How AIDS goals fueled the rise of transgender ideology

Self-ID, hormones and social protections are global policy goals for an extremely marginalised group

Hijra in Tamil Nadu, India. Image by WBEZ.

This is a longer version of an article I wrote for Unherd.

We can end the AIDS epidemic by “ending the wait in gender-affirming healthcare!” Those were the words of Richard Angell, the head of the UK’s largest AIDS charity to an elated crowd during a Pride London in early July. What’s more, Angell roared from the stage, we could do it “without a vaccine and without a cure.” Another cheer went up. 

Ending the AIDS epidemic is, of course, a decades-long gay advocacy goal. But how exactly does it relate to wait times for transgender healthcare? Even the day-drunk crowd must have done a double take. A video of Angell’s speech made the rounds on social media and shocked speculation was quick to circulate. How are the two things connected? Did he reveal some secret plan, some wondered, to “trans away the gay”? 

In his eagerness to inspire the assembled, Angell may have inadvertently let slip one of the lesser-known strategies of the global AIDS response, one that, despite appearing in policy papers and scientific publications over the years, had yet to be articulated clearly on any public platform. 

The most marginalised people in society

HIV disproportionately affects a very specific sub-population of people: transgender-identifying men who have sex with other men. Depending on the region, they are up to 80 times more likely than anyone else to be HIV positive. It’s estimated, for example, that as many as a third of all travestis in Brazil are HIV positive. 

They are hard to track because they often exist on the outermost margins of society. In order to get them on the health radar and into treatment or prevention programmes, experts are now offering something they highly prize but have difficulty getting their hands on: hormones, surgery referrals and other “affirming” services. 

This effort has ramped up recently because the HIV PreP drug (preventative prophylaxis), Truvada, has recently become accessible . Despite being on the market since 2012, its maker, Gilead Sciences, has kept the price cruelly high. The expiration of Truvada’s patent in 2021 has meant that public health systems can finally afford to offer it to everyone for free. 

This strategy is not unique to the UK: in the US: in 2021, the Department of health and human services ordered all HIV clinics on a federal network to find a way to start offering gender affirming care. This is despite the fact that the Bush-era legislation that underpins the programme forbids this. Never mind, wrote Laura Cheever of the DHHS, find a way around it. 

In India, a governmental white paper spelled out the same scheme. In the Philippines, Myanmar and Nepal, the model was trialled in 2022 based on a successful programme in Thailand (that model also features clinics staffed and run by transgender women, another factor that encourages kathoeys to show up).  

The plan isn’t really hidden, it’s just not widely advertised. It’s also obfuscated by language like “key populations” for whom states must “remove barriers to care”, and “integrate community-led services.” And the strategy doesn’t only concern aesthetic interventions: for many years now, UNAIDS and its affiliate agencies have appealed for states to introduce legal gender self-ID  (“facilitate supportive legal and policy frameworks” in the lingo). Self-ID – that is, allowing people to change their official sex marker with minimal effort - will help to further destigmatise these people’s identities, the thinking goes, and get them into the official records. 

To understand why such a coordinated effort is being expended on just one at-risk “key population”, it’s important to look at the role of transsexual men in transmitting the virus the to the wider population. We have to look at who their sexual partners are.

Gay, bisexual, MSM, or GAMP?

The term gynoandromophohilia (GAMP) was coined to describe an ostensibly straight man who is attracted to males with exaggerated female features (think big breasts, hips and lips). When tested for arousal, GAMPs show typical levels of attraction to women as they do towards feminised men (they have been shown not to be attracted to non-feminised males). 

These men are sometimes called “chasers” and the objects of their affection were once known (and in porn, are still known), as “she-males”. The term “bisexual” has been used to talk about GAMPs, but the scientific literature prefers “men who have sex with men” because it describes the act and not any culture-specific identity. GAMPs are a potentially important part of the transmission of HIV because their sexual relations wit high-risk transsexual men and their subsequent relations with women mean the virus has more chance of being transmitted to the general population. In the worst case, their female partners could then potentially pass the virus to their babies via pregnancy and lactation, known as vertical transmission. (This also applies, of course, to homosexual men who marry women in countries where sodomy is still a crime.)

Read: HIV transmission patterns among transgender women, their cisgender male partners, and cisgender MSM in Lima, Peru: A molecular epidemiologic and phylodynamic analysis

Thus travestis, hijra, kathoeys and waria – whatever uber-effeminate males are called in different cultures around the world - are a triple-threat for health officials because they are hard to track, prone to regular risky sexual encounters, and their partners sometimes have female partners waiting for them at home. 

Supply follows demand

The number of advertisements for “shemale” escorts, and the popularity of the search term on porn sites, demonstrate that plenty of men are fans. In the Brussels red light district, the sex workers are unequivocal: “hetero, hetero!” says a Moroccan transsexual sex worker in a skin-tight electric pink bodycon dress. He speaks none of the local languages, but he recognises the word. A woman nearby, perhaps a social worker, helps him translate from Arabic: his clients are “straight” men. 

A Romanian transsexual around the corner says the same. A group of Bulgarian female prostitutes confirm: married, straight men pay transsexual males for sex. “If I am transgender I make a lot of money,” one of them laughs in broken French. 

It’s perhaps no surprise that it was Brazil, home to a large and visible population of travestis, was the first country to propose sexual orientation as a protected characteristic to the UN general assembly in 2003, or that Argentina, where 34% of travestis have HIV (90% of whom are sex workers) was the first country to introduce legal gender self-ID. 

AIDS had hit Latin American countries hard. A 1997 Chicago Tribune article about Brazil claimed that the disease had “cast a shadow over the country’s widespread tradition of bisexuality.” Bisexuality, once seen as harmless fun for men, an AIDS NGO told the paper, had become a health risk because they were bringing the virus home to their female partners.  

An active civil society in Brazil, which flourished after the end of dictatorship, built up a robust response; by 1994 there were more than 500 AIDS-related NGOs in the country, including the considerable participation of the country’s travestis.

Brazil’s UN 2003 resolution failed when conservative countries objected, but it set things in motion; a coalition of allied countries and international NGOs, which included queer theorists, sociologists and feminists, regrouped to reformulate the resolution to make it more likely to pass the following year. It was in the course of those 2004 discussions that “gender identity” was added to the text of the resolution.

The abolition of sex

There are other fundamental ways in which AIDS has been important in the global turn transward. For one thing, it blew open our understanding of sexuality. 

When Belgian virologist Peter Piot was entrusted with leading the global AIDS response via a new agency called UNAIDS in 1995, it didn’t take him long to realise that stigma relating to sex was the real barrier to ending the epidemic. 

Shaming people “with diverse sexuality”, said Piot, forces people into the shadows and keeps the virus in circulation. How could UNAIDS hope to defeat the epidemic if society – including global governments – denied the existence of the behaviour that spread it? 

UNAIDS adopted a campaigning mantra of destigmatisation of sex and sexuality (and later, decriminalisation of prostitution). Piot also railed against gender norms, the invisible rules that dictate the behaviour of men and women, as detrimental to the AIDS response. There was no point giving men information on limiting their number of partners if society expects them to be promiscuous. Likewise, it was useless giving antiretrovirals to HIV positive women if a male relative decides he deserves them more. 

Donors concerned with poverty in the developing world were coming up against the same issues in relation to family planning programmes. Women’s identity was rooted in motherhood, and the expectation that they remain pure meant that girls weren’t getting any sex education. Violence made it harder to refuse their husband’s sexual demands. 

Technical and behavioural solutions, like education and the availability of contraceptives and condoms, were not working. Rigid and restrictive attitudes were the issue, not the lack of testing clinics, pills, and workshops. 

Philanthropists and international donors increasingly threw money at sociologists, queer theorist and feminist scholars to study sex, sexuality and the structural roots of harmful behaviours. Money for AIDS and aid coalesced, sexual and reproductive health as a human right was born, and the forensic deconstruction of sex and gender was well underway. Academics ultimately theorised that “man” and “woman” were but illusions, collections of costumes and customs brought to life through mere repetition. Policy wonks adopted their ideas wholesale. 

The repurposing of HIV clinics as gender-affirming care centres might mean that the role of AIDS in the global trans takeover might be set to expand. The CDC, for example, has advised health providers to talk about PreP to anyone  who hasn’t consistently using a condom in the past six months. The NHS recommends PreP to all trans and non-binary people. If Richard Angell gets his way, all of those people will be able to avail of gender-affirming services as part of routine (and free) sexual health checks.

The world might well be on its way to reaching the goal of ending AIDS by 2030. But at what cost?