Open letter from public health clinicians, researchers, and academics regarding Uganda’s Anti-Homosexuality Bill

To His Excellency Yoweri Kaguta Museveni, President of the Republic of Uganda: We, the undersigned, are writing out of grave concern regarding the likely implications of Uganda’s Anti Homosexuality Bill (“the Bill”) should it be passed into law. We are clinicians, researchers and academics working in the field of public health. Many of us have extensive experience providing physical and mental health services and doing public health-focused research in sub-Saharan Africa. We note that Ugandan experts, including Uganda’s Human Rights Commission and the Uganda Law Society, have studied this Bill and found that it violates obligations under Uganda’s Constitution to protect and uphold fundamental freedoms of its people. This Bill also contradicts scientific evidence regarding lesbian, gay, bisexual and transgender people. In your letter sent on December 28 to the Rt. Hon. Speaker of Parliament, Rebecca Kadaga, you have expressed an interest in deliberating over evidence and science regarding sexual orientation and arriving at a “scientifically correct position” on the Bill.1 The purpose of this open letter is to focus on areas of particular concern to us as public health experts, beyond our fundamental support for the human rights and human dignity of all Ugandans: 1) the overwhelming evidence about homosexuality and the myths perpetuated by the Bill and 2) the likely public health implications of this Bill, should it become law in Uganda. 1. Myths and Facts About Homosexuality Your December 28 letter questions: a) whether homosexuality is an abnormality and b) whether homosexuality is a condition of which a person can be “cured” or “rescued.”2 Evidence from independent technical normative agencies and respected medical and sociological professional bodies around the world could not be more clear in response to both questions: Homosexuality is not a pathology, an abnormality, a mental disorder, or an illness—it is a variant of sexual behavior found in people around the world. Lesbian, gay, bisexual, and transgender people are normal. According to Uganda’s national diagnostics and statistical manual of mental disorders (DSM), homosexuality is not classified as a mental disorder. Neither is homosexuality a condition from which a person can be “converted.” Despite claims to the contrary, there is no rigorous and peer reviewed scientific evidence that a person who is lesbian, gay, bisexual or transgendered can be “cured.”3 The Bill’s claim to protect children and families in Uganda appears to be derived from the harmful myth that lesbian, gay, bisexual and transgender people pose a graver risk to children and families than people of other sexual orientations. There is no such evidence—lesbian, gay, bisexual and transgender people pose no greater risk to children than heterosexuals. In fact, sexual and physical violence experienced all too routinely by children and adolescents in Uganda would be unaddressed by this Bill. Implementation of this Bill would likely deplete the already limited resources invested in Uganda into robust investigations and prosecutions of cases of violence against children. Rather, the limited funds would be wasted on hunts by police for consenting adults suspected or accused of being lesbian, gay, bisexual or transgender. 2. Undermining public health and human rights This Bill would further exacerbate the marginalization, discrimination and exclusion of people known to or suspected of being homosexual. Research shows that laws and policies that increase stigma 1 The Daily Monitor, “Museveni blocks anti-homosexuality bill,” Yasiin Mugerwa. 17 January 2014. http://www.monitor.co.ug/News/National/Museveni-blocks-Anti-Homosexuality-Bill/-/688334/2148760/- /15lby8fz/-/index.html 2 Letter from President Museveni to Rt. Hon. Speaker Kadaga, 28 December 2013. Available at: http://www.scribd.com/doc/200400880/President-Museveni-s-Letter-on-Anti-Homosexuality-Bill 3 Cf. Pan American Health Organisation (PAHO). “ ‘Cures’ For an Illness that Does Not Exist: Purported Therapies Aimed at Changing Sexual Orientation Lack Medical Justification and are Ethically Unacceptable.” 15 May 2012, available at http://new.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=17703 and Psychological Society of South Africa, “Sexual and Gender Diversity Position Statement,” 7 June 2013. and discrimination among groups of people mean those people are less able to access health services because of fear of arrest, intimidation, violence, and discrimination. For example, men who have sex with men in Uganda report higher HIV prevalence and higher rates of syphilis and other sexually transmitted infections than the general population.4 HIV prevalence among men who have sex with men in Kampala is 13%, more than three times the average prevalence among heterosexual men in Kampala (4.1%) and about twice as high as the national average of 7.3%. After years of success in the fight against HIV, Uganda’s incidence has been rising since 2005—contrary to the trends of virtually all other countries with high HIV burden in sub Saharan Africa.5 We are gravely concerned that passage of this Bill will exacerbate that negative trend. All people need essential health services, not the criminalization and discrimination this Bill would foment. Furthermore, driving lesbian, gay, bisexual and transgender communities away from services endangers not only them but also the Ugandan population at large—approximately 75% of men who have sex with men participating in a recent serosurvey report having sex with women as well as men.6 Discrimination undermines their health as well as the public health of the population of Uganda as a whole. Ironically, the Bill’s clause prohibiting the “promotion of homosexuality” as well as “aiding and abetting homosexuality” would criminalize urgently needed service delivery for lesbian, gay, bisexual and transgender people. The Government of Uganda recently announced plans to implement government funded clinics designed to reach men who have sex with men and sex workers.7 This Bill, if passed into law, would sabotage such efforts by criminalizing them. This will have a disastrous impact on the response of the nation as a whole to HIV as well as other public health priorities. This clause would also put international and national health service providers funded by international donors at risk of criminal prosecution if they discuss homosexuality in the course of their work. The Bill conflicts with a health worker’s basic ethical obligation not to discriminate in the provision of medical services and would create a culture of fear of arrest and imprisonment among service providers. While a clause in earlier versions of the Bill that anyone suspected of being homosexual be reported to police might have been removed from the Bill that Parliament passed, the clause prohibiting promotion, aiding and abetting homosexuality would still force health workers to discriminate. Contrary to recent claims that health workers in Uganda do not engage in discrimination when providing services, Ugandans seeking health services in the public and private sectors frequently report being questioned by health workers about their sexual activities and marital status—creating for LGBT populations a legitimate fear of retaliation and discrimination if they are honest about their sexual orientation. This climate of fear would be markedly increased should the Bill become law. Scientific research also shows a powerful association between homophobic abuse and violence and increased vulnerability to HIV. This is not due to an intrinsic condition of homosexuality, but a harmful effect of homophobia. For example, men who have sex with men in Kampala who have experienced verbal or physical homophobic abuse are five times more likely to be HIV positive than men who have sex with men who have not experienced such abuse,8 indicating a strong association between stigma and intolerance and HIV infection risk. Hatred and stigma drives vulnerable and isolated communities such as men who have sex with men further from essential preventative and curative health services. We believe this Bill should not be passed into law—it blatantly defies highly corroborated scientific evidence and it would have a harmful impact on public health, human rights, and the freedom of all 4 Hladik W, Barker J, Ssenkusu JM, Opio A, Tappero JW, et al. (2012) HIV Infection among Men Who Have Sex with Men in Kampala, Uganda–A Respondent Driven Sampling Survey. PLoS ONE 7(5): e38143. doi:10.1371/journal.pone.0038143 5 WHO: Global HIV/AIDS Response, Epidemic Update and Health Sector Progress Towards Universal Access, Progress Report, 2011. p. 12-17. 6 Supra note 4. 7 “Outrage, scepticism at Uganda U-turn on LGBTI clinics,” 9 Dec 2013. Available at: http://www.irinnews.org/report/99289/outrage-scepticism-at-uganda-u-turn-on-lgbti-clinics 8 Supra note 4. people to enjoy freedom from discrimination in Uganda. We implore that you veto this Bill in all forms. We note that Ugandan politicians and policymakers will meet February 6 in Kyankwanzi, Uganda where this issue will be discussed amongst the National Resistance Movement Caucus. Representatives of our group of signatories request the opportunity to join you in Kyankwanzi to share scientific evidence face-to-face, given the intense interest this topic has generated, apparent misinformation among decision makers, and the Bill’s serious consequences for Ugandans should it be passed into law. Signed, [list in formation] Organizations: International AIDS Society (IAS), Geneva, Switzerland Southern African HIV Clinicians Society HIV Medicine Association (HIVMA) Infectious Diseases Society of America, Center for Global Health Policy The Desmond Tutu HIV Centre, University of Cape Town, South Africa The Desmond Tutu HIV Foundation, Cape Town, South Africa The Civil Society Coalition on Human Rights and Constitutional Law, Uganda Fenway Health, Boston, USA Individuals: Noerine Kaleeba, PhD Founder and Patron The AIDS Support Organisation Uganda Dr. Ian Clarke Chairman and CEO International Medical Group Kampala, Uganda Dr. Geoffrey Mujisha Executive Director, MARPs Network Kampala, Uganda Edith Mukisa Executive Director Community Health Alliance Uganda Kampala, Uganda Dr. Stephen Watiti Chairperson, Board of Directors Community Health Alliance Uganda Kampala, Uganda Dennis Odwe Executive Director Action Group for Health, Human Rights and Development (AGHA) Uganda Kampala, Uganda Professor Hoosen Coovadia Emeritus Professor of Paediatrics and Child Health, Emeritus Victor Daitz Professor of HIV/AIDS Research, University of KwaZulu-Natal Director, Maternal Adolescent and Child Health, University of the Witwatersrand Commissioner, National Planning Commission, The Presidency South Africa Professor Helen Rees Executive Director, Wits Reproductive Health and HIV Institute University of the Witwatersrand Johannesburg, South Africa Professor Quarraisha Abdool Karim Associate Scientific Director Center for the AIDS Programme of Research in South Africa (CAPRISA) Durban, South Africa Sergii Dvoriak MD, Ph.D. Head of the Board Ukrainian Institute of Public Health Policy Kiev, Ukraine Richard E. Chaisson, MD Professor of Medicine, Epidemiology and International Health Director, Center for TB Research and Center for AIDS Research Johns Hopkins University Baltimore, USA Professor Adeeba Kamarulzaman Dean, Faculty of Medicine University of Malaya Kuala Lumpur, Malaysia Professor Francois Venter Deputy Executive Director, Wits Reproductive Health and HIV Institute University of the Witwatersrand Johannesburg, South Africa Joel E. Gallant, MD, MPH Adjunct Professor of Medicine Division of Infectious Diseases Johns Hopkins University School of Medicine Baltimore, USA Allan Raggi Executive Director Kenya AIDS NGOs Consortium (KANCO) Nairobi, Kenya Professor Michael Adler, CBE Emeritus Professor of Genitourinary Medicine and Sexually Transmitted Diseases University College Medical School London, UK Casper W. Erichsen Executive Director Positive Vibes Trust Windhoek, Namibia Richard B. Krueger, MD Medical Director, Sexual Behavior Clinic New York State Psychiatric Institute & Columbia University Department of Psychiatry Associate Clinical Professor of Psychiatry Columbia University, Department of Psychiatry New York, USA Jens Lundgren, MD DMSc Rigshospitalet, University of Copenhagen Professor, Director of Copenhagen HIV Programme, Centre of Global Excellence (CHIP) Department of Infectious Diseases and Rheumatology Copenhagen, Denmark Ambrose Agweyu, MBChB, MSc Clinical Epidemiologist Kenya Medical Research Institute Nairobi, Kenya Kenneth Mayer MD Director of HIV Prevention Research Beth Israel Deaconess Medical Center Professor of Medicine Harvard Medical School Sten H. Vermund, MD, PhD Amos Christie Chair of Global Health Vanderbilt University School of Medicine Nashville, USA Coleen K. Cunningham, MD Chief, Infectious Diseases Pediatrics Chief, Global Health Pediatrics Duke University Medical Center Durham, USA Professor Yousuf A Vawda Academic Leader, Public Law School of Law, University of KwaZulu-Natal Durban, South Africa Professor Jeam van Bergen, MD, MPh, PhD Professor STI in Primary Care, University of Amsterdam-AMC Department of General Practice Amsterdam, The Netherlands Jürgen Rockstroh, Professor of Medicine Chair of the German National AIDS Council Head of HIV-Clinic Department of Medicine I University of Bonn Germany Anand Pandya, MD Vice Chair for Clinical Affairs, University of Southern California Department of Psychiatry Chief of Psychiatry, Los Angeles County General Hospital Los Angeles, USA Lisa Hirschhorn, MD MPH Partners in Health Harvard Medical School Boston, USA Professor Brook K. Baker Northeastern University School of Law Program on Human Rights and the Global Economy Honorary Research Fellow, University of KwaZulu Natal, Durban, South Africa Professor Linda-Gail Bekker Professor of Medicine Deputy Director, The Desmond Tutu HIV Centre University of Cape Town South Africa Frederick L. Altice, MD Professor of Medicine and Public Health Yale University New Haven, USA Professor Aikichi Iwamoto, MD Division of Infectious Diseases Advanced Clinical Research Center The Institute of Medical Science The University of Tokyo (IMSUT) Alvaro Bermejo, MD, MPH Executive Director International HIV/AIDS Alliance Hove, UK Dr Natasha Davies, MBBCH, HIV Management Diploma, MPH Technical Specialist, Adult Care & Treatment Wits Reproductive Health & HIV Institute Johannesburg, South Africa Andy Gray BPharm MSc (Pharm) FPS FFIP Senior Lecturer, Division of Pharmacology Discipline of Pharmaceutical Sciences School of Health Sciences Consultant Pharmacist (Research Associate) Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu- Natal South Africa Stephen L. Boswell, MD President and CEO Fenway Health Boston, MA Assistant Professor of Medicine Harvard Medical School Melanie Thompson, MD Principal Investigator AIDS Research Consortium of Atlanta Atlanta, USA Lyn van Rooyen Director, CABSA Johannesburg, South Africa Noah Metheny, MPH Director of Policy The Global Forum on MSM & HIV (MSMGF) Wendy Armstrong, MD Associate Professor of Medicine, Infectious Diseases Emory University School of Medicine Atlanta, USA Wim Vandevelde Global TB Community Advisory Board, Chair Cape Town, South Africa Professor Michael Meltsner Matthews Distinguished University Professor of Law Northeastern University School of Law Boston, USA Prof Roy Chan President Action for AIDS Singapore Dr. Andrew Scheibe HIV Key Populations Consultant Cape Town, South Africa Dr Michelle Moorhouse Member, Board of Directors, Southern African HIV Clinicians Society Elizabeth Levy Paluck Assistant Professor of Psychology and Public and International Affairs Princeton University Princeton, USA Wendy E. Parmet Associate Dean for Academic Affairs Matthews Distinguished University Professor of Law Northeastern University School of Law Boston, USA Polly Clayden HIV i-Base London, UK Veronica Miller, PhD Director, Forum for Collaborative HIV Research Visiting Professor, University of California, Berkeley School of Public Health USA Benjamin Hauschild, MPH Senior Research Associate, Forum for Collaborative HIV Research University of California, Berkeley School of Public Health USA Professor Gwynne Skinner Willamette University College of Law Salem, USA Keith M Mullei, MPH Health systems and health policy researcher Nairobi, Kenya Christine L. Lin Clinical Instructor and Staff Attorney Center for Gender & Refugee Studies Refugee & Human Rights Clinic University of California, Hastings College of the Law San Francisco, USA Deborah A. Ramirez Professor of Law Northeastern University School of Law Boston, USA Francisco J. Rivera Juaristi Director, International Human Rights Clinic Assistant Clinical Professor of Law Santa Clara University School of Law Santa Clara, USA Stephen A. Rosenbaum Visiting Senior Lecturer, University of Washington School of Law John & Elizabeth Boalt Lecturer, University of California, Berkeley School of Law USA Felicia Price, RN, BSN, MIA Technical Advisor - Community Health and HIV Christian Aid Bujumbura, Burundi Judith D. Auerbach, PhD Adjunct Professor School of Medicine University of California San Francisco, USA Anna Forbes, MSS Independent consultant specializing in HIV, rights, women and gender Washington DC, USA Rosalind P. Petchesky Distinguished Professor of Political Science (Emerita) Hunter College & the Graduate Center, City University of New York USA