Trans-women, are defined as individuals who were assigned the male sex at birth but identify as women, globally, they are at an elevated risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). More than 19.1% of trans-women are living with HIV. Also, the risk of HIV infection is 49 times higher among trans-women compared to the general population. In Sub-Saharan Africa, the HIV prevalence among trans-women is as high as 59%. Although there are no reliable national estimates for the HIV burden among the trans-women in Uganda, King, Nanteza reported a prevalence as high as 20%.
Sex work, which is the main source of livelihood for the majority of the trans-women, is usually associated with high-risk behaviors such as incorrect and inconsistent condom use, having sex under influence of drugs and other substances, and multiple sexual partnerships/relationships , which are all known to escalate the risk of HIV transmission. Thus, trans-women sex workers, who are the focus of this study, experience higher rates of STIs including HIV compared to non- trans-women sex workers. Besides, the high prevalence of STIs and HIV among trans-women sex workers could be linked to the absence of a conducive environment for accessing prevention, care, and treatment services. The low education status, social exclusion , and lack of empowerment that are prevalent among the trans-women sex workers also make it difficult for them to negotiate for HIV prevention strategies such as the correct and consistent use of condoms. There is also evidence that social, cultural and policy issues such as internalized stigma and violence, limited access to non-stigmatizing healthcare services, inaccurate perceptions of self and partners’ risk escalate STI/HIV acquisition among the trans-women sex workers.
Whereas STIs and HIV are highly prevalent among trans-women sex workers, there is limited evidence of the facilitators and barriers to access and utilization of STI/HIV prevention and care services globally. The majority of the key population studies focus on understanding access to HIV and prevention services among the men who have sex with men and female sex workers. Besides, trans-women sex workers’ vulnerabilities, frustrations, and insecurities have been historically overlooked by mainstream society (Khan et al., 2009), including among healthcare providers. For example, trans-women sex workers were (and are still in Uganda) originally misclassified as men who have sex with men (MSM), and remain absent from national HIV surveillance systems and program interventions.
 CDC. HIV and Transgender People 2019 [cited 2020 19-11-2020]. Available from: https://www.cdc.gov/hiv/group/gender/transgender/index.html.
 Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3):214–22.
 Poteat T, Ackerman B, Diouf D, Ceesay N, Mothopeng T, Odette K-Z, et al. HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: a cross-sectional analysis. PLoS Med. 2017; 14(11):e1002422.
 King R, Nanteza J, Sebyala Z, Bbaale J, Sande E, Poteat T, et al. HIV and transgender women in Kampala, Uganda – double jeopardy. Cult Health Sex. 2019;21(6):727–40.
 Arayasirikul S, Pomart WA, Raymond HF, Wilson EC. Unevenness in health at the intersection of gender and sexuality: sexual minority disparities in alcohol and drug use among transwomen in the San Francisco Bay Area. J Homosex. 2018;65(1):66–79
 Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet. 2015;385(9964):274–86.
 Reback CJ, Fletcher JB. HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach. AIDS Behav. 2014;18(7):1359–67
 UNAIDS. UNAIDS guidance note on HIV and sex work. Geneva: UNAIDS; 2012.
 UNAIDS. The gap report Joint United Nations Programme on HIV/AIDS; 2014.
 The Crane survey. Bio-Behavioral Surveys among Groups at Increased Risk for HIV in Kampala-Uganda 2017.
 Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13(4):165–232.
 The Crane survey. Bio-Behavioral Surveys among Groups at Increased Risk for HIV in Kampala-Uganda 2017
 Bianchi FT, Reisen CA, Zea MC, Vidal-Ortiz S, Gonzales FA, Betancourt F, et al. Sex work among men who have sex with men and transgender women in Bogotá. Arch Sex Behav. 2014;43(8):1637–50.
Bianchi FT, Reisen CA, Zea MC, Vidal-Ortiz S, Gonzales FA, Betancourt F, et al. Sex work among men who have sex with men and transgender women in Bogotá. Arch Sex Behav. 2014;43(8):1637–50.
This is a report of a gap analysis that has been done by a thorough study of the data available on transgender persons all over the world. This has been done to lay a concrete foundation for a crystal understanding of the gaps that hinder access to health and justice of transgender persons from our target communities as an organization working with communities from the Greater Masaka, the southern region of Uganda.
We seek to focus on access to the health of transgender persons under all circumstances. Hereunder we have examined the possibility of transgender women being at Higher risk over and above any other Key Population persons which would in that regard require specialized and well thought approaches to ensure meaningful engagements, advocacy, and strategy to mitigate such risk and in the same spirit improve or better still create a standard at which transgender persons can access Health care in Uganda but also and most importantly in the Greater Masaka region.
We have made an effort to study the environment in which transgender persons live, work and go about their daily routine. Hereunder we have focused on seeking to understand how the environment affects the social capital of transgender persons in the greater Masaka region. We seek to examine how the social constructs, cultural beliefs, and practices affect transgender persons given the rural setting in which these transgender persons live.
Does being a transgender person only mean that one is weird and abnormal? Does being a transgender person automatically brand the person gay? Do the communities understand or have any ideas about transgender persons and if not, how does that affect the transgender persons but also how does it eventually affect their access to Sexual Reproductive Health and justice in the times where there is a need.
Historically, research across Africa has shown that cultures across the continent recognized, and often accepted gender non-conforming individuals as members of their communities , However, the current context is one in which same-sex behavior between consenting adults is criminalized in most African countries Transgender individuals may be relatively more visible as not conforming to gender and sexual norms in their local communities, which in turn may increase their exposure to violence and victimization. This increased exposure to violence and victimization may play a significant role in keeping transgender individuals invisible in “epidemiological research” as they may avoid participation in activities that could be perceived as potentially risky to them.
Onyango-Ouma, Birungi & Geibel 2006 in their wisdom noted that where research on HIV risk and prevalence in Africa has included transgender persons, it has primarily focused on the behaviourally defined category of men who have sex with men (MSM). The challenge with this, is that while these categories may, to some extent describe the behavioral aspects of transgender sexual practices, they do not provide sufficient insight into the social contexts and processes that uniquely affect HIV risk for transgender individuals.
In the greater Masaka region, which is at the central of Uganda, Transgender persons are not the most pronounced of people, to say the least. This is a societal rather than cultural issue. Societies, as they are in the said region, do not in any way take cognizance of the mere fact that someone can be born in a wrong body and therefore be inclined to the desire to transition into their comfortable self. The closest these communities come to any such reality is the sight of effeminate men, which, their existence alone does not ring trans-person bells to the communities in which any such persons live.
From our study and subsequent analysis, the gap here is in the research and subsequently the information available regarding Transgender persons in the region. Save for stigmatization and discrimination, it wouldn’t have mattered so much that the local people have accesso to that much information about transgender persons because it does not in any way help their fundamental access to health. What is most important is this information being available at health facilities at various levels. For it is at the health centers that transgender persons go to access services, the need to enrich these access points with information about the transgender persons and the health challenges that are unique to them is key and as such, there is a gap that cannot be filled by basic sensitization but the rather entrenched engagement of persons with fiduciary duty towards the transgender persons to ensure that the latter allow transgender persons basic access to health.
We take cognizance of the fact that the people that work in these facilities are part of these same communities and therefore share similar sentiments as the general communities from which they hail and work. Our idea is that constructive information could be fed to those that are deemed and held in high regard courtesy of the services they offer.
The idea that sensitization would wipe away the challenges that transgender persons face to access General Health Care, Sexual Reproductive Health, and Justice is wild. The idea is to harmonize positions of the various engagement levels. The advocacy that we seek to engage in is to fill up the gap in information about transgender persons will help us to harmonize these positions. An informed health worker, court clerk, our registrar will be primary in helping a transgender person accesses the services offered and also probably help mitigate the negativity in the communities from which they come.
 Cf. Murray 2004
 Bryer 2008
 Nel & Judge 2009
 Transgender in Africa: Invisible, inaccessible or ignored; Vol. 9 No. 3 09/2012
Attitude, mindsets of transgender persons;
We want to examine what the transgender persons think about themselves, do they know and understand the biology of their bodies, do they have knowledge on why their voices may not have deepened for instance like they normally would, does the biology even matter to them, does it affect the way they live and work? We seek to know what the ideas could be from a collective voice of transgender persons, but also what individual transgender persons think about their situation. We seek the first-hand story.
We spoke to transgender women in kyotera, a couple of young transwomen consented to speak to us about their experiences and ways of life. They shared what it took for them to accept who they were and what they felt inside. We particularly sought to understand how they go about with the effort to access Health, most especially Sexual Reproductive health.
The young transgender persons fear to present themselves to access health care services and from their own words, they only have one access point who also suffices as their alpha figure. The said Alpha figure is peer under the Masaka KP HIV Prevention and Support Organization. They suffice as Alpha because they have gathered the experience to be able to find their way around accessing health care. The young persons have to go through the peer to access health care at their nearest health center. They have fear of discrimination at the health center, they say Sexual Reproductive Health is even harder for them to access for they have not found access to the basic consumables like lubricants and things of the like.
Sex work is the only source of livelihood for these young transgender persons. The question of whether or not their inability to access Sexual Reproductive Health affects the way they live and work is in the affirmative. As an organization, we take cognizance of sex work as a legitimate source of income for our target beneficiaries, and as such inaccessibility to Sexual Reproductive Health as a result of mindset is a gap in our effort to support KP HIV prevention.
The feelings of inferiority, not being good enough, being abnormal, and possible outcasts fueled by the communities in which these transgender persons live retard the efforts to make good of the movement.
From the study, transgender persons from the Greater Masaka region need to understand their capacity as human beings, as citizens of Uganda before their identity as transgender persons. The mindset that because they are transgender persons, they are less human is an idea orchestrated by society, and as such empowerment of these transgender persons is one of the most effective ways this gap can be filled, and its effects on access to health and justice can be managed.
We hope to have a more vibrant and assertive transgender community to put up a spirited focused fight to ensure that they are allowed and accepted in the spaces in which they are by being human and citizens of Uganda are allowed to be. Public Hospitals for instance.
We have come to an understanding that our effort to emancipate transgender persons to make them more vocal and assertive on issues concerning their access to Sexual Reproductive health should not advance to the creation of a socially unacceptable cult.
We take cognizance that most transgender persons are young persons that have lived in these communities for their entire lifetimes and as such their sustenance in their respective communities is not only wise but also the best strategy to ensure that they are happier, healthy, and protected.
Given the indigenous, rural setting of the communities within which we work, it is in our best interest as an organization that our target beneficiaries remain sensitive to what is socially acceptable within their communities without necessarily allowing the said acceptable tendencies to weigh down on their livelihood including but not limited to access to health, most especially SRH. Take cross-dressing, for instance, we seek to harmonize the positions of our target beneficiaries and their home communities to facilitate co-existence void of stigma and discrimination. Things like “men” treating and dressing their hair have over time been acceptable even in the most remote of villages in Greater Masaka. Locking one’s hair could come with certain connotations but never warrants intense discrimination, piercings on the ears have also been accepted for a while now. It is different however if a local’s son all of a sudden starts wearing dresses as a sign of emancipation and pride. That would probably worsen their lives instead of making them better.
We believe that the focus should be on the already existing problems as opposed to creating new ones just to prove a point of existence and freedom of expression. We hope to cover the mindset gap by carrying out deeper studies into what is socially acceptable in the various communities, to inform our engagements with our target beneficiaries on how they can ably maneuver but also inform the strategy development to counter the social myths and misconceptions of society against transgender persons.
Once we can successfully create a transgender community with the right mindset, the right attitude, a community with an attitude that empowers them socially and economically, we will have moved significantly towards improving access to the health of transgender persons in the greater Masaka region.
This is because an empowered, confident, and socially befitting member of society will ably access what rightfully accrues to them by being members of that society including SRH and justice regardless of their sexual orientation or gender identity. We want to create attitudes that warrant definite acceptance of Transgender persons to the extent that we are willing to take acceptance that is a result of compromise on the rigidity of these communities all doctored by the positivity and responsibility of the transgender persons against whom such rigidity would ordinarily be directed.
We have also set out to study mental health patterns amongst the transgender communities of the greater Masaka Region and how if ever have these persons managed to overcome or handle their mental health. What are the key aspects of life that require more attention to create a fertile ground to breed a mentally stable transgender community where ever they are in the Greater Masaka region? We have set out to understand whether there is any access to mental health support for the transgender community in the greater Masaka region and if not, how we as an organization can strategize to ensure that these services reach these particular persons that are in dire need of the same.
Anna Morena of the Anna Foundation Uganda shared a story of her experience as a young “trans-girl” that features on the UNAIDS website the story points out very intriguing facts that are key in a discussion of the mental health of transgender persons. Anna says that most of the Trans women she knows are doing sex work and are usually between the age of 16 and 25 years at a time when hormones are high and one’s understanding of sexuality and gender identity is still developing. “In their daily lives transgender people experience exclusion from family and society, barriers to employment and extreme forms of sexual, physical, emotional and psychological violence”
During our field study in Kalisizo one of the districts that make up the greater Masaka, discussions on sex work by transgender persons were heartbreaking even for us who were only listening to the narrations. It felt like we were living the experiences all over again with the victims. Ciara (not real name) a Trans young woman aged 19 narrated her different experiences when it came to sex work. She firstly pointed out the fact that she understands that the dangers of sex work for a “Trans-girl” like her in the setting she is in could outweigh the additions. She makes mention of how rough and uncultured her clients tend to be during their engagements citing the fact that they are paying for the service and therefore deserve satisfaction without limitations. Ciara illustrated how such ordeals make her feel, she says she feels worthless, she feels like she is being used in the most disrespectful of ways just to survive. Ciara makes mention of the fact due to such behavior of her clients, she normally suffers severe abdominal pain, that she has to endure until she reaches out to her peer for help to access pain-relieving medication.
Ciara says that the repetition of these moments only means repetition of the feeling of worthlessness and helplessness most especially the helplessness that comes with reckless, disrespectful, rough clients that pay no attention to her needs for basic humane treatment although they are paying for the service.
The first hereunder is the fact that there is limited data on transgender people in the Eastern and Southern African region and the reality is that donors are not primarily motivated to fund community-led research, which research is critical in the struggle to cause and effect change in the lives of transgender persons. “The research is a way to help our governments understand the specific needs we have”, which helps influence change in policy for the betterment of the transgender persons’ community.
Trans persons do not have the support of their families, their communities, and for the case of Uganda, their Governments to live up to the full glory of their lives. Most transwomen are living in bodies they do not want, but do not have the support, financial ability to transition. The best they can do is wear products to make them look and feel as they would naturally have, had they had the chance to transition. Trans women need safe spaces, places to go, and access to Mental Health Services. There have not been many efforts by the Government of Uganda to create such spaces and as such Mental Health alone has a very significant role to play in the access to Health and Justice for Transgender Persons.
To probe for mental health aspects in Ciara’s story, we sought to understand how often she shares her escapades and challenges from her sex work experience with anyone she can trust. Ciara’s answers were in the negative, Ciara explains that she can only confide in our organization peer, and she says, it is to the peer that she runs when she needs medical attention, it is to the same peer she runs when she is drowning emotionally, and as such, due to the frequency of her troubles, she hesitates to keep burdening the same person.
As an organization, we would have loved to hire and bring more peer educators on board, we would have loved to have professional councilors on board to be able to handle mental health issues of transgender persons and prevent escalation. We are however incapacitated to do so due to limitations in funding. Funding is very tricky, limited, and competitive, and yet different donors have different policies through which they fund but are also very specific to what they are willing to support and as such, even in circumstances where we could receive some funding to support our HIV prevention and support programs, mental health will remain wanting.
We take cognizance of the fact that Mental Health in humanity is like a foundation for a building, the weaker the foundation, the less likely the building will stand. Where a person’s mental health is unstable, the assurance that they will heed professional advice on how to improve their health and livelihood is not there. Unstable mental health orchestrates feelings of worthlessness and helplessness. These, in the long run, result in people giving up on protecting their lives, working hard to improve their livelihood, people give up on making effort to be independent, able and normally resort to short term remedies like Alcohol and drugs as a means to forget their challenges.
We seek to make an effort and contribution to improving the stability of transgender person’s mental health in the Greater Masaka Region. We strongly believe that if we ignore mental health, we shall not achieve as much in HIV Support and the move to ensure Acess to Health by Transgender persons. In as much as we strive to change the attitudes and mindsets of the latter, we also need to facilitate stability of their Mental Health to yield results from our efforts.
We can ably cover the gaps as identified hereinabove if we had the opportunity to receive funding for researching to avail adequate data on transgender persons, funding to facilitate professionals to counter the increasing mental health cases among transgender people. Funding to facilitate economic empowerment of transgender persons which we believe will help them make better and informed decisions on sex work as opposed to being inclined to the same as the only option hence adherence to abuse from clients. Above all, every effort made in that regard will improve Access to health but also the sustenance of a healthy community.
Stakeholder Engagement and Management;
We have also taken it upon ourselves to tap into our potential to stand where the angels don’t dare. We have gone ahead to engage government officials, we have put them in positions where they had to talk to us about Transgender persons. We have examined their roles in the lives of transgender persons, directly or otherwise. We have also examined whether or not the officials understand the said roles or not. We have also read into what mechanisms and policies are in place to ensure that transgender persons have access to the services that the various district health officials are by law, required to render to the citizens of this country who, include, transgender persons.
We began with the District Health Officers of three of the Districts that make up the Greater Masaka Region, which included; Masaka, Rakai, and Lyantonde. We made official visits to the different DHOs in a bid to engage them on how they have dealt with the question of transgender persons in their districts accessing Health. We sought to engage in policy and practice of the district health systems to identify how much they have covered transgender persons as well.
One thing that stood the most from all three engagements is that there are no Policies at the district level or even Policies at the National level that the said DHOs are aware of that speak to addressing the Health Challenges of Transgender persons. All three DHOs answered in the negative the question of policy, however, they were aware of the inclusion of Key Populations in HIV Programming of the Ministry of Health.
The idea of the uniqueness of challenges to transgender persons was not one the DHOs had given any attention, in fact they kept making mention of the fact that transgender persons are people that suffer Health issues that could affect any other person.
It would be both untrue and misrepresentative for this report to say directly or impliedly that the DHOs were in absolute oblivion of Transgender persons, it was clear that they had slight ideas of the latter’s existence but, that’s just about all they knew. There is a huge knowledge gap here that must be handled.
The reason why Health Care service providers need to know transgender persons is to eliminate incidents where they are faced with a transgender person and do not know what to do. In a study done in the greater Kampala metropolitan area, it was reported that it was common in both general and key population-friendly health care facilities to find healthcare providers that we’re ignorant about the transgender. Respondents revealed that some health care providers, despite working in key- population-friendly facilities did not understand the transgender identity. About a healthcare facility, one transwoman was quoted to have said; “My friend took me to this healthcare facility. The first time I went to the facility, healthcare providers asked me several questions. They asked me why I behave like a woman and I told them I was a Trans woman. Again, they asked; “what are you? Are you gay?” they had not been taught much about us”
We spoke to Rema, one of the trans-women that participated in our study, and she said that she never wishes to have a conversation about her gender identity with a health worker because she does not think they understand what being a trans-woman is. She says the discriminatory gestures and stares are bad enough and she does not think that a discussion would make it better.
To address the question of access to SRH, Health workers are key stakeholders that we cannot afford to ignore. They are primary in this cause. Transgender issues could be handled at DICEs of organizations, but even there, professional health workers are required to handle Health Issues.
The Police Force is a key stakeholder that has to be engaged and properly managed if we are to see success in improving Acess to Health Care and Justice among Transgender persons in the Greater Masaka region. The random arrests, the targeted arrests, arrests aimed at “disinfecting” society increase insecurity amongst transgender persons. This keeps the latter in hiding and fear, they fail to express themselves or even seek help from healthcare professionals for fear of being outed and victimized. Transgender persons even fear to report crimes committed against them for they are not perceived as worthy of attention in incidents as those because on several occasions criminals blackmail them, and use their gender identity as a scapegoat, and in most cases, the police are reported to buy into the narrative.
Eric Ssali the Programs Director of MAHIPSO will tell you how he and his team faced arrest in Rakai when they went out to extend HIV services to the Key Population persons in the area. Eric narrates that hardly had they even settled in the hotel premises than they saw police raid the hotel straight to where they had stationed to operate that day, he describes the shock and confusion that covered the room when Police shut down and arrested the team on grounds of “promoting Homosexuality”
IN HIV programing, Key Populations, are people who belong to communities most at risk of contracting HIV but are criminalized. By and large, transgender persons are part of the KP population, and MAHIPSO as an organization took up the mantle to extend such services to them. The idea is that people already belong to these communities and that, whether or not MAHIPSO existed, they would still be who they are. For MAHIPSO to take up the mantle to ensure that they live a healthy HIV-free life, does not mean that they are promoting acts of Homosexuality.
Therefore, arresting and detaining a team of social workers reaching out to the underprivileged on grounds that they are promoting “unbecoming behavior “is only tantamount to saying that, KPs should be left to die of HIV, and that way, they will be no more and so will their way of life. This would be a notion tainted with absolute myopia.
The behavior of these various stakeholders towards transgender persons and Civil Society, the amount of knowledge and information about the gender identity of the former, the attitude and mindsets of individual health workers and police officers as well as officials must change towards acceptance and recognition of transgender persons to guarantee safe spaces, access to Healthcare and Justice. We take cognizance of the fact that, as an organization that implements in the region, the onus is on us to cover this knowledge gap, to engage and sensitize these various stakeholders to ensure their compliance and recognition. We appreciate that it may not be as easy, but are willing to take it as gradually as possible for the result.
The Legal Question;
We have set out to examine the legal provisions that relate to access to health by Transgender persons. We are in a position where we are assigned to comb, International law, for provisions that not only protect but also provide for the explicit rights for transgender persons to access Health care. Mental health is key in all our endeavors. We have set out to comb regional law for provisions that speak to aces to health for transgender persons. Ugandan law is where our interest lies the most. They could be baby steps, for now, however, we are the kind of baby’s that have Rocket science dreams. Measured against all odds, it is one thing being criminalized by law, it is another being ignored and unrecognized by the legal sphere of your motherland. Because we look forward to the day, transgender persons will freely live in their country, we understand the importance of handling the first things first.
When we speak about legal issues in light of persons whose mere existence is criminalized in Uganda, we stem our discussion in Human Rights Law. The need to respect Human Rights can be traced from as far back as the 10th of December 1948 when the universal Declaration of Human Rights was adopted by the UN General Assembly after World War 11. The Human Rights revolution against this background spread the world over which brought about the signing of various International and National Commitments.
Uganda has taken it upon herself to ratify most of the said International Commitments to protect Human Rights, these include:
- The International Convention on Economic, Social and Cultural Rights (ICESCR) on 21 April 1987.
- Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment on the 26 June 1987.
- Convention on Elimination of All Forms of Discrimination against Women. On 21 August 1985.
- International Convention on Civil and Political Rights on 14 February 1996
The 1995 Constitution of the Republic of Uganda is the supreme law of the land and as such, in a discussion on legal matters concerning a given issue, provisions of the same are supreme. Article 2 of the Constitution speaks to the said supremacy and as such alludes to the fact that any other law that is inconsistent with the Constitution shall be null and void to the extent of its inconsistency. Article 21(1) states that all persons are equal before and under the law… in every respect and shall enjoy equal protection of the law. Article 21(2) also states that … a person shall not be discriminated against on the ground of sex, race, color, ethnic origin, tribe, birth, creed, or religion, social or economic standing, political opinion, or disability.
The above provisions speak to equality and Non- discrimination of all persons in Uganda. According to the International Bar Association, many African countries have provisions that prohibit discrimination in their constitutions, but, do not have any specific ones to protect transgender persons from such discrimination or specifically prohibiting discrimination on grounds of gender identity. The Oxford Dictionary defines “discrimination” to mean the practice of treating someone or a particular group in a society less fairly than others.
In that regard, to entrench Non- discrimination, the framers of the constitution under Article 32(1) of the same mandated the state to take affirmative action in favor of groups marginalized based on gender, age, disability, or any other reason created by history, tradition or custom, to redress imbalances which exist against them. There is no doubt that over the years, the state has come up with various affirmative actions in favor of the different marginalized groups, women, and girls being the biggest beneficiaries. The affirmative action in favor of women has not been extended to transgender women and as such marginalized as they are, transgender women have not benefited from any form of affirmative action whatsoever even though, they identify as women and are most at risk to contract HIV/AIDS.
Article 32(2) states that laws, cultures, customs, and traditions which are against the dignity, welfare, or interest of women or any other marginalized group which undermines their status, are prohibited by this constitution. Article 32(5) mandates parliament to make laws to give full effect to this article. The gap in the law thus far is that it does not specifically make mention of transgender persons and therefore many times the interpreters of the law and those in charge of enforcement simply pay a deaf ear to the fact that many more marginalized groups had been envisaged including those they may not directly approve of, and they have to be protected, laws have to be made to cure the gaps that may be prohibitive to them living life to their full potential as well as eliminate discrimination against them.
It is key to advance the prohibition of discrimination against transgender persons because such discrimination is the reason why we have to explain why transgender persons deserve Healthcare that is unique to their special needs. The law does not speak to these challenges that transgender person’s face and the fact they need to be provided for, instead, there have been laws passed to persecute transgender persons further.
As an organization we believe in influencing policy and the law, by starting at the grassroots, through evidence-based advocacy and continuous engagements, advocacy at every level will help us achieve a uniform attitude towards transgender persons, right from the communities, to the various stakeholders, all the way to the lead up to the Member of Parliament level in a bid to influence for policies to enable transgender persons to access SRH services by also Health Care in General as well as Acess to justice.
According to a handbook for Community Health Advocates prepared and published by Initiative For Social and Economic Rights [ISER] the right to health is a fundamental human right defined as the right to the highest attainable standard of physical and mental health and it includes other underlying determinants of health such as the right to a clean and healthy environment, access to shelter. Safe water, safe food, and nutrition among others.
The said right to health requires the participation of the population in all health-related decision-making at community, national and international levels, it has principles of equity and non-discrimination and prioritizes the needs of the poor and vulnerable. Essentially, key elements include availability, acceptability [health care providers must respect the dignity, provide culturally appropriate care, be responsive to the needs based on gender, age, culture language, and different ways of life and abilities, respect medical ethics and protect confidentiality], accessibility [Health Care must be universal and guaranteed for all on an equal basis. Health care must be affordable and comprehensive for everyone and physically accessible where and when needed], quality [all health care must be medically appropriate and of good quality, provided in a timely, safe, and patient-centered manner and have quality standards.] Non Discrimination, Equality, and Equity, Transparency, participation, and Accountability.
What is key to us is to examine the Legal protection for the right to health for transgender persons in Uganda. Internationally, Uganda has ratified many international covenants and charters that include The International Covenant on Economic, Social and Cultural Rights (ICESCR) The African Charter on Human and People’s Rights (ACHPR) as such international commitments to human rights, including the right to health should ordinarily provide a guiding framework for legislation, policies, and programming at National level. Ratifying states are expected to provide for the progressive realization of the full attainment of the right to health for all, but most importantly states are required to guarantee non-discrimination in the said realization of the right to health.
One could argue, rightly so, that no one stops transgender persons from walking into Government Health Facilities to access medication and as such the insinuation that there is no gap. Our effort is targeted towards creating an enabling environment for the criminalized transgender persons to access health care. The state must ensure that the right to health is enjoying to the maximum by everyone including transgender persons and as such, the state ought to address the hindrances that prohibit transgender persons from accessing health care. The state can ably train and sensitize health workers to be accommodative and receptive of transgender persons in need of healthcare. The government could enact laws prohibiting any form of discrimination against transgender persons in light of accessing SRH as well as ensure that the already existing relevant laws and enforcement institutions are empowered funded and held accountable for the shortcomings. That way, the state will have complied with the above-mentioned international law to which it subscribes for and on behalf of the common ordinary Ugandans that include the transgender persons in the greater Masaka region.
Uganda as a country has put in place policies that elaborate on the right to health and provide a framework for realizing the right to health and these include the National Development Plan (NDP) II 2015/15-19/20. National Health Policy (2010) to attain a good standard of health for the people of Uganda
The gap in the law is created by the inadequacy in enforcement mechanisms, underfunding of enforcement bodies, corruption, negligence of the concerned persons among others, and above all ambiguity of law in addressing concerns that directly affect transgender persons. Where the law is wanting in enforcement, it is a good as no law, where policies are not implemented as envisaged, they are as good as no policies but also where there are no specific laws and policies to address a particular issue, such issue may forever be mishandled.
We have also decided to act upon our urge to examine the political space in this extremely politically charged country where everything has a political connotation attached to it. In a country where political actors seem to think that bashing the LGBTQI community creates political capital for them against their opponents that are seen to be more liberal and alive to Human Rights of the citizens of this country void of discrimination. We hope to understand why politicians say the things they say, whether or not they care what effects the said statements have on the transgender community but most importantly the latter’s access to Health care and Justice. We hope to understand what is involved for us to ably lay strategy on how to counter this damning energy. For persons who are still struggling with themselves and their bodies, turning their situation into a political horse to ride on for mileage could have very damning effects.
The way Governance in Uganda works is that the Government has three arms namely, the Executive, the Legislature, and the Judiciary. The Constitution of Uganda gives each of these arms of government different roles and powers to determine issues that affect the citizens of this country directly or otherwise. The challenge with this setting is the fusion of the three, which in the long run makes the whole system seemingly one man managed and in this case, the one man being the President of Uganda.
The Judiciary, for instance, is made up of Magistrates, Judges, and Justices whose deployment is managed by the Judicial Service Commission of Uganda. Under the law, the Commissioner’s that seat on the Judicial Service Commission is appointed by the president, above all, the heads of the Judiciary are by law respectively appointed by the president who in that regard reserves the power to dismiss the same, lawfully or otherwise. The question of whom the said judicial officers owe their allegiance is answered in the positive in favor of the President. This may not be on paper, but in the circumstances, the independence of the judiciary as envisaged under Uganda is highly questionable.
Parliament, on the other hand, is made up of members of Parliament sent to it by the people in their respective constituencies. In the multi-party dispensation in which Uganda is, various registered political parties register MPs that run and win parliamentary seats and as such, the system in Parliament is that the majority will always take the day. For the last fifteen years, the NRM has always had majority representation in parliament and has always been in the lead of making decisions that affect this country. The same NRM, has the president of the Country as their party chairperson, and more often than not, matters of national importance, are discussed first in the NRM caucus before being presented on the floor of parliament and by this procedure, by and large, the president of this country has an undeniable influence on the decisions that are made in the caucus and thus in parliament.
The Executive is by law headed by the president, and a discussion on his influence on the decisions made hereunder would be a complete roller-coaster. As such, we can ably submit that the President of this country is at the helm of the political situation in this country given his direct and indirect control of all three arms of Government but also government ideology at almost all levels of governance.
Having said that, we examined the president’s position on Key Populations and how big a gap this had created in the bid to ensure that transgender persons have access to Health Care, [SRH], and Justice.
According to an article by Nita Bhalla, Frank Mugisha stated that Politicians are using the LGBT+ community as a scapegoat to gain support and win votes and as such fueling homophobia as he spoke to Thomson Reuters Foundation.
On the 25th February 2014, shortly after His Excellence the President of Uganda had signed the Anti-Homosexuality Bill into law, in an interview with CNN’s Zain Verjee, stated that in his view, being homosexual is “unnatural” and not a human right. “They are disgusting”. “What sort of people are they”? “I never knew what they were doing” “I have been told recently that what they do is terrible”. “Disgusting.” The narrative of the parliamentarians at the time was that the influence of western lifestyles risked destroying family units. Meanwhile, President Museveni further stated that the West should not force its beliefs onto Ugandans. That Westerners brought homosexuality to his country, corrupting society by teaching Ugandans about homosexuality. It was in the wake of the president and parliamentarians’ statements against the LGBT+ community that escalated persecution of the community, tabloids published pictures and names of community members. Criminal elements used this as an opportunity to blackmail and exploit community members for money. Kidnaps, killings, were reported and transgender persons being more pronounced were most endangered to the extent that even seeking medical help could expose them.
Fast forward to the 2020-2021 campaign period ahead of January 2021 Presidential and parliamentary elections, similar anti- LGBT+ rhetoric was reported to have been uttered numerous times by the Head of state and other politicians as a means to gain some political mileage riding of the uniformed homophobic sentiments the ordinary Ugandans to the extent that in some contexts the rhetoric was used to discredit other politicians basing on the narrative that they were being funded by foreign homosexuals. While addressing the nation officially just days after the November riots that saw over seventy people lose their lives to the gun -shot wounds inflicted on them by the Ugandan security agencies all over the country, His Excellency the President of Uganda is reported to have blamed the protests on groups funded by foreign LGBT+ rights organizations. “Some of these groups are being used by outsiders…homosexuals… who don’t like the stability of Uganda and the independence of Uganda” said Museveni.
H.E the president only gets much more media coverage than the rest of the politicians but many other politicians made and continue to make anti- LGBT+ utterances, for instance, Real Raymond, a human rights activist vide the Charity Mbarara Rise Foundation reported that politicians were also making “hate speeches” on the campaign trail, such as pledges to eradicate homosexuality in Uganda if they were to be elected.
The attack on renowned Human Rights Lawyer Nicholas Opio one of Uganda’s most prominent human rights lawyers was heavily politically motivated in a bid to silence his criticism against the unbecoming behavior of the state. What is key in his arrest for us is the fact what was being sold to justify his brutal arrest was the fact that part of his human rights involves the protection of LGBT+ human rights. The politicians have mastered the art of riding on the sentiments of the common Ugandan alongside the narrative that community members are a threat to society and their children.
The politically motivated attacks on civil society and the LGBT+ community create a very huge gap in access to health and justice for transgender persons. First off it creates a whole dangerous narrative about the safety of transgender persons, in an environment where the head of state, portrays people as disgusting there will be little or no motivation for service providers to hold such person in high regard as they ought to, which is why, nurses at health centers will treat them as outcasts, policymakers, district leader will not realize the obligation to make policies aimed at securing the safety and the livelihoods of such persons. Statements from politicians or the president for that matter have an enabling effect for wrong elements in police to witch hunt and extort transgender persons knowing that there will be no consequences for their actions.
To cure the gap created by the political question is not something we can do in the day most especially in the rural greater Masala. Our effort shall emanate from empowering transgender persons as well as from the gradual engagement of authorities at different levels. Political mileage solicited from bad-mouthing a group of marginalized people greatly deters their advance in life and also equally retards all efforts to ensure access to health and justice as desired.
The above-identified gaps in Access to Health Care, Sexual Reproductive Health, and Justice of Transgender Persons are not mentioned in their entirety which only means that more gaps have the same effect on the said subject matter. The goal is to conduct effective research on the ground, identify the challenges, study for the remedies to the said challenges, and develop strategies to cure the above gaps but also to improve the lives of transgender persons in the greater Masaka region.
As an organization we are only limited by insufficiency of funding to do the work in question, we are equipped with professionals to handle the above challenges, the funding through to facilitate is what is greatly short, thereby stifling the efforts we have managed to make so far. Continuity and consistency are what we need, for we are a support organization that seeks to create a change in the lives of transgender persons, and access to health care one of the basics we think transgender persons must-have.
Fig 1. The picture below shows our Programs Director engaging a group of transgender persons in a Focused Group Discussion during the study in Rakai District.
.Fig 2. The picture below shows MAHIPSO team meet up with the DHO at MAHIPSO office
 article by unaids on the Anna Morena’s story
 Anna Morena, in her story as written and posted on the unaids page; uraids.org
 Barriers to acess and utilization of HIV/STIs prevention and care services among trans-women sex workers in the greater Kampala metropolitan area, Uganda.
 “What About Us” an article written by Dahlyn Bamuloze, the legal officer of MAHIPSO, mahipso.org
 Introduction to the Right to Health in Uganda; iser-uganda.org
 Anti –gay rhetoric ramps up fear among LGBT+ Ugandans ahead of polls; reuter.com