LGBTQ+：因恥辱而團結在一起的社區
資料來源：2023 年 6 月 22 日在線發布 https://doi.org/10.1016/S2352-3018(23)00147-9
五月，烏干達總統約韋里•穆塞韋尼簽署了一項法案，將同性戀定為刑事犯罪。 烏干達的《2023 年反同性戀法》將對同性行為未遂的處罰增加至 10 年徒刑，並對所謂的嚴重同性戀案件（包括與愛滋病毒感染者發生同性性關係）引入死刑。 該法案增加了新的罪行，例如宣揚同性戀，最高可判處 20 年監禁。 該法律引起了全世界的譴責，其中包括美國總統喬•拜登。 全球抗擊愛滋病、結核病和瘧疾基金、總統防治愛滋病緊急救援計畫和聯合國愛滋病規劃署表示，法律的改變威脅到該國愛滋病毒應對工作的進展，而該國的愛滋病毒應對工作曾是非洲地區最成功的國家之一。 據估計，有 64 個國家將雙方同意的同性性行為定為刑事犯罪，52 個國家對 LGBTQ+ 問題的言論自由設置了法律障礙。對此類法律的任何加強或擴大都是朝著錯誤方向邁出的一步。將同性行為定為刑事犯罪會降低愛滋病毒檢測率並增加愛滋病毒負擔。在男男性行為者 (MSM) 中，刑事定罪可能會使接受檢測和接受治療成為高風險活動。在奈及利亞，MSM 報告稱，2014 年刑事定罪範圍擴大後，他們對尋求醫療保健的恐懼有所增加。與反LGBT 立法最嚴厲的國家相比，那些立法最嚴厲的國家的MSM 的檢測水平降低了20%，而且MSM 的地位意識也降低了70% 。此外，對 LGBTQ+ 問題言論自由的障礙和刑事定罪可能會阻礙提供愛滋病毒檢測和藥物治療的機構的工作。在同性性行為被定為刑事犯罪的地區，盛行率高出 5 倍，在最近有起訴的地區，盛行率高出 12 倍。國際男女同性戀、雙性戀、跨性別者和雙性人協會關於將成年人之間的同性性行為定為刑事犯罪的法律執行情況的報告發現，攜帶愛滋病毒相關藥物、保險套和有關性健康的文獻被用作藉口以及起訴嫌疑人的證據。
旨在損害 LGBTQ+ 群體人權的法律阻礙了抗擊愛滋病毒的鬥爭。 在跨國比較中，防止基於性取向、性別認同和愛滋病毒狀況的歧視與愛滋病毒感染者中較高的愛滋病毒狀況之知識和病毒載量抑制率相關。 來自美國的數據顯示，州級對性少數群體的支持（例如，承認同性婚姻以及擁有防止在就業、住房和公共住宿方面上歧視的法律）與較低的愛滋病毒診斷率、較低的晚期診斷率和MSM的死亡率的降低有關。 在《剌胳針》愛滋病毒雜誌最近的一項研究中，Andrea Wirtz 及其同事調查了美國東部和南部部分地區跨性別女性的愛滋病毒和死亡率。 尋求性別轉變的參與者的愛滋病毒血清轉化和死亡風險低於未尋求性別轉變的參與者，這顯示獲得照護具有積極影響。 證據清楚地顯示，LGBTQ+ 群體所有成員的權利狀況越好，愛滋病毒防治效果就越好。
除了烏干達的反人權立法之外，世界範圍內還存在令人擔憂的意識形態傾向，特別是在為跨性別者提供全面醫療保健方面。 2023年到目前為止，僅美國就簽署了超過75項反LGBTQ+法案，包括禁止性別確認照護、根據人們的性別認同使用浴室和類似設施，以及以學校為本的法案以及法律禁止討論性取向、性別認同和LGBTQ+ 人群等，並禁止學校工作人員使用兒童選擇的名字和代詞。 與 LGBTQ+ 歧視和恥辱相關的愛滋病毒風險展示了性少數群體和性別少數群體的相互關聯性。 此外，許多性別少數群體是性少數群體的一部分，並透過挑戰異性戀和二元性別表達而團結起來。在 Wirtz 及其同事對跨性別女性的研究中，只有三分之一的人被認為是異性戀或直人——任何針對跨性別者的權利限制都會影響整個 LGBTQ+ 群體。
在這個驕傲月，我們與其他人一起譴責烏干達的立法以及任何限制 LGBTQ+ 人群人權的法律。 自石牆暴動（註）以來，許多地區 LGBTQ+ 人群的生活有所改善，但意識形態和道德恐慌驅動的立法和政治言論依然存在。 愛滋病毒應對措施的成功與 LGBTQ+ 人群的健康和福祉息息相關。 各國政府必須採取行動保護整個 LGBTQ+ 群體的人權。 ■ 刺胳針愛滋病毒
註：石牆暴動 (the Stonewall riots)，又稱石牆騷亂、石牆起義、石牆反抗，是指1969年6月28日凌晨發生在美國紐約市格林威治村石牆酒吧的一連串自發性暴力示威衝突。警察臨檢直接導致了衝突的發生。石牆暴動常被認是美國史上同性戀者首次反抗政府主導之迫害性別弱勢群體的實例，亦被認為是美國及全球同性戀權利運動發跡的關鍵事件。
LGBTQ+: a community united by stigma
Published Online June 22, 2023 https://doi.org/10.1016/ S2352-3018(23)00147-9
In May, President Yoweri Museveni of Uganda signed a bill into law extending the criminalisation of homosexuality in the country. Uganda’s Anti-Homosexuality Act 2023 increases penalties for attempted same-sex conduct to a 10-year sentence and introduces the death penalty for cases of so-called aggravated homosexuality including same-sex sexual relations with people with HIV. The bill added new offences, such as promoting homosexuality, with a prison term of up to 20 years. The law prompted worldwide condemnation, including from US President Joe Biden. The Global Fund to fight AIDS, Tuberculosis and Malaria, PEPFAR, and UNAIDS have said the change in law threatens progress in the country’s HIV response, which has been one of the most successful in the African region. An estimated 64 countries criminalise consensual same-sex sexual acts, and 52 employ legal barriers to freedom of expression on LGBTQ+ issues. Any toughening or broadening of such laws is a move in the wrong direction. Criminalisation of same-sex conduct reduces HIV testing uptake and increases HIV burden. Among men who have sex with men (MSM), criminalisation can make getting tested and receiving treatment a highrisk activity. In Nigeria, MSM reported increased fear of seeking health care after criminalisation was expanded in 2014. Compared with countries with the least severe antiLGBT legislation, those with the most severe had 20% lower ever testing levels, and 70% lower status awareness among MSM. Furthermore, barriers and criminalisation to freedom of expression on LGBTQ+ issues can hinder the work of agencies that offer HIV testing and medication. Prevalence was five times higher in settings where samesex sexual acts were criminalised and 12 times higher in settings where there had been recent prosecutions. A report by the International Lesbian, Gay, Bisexual, Trans, and Intersex Association on the enforcement of laws criminalising same-sex sexual acts between adults found that carrying HIV-related medication, condoms, and literature on sexual health had been used as a pretext and evidence for prosecuting suspects.
The fight against HIV is hampered by laws designed to undermine the human rights of the LGBTQ+ community. In cross-country comparisons, protection against discrimination on the basis of sexual orientation, gender identity, and HIV status was associated with higher rates of HIV status knowledge and viral load suppression among people with HIV. Data from the USA show that state-level support for sexual minorities (eg, recognition of same-sex marriage and laws that protect against discrimination in employment, housing, and public accommodation) were associated with fewer HIV diagnoses, fewer late diagnoses, and lower mortality in MSM. In a recent study in The Lancet HIV, Andrea Wirtz and colleagues, investigated HIV and mortality in transgender women in parts of eastern and southern USA. Risks of HIV seroconversion and death were lower in participants who had sought gender transition than in those who had not, suggesting a positive impact of access to care. Evidence clearly shows that the better the rights situation for all members of the LGBTQ+ community the better the outcomes are for HIV.
Beyond Uganda´s anti-human-rights legislation, there is a concerning ideological drift worldwide, especially in regard to provision of comprehensive health care for transgender people. So far in 2023, the USA alone has signed into law more than 75 anti-LGBTQ+ bills, including bans to gender-affirming care, the use of bathrooms and similar facilities in accordance with people’s gender identity, and school-based laws such as bills banning discussions about sexual orientation, gender identity, and LGBTQ+ people and prohibiting the use of a child’s chosen name and pronouns by school staff. HIV risks associated with LGBTQ+ discrimination and stigma showcase the interconnectedness of sexual and gender minorities. Furthermore, many gender minorities are part of sexual minority groups, and are united by challenging heteronormative and binary gender expression. In Wirtz and colleagues’ study on transgender women, only a third identified as straight or heterosexual—any limitation of rights that targets transgender people affects the LGBTQ+ community as a whole.
This Pride month, we join others in condemning Uganda’s legislation alongside any laws that limit human rights of LGBTQ+ people. Since the Stonewall riots the lives of LGBTQ+ people have improved in many regions, but legislation and political rhetoric driven by ideology and moral panic persist. The success of the HIV response and the health and wellbeing of LGBTQ+ people are on the line. Governments must act to protect the human rights of the whole LGBTQ+ community. ■ The Lancet HIV