law... Everyone, without any discrimination, has the right to equal pay for equal work...."2 · The findings of the U.N. Human Rights Committee has declared that article 26 "prohibits discrimination in law or in fact in any field regulated and protected by the public authorities". The article bars acts and policies that are discriminatory in effect, as well as those that intend to discriminate. · In the 1994 case of Nicolas Toonen vs. Australia, the UN Human Rights Committee struck down the Tasmania sodomy law and in that judgment held that "such laws violate protections against discrimination in the ICCPR, as well as article 17, which protects the right to privacy". Specifically, 3 the Committee held that "sexual orientation" was a status protected under the ICCPR from discrimination, finding that "the reference to 'sex' in articles 2, para.1, and 26 is to be taken as including sexual orientation". · At the last session of the United Nations Commission on Human Rights (UNCHR), Brazil moved a resolution on "human rights and sexual orientation" (E/CN.4/2003/L.92) which states that sexual diversity is an integral part of Universal Human Rights. The resolution expressed "deep concern at the occurrence of violations of human rights in the world against persons on the grounds of their sexual orientation," Under pressure from the Vatican and a group of Muslim countries, Brazil decided to withdraw the resolution at the 60th session in Geneva of the Commission in March 20044 2 Universal Declaration of Human Rights, Articles 1, 2, 7, and 23 3 Article 17 reads: "(1) No one shall be subjected to arbitrary or unlawful interference with his privacy, family, home or correspondence, nor to unlawful attacks on his honour and reputation. (2) Everyone has the right to the protection of the law against such interference or attacks" 4http://www.brazilianresolution.com/ 4 Despite the highly adverse impact of criminalizing same sex behavior on sexual minorities described in the UN documents summarized in Box 2, more than two thirds of African countries criminalize same sex behavior in one way or another, as shown in Figure 2. The criminalization of same sex behavior in Africa is not an old African tradition but rather a colonial legacy (Seabrook, 2004). Most laws criminalizing same sex behavior were introduced by the colonial powers during the 20th century. Figure 2: The Legal Situation of Homosexuality in Africa5 Until the mid-1990s, there had been virtually no discussion in the Region on the behavior and rights of sexual minorities. The turning point occurred in 1994 when South Africa, emerging from decades of oppression and inequality, in its new Constitution guarantee the fundamental rights of all, including LGBT persons, and promised an end to direct or indirect discrimination against anyone on one or many grounds, including, inter alia, gender, sex, culture, marital status, belief, conscience and sexual orientation. The new South African constitutional protection rapidly triggered discussion across the entire continent. This spurred massive opposition from religious and traditional groups, culminating in attacks by political leaders such as Robert Mugabe, who, in a widely publicized statement, declared "...we don't believe that they [gay men and lesbians] have any rights at all" stating that homosexuals are "worse than dogs and pigs" (Human rights Watch and IGLHRC, 2003). While political campaigns against LGBT persons have intensified the incidence of discrimination, persecution and violence across the continent, they have also increased public discussion and organizational efforts. For the most part, however, little research 5Source: http://www.afrol.com/Categories/Gay/index_legal.htm Accessed in April, 2004. N.B.: The legal status of homosexuality in Namibia is ambiguous. While government statements have been extremely homophobic, laws criminalizing same-sex behavior are absent and, similarly to Zimbabwe, local gay associations are present and visible. 5 and fact-finding has been conducted thus far and only very little is known about the magnitude and situation of sexual minorities in Africa. Box 3. A Transgender Person in Uganda Biologically a male, Kiiza Brenda dresses as an attractive women in her early 20s. She has always been uncomfortable with being a man. She left the small village in which she was born and moved to Kampala where the large city environment afforded more privacy. She thought that one of the only ways of working which was compatible with her gender identity was to work as a nanny. For three years she worked for a family who did not know she was a man, and both the parents and the children liked her and eventually testified on TV that she was a good nanny. After three years her landlord discovered that she was a transgender person and revealed it to her employers, and the police. As a consequence she was arrested three times in a two year period. She was paraded completely naked to journalists and the public by the police to prove that she was not a women. The law could not pin her for any homosexual acts. Despite the fact that she was employed she was charged with being idle and disorderly, and later released with a simple fine. She eventually lost her job as house nanny, since her employer could not understand a transsexual looking after her children for fear that she would contaminate them. She is now unemployable and on the streets of Kampala. Source: Personal interview during the fact-finding mission The three sections that follow explore the individual issues of violence, social risks and HIV/AIDS among MSM and WSW. Throughout these sections evidence will be presented from the findings of the risk assessment undertaken in eight selected countries by the All Africa Symposium on HIV/AIDS and Human Rights, and from a fact-finding mission to Eastern, Central, and Southern Africa. These sources and the methodology for the risk assessment are described in Annexes 1 and 2. The three sections, which follow describe a bleak picture. To put it into perspective, it needs to be kept in mind that stigmatization, discrimination, the systematic violation of the human rights of sexual minorities and violence against them has been a global phenomenon. In the developed world the gay liberation movement started to gain importance only since 1969, and even there violence on account of sexual orientation has not yet been rooted out. Moreover, while in some middle-income countries such as Brazil, important gains have been made, violence against sexual minorities in most middle-income countries is still highly prevalent. In Egypt, in a widely publicized event, several gay men were sentenced to prison solely for sexual activity (Human Rights Watch and IGLHRC, 2001). In Romania, Gabriel Presnac and Radu Vasiliu were beaten by police, prosecuted and imprisoned for holding hands and kissing in public (Amnesty International, 1998). In India, homosexual acts are punishable by life in prison (Donelly, 2003). The violence described for Africa in the next section is therefore far from an Africa-specific phenomenon. 6 4. Violence Instead of protecting the rights of sexual minorities and addressing HIV/AIDS among MSM, politicians and especially religious leaders across Africa have been actively condemning LGBT people, making calls to persecute and cast them out. As shown in Box 2, the impact of these attacks has been to create an atmosphere of intolerance in which the basic human rights of sexual minorities are eroded and individuals at large can abuse MSM and WSW with impunity. The adverse consequences have been carefully documented in the recent joint report of the Human Rights Watch and IGLHRC on "State-sponsored Homophobia and Its Consequences in Southern Africa" (2002). Violence can take many forms, including verbal abuse, physical violence, and sexual violence, including rape. Even where politicians have not attacked homosexuality, the level of violence against men having sex with men can take frightening proportions, as documented in a recent study of 250 men who have sex with men in Senegal summarized in Box 4. Box 4: Rejection and Violence against MSM in Dakar · The lives of MSM in Dakar are characterized by rejection and violence · Half of MSM are verbally abused by family members · A fourth were forced to move in the last 12 months · 37 percent were forced to have sex in last 12 months · 13 percent have been raped by a policeman Source: Niang et al., 2002. The recent WHO World Report on Violence and Health (2002) reports that violence against MSM is also frequently of a sexual nature: · Sexual violence against men takes place in homes, schools, on the street, in the military, during wars, in prison, and at police posts. 3.6 percent of men in Namibia, and 20 percent of men in Peru report such violence. · Forced sexual initiation during adolescence is common for both men and women, but more for women. (More likely to be underreported for men). Among men in Africa, this ranges from 6. 4 percent of men in a South African study to 30 percent in a Cameroon study. The All-Africa Symposium on Human Rights and HIV/AIDS did an analysis of the risks faced by MSM and WSW in selected African countries. Based on the Senegal study of 250 MSM (Niang et al., 2002), a scoring system was developed for risk faced by LGBT people, which was then used by a group of at least three knowledgeable participants of each of the countries to score the risk situation in their respective countries. Scores were developed for three classes of risks: Discrimination and Violence, Other Social Risks such as loss of livelihood and housing, and risks associated with HIV/AIDS such as risk of death from AIDS, and absence of prevention and care programs. Table 1 shows the results of the risk assessment on the first of these categories: 7 Discrimination and Violence. In support of the literature, the evidence from the Symposium shows widespread and high intolerance and violence towards LGBT persons on the part of both governments and the population at large. Table 1: Discrimination and Violence against LGBT people in Selected African Countries Intolerance Violence Rape Sexual Abuse Country Location Official Populati Population8 Police9 Population Police Jail Girls Boys 6 on7 10 11 12 13 14 Senegal Urban M H H H H H H H H 15 (Baseline) and periurban Kenya Nairobi H H H M M M H H H Zimbabwe Urban H M H H M M M H M Uganda Urban H H H H H M H M M Tanzania Urban H H M L H L H M M Nigeria Lagos M H H M M L H H H Sierra Leone Freetown L H H L L L L H16 H17 Namibia Urban H M M L L L H H M Rwanda Kigali L M L L L L L H L South Africa Gay L M M L M L H NA M Youth South Africa Township L M M L H L M H NA Lesbians Source: All-Africa Symposium on HIV/AIDS and Human Rights 6 H: Regular adverse comments by presidents, prime ministers, ministers, the state owned media, M: Regular comments by top religious leader but not top politicians. Low: neither 7 H: more than half of members ever suffered verbal abuse. L: Less than 10 percent of members have suffered from verbal abuse. 8H: More than a third of members would have suffered from violence from their families, in schools, or in the streets. L: Less than 5 percent 9H: More than 20 percent of members would have been ever beaten up by police. L: Less than 1 percent of members 10H: more than 30 % ever raped: L: Less than 3% 11H: more than 10 % ever raped by police: L: Less than 1 % 12H: informants know of many cases from media and other sources. L: Informants have almost never heard about it. 13H: More than 30 percent of girls in population are thought by informants to ever suffer from sexual abuse by males. L: Less than 3 percent 14More than 30 percent of male members have been sexually abused as children by males 15Total score for discrimination and violence by assigning a value of 2 to H, and 1 to M in each cell 16Information from an informant who is a medical doctor and rape examiner in Freetown 17Same Rape examiner designed survey for the Sierra Leone Gay and Lesbian Group 8 As shown in Table 1, the risk of intolerance and violence is highest in Senegal, followed by the Eastern and Southern African countries Kenya, Zimbabwe, Uganda and Tanzania, and by Sierra Leone. The high risk scores in Kenya reflect the fact that the groups represented were mostly from lower socio-economic classes, where the vulnerability of LGBT people is compounded by poverty. Box 5. A Traditional System for Integrating Sexual Minority Persons In Coastal Kenya homosexual behavior has traditionally been accepted in the following form: Young males are welcome to join the training traditionally provided by older women called Mkungas whose main role is to educate young girls in the duties of marriage. The boys receive similar training, which last about a month. At the end, the young man gives the Mkunga a special cloth and kitchen utensils as payment. After that the men typically live with an older lover, who may be married to a woman as well and have a family. While they dress as males, they do much of the domestic work. The bond is more like a marriage, and has traditionally been widely accepted. Source: Fact-finding mission Sexual violence can be perpetrated either by the general population towards MSM, or by MSM towards other males. Two particularly distressing instances of sexual violence are rape by the police force, and sexual abuse of children. Although rape by the police force is frequent only in Botswana, Kenya and Uganda, the phenomenon has been reported to occur in all other visited locations. Informants also ranked sexual abuse against children for both boys and girls. While it is particularly high for girls, boys in this region seem to be almost as much at risk from sexual abuse than girls, except in Rwanda. 5. Other Social Risks As Table 2 shows, intolerance and stigma lead to a variety of other social risks faced by members of sexual minorities who either declare their sexual preference or cannot hide it. These include loss of employment or livelihood, being thrown out of their homes, which is especially common for adolescents, and eviction from housing by neighbors and landlords. As a consequence, sexual minorities face a high risk of social isolation and loss of the effective social safety nets normally provided by their family members and wider social or religious groups. It is well known that, in the absence of a customary social safety net, any adverse event in life such as unemployment or sickness can turn into a catastrophe, leading to destitution, disability, or loss of life. For members of sexual minorities, therefore, the social risks described in this table, will increase the risk of prostitution, with all the associated risks of violence, STI and AIDS. 9 Table 2: Other Social Risks for LGBT people in Selected African Countries Country Location Loss of Thrown Evicted Becoming Becoming a Livelihood out of from a male female sex 18 home19 housing sex worker with 20 worker21 men22 Senegal Urban, M H H H ?23 (Baseline) periurban Kenya Urban H H H H L Zimbabwe Urban M M M H H Uganda Urban M M M M H Tanzania Urban H H H M L Sierra Freetown H H H H H Leone Nigeria Lagos L H H H ? Namibia Urban M H L H M Rwanda Kigali M L L L L South Gay Youth L L L M NA Africa South Township L M L NA L Africa Lesbians Source: All-Africa Symposium on HIV/AIDS and Human Rights The results indicate that social risks are especially high in Kenya, Tanzania, Sierra Leone, and Senegal, and more moderate in the other countries. In Rwanda the risks are lower because the informants were reporting about the risks faced by a small group of mostly middle or upper class gay and lesbians who are highly secretive about their sexual 18H: In more than 50 percent of cases where sexual orientation becomes known. L: In less than 10 percent of cases where sexual orientation becomes known 19H: In more than 50 percent of cases where sexual orientation becomes known. L: In less than 10 percent of cases where sexual orientation becomes known 20H: In more than 50 percent of cases where sexual orientation becomes known. L: In less than 10 percent of cases where sexual orientation becomes known 21H: More than 50 percent of members are thought to occasionally or frequently engage in sex to earn money. L: Less than 10 percent of members are thought to occasionally or frequently engage in sex to earn money 22H: More than 50 percent of members are thought to occasionally or frequently engage in sex to earn money. L: Less than 10 percent of members are thought to occasionally or frequently engage in sex to earn money 23Total score for "Other Social Risk" by assigning a value of 2 to H and 1 to M in each cell 10 orientation. The contrast between Kenya and Rwanda therefore is partly a reflection of the difference in social class between the reference groups which the informants were reporting on. Where the rights of sexual minorities are protected by the constitution, such as in South Africa, the risk of losing one's livelihood or housing is lower than for other countries. Although "risk" and "vulnerability" are normally different concepts, they are intricately linked in the case of sexual minorities. The high risks of social exclusion indicated above translate directly into extreme vulnerability to both violence and HIV/AIDS, in particular for individuals already living in poverty and destitution. Box 6. Repression of free speech about sexual diversity in Uganda In September of 2004 the popular radio SIMBA in Kampala interviewed two gay men and one lesbian woman on a popular talk show. Two weeks later the Broadcasting Council asked the radio station staff to appear before a disciplinary committee of the Broadcasting Councilof Uganda. The committee was composed of government officials and religious leaders. It fined the station an amount of approximately 1000 dollars for airing a culturally inappropriate program. Despite local and international public outcry and support for the radio station, the Broadcasting Council promised to impose even larger fines and possibly close radio and TV stations that would broadcast a similar program. Source: Radio SIMBA and the government owned daily newspaper New Vision. 11 6. HIV/AIDS In the more than 20 years since the HIV/AIDS epidemic started in Africa, almost no attention has been focused on fighting HIV/AIDS among MSM, or on the risks of anal intercourse. Yet, anal intercourse is by far the riskiest sexual behavior with a probability of HIV transmission at least five times as high as vaginal sex (Brody and Potterat, 2003). Anal intercourse is not only common between MSM, but also fairly widespread between men and women. The ways in which sexual identity and sexual behavior are configured in Africa moreover implies that there is a significant "bridge" of HIV transmission between MSM and the general population. Figure 3 summarizes the several pathways through which HIV can be transmitted across the population. A significant portion of MSM have sexual partners of the opposite sex, are married, and/or have children, whether they are gay identified or not. Therefore, HIV acquired as part of intercourse with other men can be transmitted to the women with whom they have sex and from there to their children during pregnancy, at birth, or during breastfeeding. Figure 3: The HIV Bridges Between MSM Groups and the General Population Sexual Orientation, Behavior, and AIDS MSM Population LGBT Special Groups Risk of being subject to violence due to personal sexual orientation MSM: Men who have Sex with Men Non-existent LGBT: Lesbian, Gay, Bisexual and Transgender people Medium Special Groups: e.g. Inmates of correctional institutions High Spillover of HIV/AIDS Very High The pathways of the bridge are also evident from the study of the 250 MSM in Dakar, most of whom are gay identified. Nearly ninety percent of them had sex with women 12 during the month preceding the interview, 13 percent are married, and 25 percent have children. It is likely that a sample of older MSM would have shown a higher rate of marriage, especially if it were possible to sample MSM who are not identified as gay. A scary finding from the study is that these men, even though they have knowledge of condoms, rarely use them, even in anal sex. Box 7. The Sexual Behavior of MSM in Dakar · Mean age of sample: 25 years · Mean age at first sexual contact: 15 years · The first male sexual encounter was initiated by a family member for one third of the sample · The vast majority of MSM have had sex with women, of these 88 % had vaginal sex, 25 % anal sex · 13 percent are married, 25 percent have children · MSM generally have good knowledge about condoms, but condom use is low, even in anal sex · Most reporting have had STI · MSM are scared of seeking medical care Source: Niang, et al, (2002). In addition to the HIV/AIDS bridge between MSM and the general population, ignoring anal sex between men and women also increases HIV transmission. Anal sex between men and women also involves men who never had sex with men, and therefore constitutes an additional risk factor accelerating the spread of AIDS among the general population. Popular conceptions of sexual behavior and HIV transmission usually set apart "heterosexual" and "homosexual" transmission, mistakenly characterizing them with vaginal and anal intercourse respectively. However, as James Robertson states in his study on AIDS and Sex in Sub-Saharan Africa: "This reliance on a `homo/hetero' binary recalls a static paradigm of sexual identity that fails to recognize the more fluid nature of sexual behavior and how it informs sexual risk for HIV. Not all `homosexual sex' is anal and not all `heterosexual sex' is vaginal" (Robertson, 2003). HIV is a minor health risk for WSW in the developed world, but the fact that in Africa most of them get married and have children exposes them to the same risks of contracting the disease as heterosexual women. Moreover lesbian women's risk of rape is not just the same as for women in general, but may even be higher than for heterosexual women, as they may become special targets for punitive rape once their sexual identity is known. A recent paper in the International Journal of STDs and AIDS shows that the patterns of the spread of the epidemic cannot be fully explained by heterosexual transmission involving only vaginal intercourse, and that the observed patterns require either a significant transmission from contaminated needles in the health system, or a significant incidence of anal sex among men and between men and women (Brody and Potterat, 2003). Unfortunately there are few systematic studies on the prevalence of anal intercourse in Africa, but the study summarizes a large body of fragmentary evidence 13 showing that this behavior is not uncommon (Box 8). As anal sex is the most efficient way to transmit HIV sexually, the implications for HIV prevention become evident: radical change to prevention messages and practices in Africa is needed. Box 8: Selected Facts About Anal Intercourse in Africa Anthropological Reports: · In 1925, 90% of the male population in Angola was behaviourally bisexual and 3.5% exclusively homosexual. · Homosexuals reported sex with women, or were even married Epidemiological reports: · Given our limited understanding of social mores in sub-Saharan Africa and given criminal codes against anal intercourse, such behaviors are likely to be heavily under-reported · 42% of a sample of South African truck drivers admitted to engaging in anal intercourse. · 42.9% of prostitutes in a South African sample admitted engaging in anal intercourse · 9% of male and female students in a Tanzanian study reported that anal intercourse was their first sexual act · 18% of males and 44% of females in a Senagalese survey reported homosexual experience. · In Zimbabwe, 35% of a large representative sample of persons aged 18-27 reported having engaged in anal intercourse in the preceding two months. · MSM are scared of seeking medical care Source: Brody and Potterat,(2003) There are no epidemiological studies measuring the prevalence of HIV and AIDS among MSM in general, male sex workers, or LGBT people. However, the Symposium assessment provides an informative glance at the magnitude of the epidemic among sexual minorities in the eight selected countries. The results indicate that the risk of dying from HIV/AIDS within the LGBT population is generally medium to high, irrespective of the legal or political situation. The most seriously affected group are male sex workers for whom the risk of dying from AIDS is high in all countries. Astoundingly, the second most seriously affected group are lesbians for whom HIV/AIDS prevalence is high in more than half of the locations and medium in three locations. For gay men other than sex workers it is medium to high in most locations except Namibia and Rwanda. The two columns on absence of HIV/AIDS prevention efforts are scored in such a way that H means that prevention messages are available only from associations of LGBT people, while L means that there is a more systematic effort from several AIDS service organizations. Despite the high HIV/AIDS prevalence within the MSM/WSW population, Only in South Africa can HIV prevention messages and inputs be obtained from other sources than the associations. Likewise, AIDS care and treatment generally neither reaches, nor targets the LGBT population, even in cities where these services are offered to the general population, showing that even the public health sector discriminates against LGBT persons.24 24It is important to note here that there is virtually no information in the literature about the prevalence or infection rate of people who are self-defined as gay or lesbian in any country in Africa. Even the South African government with its constitution that is supportive of Human Rights has not ventured to establish such a study. There are many reasons why there is no such information in the published literature. The fact that lesbians and gays in Africa are hidden remains a major obstacle. Given the legal or social 14 Table 3: HIV/AIDS risk for LGBT people in Selected African Countries Frequency of Suspected AIDS Lack of Absence of Absence of Anti- Deaths Condom HIV/AIDS Retroviral Use Prevention Prgs Treatment Country Location Male Sex Gay Lesbians27 MSM28 MSM WSW30 Popul GLBT32 workers25 Men26 29 ation31 Senegal Urban H? L ? L M H L L (Baseline) Kenya Urban H M? H H H H M M Zimbabwe Urban H H H M H H M33 H Uganda Urban H M M M H H M H Tanzania Urban H M M H H H H H Nigeria Lagos M M ? H H H M H Sierra Freetown H L H M H H H H Leone Namibia Urban M M L H H H H H Rwanda Kigali M? L L M? H H H H South Gay Youth M M NA M L NA L L34 Africa South Township NA NA H H NA H L L Africa Lesbians 35 Source: All-Africa Symposium on HIV/AIDS and Human Rights The overall risk situation is summarized in Table 4, which sums up the risk scores for LGBT populations in the selected countries across the three classes of risks. The findings implications of "coming out", this issue will continue to represent a significant obstacle to governments and official groups that try to access this population. 25Informants were asked about the number of funerals they or other association members had attended for which they suspected that the death was due to AIDS, either because the person died of TB or another infectious disease normally treatable with antibiotics, or because they knew the persons circumstances from counseling or home based care. H: More than 10 percent of members died, L: Less than one percent of members died 26same as 17 27same as 17 28L: More than 80 percent of members are believed to use condoms regularly. L: Less than 20 percent of members believed to use condoms regularly 29L: Prevention messages of the several AIDS Service Organizations include Messages relevant to MSMs H: The associations are the only places from which MSM can receive prevention messages 30Same as previous footnote, but for WSW 31L: The country has decided to introduce ART for the population at large. M: There are significant pilot programs available for ART for those unable to pay. H: The only people who can get ART are those able to pay 32L: The country has a policy to include MSM in free ART as Senegal. M: Some GLBT people have been obtained ART in pilot programs. H: The only GLBT people who can get ART are those able to pay. 33Government announced in February 2004 that it will introduce a free ARV program for 140,000 people. 34Score normalized by adding the missing value from the township lesbian row. 35Score normalized by adding the missing value from the gay youth row 15 show that in six of the eight countries the total risks categories of Intolerance and Violence, Other Social Risks and HIV/AIDS risks faced by LGBT people are about as high as in Senegal. Senegal's exceptionally high risks of intolerance and violence is compensated for by the lower risks of HIV/AIDS, as the National AIDS program of Senegal has decided last year to include prevention, care and treatment for MSM in its national program. Table 4: Total Risk Scores for LGBT populations in selected African Countries36 Country Intolerance Other Social HIV/AIDS Total Risk and Violence Risks Risks Senegal (Baseline) H H M H Kenya H H H H Zimbabwe H H H H Uganda H M H H Tanzania H H H H Nigeria H H H H Sierra Leone H H H H Namibia H M H H Rwanda L L H M SA Gay Youth H L M M SA Township Lesbians H L M M Source: All Africa Symposium on HIV/AIDS and Human Rights. Johannesburg, South Africa. Feb, 2004. In Rwanda there are no laws against sodomy, and the informants came from a small group of mainly middle and upper class members, and consequently faced significantly lower risks, except for HIV/AIDS. Although an under-researched area, studies from countries in Asia, Latin America and Africa have indicated that class is a determining factor in assessing the vulnerability of individuals and groups to HIV/AIDS and violence. Economically marginalized sexual minorities face exacerbated hardships including discrimination in employment and barred access to common social institutions (Gosine, 2002, NAZ Foundation 2002). In South Africa where gays and lesbians have constitutional rights, risks are also lower, because the state institutions cannot discriminate any more and have decided to roll out comprehensive HIV/AIDS treatment which will in principle be accessible to gays and lesbians. However risks of intolerance and violence remain fairly high, illustrating that change in social attitudes must accompany constitutional and legal changes. 36Aggregative scores were constructed for each category by transforming L, M and H into scores of 0, 1, and 2 in each of the previous tables, and adding the numbers for each country and category of risk. Cut off points were selected at 10 for high, and at 5 for medium. 16 On the whole, some individual categories were found to be low in Rwanda and South Africa. However, even in those countries, total risk could never be viewed as low. The results thus show that the high risk and vulnerability of MSM to violence and AIDS is not an isolated case in Africa, but rather a generalized situation which calls for urgent actions by governments, international organizations, and civil society. 7. Towards an Inclusive Strategy Against Violence and AIDS Why Should Policy Makers Care: Violence: The level of general and sexual violence against MSM/WSW people documented in this paper clearly is completely unacceptable. Even more shocking is that some of this violence is perpetrated by policemen and tolerated in correctional institutions. A particularly distressing form of violence is sexual assault against girls and boys. This paper shows that sexual violence against boys to be quite common. Boys deserve protection against sexual abuse just like girls. Marginalization, destitution and poverty: MSM/WSW have been shown to be among the most vulnerable minorities: unless they successfully hide their sexual orientation and activities, they are not only stigmatized and discriminated against, but also at an exceptionally high risk of losing any social support and safety net from their families or society at large. This marginalization of MSM and WSW increases their disease burden, livelihood loss, destitution, and poverty, and exposes them to an increased risk of loss of life. HIV/AIDS: Given the special risks associated with anal sex, the prevalence of HIV/AIDS is likely to be significantly worse among MSM than the general population. In addition, the fact that sexual identity and behavior are not the same has profound epidemiological implications, manifested by the significant spillover of the HIV epidemic to women and children. Because of marginalization and their frequent loss of social support and safety net, many MSM and WSW will be even more isolated than AIDS victims in general and may have to face terminal illness and death alone. In spite of these facts, in most countries there are as yet no prevention, care or treatment programs that reach sexual minorities, and this is unacceptable for them as well as the population at large. 17 Box 9: Boys are at risk of sexual abuse A 15 year old in a Southern African Country lost both his parents to AIDS and was subsequently fostered in the home of a sister of his mother. According to family members he was a bright boy who enjoyed playing football. For about six months, the boy was frequently beaten up and sexually abused by the sister's husband and another male family member. The damage to his body was so severe that he is now brain damaged, paralyzed from the waist down, and incontinent. He spends his life in a wheel chair, and requires intensive care and support. In addition he is infected with HIV. He now lives in a different home. Fortunately he found a sponsor who finances his health care and rehabilitation, as well as a full time helper to take care of him. In rehabilitation, he has learned to speak a few words again and sit up, but still cannot walk. He is very loving and his most preferred activity is being taken for drives in a car. Because he has such a sunny disposition, he is loved by everyone around him. Source: Personal interview during fact-finding mission 18 Existing Recommendations: From HIV/AIDS Prevention to Human Rights The review of existing recommendation shows that among HIV/AIDS professional and LGBT activists a broad consensus exists on the importance of combating the HIV/AIDS epidemic among sexual minorities. Clearly it is not lack of consensus and recommendations which has prevented these recommendations from being implemented in Africa and other low income countries. Recommendations from UNAIDS on prevention, care and support According to UNAIDS, (1998) "sex between men is the main route of transmission of HIV in some parts of the world. In some other places it is a secondary route of transmission. Nearly everywhere, it is a significant and interconnected part of the epidemic and needs to be taken seriously and into consideration" in all HIV/AIDS care and prevention programs. Already in 1998 it advocated a broad approach including the epidemiological, anthropological and empowerment approaches discussed further below, even before they were fully articulated by Pecheny and Manzelli, (2002) and the NAZ foundation (2002). UNAIDS recommendations also go beyond prevention and include care and support. According to UNAIDS, the key steps that need to be taken to effectively deal with HIV transmission in male-to-male sex are: · For political leaders, and all other key players to accept that sex between men exists and is relevant for AIDS prevention, care and support work; · For national AIDS programmes to include the issue of male-to-male sexual transmission of HIV in their planning and implementation; · For donor agencies to commit themselves to giving serious consideration to funding AIDS prevention care and support among MSM; · For both governments and nongovernmental organizations (NGOs) to promote safer sex and the provision of condoms, conducting programmes involving: outreachwork; peer education projects; and mass media and 'small media' campaigns, as appropriate; · For national AIDS programmes and other partners to encourage the creation of gay organizations and strengthen existing networks of men who have sex with men; · For national AIDS programmes and other partners to reproduce or expand HIV prevention approaches that have proved successful among MSM, locally and abroad; · For political leaders and influential people in society to support HIV programmes directed to MSM; and · For national AIDS programmes and donor agencies to ensure that effective HIV interventions among MSM are maintained. In the past, good projects have sometimes been stopped, or had funding decreased, when it was thought that they had been successful, or that risk to MSM had declined. Unfortunately, in Africa, until recently only South Africa was starting to implement programs along the lines of these recommendations. Over the last two years Senegal and Uganda, for long the most innovative and committed to the fight against HIV/AIDS, and 19 Malawi, Nigeria and Uganda, have recognized that homosexual transmission could be a significant issue in their countries. They are now starting to follow the above UNAIDS recommendations. Prevention: Three Basic Models In their study focused on Latin America and the Caribbean, Pecheny and Manzelli (2003) identify three basic models for HIV prevention among sexual minorities: · The epidemiological-behavioral model is centered on perceptions and behaviors of high-risk groups and seeks to alter such behaviors through interventions addressing information, risk perception, perception of control over one's behavior, self-confidence, and the attitudes of different population groups to the disease. · The anthropological-cultural model focuses on meanings of behavior, change codes and values that enhance risks and impede preventive behaviors. · The political-economic model seeks to reduce social, rather than individual, vulnerability through community mobilization. (It could therefore also be called the empowerment model, and incorporates the human rights agenda).According to this model, the root of the epidemic among sexual minorities lies in structural (i.e., class, gender, and lifestyle) inequality. James Robertson (2003) advocates the epidemiological approach which would makes information available to everybody irrespective of their sexual preference on the risks of specific sexual activities which they might engage in. He recommend to divorce HIV prevention among MSM from the GLBT and human rights agendas and instead disseminate general AIDS education messages that focus on sexual behavior. More specifically: Stop talking about "homosexual" transmission or "heterosexual" transmission and start talking about "sexual" transmission: vaginal, anal, oral. Educate people about the risks of sexual acts, graphically described. While this epidemiological approach clearly has to be a component of an overall strategy, it is clearly not enough. The cultural-anthropological approach calls for in depth studies and understanding of the complex sexual identities of men having sex with men within the specific cultural environment, and the design of interventions to the various identity sub-groups based on this understanding (Jenkins, 2004). The political-economic model calls for sexual minorities to organize based on an understanding of the structural inequalities, press for their rights and organize their own fight against violence and AIDS. The three prevention models have traditionally been implemented in sequence, each addressing a broader set of issues than the previous one (Parker, 200?). However, as Pecheny and Manzelli show, no single model can hope to incorporate the vast range of factors inherent to HIV/AIDS among sexual minorities. The authors therefore recommend that in order to implement an effective response to the different areas of prevention the models need to be implemented not separately, but in a parallel and unified effort. 20 The authors further recommend the integration of the three approaches within a Human Rights Perspective. Indeed, in the case of HIV/AIDS, the decline in the quality of life and the exercise of rights of many individuals and groups can be directly linked to discrimination and exclusion, which contribute to the spread of the epidemic. As the authors state: "Recognition of human rights - including the right to health and to free expression of sexuality - makes it possible to improve implementation of primary, secondary, and tertiary HIV/AIDS prevention, and such prevention does nothing if not respect the universal and inalienable nature of human rights". This view is echoed by South Asian researchers working in this area. Following demands made by participants during an April 2003 Partners meeting held in New Delhi, NAZ Foundation International adopted a "Charter for Social Justice" which identifies the achievement of human rights as critically necessary to HIV/AIDS prevention and care. Box 10. Charter for Social Justice Do hereby demand the respect and dignity of all MSM, irrespective of their specific gender and/or sexual identity, or the lack of, the creation of a supportive social, policy and legal environment to enable MSM to more effectively respond to the HIV/AIDS epidemics in our countries and to be seen as equal partners in the struggle against the spread of AIDS. Such an enabling environment should include the realization by all, irrespective of sexual or gender choices, the following rights: · The right to equality before the law and non-discrimination · The right to liberty and security of person · The right not to be subjected to torture or to cruel, inhuman or degrading treatment or punishment · The right to work, with free choice of employment, to just and favourable conditions of work · The right to freedom of opinion and expression, including freedom to hold opinions without interference, and to seek, receive and impart information and ideas · The right not to subjected to arbitrary interference with our privacy, family, home or correspondence, nor to attacks upon our honour and reputation · The right not to be subjected to arbitrary arrest, detention or exile, or the creation of such circumstances that force one to adopt exile Source: NAZ Foundation International, 2003 A Political and Human Rights Approach: This approach is articulated in the report of the Human Rights Watch and IGLHRC on "More than a Name: State-Sponsored Homophobia and Its Consequences in Southern Africa (2003). Unlike the other sets of recommendations, this report fully integrates the viewpoint of Lesbian women and women's groups. After a careful review of the nature and impact of state-sponsored homophobia on sexual minorities in Southern Africa, this report calls on states to: · Publicize and promote awareness of rights protections and how to use them; 21 · Create and allocate adequate resources to accessible forms of remedy for human rights violations, with mechanisms empowered and informed to address the specific needs of vulnerable populations; · Ensure that legal representation and legal remedy are economically and practically accessible to everyone; and · Train state officials, particularly throughout the criminal justice system, in human rights and non-discrimination, and in sensitivity to gender and to minorities and vulnerable groups. It calls on civil society to: · Speak out whenever state officials incite or practice discrimination and abuse; · Seek out marginalized and stigmatized groups, and work to bring their concerns into the mainstream of human rights and other social movements. Recommendations of the African Lesbian and Gay Groups at the All- Africa Rights Initiative (2004) While focused on HIV/AIDS, this Symposium reviewed the situation of LGBT groups in their entirety within a broad human rights framework. The fifty LGBT groups who participated at the Symposium stressed the importance of capacity building for program development of the communities within countries and for their network. For these purposes, they made the following specific recommendations: HIV AIDS: · Advocate for access to healthcare for LGBT associations · Sensitize African LGBT about HIV and AIDS · Mainstream LGBT issues in HIV/AIDS literature, and in media programming Human Rights: · Denounce all human rights abuses among LGBT groups · Advocate for access to, and the protection of, legal systems · Engage African Union in LGBTI rights talks; Capacity Building: · Build networks between LGBT associations and HIV/AIDS organizations · Training for LGBT groups in organizational development and mobilization · Develop information, education and communication (IEC) and behavior change communication (BCC) for LGBTI issues; 22 Additional Recommendations Why GLBT Organizations Are Needed African states, international organizations, donors, and civil society organizations have not responded to the needs of sexual minorities. Throughout the world, social movements to protect oppressed and discriminated minorities have neither started nor been successful without the active participation and organization of the minorities themselves in the struggle for their rights. The movements usually involve alliances between the minorities themselves and a broad range of allies in order to move governments, society at large and the courts to effect real change. In the developed world it was gay and lesbian groups who first advocated for and organized the fight against HIV/AIDS. A recent global review has confirmed that in all developing where there are prevention, care and support activities for sexual minorities they are similarly led and largely conducted by gay, lesbian and transgender groups themselves (Gosine and Binswanger, 2004). Moreover, even where governments are willing to assist, the South African example shows that government efforts can yield only limited results when they are not backed up by civil society. In South Africa, intolerance from the population still persists despite the constitutional protection of sexual minorities. LGBT organizations are therefore needed to deepen the fight against discrimination, marginalization and violence from families the population at large, and the police. Box 11. Secrecy Surrounding Same­gender Relationships · n Africa it is the duty of men and women to marry and bring up children. By the time they reach their late twenties, people are pressured hard by their families and friends to get married and start a family. Members of sexual minorities feel this pressure intensly because of their need to hide their sexual orientation, and most of them eventually marry. Prior to marriage they will also try to hide by having girl friends. Frequently they will continue their same sex behavior and many also continue emotional and friendships with other sexual minority members. Frequently the spouses are or become aware of the emotional and sexual relationships with same sex people, but others remain ignorant. Those who find out seek counseling, hoping their husbands will change, or, if they are economically independent, they walk out. · 50 year old property developer who has never been married, is frequently seen at social gatherings with young women. When the party is over, he drops the girls off, and goes to gay parties. At the end of the party he picks up a man and takes him home. · 44 year old Luo gas station attendant from Kisumu lived in Mombasa for several yeas while his wife stayed back in Kisumu. During his stay in Mombasa he became familiar with sex with other men. When he returned back to Kisumu a few years ago he was unable to resume an intimate relationship with his wife. He goes to bars and finds male partners whom he pays for sex. Most of his male partners are married. Source: Fact finding mission 23 Given the high level of secrecy surrounding same-gender relationships, HIV prevention and care among MSM/WSW cannot possibly be managed without deeply involving LGBT people and organizations. The bulk of the MSM/WSW population is hiding their sexual behavior and may be denying it even to themselves. A service delivery model from the public sector, NGOs and other service providers therefore cannot reach the MSM and WSW populations. Only LGBT people who have committed to the fight against AIDS can reach these people, as they can encounter them when they are seeking sex. Many MSM will have sex with male prostitutes, with gay identified men, and in locations which are generally known by gay people. MSMs can therefore be educated to protect themselves by gays who have accepted and been trained to act as peer educators, and in sexual encounters with gays who have already learned to protect themselves. Where Are LGBT Groups in their Efforts to Organize: The fact-finding mission revealed the presence of no less than 25 groupings of LGBT people in the nine countries of the Sub-region and the All-Africa Symposium for HIV/AIDS and Human Rights had gathered an additional 35 groups from Anglophone Africa. With the exception of South Africa, Zimbabwe and Namibia, most associations take the form of house gatherings or small informal networks of friends, which are poorly organized and cannot sustain themselves. It is indeed nearly impossible for LGBT groups to meet or organize because of oppressive laws, official campaigns against them, lack of information, negative media, deep cultural and religious disapproval, risk of social isolation, loss of livelihood and violence, absence of safe meeting places and lack of financial support. Table 5 illustrates the difficulties to find places other than private homes to organize and socialize. In only a third of the cities studied LGBT people can hold a meeting in a restaurant or bar, and in less than a third of the cities are there any other organizations which make meeting places available to them. Gay bars exist only in South Africa. 24 Table 5: Opportunities for LGBT people to Socialize and Meet in Selected African Countries Where can they socialize Where can they meet Country Location Friendly GLBT Organi- Restaurants Organi Clubs Bars zations37 Bars Zations Senegal Y N Y Y Y (Baseline) Kenya Urban Y N Y Y Y Zimbabwe Urban Y N Y Y Y Uganda Urban Y N Y N Y Tanzania Urban Y N Y Y Y Sierra Freetown Y N N N N Leone Namibia Urban Y N Y Y Y Rwanda Kigali N N N N N South Gay Y Y Y Y Y Africa Youth South Township N N Y Y Y Africa Lesbians Embedding LGBT Issues into Broader Issues The discussion above has provided a holistic view of the broad issues of sexual minorities. Falling within the frameworks of poverty reduction and human rights, these include the complexities of gender identities, violence, HIV/AIDS and prostitution. While strategic thinking in each of these individual areas is already starting to take place, the individual strategies fail to consider the problems of sexual minorities in their entirety, and therefore fail to capitalize on potential alliances among different stakeholders dealing with these issues. The strategies are also limited in the actors which they call on to deal with these issues, and in particular do not assign a significant role to the sexual minorities themselves nor call for their empowerment; finally their fact finding and research agendas are limited to the epidemiology of HIV. 37Their own organization or premises of a GLBT friendly organization 25 Figure 4: Mainstreaming the Problem of Sexual Minorities into Broader Agendas, Policies and Programs Poverty Reduction Human Rights Violence MSM Gender Issues LGBT Prostitution, Abductions AIDS The issues confronting sexual minorities include human rights, gender identity, violence, HIV/AIDS, GLBT empowerment, sexual minority youth, abductions, and prostitution. As shown in Figure 4, most of these issues are not only confronted by sexual minorities, but also by other population groups and minorities, such as women, youth, people living with HIV/AIDS, sex workers, and other discriminated and stigmatized minorities. On each of these broader issues a variety of international organizations, government agencies and civil society organizations are already active. Rather than singling out issues of sexual minorities as a separate agenda, mainstreaming these issues into the broader sets of issues and the work programs of the respective organizations would be more likely to lead to progress, capitalize on a broad set of alliances, and reduce the likely negative reaction of policy makers, religious groups and the population at large which a single issue program could provoke. Opportunities Since 1994, issues of sexual minorities in Africa have generated growing public discussion and attracted increasing interest in academic circles. There are now traces of recognition of the problem among government authorities and national AIDS programs, and the issue has gained increasing attention from international organizations, including the Human Rights organizations of the United Nations, UNAIDS and its co-sponsors, the 26 World Bank, UNHCR, and a number of civil society organizations such as Amnesty International, the Human Rights Watch, IGLHRC, the HIVOS, and the Astraea Foundation. As the Symposium's assessment shows, there are increasingly small groups of LGBT people who are willing and eager to organize to defend their rights and take on the challenge of fighting AIDS within their own ranks. Finally, the community funds of National AIDS programs financed by the World Bank could be accessed by AIDS service organizations and LGBT groups to support their programs to fight AIDS among MSM and WSW. 27 Key Actors and Their Roles Key actors in improving the conditions of sexual minorities are states, civil society, and LGBT people and associations. Their roles are suggested in figure 6. In addition to the roles that we recommend for GLBT associations, we also suggest additional roles for states and civil society. In addition to protect the rights of sexual minorities and take their needs into account in the fight against HIV/AIDS, states should be encouraged to provide equitable service delivery, especially in health, education, and HIV/AIDS prevention, care and treatment; and non-LGBT civil society organizations should be encouraged to provide HIV/AIDS prevention, care and treatment services to special MSM populations such as migrants, inmates of correctional institutions, and street children. Some of them could also provide capacity building support to fledgling associations of LGBT people. Figure 5: Key actors to improve the conditions of sexual minorities The State · To improve the climate and legislation in support of: - human rights, prevention of violence and access to economic opportunities · To focus HIV/AIDS prevention messages on sex: vaginal, anal, oral · To ensure equitable access to health and education services and legal systems NGOs ·To spread knowledge about the conditions of sexual minorities ·To advocate for human rights of sexual minorities and to provide capacity building support to LGBT ·To provide health and other services to special populations ·To spread general messages about the risks of STs and HIV associated with anal intercourse GLBT Associations · Advocacy for and defense of their own human rights · Put pressure on states and civil society · Effots to reduce violence and prevent HIV/AIDS ·At the core of targeted prevention efforts, care, treatment and livelihood development In addition to these actions, there is also a need for intensive research and fact finding about the conditions and problems facing sexual minorities, including epidemiological surveys of the prevalence of HIV/AIDS among sexual minorities, studies of prevalence of same-gender sexual behavior, etc. Such research should be commissioned either by the responsible government organizations, such as national HIV/AIDS councils, or by non-GLBT civil society organizations. Clearly GLBT people need to be partners in the resulting research efforts, as only they can overcome the barriers associated with stigma and secrecy. However, the research is better done by independent researchers who can be more objective than the affected people themselves. 28 Finally the donor community and international organizations and donors also need to become much more active in advocating for improvements in the lives of sexual minorities. Donors also need to assist with the financing of an aggressive response to the AIDS crisis associated with same sex behavior, service delivery programs for these groups of people, capacity building of their organizations, and fact finding and research. Building Implementation Capacities At the present time the capacity to implement research, policies and programs for sexual minorities is almost non-existent in governments, civil society organizations and LGBT groups. Capacity building involves a combination of formal training, learning by doing, and empowerment. Specific actions include the capacity building proposals for states of the Human Rights Watch/IGLHRC report, as well as the following additional ones: · Assist in the capacity building of specialized NGOs to reach special MSM groups (e.g., street children, inmates of correctional institutions, migrants) · Empower and build the capacity of GLBT groups to become fully functional and self- sufficient organizations · Facilitate a GLBT-led participatory approach to behavior change and use GLBT people to reach the general MSM population with whom they interact Recommendations for UNAIDS and its Co-Sponsors, including the World Bank: As discussed above, UNAIDS has a well articulated strategy for comating HIV/AIDS among sexual minorities, but that strategy has not so far led to much action in low income countries. As part of the revision of their prevention strategy the UNAIDS co- sponsors are in the process of further developing their policies and policy recommendations on sexual diversity, violence and AIDS. As part of this they should especially focus on the following actions: · Develop the authorizing environment for working on GLBT, MSM, and WSW issues by facilitating discussions on sexual minority issues in international fora and at the national level, involving national governments, civil society, UNAIDS and Co- sponsors, the Global Fund, and gender and human rights groups. · Survey existing programs to combat violence, foster human rights, and deal with HIV/AIDS among sexual minorities and derive best practices · Facilitate further development of policies of the different agencies and their learning by doing · Help coordinate and finance capacity Building for agencies, NGOs, LGBT groups Within this approach UNAIDS has a particularly important role to play: · UNAIDS Country Coordinators (UCC) and UN Theme Groups can raise MSM and WSW issues with their National AIDS Councils 29 · UCCs can facilitate financing of strategic planning workshops by the LGBT groups and NGOs who might be interested in taking up MSM and WSW issues. These could be supported through Program Accelerating Funds, a bilateral donor, or from National AIDS program funds. · Such workshops can lead to funding proposals for capacity building of LGBT groups and other civil society groups. UCCs, together with members of the Theme Groups can facilitate dialogue about funding with National AIDS Councils · Press relations should be managed by LGBT groups themselves. UCCs and other members of the UN theme group can, however, assist the groups with facts and best practices · UCCs and theme can discuss the research issues and help identify researchers and funding sources, in collaboration with LGBT groups. Within the Multi-Sector HIV/AIDS programs (MAP) which it finances in 30 countries of Sub-Saharan Africa, the World Bank has already clearly stated that governments can use the funding for work benefiting a variety of especially vulnerable groups, including inmates in correctional institutions, sex workers, street children, and men having sex with men. Under the Sierra Leone program, for example, financing for an epidemiological and profiling study is already under preparation, and the recently formed Sierra Leone Lesbian and Gay association is has started to receive funding for capacity building. In the Brazilian HIV/AIDS program, a number of LGBT groups have been receiving financing for their HIV/AIDS programs for several years. Since these options and supports from the World Bank are not special programs but mainstreamed into general HIV/AIDS program, they are not widely known by government, NGOs, and LGBT groups which could benefit from them. The Bank should therefore take a more active role in disseminating this information to governments, civil society groups, and potential LGBT associations, as well as to its development partners. But issues of sexual minorities could also be mainstreamed into the routine analytical work and lending operations of the World Bank. In particular, assessments of the status and problems of sexual minorities could be mainstreamed into gender, social, and poverty assessments. Operations in social protection could include protection of sexual minorities, and health sector operations could ensure better access to health care for sexual minorities, including HIV/AIDS care and treatment. Finally, family planning and sexual health and education programs should include the provision of knowledge about sexual minorities and promote a reduction in stigma and discrimination. 30 Annex 1: LGBT Risk Assessment for Selected African Countries The All Africa Symposium on HIV/AIDS and Human Rights The All Africa Symposium on HIV/AIDS and Human Rights was initiated by GALZ (Gays and Lesbians of Zimbabwe) and Livelihood Development (Uganda), with financial support from HIVOS and the World Bank. It was organized in collaboration with the South African based NGO "Behind the Mask" and ICC from Zimbabwe. The risk assessment is published in the final report of the Symposium38 The main objective was to bring together activists in the field of Lesbian Gay Bisexual and Transgender (LGBT) issues and HIV/AIDS in order to develop strategies for African LGBT organizing at local, sub-regional and regional levels as a coordinated response to HIV/AIDS amongst men who have sex with men (MSM), women who have sex with women (WSW) and bisexuals in Africa. Issues to be covered included organizing and mobilizing LGBT groups in hostile environments, legal concerns, activism, establishing an African network, defining a strategy for capacity building, developing a work plan and documenting information for seeking further financial support. The meeting gathered 55 participants from 17 English speaking countries (Ghana, Sierra Leone, Nigeria, Egypt, Ethiopia, Uganda, Somalia, Kenya, Tanzania, Rwanda, Burundi, Malawi, Zimbabwe, Botswana, Namibia, Swaziland and South Africa) plus experts and researchers from Senegal. Almost all country delegations included at lease one Lesbian leader in order that the viewpoint of the women would be fully integrated. All of the countries have LGBT groups aimed at addressing the seriousness of their situation, including violence, discrimination, lack of access to health, rising mortality among LGBT people. Risk Assessment Methodology and standards: The risk assessment was based on some initial prior work conducted during the fact finding mission to East and Southern Africa (see Annex 2). It started out from the study of the Population Council Horizons Program, Population Council, "Meeting the Sexual Health Needs of Men Who Have Sex with Men in Senegal," New York, 2002, which quantified the risks faced by a sample of 250 men having sex with men in Senegal. The study measures three classes of risks: Discrimination and Violence, Other Social Risks, and Risks associated with HIV/AIDS. The quantitative measures of that study were used as a baseline to develop a scoring system for these risks. In developing the scoring system we added a number of additional risk, such as the risk of death from HIV/AIDS or the risk of becoming a sex 38ICC Africa and GALZ. "All Africa Symposium on HIV/AIDS and Human Rights, Official Report." June, 2004 31 worker, and also added risks for Lesbians. The scoring system was then applied to provide an risk assessment for 8 other countries which were represented by full delegations at the symposium. 39 Ronald Lwabaayi, Hans Binswanger, and Tuu-Van Nguyen then converted the Senegal data to the scores. At least three leaders of gay and lesbian associations from 8 of the 16 countries which were present at the All African HIV/AIDS and Human Rights Symposium in Johannesburg, South Africa from February 7 to 15, 2004 were interviewed as a group by Ronald Lwabaayi and Hans Binswanger to develop the scores for their respective countries. These leaders had been sent a questionnaire addressing the issues covered in the tables and asked to discuss them with members of their own and other organizations in their countries. Not all countries returned the questionnaires. Group interviews to fill out the tables were conducted with each country delegation so that the informants could reach a consensus on the answers. Countries which did not have at least three participants were left out. Participants usually included a male leader, a female leader, and a gay or lesbian person with a professional background in health, or HIV/AIDS prevention and counseling. The participants were explained the standards for ranking of their countries which are given in the footnote of each table and then provided the rankings High, Medium or Low. For the questions on HIV/AIDS prevention, care and treatment, a score of H means that the respective risk remains high, i.e. condom use is low, or programs are not in place. For South Africa we had to disaggregate the gay and lesbian populations further. We were fortunate that there are two research studies ongoing in South Africa, one on Black gay youth, and one on Township Lesbians, and the scores were provided by the main investigators in these studies, and cross-checked between them and with another member of the South African delegation. The main researcher and main health care provider for MSMs in Senegal were asked to score the additional questions not initially asked in their survey. In order to arrive at numerical score, H, M, and L were assigned the numerical scores of 2, 1, and 0 respectively. The scores were then added for the three risk categories separately, and the combined score is the simple total of all the individual scores. In each table the total table score is given in the last column. The countries are presented in the order of total risk. 39Senegal is used as the baseline because most of the data come from a quantitative survey of gay men. The data on Risk and violence faced MSMs in the Senegal survey were assumed to be the high level of risk for the scoring system developed for the other countries. Horizons Program, Population Council, "Meeting the Sexual Health Needs of Men Who Have Sex with Men in Senegal," New York, 2002. 32 The informants represented studies, programs, and associations comprising a total of 4600 African LGBT people, around 1300 women, and 3300 men. Number of GLBT men and women represented by the informants (participants in studies, programs or associations) Estimated GLBT Group Size, characteristics Senegal, (Baseline) 450 to 500 M in associations; 250 participated in the research study which serves as the baseline Kenya 40 F, 365 M, men majority poor 40 Zimbabwe41 46 W, 217 M mostly poor blacks, some working/middle class, some whites Uganda 70 W, 200 M mostly middle class Tanzania 200 W, 400 M, majority poor Sierra Leone 20 W, 70 M, majority poor Namibia42 110 W, 155 M, 10 Transgender43, majority poor Rwanda 16 W, 7 M, mostly middle class South Africa, Gay 1500, mostly poor black Youth44 South Africa 1000, mostly poor black Township Lesbians45 40Three groups in total of which the two smaller ones were mainly working and middle class, the large one mainly poor 41Paid up members only. More come to social functions and training and counseling 42TRP has converted from a membership organization to a trust, however TRB now has contact with a much larger group of LGBT people than before, as many did not want to become members so as not to be documented 43Transgender are all biologically female 44From an ongoing research and advisory program for gay male youth managed by Behind the Mask 45From and ongoing research program on sexual violence managed by Behind the Mask 33 Annex 2: Fact-Finding Mission To Eastern, Central and Southern Africa A fact finding mission was sent by the World Bank to Eastern, Central, and Southern Africa in February 2003 to (1) help prepare for the Symposium on AIDS and Human Rights, (2) gather facts and stories about the risks faced by MSM and WSW in Africa, and (3) identify groups of LGBT people which were at various stages of organization, and (4) assess their needs and ideas for the forthcoming symposium. The fact-finding mission was carried out by Ronald Lwabaayi from the NGO Livelihood Development International (LDI) in February and March 2003, and visited 9 countries (Botswana, Kenya, Malawi, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). Evidence was gathered from discussions with the organizers of informal GLBT groups and people living with HIV/AIDS (PLWHA). Informants were selected for their hands-on knowledge of the MSM milieu and included include: five organizations and three activists in Kenya; four organizations in Tanzania; four organizations and three activists in Rwanda; one formal organization in Zimbabwe, Gay and Lesbians of Zimbabwe (GALZ); one activist in Malawi; one activist in Zambia; seven organizations in Uganda; one AIDS organization in Botswana; and one activist in South Africa. These informants provided the personal stories which are reflected in the boxes of the paper. 34 Bibliography Afrol News, "The Legal Situation of Homosexuality in Africa", http://www.afrol.com/Categories/Gay/index_legal.htm Accessed in May, 2004. Altman, Dennis, 2004), "Rights Matter: structural interventions and vulnerable communities," Bangkok: International AIDS Conference: Jonathan Mann Memorial Lecture, 14, 2004 All Africa Rights Initiative, 2004, All Africa Symposium on HIV/AIDS and Human Rights, Official Report, Johannesburg, South Africa February 7-14, 2004 Aldrich, Robert, 2003, "Homosexuality and Colonialism," London: Routledge Amnesty International: 1998, "Romania: A Summary of Human Rights Concern," Amnesty International, INDEX EUR 39/06/98 Brody, Stuart and Potterat, John, 2003, "Assessing the Role of Anal Intercourse in the Epidemiology of AIDS in Africa". International Journal of STD and AIDS: 14:431-436. Donnelly, J., 2003, "Universal Human Rights in Theory and Practice," 2nd Edition, Ithaca and London: Cornell University Press Gosine, A., 2004, "Sex for pleasure, rights to participation and alternatives to AIDS: placing sexual minorities in development," Institute of Development Studies, University of Sussex (2004). Gosine, Andil, and Hans P. Binswanger, 2004, "Sexual Minorities, Violence and HIV/AIDS: The Response in the Developing World," Washington DC: World Bank, mimeo Human Rights Watch and the International Gay and Lesbian Human Rights Commission, 2003, "More than a Name: State-Sponsored Homophobia and Its Consequences in Southern Africa." New York: Human Rights Watch Human Rights Watch and the International Gay and Lesbian Human Rights Commission, 2001, "Egypt: Emergency Court Trials for Homosexual Suspects", Press Release, July 3, Jenkins, Carol, 2004), HIV/AIDS and Culture: Implications for Policy," Bangkok, Thailand, International AIDS Conference, Preconference symposium on Sexual Minorities, Violence, and AIDS, July Murray, Stephen O., 2000 "Homosexualities," Chicago: Chicago University Press Murray, Stephen O., and Paul Roscoe, 1998, "Boy Wives and Female Husbands: Studies in African Homosexualities,", New York, Palgrave Pecheny M, Manzelli H. "HIV/AIDS Prevention in Men Who Have Sex with Men", HIV/AIDS among Latin American MSM: tailoring programmes to their specific needs. Sexual Health Exchange. pp. 99-132. 2003 35 NAZ Foundation, 2002, Strategy Paper No. 7, London Niang C.I., Diagne M., Niang Y., Mody Moreau A., Gomis D., Diouf M., Seck K., Sidibé Wade A., Tapsoba P., and Castle C., 2002, "Meeting the Sexual Health Needs of Men Who Have Sex With Men in Senegal." Horizons Program, USAID. New York: The Population Council Inc. Parker, R.. "Empowerment, Community Mobilization, and Social Change in the Face of HIV/AIDS", AIDS, Vol. 10 (3), ppS27-S31 Robertson, James, 2003, "The Black Swans of Africa: AIDS and Sex Between Men in Sub- Saharan Africa", The Harvard School of Public Health, Harvard University. In press. 2003. Seabrook, Jeremy, 2004, "The Developing World's Homophobia is a Legazy of Colonialism," Manchester, UK: The Guardian, July 3, 2004, http://www.guardian.co.uk/gayrights/story/0,12592,1253130,00.html South African Aids Trust (SAT), 2004 Guidelines for Counselling Men who have Sex with Men, HIV Counselling Series No. 9 January 2004 ISBN: 07974-2557-8 United Nations, Universal Declaration of Human Rights, Articles 1, 2, 7, and 23 UNAIDS, 1998, "AIDS and Men Who Have Sex With Men", Geneva, UNAIDS Point of View World Health Organization, 2002, "World report on Violence and Health," Edited by Etienne G. Krug, Linda L. Dahlberg, James A. Mercy, Anthony B. Zwi and Rafael Lozano, Geneva: World Health Organization 36 Africa Region Working Paper Series Series # Title Date Author ARWPS 1 Progress in Public Expenditure Management in January 1999 C. Kostopoulos Africa: Evidence from World Bank Surveys ARWPS 2 Toward Inclusive and Sustainable Development in March 1999 Markus Kostner the Democratic Republic of the Congo ARWPS 3 Business Taxation in a Low-Revenue Economy: A June 1999 Ritva Reinikka Study on Uganda in Comparison with Neighboring Duanjie Chen Countries ARWPS 4 Pensions and Social Security in Sub-Saharan October 1999 Luca Barbone Africa: Issues and Options Luis-A. Sanchez B. ARWPS 5 Forest Taxes, Government Revenues and the January 2000 Luca Barbone Sustainable Exploitation of Tropical Forests Juan Zalduendo ARWPS 6 The Cost of Doing Business: Firms' Experience June 2000 Jacob Svensson with Corruption in Uganda ARWPS 7 On the Recent Trade Performance of Sub-Saharan August 2000 Francis Ng and African Countries: Cause for Hope or More of the Alexander J. Yeats Same ARWPS 8 Foreign Direct Investment in Africa: Old Tales November 2000 Miria Pigato and New Evidence ARWPS 9 The Macro Implications of HIV/AIDS in South November 2000 Channing Arndt Africa: A Preliminary Assessment Jeffrey D. Lewis ARWPS 10 Revisiting Growth and Convergence: Is Africa December 2000 C. G. Tsangarides Catching Up? ARWPS 11 Spending on Safety Nets for the Poor: How Much, January 2001 William J. Smith for How Many? The Case of Malawi ARWPS 12 Tourism in Africa February 2001 Iain T. Christie D. E. Crompton ARWPS 13 Conflict Diamonds February 2001 Louis Goreux ARWPS 14 Reform and Opportunity: The Changing Role and March 2001 Jeffrey D. Lewis Patterns of Trade in South Africa and SADC 37 Africa Region Working Paper Series Series # Title Date Author ARWPS 15 The Foreign Direct Investment Environment in March 2001 Miria Pigato Africa ARWPS 16 Choice of Exchange Rate Regimes for Developing April 2001 Fahrettin Yagci Countries ARWPS 18 Rural Infrastructure in Africa: Policy Directions June 2001 Robert Fishbein ARWPS 19 Changes in Poverty in Madagascar: 1993-1999 July 2001 S. Paternostro J. Razafindravonona David Stifel ARWPS 20 Information and Communication Technology, August 2001 Miria Pigato Poverty, and Development in sub-Saharan Africa and South Asia ARWPS 21 Handling Hierarchy in Decentralized Settings: September 2001 Navin Girishankar A. Governance Underpinnings of School Alemayehu Performance in Tikur Inchini, West Shewa Zone, Yusuf Ahmad Oromia Region ARWPS 22 Child Malnutrition in Ethiopia: Can Maternal October 2001 Luc Christiaensen Knowledge Augment The Role of Income? Harold Alderman ARWPS 23 Child Soldiers: Preventing, Demobilizing and November 2001 Beth Verhey Reintegrating ARWPS 24 The Budget and Medium-Term Expenditure December 2001 David L. Bevan Framework in Uganda ARWPS 25 Design and Implementation of Financial January 2002 Guenter Heidenhof H. Management Systems: An African Perspective Grandvoinnet Daryoush Kianpour B. Rezaian ARWPS 26 What Can Africa Expect From Its Traditional February 2002 Francis Ng Exports? Alexander Yeats ARWPS 27 Free Trade Agreements and the SADC Economies February 2002 Jeffrey D. Lewis Sherman Robinson Karen Thierfelder ARWPS 28 Medium Term Expenditure Frameworks: From February 2002 P. Le Houerou Robert 38 Africa Region Working Paper Series Series # Title Date Author Concept to Practice. Preliminary Lessons from Taliercio Africa ARWPS 29 The Changing Distribution of Public Education February 2002 Samer Al-Samarrai Expenditure in Malawi Hassan Zaman ARWPS 30 Post-Conflict Recovery in Africa: An Agenda for April 2002 Serge Michailof the Africa Region Markus Kostner Xavier Devictor ARWPS 31 Efficiency of Public Expenditure Distribution and May 2002 Xiao Ye Beyond: A report on Ghana's 2000 Public S. Canagaraja Expenditure Tracking Survey in the Sectors of Primary Health and Education ARWPS 33 Addressing Gender Issues in Demobilization and August 2002 N. de Watteville Reintegration Programs ARWPS 34 Putting Welfare on the Map in Madagascar August 2002 Johan A. Mistiaen Berk Soler T. Razafimanantena J. Razafindravonona ARWPS 35 A Review of the Rural Firewood Market Strategy August 2002 Gerald Foley in West Africa Paul Kerkhof Djibrilla Madougou ARWPS 36 Patterns of Governance in Africa September 2002 Brian D. Levy ARWPS 37 Obstacles and Opportunities for Senegal's September 2002 Stephen Golub International Competitiveness: Case Studies of the Ahmadou Aly Mbaye Peanut Oil, Fishing and Textile Industries ARWPS 38 A Macroeconomic Framework for Poverty October 2002 S. Devarajan Reduction Strategy Papers : With an Application Delfin S. Go to Zambia ARWPS 39 The Impact of Cash Budgets on Poverty Reduction November 2002 Hinh T. Dinh in Zambia: A Case Study of the Conflict between Abebe Adugna Well Intentioned Macroeconomic Policy and Bernard Myers Service Delivery to the Poor ARWPS 40 Decentralization in Africa: A Stocktaking Survey November 2002 Stephen N. Ndegwa ARWPS 41 An Industry Level Analysis of Manufacturing December 2002 Professor A. Mbaye Productivity in Senegal 39 Africa Region Working Paper Series Series # Title Date Author ARWPS 42 Tanzania's Cotton Sector: Constraints and December 2002 John Baffes Challenges in a Global Environment ARWPS 43 Analyzing Financial and Private Sector Linkages January 2003 Abayomi Alawode in Africa ARWPS 44 Modernizing Africa's Agro-Food System: February 2003 Steven Jaffee Analytical Framework and Implications for Ron Kopicki Operations Patrick Labaste Iain Christie ARWPS 45 Public Expenditure Performance in Rwanda March 2003 Hippolyte Fofack C. Obidegwu Robert Ngong ARWPS 46 Senegal Tourism Sector Study March 2003 Elizabeth Crompton Iain T. Christie ARWPS 47 Reforming the Cotton Sector in SSA March 2003 Louis Goreux John Macrae ARWPS 48 HIV/AIDS, Human Capital, and Economic April 2003 Channing Arndt Growth Prospects for Mozambique ARWPS 49 Rural and Micro Finance Regulation in Ghana: June 2003 William F. Steel Implications for Development and Performance of David O. Andah the Industry ARWPS 50 Microfinance Regulation in Benin: Implications of June 2003 K. Ouattara the PARMEC LAW for Development and Performance of the Industry ARWPS 51 Microfinance Regulation in Tanzania: June 2003 Bikki Randhawa Implications for Development and Performance of Joselito Gallardo the Industry ARWPS 52 Regional Integration in Central Africa: Key Issues June 2003 Ali Zafar Keiko Kubota ARWPS 53 Evaluating Banking Supervision in Africa June 2003 Abayomi Alawode ARWPS 54 Microfinance Institutions' Response in Conflict June 2003 Marilyn S. Manalo Environments: Eritrea- Savings and Micro Credit Program; West Bank and Gaza ­ Palestine for Credit and Development; Haiti ­ Micro Credit 40 Africa Region Working Paper Series Series # Title Date Author National, S.A. AWPS 55 Malawi's Tobacco Sector: Standing on One Strong June 2003 Steven Jaffee leg is Better than on None AWPS 56 Tanzania's Coffee Sector: Constraints and June 2003 John Baffes Challenges in a Global Environment AWPS 57 The New Southern AfricanCustoms Union June 2003 Robert Kirk Agreement Matthew Stern AWPS 58a How Far Did Africa's First Generation Trade June 2003 Lawrence Hinkle Reforms Go? An Intermediate Methodology for A. Herrou-Aragon Comparative Analysis of Trade Policies Keiko Kubota AWPS 58b How Far Did Africa's First Generation Trade June 2003 Lawrence Hinkle Reforms Go? An Intermediate Methodology for A. Herrou-Aragon Comparative Analysis of Trade Policies Keiko Kubota AWPS 59 Rwanda: The Search for Post-Conflict Socio- October 2003 C. Obidegwu Economic Change, 1995-2001 AWPS 60 Linking Farmers to Markets: Exporting Malian October 2003 Morgane Danielou Mangoes to Europe Patrick Labaste J-M. Voisard AWPS 61 Evolution of Poverty and Welfare in Ghana in the October 2003 S. Canagarajah 1990s: Achievements and Challenges Claus C. Pörtner AWPS 62 Reforming The Cotton Sector in Sub-Saharan November 2003 Louis Goreux Africa: SECOND EDITION AWPS 63 Republic of Madagascar: Tourism Sector Study November 2003 Iain T. Christie (E) D. E. Crompton AWPS 63 République de Madagascar: Etude du Secteur November 2003 Iain T. Christie (F) Tourisme D. E. Crompton AWPS 64 Migrant Labor Remittances in Africa: Reducing Novembre 2003 Cerstin Sander Obstacles to Development Contributions Samuel M. Maimbo AWPS 65 Government Revenues and Expenditures in January 2004 Francisco G. Carneiro Guinea-Bissau: Casualty and Cointegration Joao R. Faria Boubacar S. Barry 41 Africa Region Working Paper Series Series # Title Date Author AWPS 66 How will we know Development Results when we June 2004 Jody Zall Kusek see them? Building a Results-Based Monitoring Ray C. Rist and Evaluation System to Give us the Answer Elizabeth M. White AWPS 67 An Analysis of the Trade Regime in Senegal June 2004 Alberto Herrou-Arago (2001) and UEMOA's Common External Trade Keiko Kubota Policies AWPS 68 Bottom-Up Administrative Reform: Designing June 2004 Talib Esmail Indicators for a Local Governance Scorecard in Nick Manning Nigeria Jana Orac Galia Schechter AWPS 69 Tanzania's Tea Sector: Constraints and June 2004 John Baffes Challenges AWPS 70 Tanzania's Cashew Sector: Constraints and June 2004 Donald Mitchell Challenges in a Global Environment AWPS 71 An Analysis of Chile's Trade Regime in 1998 and July 2004 Francesca Castellani 2001: A Good Practice Trade Policy Benchmark A. Herrou-Arago Lawrence E. Hinkle AWPS 72 Regional Trade Integration inEast Africa: Trade August 2004 Lucio Castro and Revenue Impacts of the Planned East African Christiane Kraus Community Customs Union Manuel de la Rocha AWPS 73 Post-Conflict Peace Building in Africa: The August 2004 Chukwuma Obidegwu Challenges of Socio-Economic Recovery and Development AWPS 74 An Analysis of the Trade Regime in Bolivia August 2004 Francesca Castellani in2001: A Trade Policy Benchmark for low Alberto Herrou-Aragon Income Countries Lawrence E. Hinkle AWPS 75 Remittances to Comoros- Volumes, Trends, October 2004 Vincent da Cruz Impact and Implications Wolfgang Fendler Adam Schwartzman AWPS 76 Salient Features of Trade Performance in Eastern October 2004 Fahrettin Yagci and Southern Africa Enrique Aldaz-Carroll AWPS 77 Implementing Performance-Based Aid in Africa November 2004 Alan Gelb Brian Ngo Xiao Ye AWPS 78 Poverty Reduction Strategy Papers: Do they December 2004 Rene Bonnel matter for children and Young people made Miriam Temin vulnerable by HIV/AIDS? Faith Tempest AWPS 79 Experience in Scaling up Support to Local December 2004 Jean Delion Response in Multi-Country Aids Programs (map) Pia Peeters in Africa Ann Klofkorn Bloome 42 Africa Region Working Paper Series Series # Title Date Author AWPS 80 · What makes FDI work? A Panel Analysis of the February 2005 Kevin N. Lumbila Growth Effect of FDI in Africa AWPS 81 Earnings Differences between Men and Women in February 2005 Kene Ezemenari Rwanda Rui Wu AWPS 82 The Medium-Term Expenditure Framework April 2005 Chukwuma Obidegwu The Challenge of Budget Integration in SSA countries AWPS 83 Rules of Origin and SADC: The Case for change June 2005 Paul Brenton in the Mid Term Review of the Trade Protocol Frank Flatters Paul Kalenga AWPS 84 Sexual Minorities, July 2005 Chukwuemeka Violence and AIDS in Africa Anyamele Ronald Lwabaayi Tuu-Van Nguyen, and Hans Binswanger 43