The article is a part of Saadat Abdullazada’s diploma thesis at the University of Essex.
This article was supported by QueeRadar's Mentoring Program.
Societal stigma and taboos present significant hurdles in upholding the rights of trans women in Azerbaijan. The impact of the patriarchal system extends beyond merely affecting their health rights, encompassing a broader spectrum of rights. This article will delve into the specific challenges trans women face concerning sexual health and rights, as well as their access to sexual health services within the country. Utilizing the latest research on the subject, the article will shed light on impediments to trans women's access to sexual health services, the country's responsibility in delivering healthcare, and the efficacy of the healthcare system. An examination of how systematic violence against trans women contributes to the infringement of their health rights will also be undertaken.
Sexual and reproductive health and rights as a human rights issue
The situation regarding LGBTIQ+ rights in Azerbaijan continues to deteriorate year by year. According to ILGA Europe's "Rainbow Map and Index 2022 on Human Rights of LGBTI people", Azerbaijan ranks last in Europe in terms of rights protection and security.[1] Hate speech and crimes are normalized without prevention, and attacks and convictions against trans women go beyond without gender-stereotyped investigations and prosecutions.
The failure to address these issues reflects the influence of the patriarchal system, suggesting a deliberate lack of progress. The pervasive violence and discrimination against trans women extend across various facets of life, including education, health, legal, and social protection, indicating a systematic problem. Sexual health, being an integral part of the overall health system, requires thorough investigation in the context of this systematic violence.
Since health is defined in a broader sense, it includes not only physical health, but also mental and social well-being. When looking at sexual and reproductive health beyond health, it includes people feeling safe and having a good sex life. The freedom to determine when, where, how, and how much a person will use their reproductive function is the basis of sexual and reproductive health. [2] Therefore, some scholars consider this issue not only a development issue but also a human rights issue.[3] After the concept of sexual health was first expressed in 1975, the concept of “sexual rights” began to develop. At the next stage, it led to the recognition of human rights by integrating them into sexual rights.
Cook, Dickens, and Fathalla (2003) discuss the context of women’s sexual and reproductive health and note that being a woman affects health. This is justified by the fact that women have unique health needs related to their sexual and reproductive functions.[4] The authors emphasize that violating women’s sexual and reproductive health rights results from violating all their other human rights. Based on this, it is possible to conclude that the health needs of trans women may be high due to hormone intake, surgery, social pressure, or mistreatment.
Consequently, the inability of trans women to access sexual health facilities can be attributed to the fundamental violation of their human rights. The paper aims to explore the roots of barriers hindering trans women's access to sexual and reproductive health services and investigate the impact of systematic violence in the context of sexual and reproductive health in Azerbaijan. The central question guiding this exploration is: How does systematic violence against trans women in Azerbaijan affect their right to sexual health?
Trans women’s Access to Sexual and Reproductive Health Services
The definition of sexual health is about health that includes enjoying sex, being free from violence and aggression, and being protected from sexually transmitted diseases.[5] In this regard, two issues are particularly in focus: regulating and controlling fertility and regulating safety against sexually transmitted diseases.[6] Unprotected sex creates fertile conditions for sexually transmitted diseases and HIV transmission. For this reason, unprotected sex is considered one of the essential factors in the transmission of HIV. For example, if sex work can be taken as a risk group access to sexual health centers and contraceptives is essential to prevent this ongoing chain. Given that socioeconomic conditions play an essential role in promoting or impairing reproductive health, the discrimination sex workers face in accessing health services may be exacerbated by the vulnerable group they represent in the case of trans women.[7]
The trans community encounters discrimination and mistreatment rooted in power dynamics when attempting to access health services. Trans women, facing challenges in obtaining health services in Azerbaijan, experience particular hardship, especially during the transition phase. Vusala Hajiyeva, a trans activist and a film-maker with whom I discussed this matter, portrays the scenario concerning trans women's access to sexual health services as follows:
"Trans women's access to sexual health services is the same as all other medical services. To be precise, it's more out of reach. In many practices, trans women cannot even access primary care. Such cases occur in both public and private hospitals. Since this issue and other issues related to medical services are not included in the legislation in any form, hospitals, or specifically doctors, behave according to their wishes. Usually, the negative behavior is caused by both general transphobia and the belief that they will get away with it."
There is no regulation on hormone therapy in Azerbaijan's healthcare legislation, "Law on Population Health" and related acts. Because hormone therapy is not regulated by law, neither state nor private hospitals provide this service.[8] In the country, trans women who cannot undergo hormonal therapy and adaptation surgery find it difficult to find a reliable doctor for their sexual health problems at a later stage.
It is difficult to obtain accurate data on the transmission of HIV and sexually transmitted diseases among trans women in Azerbaijan. So, according to the latest report from the AIDS center, the number of HIV infections in the first 5 months of 2022 was 341. The center's report noted that "4.3 percent of those infected were infected as a result of homosexual contact."[9]
At the stage of researching the topic, due to the lack of resources in Azerbaijan, the local youth network operating in the field in the country was addressed. The Gender Resource Center, which works with the LGBTQI community, shared an internal report of the needs and concerns of its beneficiaries to contribute to the article.[10] Twenty-three trans women who applied to the Gender Resource Center noted that they did not have access to sexual reproductive health centers. Many applicants did not know where to undergo the examination, and many of those who passed the examination encountered transphobia. Trans women who applied to the Centre for Sexual and Reproductive Health Services were not considered at any hospital under the Ministry of Health. Because in the hospitals they applied to, insurance and psychiatric certificates were requested from them, and the applicants did not have the mentioned documents.
However, in general, it is noted that talking about the topic remains taboo in the community of trans women, and they do not talk about it when sexual and reproductive problems have not escalated. Some applicants, who are engaged in sex work, noted that they did not apply when the disease appeared. They were forced to consult a doctor for intervention only after the disease became much more acute. They mentioned that their economic situation is not stable enough to go to hospitals in a country without free medical services. In general, trans women mentioned their financial situation and unemployment as reasons for not using paid sexual and reproductive health services. Secondly, when they can afford to pay for sexual and reproductive health services, it is noted that they have difficulty finding a doctor who is not transphobic.
Vusala sees the lack of law as one of the reasons why trans women do not have access to sexual health services:
"The main reason for this is the state's attitude towards transgenders and other LGBTQI+ people. Since 2000, only one law has been passed regarding LGBTQI+ people. It is the law on the decriminalization of homosexual relations, which was provided for Azerbaijan to join the Council of Europe. Currently, there is no law specifically related to transgender people, increasing their access to medical services, creating trans-specific healthcare facilities, or taking anti-discrimination steps. This leads to the fact that access to medical services depends on the ethics of the employees of the institution you are applying to. This is not true. The doctor is a doctor and must perform their work according to the professional principle. This is not usually the case with us. In my personal experience, the main problem of the specialists I met was related to the use of the correct vocabulary. But I was able to get service. But I could only find the doctors from whom I received these services online and after long searches."
Describing her transition period, Vusala says, "I was looking for an endocrinologist for 6 months before I decided to start transitioning. At the end of these searches, I found an endocrinologist working in one of the private hospitals in Baku. Until then, when I contacted other endocrinologists and attended appointments, they said that they do not work with transgenders (transphobic subjective reasons) or that there is no protocol in the law. That is, the protocol does not allow prescribing hormonal therapy to transgender people. Although several endocrinologists were willing to accept me, I was not satisfied with their experience and could not answer very simple questions. The doctor I found had experience working with transgender people because he had experience working in Turkey. This was the first factor that gave me confidence. However, the problems did not end there, because, after the prescription I eagerly awaited, I could not find the hormonal preparations prescribed for me in Baku for a long time. Sales in pharmacies had stopped for 4-5 years. The pharmacists said that "these drugs are not brought because they are for trans people". In a recent conversation with another trans woman from the community, it became clear that the situation is still the same. I also want them to always bring medicine from friends and acquaintances from Turkey. This causes a big problem because we have to take these drugs daily. In this case, we take a forced break. This leads to a worsening of the hormonal balance and more dysphoria."
Health rights in national legislation
As the interviewer noted, when looking at the specific legislation covering the problem, it is possible to see the first problem in the gap or non-acceptance of the laws themselves. Article 41 of the Constitution is about the right to health protection. As paragraph 1 of the article states, “Everyone has the right to health care and medical care. The state takes necessary measures for developing all types of healthcare operating based on different types of ownership, ensures sanitary-epidemiological safety, and creates opportunities for various types of medical insurance”.[11] Access to health services, despite the passage of more than 20 years since the adoption of the constitution, has become a problematic right for groups with financial difficulties to obtain because of the lack of health insurance.
In 2010, the law of the Republic of Azerbaijan, “On Combating the Disease Caused by the Human Immunodeficiency Virus,” was adopted. Article 4 of the law lists the guarantees undertaken by the state in the field of combating HIV infection. Thus, the adoption and implementation of the national strategy and state programs for the fight against HIV infection; ensuring the organization of infection control services throughout the country; comprehensive information and education of the population in the field of infection and its control; the implementation of complex measures for effective prevention of HIV infection among high-risk population groups, etc.; such obligations are reflected in the law. The definition of the high-risk population group is reflected in 1.0.9: “high-risk population groups—population groups that practice risky behavior concerning HIV infection and pose a threat to public health (injection drug users, people who practice irregular sex, sexual minorities, etc.).”[12] It is now clear that HIV is not just a health issue.
Sex workers, a group vulnerable to HIV infection, continue to face human rights violations such as crime, violence, and discrimination that increase the risk of HIV infection. [13] According to WHO estimates, transgender women are 49 times more likely to contract HIV than all adults of reproductive age.[14] In this regard, criminalization has been recorded as preventing transgender people from using health services, including HIV.[15] On the other hand, it is possible to consider that the expression “sexual minority” in Azerbaijani legislation is related to the non-acceptance of trans women and LGBTQI as a group in general. According to Azerbaijani legislation, sex work is not legal. Sex work is one of the jobs that transgender women in Azerbaijan turn to because of the problem of finding work.[16] Because they do not have access to health services and protective equipment, the risks to their lives and the deterioration of their well-being continue to increase.
The draft law on “Protection of Reproductive Health of the Population and Family Planning,” which should cover sexual and reproductive health, was prepared and presented to the parliament but was not accepted. Although the working group that put forward the law stated that the law to be adopted will have a positive effect on the risk of HIV spreading in the country, divorce and infertility, as opponents argue that parts of the law, such as artificial insemination, surrogacy, and sperm donors, are incompatible with the “national mentality.”[17]
The rights need to be transformative in order to be both functional, equal, and accessible. Fredman (2016), one of the theorists who emphasize the importance of equality, proposes a four-dimensional approach to understand its content.[18] Based on Fredman's approach, we can determine what needs to be done and the situation of trans women in Azerbaijan.
Fredman suggests that the initial disadvantage must be removed on the road to equality. Based on this suggestion by the author, who mentions both financial and social disadvantages, it would be appropriate to mention the financial hardships faced by trans women. Trans women are forced to engage in sex work, which further endangers their sexual health. In particular, trans women in the transition period should bring drugs which are unavailable in the country from foreign countries or spend enough money on expensive drugs. On the other hand, they need long-term financial support for the operation and recovery. Nevertheless, they have to cut the process in half due to economic difficulties.
As a second dimension, it emphasizes the importance of eliminating stigma, stereotyping, and gender-based violence. Employers will not hire trans women because of the stigma and stereotypes they face when applying for jobs. For this reason, they avoid making job applications to avoid humiliating relationships.
The third dimension involves changing structures to accommodate diversity.[19] The transphobic approach covers all structures of the state. Murders of trans women are not investigated in detail by the police, pro-government journalists broadcast photos and videos of trans women on television and social media, mocking them, fueling the rise of hate speech in society.
The last stage proposed by Fredman is the promotion of social and political participation. From this point of view, it can be said that trans women in Azerbaijan are excluded from all social and political processes in the country. Undoubtedly, laws and mechanisms are necessary to ensure the political participation of trans women who cannot walk freely on the street.
The importance of effective health care
This is what Vusala says about the source of health care access problems:
"One of the main problems is lack of adequate and experienced gynecologists, mammologists, etc. is to be found. Finding an experienced doctor does not mean that you will be served on a fee-for-service basis, even within a private hospital. Another major challenge is related to the availability of HIV preventive drugs such as PEP (Post Exposure Prophylaxis) and PrEP (HIV Pre Exposure Prophylaxis). We do not have any regulation or service related to providing these drugs free of charge. At the same time, it can be added to conduct tests related to sexually transmitted viruses. Although not directly related to sexual health, access to endocrinology services is also nil. Access to endocrinology services is imperative for trans women - especially those undergoing hormone therapy. But the endocrinologist I found three years ago in Baku, after long research, is the only specialist who makes admissions, has experience and is relatively not transphobic."
Reproductive health has become a development and human rights issue, embracing broader aspects than health.[20] These indicators, called the four P's, include provision, people, politicians and health services. These indicators help determine sexual and reproductive health, making conditions either better or worse for those in need of services. Because politicians and legislators play an important role in the formation of societies with the policies and laws they apply.
The WHO's policy brief on trans people and HIV specifically mentions codes of conduct for health professionals with trans people. Health care providers are required to be both sensitive and aware of the sexual and reproductive health needs and concerns of trans women. This sensitivity should also be reflected in the discourse used, so healthcare providers should avoid making assumptions about the anatomy or sexual behavior of trans women. Health care providers should consider that trans women or men may be victims of physical and sexual violence, or may be uncomfortable with their own anatomy, so genital examinations may be particularly physically and psychologically difficult for them.[21] It is difficult for health services to provide non-discriminatory services to trans women in a system that systematically abuses trans women. Because the first thing to be accepted and applied is its basic human rights aspect. Being able to define and express one's gender identity free from stigma and discrimination is an important dimension of the enjoyment of human rights.[22]
Guidelines for trans-specific healthcare based on human rights state that judgment and disrespect for the experience and needs of trans women by medical professionals, sharing of personal information of trans women, forced treatment or surgery, any kind of violence, unreasonable questioning of a person's private life, etc. . is unacceptable.[23]
Trans women have the right to accessible and human rights-based trans-specific services and access to detailed information about services, and to care from health professionals who are specialized and trained in gender, sexuality and diversity, and who maintain confidentiality, for quality health care.[24]At this point, health workers should focus on how to fulfill their duties and contribute to people's living conditions.
Educating medical staff about gender and sexuality during their education and training LGBTIQ+ friendly medical professionals will create a chance for people to benefit from health services without being mistreated. Healthcare needs innovation to evolve and become accessible to everyone. As Hunt (2006) points out, such innovations only occur in close collaboration with health professionals. Only in this way can health workers become part of the human rights movement.[25] The way to do this is to establish sustainable and safe conditions. Unless rights are guaranteed in all areas, the health services offered will also maintain their discriminatory approach.
Conclusion
Vusala's answer to the question "What do you expect from the health care system regarding sexual health" is sad, but it reflects the complete truth:
"In fact, the situation for trans women in Azerbaijan is so bad that we are fighting for access to simple medical services and procedures when we should be talking about trans-specific health care and making demands for it. That is, my only expectation at the moment is the formation of access to basic medical services for transgender people. Conducting any training programs for doctors to be more informed and, of course, adopting an anti-discrimination law. After these major steps are taken, maybe I will have expectations about other important issues."
Because the health system cannot address reproductive and sexual health deficiencies alone, improving the quality and accessibility of sexual health needs action outside the health sector.[26] Because the indicator that negatively affects the health of trans women comes from the tradition of gender discrimination. As the social, economic, legal and cultural rights of trans women are violated, their health rights are also violated. Providing accessible health services is difficult and ineffective unless trans women's rights and freedoms are guaranteed. Laws that limit access to health care services can exclude or discourage people from seeking and receiving information and services. Trans women's lack of equal access to work, housing, protection system, education and healthcare with other citizens can be considered as a part of gender politics.
Because the application of institutional discrimination based on sexual orientation and gender identity is part of state policy. This discrimination has been injected into all spheres of life, starting from educational centers and ending with the health care system. There is a need to carry out the work to be done in a chain with each other. For this reason, everyone should be informed, from the police to the deputy, from the teacher to all civil servants. Mechanisms are needed not only to improve the sexual health of trans women, but also to ensure all their human rights. Because access to sexual health services will be incomplete or impossible unless trans women's fundamental human rights violations are eliminated. The human rights of trans women must be recognized and respected, without which no rights can be guaranteed.
References
[1] ILGA Europe, ANNUAL REVIEW OF THE HUMAN RIGHTS SITUATION OF LESBIAN,
GAY, BISEXUAL, TRANS AND INTERSEX PEOPLE IN EUROPE AND CENTRAL ASIA, Annual Review of The Human Rights Situation of Lesbian, gay, Bisexual, Trans, and Intersex People in Azerbaijan Covering the Period of January To December 2022, 34
[2] United Nations Population Fund, “Sexual & Reproductive Health” (04 April, 2022) <https://www.unfpa.org/sexual-reproductive-health> accessed 03 June, 2023.
[3] Rebecca J. Cook, Bernard M. Dickens, Mahmoud F. Fathalla, “Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law” (Oxford, 2003; online edn, Oxford Academic, 3 Oct. 2011) p.1.
[4] Ibid. p.2.
[5] Rebecca J. Cook, Bernard M. Dickens, Mahmoud F. Fathalla, “Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law” p.2.
[6] Ibid. p.6.
[7] Ann Burton, Jennifer Butler, Priya Marwah, Cecile Mazzacurati, Marian Schilperoord and Richard Steen, “Addressing HIV and Sex work” (2010), FMR p.26.
[8] Queer Radar 30 iyun 2022, Nuranə Məmməd, Hormon terapiyasından məhrum trans vətəndaşlar < https://queeradar.com/hormon-terapiyasindan-m%c9%99hrum-trans-v%c9%99t%c9%99ndaslar/> accessed 01 june, 2023.
[9] Azərbaycan Respublikası Səhiyyə Nazirliyi QİÇS-lə Mübarizə Mərkəzi, <https://aids.az/bu-ilin-bes-ayinda-341-n%c9%99f%c9%99rd%c9%99-iiv-%c9%99-yoluxma-hali-askarlanib-statistika/> accessed 01 june,,2023.
[10] Gender Resource Center is a local network. In 2020, they started implementing the “Counseling and psychosocial support for LGBTQI communities” project. From the beginning, they created an internal database that covered all the beneficiaries’ concerns and obstacles. https://en.grcenter.org/psixososial-konsultasiya.
[11] Azərbaycan Respublikasının Konstitusiyası, (adopted 12 November 1995) article 41.
[12]“İnsanın immunçatışmazlığı virusunun törətdiyi xəstəliklə mübarizə haqqında” Azərbaycan Respublikasının qanunu, https://e-qanun.az/framework/19707
[13] Ibid. p.47.
[14] World Health Organization, “Policy brief: Transgender people and HIV”, (2015) p.6.
[15] Ibid. p. 9.
[16]ILGA Europe, Annual review of the Human Rights of Lesbian, Gay, Bisexual, Trans, and Intersex people in Azerbaijan Covering the Period of January to December 2022, p.37.
[17] United Nation Population Fund Azerbaijan, Assessment of the implementation status of treaty body recommendations on sexual and reproductive health and rights in the Republic of Azerbaijan p.20.
[18] Fredman, S., ‘Women and Poverty: A Human Rights Approach’, 24(4) African Journal of International and Comparative Law 2016, p. 505-506.
[19] İbid. p 506.
[20] Rebecca J. Cook, Bernard M. Dickens, Mahmoud F. Fathalla, (2003) “Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law” p. 6.
[21] WHO policy brief on transgender and HIV, 2015, p. 21.
[22] Rebecca J. Cook, Bernard M. Dickens, Mahmoud F. Fathalla (2003) “Reproductive and Sexual Health” p. 11.
[23] Transgender Europe, September 2019, Guidelines to human rights-based trans-specific healthcare, p. 12.
[24] İbid. p. 14.
[25] Hunt P, “The human right to the highest attainable standard of health: new opportunities and
challenges” (2006) Transactions of the Royal Society of Tropical Medicine and Hygiene 100, p. 607.
[26] Rebecca J. Cook, Bernard M. Dickens, Mahmoud F. Fathalla (2003) “Reproductive and Sexual Health” p. 25.