Different Needs But Equal Rights: Giving Voice to Transgender Communities through ASPIDH in El Salvador
Although transgender individuals are a highly vulnerable segment of El Salvador's population, the national political climate has only recently begun to support HIV programming that is tailored to their needs. Additionally, limited access to medical services and legal protection and considerable societal stigma and discrimination means that organizations working with transgender individuals must meet a variety of complex and varied needs. This case study, one of 9 in a series, describes the challenges and successes of the Solidarity Association to Promote Human Development (ASPIDH), an NGO that promotes transgender rights via sensitization, education, and advocacy activities.
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Different Needs But Equal Rights
by Myra Betron
Giving Voice to Transgender Communities through ASPIDH in El Salvador
It is approaching midnight on the Alameda Roosevelt in San Salvador. Women stand along the sidewalk dressed in mini-skirts and high heels, waiting for their next client. These women, however, are transgender women—once named Omar and Guillermo, they now identify as Andrea and Patricia. (1) Facing extreme discrimination for transgressing traditional gender norms, many transgender people have been thrown out of their homes and schools, or simply cannot find a job. Sex work is one of the very few ways they can make a living. On the streets transgender people face even greater risk, including exposure to HIV, extreme violence, and even murder. In the first six months of 2010 alone, five transgender individuals were murdered in the city.
Lissa, an outreach worker with the Solidarity Association to Promote Human Development (ASPIDH), El Salvador's only legally recognized transgender organization, approaches Patricia and Andrea. She talks to them about the dangers of HIV and other sexually transmitted infections (STIs) and the importance of condom use and safe-sex behaviors, as well as how to defend themselves against discrimination and abuse. She then invites the women to ASPIDH's offices downtown for a workshop on HIV prevention and transgender rights later that week.
ASPIDH is a nongovernmental, nonprofit organization that aims to improve the human development and quality of life of transgender populations (including transvestites and transsexuals) in El Salvador. To that end, ASPIDH conducts sensitization, education, and advocacy activities to promote the human rights of transgender people and contribute to the reduction of stigma and discrimination against them; facilitate their access to employment, education, health, and safety; and reduce the prevalence of HIV and other STIs within the transgender population.
This case study describes ASPIDH's efforts and challenges to achieving these objectives. Data collection for this case study consisted of a series of key informant interviews with ASPIDH staff and volunteers, partner organizations, funders, and representatives of government, as well as focus group discussions with ASPIDH's beneficiaries and participants.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Transgenders, Sexual Diversity, and HIV in El Salvador
The transgender community is one of the populations most vulnerable to HIV in El Salvador. According to the Central American Sexual Behavioral Surveillance Survey (ECVC), HIV prevalence among the transgender population in the capital city of San Salvador is 19.7 percent, compared to the gay and heterosexual/bisexual populations, where HIV prevalence is 10.6 percent and 8.8 percent, respectively (Ministerio de Salud, Programa Nacional de ITS/VIH/SIDA El Salvador 2008). The Joint U.N. Programme on HIV/AIDS (UNAIDS) estimates that HIV prevalence among all Salvadorans aged 15 to 49 is 0.8 percent (UNAIDS 2011).
Discrimination, which limits access to employment, housing, health services, education, information, and other resources, contributes to the vulnerability of transgender people. As a result, many enter into sex work as the only means of economic livelihood they can find. The ECVC found that more than half of men who have sex with men (MSM) who self-identify as transsexuals or transvestites were selling sex at the time of the study. Sex work can bring a whole host of additional vulnerabilities, including rape, physical abuse, drug addiction, and extortion (Ministerio de Salud, Programa Nacional de ITS/VIH/SIDA El Salvador 2008).
Other barriers to health services can directly affect HIV vulnerability by blocking access to sexual and reproductive health information and care. Discriminatory behavior by health providers and the humiliation of being called a male name in front of other patients discourage many transgender women from seeking health services. Outright denial of service by providers is also commonplace. Finally, transgender women may make sex reassignment their primary health concern, which may compete with HIV prevention or relegate prevention to a secondary health need.
Until very recently there has been little HIV programming in El Salvador specifically for the transgender population. Instead, transgender women have been historically categorized as MSM, rendering them an "invisible" group whose special needs and risks are neglected. An evaluation of El Salvador's National Strategic Plan for the Prevention, Attention and Control of HIV/AIDS and STIs (2005–2010) (PDF, 3.81 MB) by the U.S. Agency for International Development's (USAID's) Program for Strengthening the Central American Response to HIV/AIDS (PASCA) project found that the plan lacks a strategy specifically for transgender people, gender equality, and sexual diversity (USAID PASCA 2010). Moreover, the government invests most of its funds in prevention of vertical transmission and prevention in the general population, whereas few resources are directed to most-at-risk populations. In 2006 and 2007, for example, government, donors, and nongovernmental organizations (NGOs) spent just U.S.$30,000 on HIV prevention programs with transgender people out of a total budget of over U.S.$16 million (Ministerio de Salud 2007).
Advances in the Policy Environment
BOX 1. PRESIDENTIAL DECREE NO. 56
Key articles that reflect and summarize points relevant to LGBT groups.
Article 1: Prohibits all forms of discrimination based on gender identity and/or sexual orientation in any activities of the Executive Office.
Article 3: Directs the institutions under the Executive Office to conduct an exhaustive review of policies, programs, and projects and institute any corrective measure necessary to ensure that they do not directly or indirectly discriminate based on gender identity or sexual orientation.
Article 4: Guarantees the creation of a culture of respect and tolerance within the institutions under the Executive Office so they conduct their activities irrespective of gender identity and/or sexual orientation.
Article 6: Establishes that no statutory provision, agreement, order, instruction, resolution, or circular would be developed that may generate or otherwise encourage discrimination based on gender identity or sexual orientation.
Over the past two years, however, a series of policies and political changes in the government have created a highly favorable political environment for HIV prevention and human rights work within El Salvador's transgender population. President Mauricio Funes, with strong support from the first lady, Dr. Vanda Pinhato, has promoted respect for sexual diversity, particularly by supporting the passage of Presidential Decree No. 56. This decree stipulates that there shall be no discrimination in any executive agencies, which includes ministries, the police, the military, and the social security office. In practical terms, Decree 56 has initiated training of government personnel on the human rights of lesbian, gay, bisexual, and transgender (LGBT) groups (see Box 1).
Similarly, in 2009, the Ministry of Public Health and Social Assistance passed a decree that guarantees access to health services and respect for the human rights of MSM, transgender people, and lesbians (UNAIDS 2009). As a result of this order and Presidential Decree No. 56, the National HIV and AIDS Program is training health providers and the police on the Law and Regulations for the Prevention and Control of Infections Provoked by the Human Immunodeficiency Virus (2), known as the HIV Law, and on stigma and discrimination and sexual diversity (Nieto 2010).
The current representatives of the National HIV and AIDS Program are also reported to have a more consultative and collaborative approach to working with civil society than the previous administration, which has allowed the transgender movement to have a greater voice in identifying their HIV-related needs. Currently being developed, the National Strategic Plan 2011–2015 will include components specifically for transgender people. Civil society organizations working in HIV, including ASPIDH, now have the opportunity to provide input into the plan in monthly meetings with the National HIV and AIDS Program. Likewise, the Global Fund to Fight AIDS, Tuberculosis and Malaria's (GFATM's) activities in El Salvador will include strategies specifically for transgender people; until 2009, there were no GFATM indicators or guidelines for transgender people (Miranda 2010).
Finally, donors have also increased attention to the transgender population in El Salvador, due largely to advocacy by ASPIDH as well as the results of the most recent ECVC, which demonstrated that transgender people are the population most vulnerable to HIV. UNAIDS and the U.N. Development Programme (UNDP), for example, are supporting ASPIDH and two smaller transgender groups in the area of organizational development, whereas the Pan American Health Organization has supported ASPIDH's advocacy events for the public and key stakeholders.
The History of ASPIDH
ASPIDH began to organize in 1996 under the leadership of Monica Hernandez (a transgender sex worker) and Edwin Aguilar (a transvestite (3) sex worker who had been working for Entre Amigos) and became a leading organization working with gay, bisexual, and transgender populations to prevent HIV and advance human rights. Tired of the discrimination, abuse, and murders of fellow transgender persons, Hernandez and Aguilar identified the need to organize a movement and services especially for this population. The organization's staff includes eight transgender persons and one transvestite, four of whom work as volunteers; the membership includes over 200 transgender people.
In 1999, ASPIDH tried to achieve legal status as a formal NGO, but the Ministry of Governorship rejected its application in an outright act of discrimination based on gender identity. Subsequently, Hernandez sued the Ministry for violating the right to free association and right to equality. Yet it was not until December 2009, after the case lay dormant for many years, that the Supreme Court decided in favor of Hernandez. During that period, in 2006, the organization received support from USAID's PASCA project to attain legal status, which it officially received in June 2008. To date, ASPIDH is the only legally recognized transgender organization in El Salvador.
Over the past two years, ASPIDH has received increasing donor support, although its funding for 2010 was still limited to U.S.$28,000, which it received from international NGOs. Most notably, in 2009, the Pan American Social Marketing Organization (PASMO) and the American Foundation for AIDS Research (amfAR) began funding to ASPIDH to adapt PASMO's HIV prevention methodology, Viviendo la Vida (Living Life More Fully), for MSM. This methodology includes dissemination of risk reduction information, skills building to increase HIV preventive behavior, distribution of male condoms and lubricants, and referrals to HIV services. To adapt the methodology for transgender persons, ASPIDH, with the help of an external consultant, included information and training on health issues related to hormone and silicone injections for those working on sex reassignment.
Support from amfAR has facilitated the establishment of a drop-in center, which offers a social space and support groups for the transgender and MSM communities. On average, the center receives about 30 transgender people a day who often come in for male condoms but also to participate in HIV prevention training that introduces concepts of gender, gender equality, and human rights. In addition, amfAR has supported workshops at the drop-in center using the Viviendo la Vida methodology.
ASPIDH has also received significant technical assistance from various organizations, which has allowed it to grow significantly in recent years as well as given it the opportunity for future growth. UNDP and amfAR have provided technical assistance in project management, monitoring and evaluation, and financial management; PASMO has provided technical methodology used by ASPIDH in their HIV prevention outreach; and REDLACTRANS, a regional network of transgender organizations in Latin America, and the Association of Christian Youth of El Salvador have provided significant technical guidance on and support for advocacy.
How ASPIDH Implements the PEPFAR Gender Strategies
Formed initially as an advocacy organization seeking to promote the rights of transgender people, ASPIDH is especially good at public campaigns aimed at increasing recognition of transgender people and their rights. This is done primarily through marches; the distribution of information, education, and communication materials; press conferences; legal petitions; and direct meetings with government personnel. Within this work, specific U.S. President's Emergency Plan for AIDS Relief (PEPFAR) gender strategies and approaches include the following:
- Increasing gender equity in HIV programs and services: ASPIDH conducts advocacy with the government and directly with health providers to ensure that they provide services to transgender people, who suffer discrimination by health providers and are often turned away from hospitals. ASPIDH also sensitizes health clinics to understand the importance of using transgender women's preferred names so that they do not feel humiliated by being called a male name when they identify as female. Finally, ASPIDH's drop-in services include the accompaniment of clients to health centers with which ASPIDH has an established relationship and more transgender-friendly services.
- Increasing legal protection: ASPIDH accompanies program users to the Human Rights Protection Office to file complaints when service providers—especially health providers and the police—violate their rights. ASPIDH also makes presentations at Ministry of Public Health-sponsored workshops for the police on human rights, the HIV Law, and discrimination against most-at-risk-populations. Finally, ASPIDH's major objective is to advocate for the passage of a gender identity law that would allow individuals to change their legal names so that transgender people can use the female- or male-identified name that matches their gender identity.
- Addressing harmful gender norms and behaviors: Through its ongoing and persistent advocacy, ASPIDH is working to increase the recognition of a range of gender identities, including transgender people and transvestites. For example, in May 2010, ASPIDH organized El Salvador's first-ever transgender pride march, which ASPIDH estimates was attended by approximately 300 individuals, many more than expected. ASPIDH also hosted a public launch of the movie Translatina, which portrays the discrimination and vulnerabilities faced by transgender women. These events attracted significant media attention and discussion. In addition, the leadership of ASPIDH often holds press conferences or talks with the media about transgender issues to bring them to broader public attention.
- Reducing violence and coercion: ASPIDH encourages friends and clients who experience violence to file complaints with the Human Rights Protection Office. To help transgender individuals cope with violence and discrimination, ASPIDH facilitates support groups and, occasionally, offers the services of a psychologist. However, the psychologist provides services on a volunteer basis and is not available consistently.
What Works Well
Peer education and outreach: ASPIDH is made up entirely of transgender staff and volunteers who conduct HIV prevention outreach using a face-to-face approach, which involves talking to transgender individuals about HIV on the streets at night where they are typically found selling sex. This is a very effective strategy for reaching the transgender population, who identify with and listen to other transgender people. Moreover, program participants commonly say that what they appreciate most about ASPIDH's activities is the opportunity to learn about sexual health. Indeed, because of ASPIDH's active outreach and promotion of their services, transgender individuals go to the ASPIDH center for workshops on HIV or for HIV testing days. Partners working in HIV note that—given their own experiences with low turnout for events they sponsor—ASPIDH's ability to attract clients is an impressive accomplishment.
Helping transgender people with their gender identity: Program participants also said that ASPIDH workshops helped them learn about their own gender identity as well as broader issues in sexual diversity. For many, these workshops were the first time they realized that their gender identity can be categorized as "transgender" and how that gender category is defined. Several participants said that they appreciated the simple fact that they could identify with others they perceived to be like them. For HIV prevention, self-identification and group identification can be very important. As experts have noted, transgender people, or any other population, will not participate in HIV prevention activities if they do not identify with the population that the activities are targeting.
Self-empowerment of volunteers and members: Increased understanding of their gender identity, as well as participating in advocacy and building the skills to lead prevention activities, has empowered the staff, volunteers, and members of ASPIDH to leave sex work to seek other work, stop abusing drugs and alcohol, and go back to school. Volunteers in particular say they feel more empowered and "useful" as a result of their work with ASPIDH. Many program participants said that they now have a better awareness of their rights. When those rights are violated, they file complaints with the Human Rights Protection Office.
Personalized attention and support to ensure gender-equitable access to health services: Program participants expressed their appreciation for ASPIDH's personalized attention and support in accompanying them to health services as well as for filing complaints with the prosecutor's or human rights offices for violation of their rights. A number of program participants also noted that other organizations do not provide this type of support and that, without it, they may not otherwise access services. In this way, ASPIDH is increasing gender equity in access to services.
Advocacy to increase the rights of transgender people: Both partners and donors noted that perhaps ASPIDH's greatest strength is its ability to effectively advocate for the rights and needs of transgender people. As the first legally recognized transgender organization in El Salvador, ASPIDH has raised the profile of transgender people so that, little by little, they are being accepted by society, accessing services, and achieving equal rights as citizens.
ASPIDH's activities go beyond public marches and campaigns to include more informal advocacy in meetings with donors and government representatives to request financial and in-kind support for their HIV prevention and human rights work.
Practicing "lateral advocacy": ASPIDH also reaches out laterally to organizations that may not be seen as traditional partners. For example, ASPIDH provides technical assistance to the conservative evangelical church El Renuevo so that the church can integrate the topic of sexual diversity into its HIV education activities. This lateral advocacy is also important for changing gender norms on a wider scale. For example, El Renuevo's partnership with ASPIDH has contributed to the church's greater acceptance and understanding of all its members, regardless of sexual orientation or gender identity.
A deeply committed staff and members: Several partners and donors identified the tireless commitment of ASPIDH members as one of the organization's greatest strengths. ASPIDH staff and members have been critical to achieving increased attention to the human rights and HIV prevention needs of transgender people. For many years, ASPIDH's leadership organized and conducted advocacy campaigns and sought funding, all without external support. Even today, five of the nine members of the ASPIDH staff work as volunteers. Others work full-time but only receive part-time pay. The staff and volunteers often pay for materials out of their own pockets. This personal commitment has been and will continue to be key to the organization's long-term sustainability.
Weak institutional capacity: As a relatively young organization, ASPIDH still has many areas to be strengthened. Key informants most commonly noted ASPIDH's weak institutional capacity, including financial management, administration, proposal development, and diversification in leadership capacity among staff to share the burden of work. Skills in proposal development are crucial to the ongoing sustainability of ASPIDH, which currently operates on a very limited budget, the majority of which will not be renewed. Most staff and volunteers barely have had a high school education, let alone formal training in public health or HIV. An advisor to the organization noted that ASPIDH likely needs further technical assistance and capacity building, especially in HIV prevention.
Lack of quality control or evaluation: To date, ASPIDH has collected some information supporting the monitoring of its work such as service statistics. However, the impact of ASPIDH's work has not been evaluated and there is little technical oversight of ASPIDH's HIV work. Although monitoring and evaluation guidance has been provided by amfAR and Population Services International, transgender people have unique vulnerabilities to HIV, which require further research to subsequently inform interventions that will respond to those vulnerabilities.
Incomplete understanding of gender-related vulnerabilities of transgender people: HIV prevention work among transgender people is fairly nascent; there has been little research or documentation of this population. Although ASPIDH addresses health issues related to sex reassignment therapy, there may be other special vulnerabilities of transgender people that have been missed, such as mental health issues related to gender dysphoria and an understanding of how embracing female gender norms can also increase HIV vulnerability. One important limitation that a few key informants mentioned regarding ASPIDH's approach to changing gender norms is that it is largely limited to issues of gender identity and does not address the disadvantages of women in society. This limited approach could increase the risk for HIV. For example, one focus group participant noted that some transgender women like to experience violence so that they "feel more like a woman."
Fierce competition for limited resources: Given the new political and donor environment that increasingly recognizes the importance of supporting transgender people, there is more competition for the scant resources available to serve El Salvador's LGBT communities. Key informants noted that in-fighting over resources among these groups has made cooperation difficult at times. This situation might jeopardize strategic alliances that could benefit the work with transgender populations.
Backlash from the public: Major social change is often accompanied by opposition. ASPIDH's work to ensure that transgender people have equal rights represents social change of great magnitude for Salvadoran society. The backlash ASPIDH has faced includes threats, grenades sometimes thrown into its office building, and insults by public officials. The Catholic Church and media have attacked the wider LGBT movement, claiming it is promoting the right to marriage to unleash criticism of the current government and bring about its demise. These threats to the lives of ASPIDH staff and members as well as to the political viability of the current government make advances in the transgender movement precarious.
Consider the full range of gender identities in the target population when designing programs and messages: Not all transgender people identify themselves as MSM or gay and, thus, may not feel HIV prevention campaigns are relevant to them. For many years, campaigns have targeted MSM as a high-risk group for HIV and have included male-to-female transgender individuals in this group. As a result, in settings with concentrated epidemics, transgender people may feel excluded from HIV activities and may not perceive themselves to be a group at risk for HIV.
Continue to research the health needs of transgender people: To fully consider and include the HIV prevention needs of transgender people, further research is necessary to understand the interplay and effects of the many vulnerabilities they face. These include mental health problems from gender dysphoria resulting from internal stigma, extreme stigma, discrimination, and violence from others, as well as lack of education and limited livelihood options.
Use a comprehensive approach, including gender needs of women, not just the issue of gender identity: Many transgender women identify as women or aspire to be women, which includes dressing like women and assuming female gender roles, as well as surgery and other medical procedures to take on female physical attributes. As such, transgender women may be perceived as women and treated like women, and therefore face the same vulnerabilities that women may face. HIV prevention strategies for transgender women should also integrate key strategies for HIV prevention for women, including empowerment to negotiate condom use, interventions to reduce risk and occurrence of sexual and intimate partner violence, and livelihood programs.
Build the capacity of transgender people to lead HIV prevention and outreach efforts within their own community: ASPIDH's experience has demonstrated that transgender people are best positioned to reach out to their own population. Given the risk involved in making their gender identity public, transgender persons can be wary of others outside of their population. HIV programmers can endanger the transgender community by bringing unwanted or unexpected attention to them from the general public. ASPIDH's careful and effective strategies of reaching transgender people in their neighborhoods and places of work are worthy of replication.
Network and collaborate with partners both nationally and internationally: ASPIDH's leaders emerged from and participated in MSM organizations and activities in El Salvador, such as Entre Amigos, which helped them gain the knowledge and experience to establish ASPIDH. They also established relationships with international organizations and advocacy groups, such as USAID PASCA and REDLACTRANS, which have helped them advocate for their rights in the higher reaches of government. However, managing these relationships can be challenging at times. Key informants pointed to the need for better coordination among MSM and transgender civil society organizations so that they can prioritize their demands from government and donors, as well as divide up the work to more efficiently achieve their objectives.
ASPIDH has developed a Strategic Plan 2010–2013 to guide its work in the next few years. Recent ASPIDH activities are ongoing to ensure stability and continuity.
At the policy level, the plan establishes the development of a bill of gender identity that guarantees the rights of transgender people and the creation of an advocacy and communication strategy that increases the visibility of the organization. To further strengthen the organization, the plan includes activities to build staff and volunteer capacities, establish an executive committee, improve financial and administrative internal operations, and strengthen networks with other organizations working in human rights and gender equality.
In the future, implementers envision activities that will provide integral support to the transgender population, including education development; access to health services; greater knowledge about gender, HIV, and human rights; and support to survivors of violence.
Joint U.N. Programme on HIV/AIDS. 2009. El Salvador: Ministerial Decree to Reduce Homophobia in Health Services. (accessed October 31, 2011)
Joint U.N. Programme on HIV/AIDS. 2011. "El Salvador HIV and AIDS Estimates (2009)." UNAIDS. (accessed October 31, 2011)
Ministerio de Salud. 2007. Medición del Gasto en SIDA (Measuring the Costs of AIDS). San Salvador, El Salvador: Ministerio de Salud.
Ministerio de Salud, Programa Nacional de ITS/VIH/SIDA El Salvador. 2008. Encuesta Centroamericana de Vigilancia de Comportamiento Sexual y Prevalencia de VIH/ITS en Poblaciones Vulnerables (ECVC) El Salvador (Central American Survey on Sexual Behavior and AIDS Prevention for Vulnerable Populations, El Salvador). San Salvador, El Salvador: Ministerio de Salud.
Miranda, Celina (Coordinator for HIV and Tuberculosis, GFATM/UNDP). Interview, July 26, 2010.
Nieto, Ana Isabel (Coordinator, National HIV/AIDS Program). Interview, July 29, 2010.
Presidencia de la República de El Salvador. Decreto 56 [Decree 56]. El Salvador: Presidencia de la República de El Salvador.
U.S. Agency for International Development's Program for Strengthening the Central American Response to HIV/AIDS. 2010. Resumen de Evaluación del Plan estratégico Nacional Para la Prevención, atención y Control del VIH-SIDA e ITS, 2005-2010 (Summary Evaluation of the Strategic Plan for the Prevention and Control of HIV/AIDS and STIs). Washington, DC: U.S. Agency for International Development.
Whittle, S. 2002. Respect and Equality: Transsexual and Transgender Rights. London, England: Cavendish Publishing Limited.
The author would like to thank the leadership of ASPIDH, in particular Edwin Hernandez and Monica Linares, for organizing the data collection visit and ASPIDH staff for accompanying her to meetings. Meg Galas of Population Services International in El Salvador was also very helpful in organizing logistics and lending the time of Edwin Hernandez, who is also her staff member. Additional thanks goes to the PEPFAR Gender Technical Working Group for its support and careful review of this case study. Finally, a warm thank you goes to all of ASPIDH's staff and volunteers for their commitment and courage in advocating for transgender rights and services.
Betron, Myra. 2011. Different Needs but Equal Rights: Giving Voice to Transgender Communities through ASPIDH in El Salvador. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.