The U.S. Government and Global LGBT Health: Opportunities and Challenges in the Current Era
Key Challenges, Opportunities, and Potential Next Steps
While collectively, U.S. efforts to date have served to bring new attention to the human rights and health needs of LGBT individuals, they are still relatively nascent, and operate within a larger context that includes complex discussions about the appropriate role of foreign aid and U.S. diplomacy in promoting health in other countries and multi-faceted bilateral relationships beyond health. Recent actions by the governments of Nigeria and Uganda, as well as others, and concerns that other countries may soon follow suit, have raised the stakes in the conversation and introduced a greater sense of urgency. Participants at two KFF roundtables discussed these topics and identified several key opportunities, challenges, and potential next steps for consideration by the U.S. in addressing the health needs of LGBT populations in the short and long terms. While there was considerable discussion of the difficulty in and sensitivity around identifying the most appropriate steps and leverage points to use at this time – in part because some of the changes at country-level are still being debated and interpreted – there was general agreement that the U.S. government should take action. Ultimately, participants felt that an overriding principle guiding any U.S. response should be to “do no harm” to LGBT individuals, that health services supported by the U.S. should be continued, and that there should be a focus on public health outcomes and program effectiveness. There was also recognition of the importance of considering the specific context and culture of each country and that growing acceptance of LGBT individuals in the U.S. took a long time, with rapid change only coming more recently. The key points from those discussions are summarized below.
Roundtable participants raised and discussed several challenges to addressing global LGBT health in the short and long term. Specific challenges raised include:
- Lack of a proactive and/or coordinated U.S. strategy. While participants recognized that the U.S. government had generally bolstered the importance of addressing LGBT human rights in its foreign policy efforts, they felt that the developments in Nigeria and Uganda were not met with a proactive or coordinated response. Without an organized response, participants were concerned about the potential for adverse health outcomes for individuals and the compromising of the effectiveness of U.S. health investments. Such a response was identified as particularly important given growing concerns that several other countries are moving in the direction of increased criminalization of same sex behavior and/or LGBT rights.
- Reaching LGBT individuals with health interventions when they are criminalized by their State. A fundamental challenge that underscored much of the discussion was how best to ensure the effectiveness of U.S. supported health programs and reach LGBT individuals with essential health interventions, including for HIV, when they are criminalized by their State. Such situations pose challenges for recipients of services and program implementers, both of whom may be at risk for seeking and providing health services (as raised by the recent raid of the MUWRP by the Ugandan police), which could have adverse effects on health outcomes. Participants felt that there was an immediate need in Uganda and Nigeria, as well as a longer term need more generally, for the U.S. government to develop policies and protocols for addressing such situations. Some suggested that there were lessons to be learned from other countries where such laws have been in effect and even enforced1,2 but services have been successfully provided, as well as in cases where U.S.-supported health interventions have been provided to other populations who may be criminalized by their State, such as sex workers and injecting drug users.
- Addressing the immediate needs of those in danger. While the U.S. and others have developed mechanisms for helping LGBT individuals facing violence and other threats in their countries, including the GEF, participants felt that many still faced numerous challenges to accessing such services, and would benefit from a more organized effort by the U.S. government and its missions in-country to provide assistance, including asylum where needed. They pointed to complex cases where LGBT individuals were leaving their country of origin to escape violence or arrest due to their sexual orientation or gender identity only to arrive in neighboring countries where similar challenges were encountered or assistance was not available.
- Limited capacity of LGBT civil society. Despite some U.S. government and other efforts to build LGBT civil society capacity, it still remains minimal in many parts of the world, in part due to the presence of criminalization laws and laws restricting LGBT organizing. As such, civil society organizations have not always been equipped to respond to changes in local laws or enforcement of those laws. Participants stated that this represented a key challenge to dealing with the immediate situation in some countries and an important long term challenge ahead, and that bolstering LGBT civil society was critically needed.
- Addressing claims of Western imperialism. A key challenge raised by participants was how to address and be sensitive to claims that the U.S. and other donors are imposing western values on other countries when they critique criminalization laws. This point was recognized as being a thorny and complicated issue for the U.S. and other Western governments, as well as NGOs, to address. Discussants felt that the U.S. and others would be well served by remaining sensitive to such claims, but also firm in expressing its position. Overcoming this perception could be helped through several approaches, such as: ensuring that any U.S./Western responses make the case for a broad vision of human rights and not focus on LGBT rights alone; emphasizing concerns about the health and safety of individuals and the success of U.S. health investments; fostering local and regional voices of authority to make statements against such discrimination; and engaging other sectors, including the private sector and faith community.
- Managing the move toward increased “country ownership” of U.S. global health programs. Beyond the immediate concerns about the health and safety of LGBT individuals in countries that are further criminalizing same sex behavior, participants discussed the challenges related to the longer term move by the U.S. government toward greater country ownership of U.S. health and development programs. As described by the U.S. government, the ultimate goal of country ownership is to support “host country partners (including local stakeholders) in planning, overseeing, managing, delivering and eventually financing a health program responsive to the needs of their people to achieve and sustain health goals.”3 As such, concerns have been raised about how the rights and health needs of those who are most marginalized will be assured and monitored during and after transitions to more country-led programs, particularly in countries that criminalize their behavior and otherwise discriminate against them in the provision of health services; this is an especially acute concern now given what has is occurring in Nigeria and Uganda.4 Roundtable participants talked about the need to be cognizant of the trade-offs that accompany decreased U.S. government involvement in such settings and discussed the importance of ensuring the health status and human rights of LGBT individuals, as well as identifying metrics for measuring their health, during such transitions. A key theme stressed was the need to include civil society in the definition of country ownership and to further build capacity of LGBT civil society organizations going forward. The recent statement by the U.S. Global AIDS Coordinator addressed this issue, stating, “PEPFAR will not transition responsibility for its assistance to host governments without a well-defined and mutually-negotiated plan in place regardless of the context.”5
- Ongoing data gaps and research needs. Despite increased awareness of and studies on LGBT health (including a growing evidence base documenting the links between criminalization, discrimination, stigma and health), more data on the extent of the health needs and barriers faced by the LGBT population in low and middle income countries are needed. This includes a need for better metrics on MSM and transgender services and epidemiology by PEPFAR, as a way to help identify needs and calibrate the response. As has been pointed out by experts on LGBT health and human rights, there is a paradox at work where we often know the least those who are most hidden and stigmatized.6 Additional research and analysis would be important for informing U.S. and broader global efforts. Indeed, roundtable participants noted that where data and evidence have been available, there has been movement to resolve challenges and create programs. At the same time, while emphasizing the importance of data, participants also stressed the need to ensure that the way in which data are collected and used does not undermine the rights and safety of LGBT individuals and those who support them.
Despite these challenges, roundtable participants pointed to several opportunities for the U.S. government to further engage on global LGBT, including:
- More conducive U.S. policy environment for addressing LGBT human rights around the world. Participants discussed how the increased attention to the human rights of LGBT individuals by the U.S. government in recent years – particularly the Presidential Memorandum and related agency efforts – and growing support for LGBT rights among the American public, provide a much more conducive policy environment for addressing the current, more urgent situations facing LGBT individuals in some countries, and for building a longer term, sustainable response. The response to date provides an important base from which to grow and build efforts that are still in their infancy. Participants underscored the need for ongoing leadership on LGBT human rights by U.S. government officials.
- Potential to augment a focus on global LGBT health within U.S. global health policy. While there has been increased attention to LGBT human rights by the Administration and other global actors, there has been less explicit focus on LGBT health in U.S. global health strategies and agency plans. Where there has been inclusion of LGBT health, it has primarily been through the HIV-lens and could be expanded. Participants noted that the current discussions and concern about increased criminalization provided new opportunities to enhance the focus on LGBT health by emphasizing the real and growing concerns both for the effectiveness of U.S. health programs and the health of LGBT individuals. Moreover, several participants felt that a focus on the public health impacts of criminalization laws, discrimination, and stigma, provided a needed and important way in which to frame the U.S. response and concern.
- Increasing coordination between broader human rights, LGBT, and health groups on LGBT health issues. One development noted by participants is increasing coordination and collaboration between constituencies that have not always worked together including human rights, LGBT, HIV, and broader global health groups. This presents new opportunities to build synergies and inform the U.S. response on LGBT health and address complex challenges on the ground. Human rights experts spoke, for example, about how the recent trends towards further criminalization of LGBT individuals often took place in the context of other violations of human rights. Global health groups with large footprints around the world also spoke about their ability to more directly engage on LGBT health issues.
- Elevating LGBT voices in-country to help inform the U.S. policy response. Many participants talked about the critical importance of elevating in-country LGBT voices, particularly from the global south, in informing U.S. policy and responses and speaking about the impacts of criminalization laws and health needs they face. There are positive examples of this already happening – for example, LGBT communities in Nigeria and Uganda, respectively, have provided guidance on how other governments and organizations can respond to the recent criminalization in their countries7,8 and more opportunities could be sought by the U.S. government and NGOs for such engagement, opportunities that would also help to build civil society and ensure that responses are grounded in the realities facing LGBT individuals on the ground. This could include funding for civil society advocacy and other work. At the same, time, participants spoke about the risks associated with this visibility and the need to ensure safety of individuals and groups willing to speak out.
- Using the post-2015 framework. As the global community approaches the 2015 deadline set to achieve the Millennium Development Goals (MDGs), agreed to by all Member States of the United Nations, it is moving toward finalizing a new, “post-2015” global development framework and attendant goals. Because of its significance in setting global goals and direction, participants saw the post-2015 framework as an important opportunity for addressing LGBT development and health needs. Discussions about the post-2015 framework have included human rights, inequality, and, more recently, non-discrimination, although discussion of LGBT rights has been minimal and primarily introduced by NGOs through external consultations. While it is unclear if LGBT health and rights will be explicitly addressed in the new framework, participants felt that it was an important process to monitor and be part of going forward.
- Growing evidence base. Despite data gaps that remain, there is a growing evidence base regarding barriers to accessing health services, health disparities, and the health effects of these barriers, including criminalization laws, on LGBT individuals. These data underscore the importance of the need to support health access in order to achieve key global goals, including achieving universal access and reaching an AIDS-free Generation. As noted above, where data and evidence have been available, there has been movement to resolve challenges and create programs. There are some recent examples of efforts to support more data collection, including the recent approval by the Global Fund’s Board of funding to support research on size estimation and surveys of key populations.9
Looking Forward: Potential Next Steps
Participants outlined a number of concrete steps that could be taken in the short and long term to facilitate the U.S. response to current, urgent situations and bolster a longer term effort to address global LGTB health. All felt that additional actions by the U.S. government were needed. These included:
- Review U.S. health and development portfolios. Several NGOs and Members of Congress have called on the State Department to review its health and development portfolios in countries that criminalize same sex behavior, beyond Uganda. While most participants echoed this view, they recognized that a more realistic, short term effort could at least be focused on those countries that have already taken steps to further criminalize same sex behavior or restrict LGBT rights (whether through law or enforcement) and others that appear to be moving in this direction now. Such efforts should include a strong emphasis on the health implications of these laws, including where they could compromise access and safety and whether they were consistent with U.S. programmatic goals.
- Develop proactive strategy for moving forward. In addition to a current review of U.S. government portfolios in select countries, participants felt strongly that a proactive strategy and greater coordination internally were needed, particularly given concerns that several other countries are moving to further criminalize same sex behavior. A proactive strategy could include development of clear protocols, guidelines and procedures and training of U.S. personnel and implementers (building on what is already starting through PEPFAR for example). The U.S. could look to other countries and organizations for best practices in this regard.
- Consider appointing a U.S. “Special Envoy” or other high-level point person on LGBT issues. Several participants spoke about the importance of having a high-level USG point person, such as a Special Envoy, on LGBT issues who could lead the government’s response in this area. Such an individual could help to ensure coordination and ongoing attention to LGBT issues in foreign policy, particularly when there was a situation that needed more urgent attention and required multi-agency responses, but also for longer term progress. It was noted that a new position of this sort would need to have sufficient seniority and authority to be successful.
- Expand efforts to help LGBT individuals facing violence, arrest, and threats due to their sexual orientation or gender identity. While it was noted that the U.S. has more broadly worked to address the needs of LGBT individuals facing violence, arrest, and other threats, many felt that the current situation in Uganda, Nigeria, and elsewhere required a stepped-up response and plan. Concerns were raised that it was still not clear where LGBT individuals in such situations could go for assistance and how quickly such assistance could be provided.
- Articulate importance of continuing U.S.-funded health services. Participants felt that it was critically urgent for the U.S. government to articulate its support for and the importance of continuing health services in countries where increased discrimination and criminalization might be occurring. They raised concern that some signals have been sent suggesting that health services support could be suspended and noted that even such a suggestion could negatively affect the health-seeking behavior of individuals needing services and was unlikely to have any effect on government laws and actions. In the wake of the recent raid by the Ugandan police on the MUWRP, the new U.S. Global AIDS Coordinator reaffirmed PEPFAR’s intention to continue services, stating that PEPFAR would not “ take actions that harm the very individuals for whom we have a responsibility to serve – such as curtailing their access to core HIV services solely because the political, cultural, or security space in which we operate gets rough.”10
- Bolster PEFPAR’s focus on LGBT health access and safety. Because PEPFAR is the largest component of the U.S. global health response and HIV has such a disproportionate impact on MSM and transgender individuals, many felt that while PEPFAR has increased its efforts to help key populations, such efforts could be expanded. In particular, participants felt that among all USG programs, the review of PEPFAR’s in-country portfolio was most urgent and that guidance from the Office of the Global AIDS Coordinator on how best to address the current situation and potential future challenges was needed, in addition to broader USG guidance.
- Use Global Health Diplomacy. In addition to foreign assistance, roundtable participants discussed the importance of using bilateral and multilateral global health diplomacy – which the U.S. has recently emphasized more generally11,12 – to address LGBT issues with country leaders, both in the short term but also longer term, given the recognition that changing views toward LGBT individuals and protections will take time. This could include a more explicit role for U.S. Ambassadors, some of whom have already been outspoken about protecting LGBT rights and health. One potential new asset that the USG has to promote health through diplomatic channels is the recently created Office of Global Health Diplomacy at the State Department which “guides diplomatic efforts to advance the United States’ global health mission to improve and save lives and foster sustainability through a shared global responsibility.”13 A key aspect of the work of this office is to support the role of U.S. Ambassadors in promoting and discussing the importance of health. This office could play a more prominent role in raising the health challenges faced by LGBT people and how violence, discrimination, and stigma affect their health and compromise the potential to reach agreed upon global health goals. Beyond bilateral diplomacy, participants underscored the important and ongoing work the U.S. government has done to raise LGBT health issues at the WHO.
- Coordinate with other donor governments and multilateral organizations. Coordinating the U.S. response with that of other donors, including governments and multilateral actors was seen as very important in this work, both to address short term needs of LGBT individuals seeking health services but also for longer term efforts. The World Bank, the Global Fund, and UNAIDS in particular were identified by participants as key organizations for the U.S. to work with more explicitly on LGBT rights, given that each has been directly involved in responding to the situation in Uganda and Nigeria as well as other countries. Some of this coordination is already underway but participants felt it could be increased and should clearly be part of any response going forward.
- Engage the private sector. The role of the private sector in responding to HIV, and other global health challenges, has been significant14 and was seen as a potential untapped resource for addressing LGBT rights and health globally (as it has also been in the U.S. domestic context15 and in response to Russia’s recent law).16 Participants discussed the possibility of finding ways to engage the private sector with business assets in countries that have been moving to further criminalize same sex behavior or restrict LGBT rights to discuss why such laws can be harmful to their employees, customers, and the broader climate for business.
- Engage the faith community. The faith community has long provided HIV and other global health services in low and middle income countries,17 including with support from the U.S. government. At the same time, some faith organizations have been directly linked to the introduction of criminalization laws and anti-gay sentiment in some countries.18 Others have spoken out against discrimination and such laws. Given the importance of the faith community in providing health services and dialoguing with country leaders, participants felt it was critically important to engage them on LGBT issues, focusing on health needs and services.
- Build LGBT Civil Society. Given the critical role played by civil society in both providing services to and advocating for individuals, and for monitoring government programs and policies, participants felt that an important next step was for the U.S. government to find new ways to build LGBT civil society capacity in low and middle income countries, beyond its current efforts. This would include additional support from PEPFAR but also from the State Department and USAID.
- Support data collection, research, and analysis on global LGBT health. Participants felt that the U.S. government was uniquely situated to support further data collection and analysis on LGBT health in low and middle income countries, including developing short term systems for documenting what is happening on the ground in countries where further criminalization is occurring and more systematically cataloguing the evidence, particularly related to the relationship between stigma, discrimination, and criminalization and health outcomes.