A/HRC/41/45/Add.2 Fund to Fight AIDS, Tuberculosis and Malaria. Given the absence of a specific focus on sexual orientation and gender identity in the national health policy, the lesbian, gay, bisexual and trans community must find allies to access lesbian, gay, bisexual and transfriendly health services, including among reproductive health communities. Several such organizations that were receiving global health assistance from the United States of America for implementing programmes related to sexual and reproductive health have been affected by the so-called global gag rule. Under this policy, foreign organizations receiving United States global health assistance are prohibited from performing or promoting abortion as a method of family planning, including by offering legal advice or counselling related to abortion.21 Given that many of these organizations often bring together a wide range of services, from HIV prevention, care and treatment to family planning, this rule has an indirect impact on the right to health of the lesbian, gay, bisexual and trans populations. Research has shown, for example, that the Mozambican Association for Family Development had to close several clinics that were considered lesbian, gay, bisexual and trans-friendly due to the dramatic reduction in its budget that resulted from its inability to comply with the requirements under the global gag rule. 22 62. The specific health needs of gay men (aside from their behaviour as men having sex with men), lesbian women, bisexual persons and trans men are completely omitted from national health policies. Only a small number of health facilities are known by the community for being lesbian, gay, bisexual and trans-friendly. The Independent Expert was told that some members of the community bribe medical doctors to be assigned a “good” caregiver, one who treats them with respect and dignity. He heard testimonies of trans persons who would conceal their gender identity and remove female clothing and attire to avoid being mocked or ridiculed by caregivers or by others when health professionals would call them using their male name. Others said they would rather resort to traditional healers to receive treatment for sexually transmitted diseases or have recourse to selfmedication. The early closure of health-care facilities, at 3 p.m., constitutes another obstacle to accessing health services by trans sex workers. 63. Health disparities facing lesbian, gay, bisexual and trans populations generally stem from a variety of factors, including from the stress they experience on the basis of sexual orientation and gender identity. This stress is induced by the discrimination, stigma and internalized homophobia, biphobia and transphobia experienced by individuals in their daily lives. It is also influenced by other factors that shape each individual’s identity, such as race, ethnicity, religion, health status and migration and economic status. It has been linked to mental health problems and other adverse health outcomes. 23 64. In the absence of psychosocial professionals trained on issues regarding sexual orientation and gender identity, Lambda has started offering free psychosocial support to lesbian, gay, bisexual and trans individuals and their families and has conducted various training programmes to expand psychosocial support. The services provided, however, remain diminutive compared with the need. 65. There is no access to gender affirmation treatment, such as surgery or hormonal therapies. As this is an essential element to affirm their gender identity, transgender persons may risk using artisanal procedures, such as the injection of industrial silicone oil for breast augmentation. Those who can afford it may go to neighbouring countries to get treatment not available in Mozambique. When they come back, however, they face risks linked to the discrepancy between their gender expression and their legal identity. 21 22 23 See Adva Saldinger and Lisa Cornish, “An atmosphere of fear under ‘global gag rule’ shows comprehensive new report”, Devex, 6 June 2018. See Center for Health and Gender Equity, Prescribing Chaos in Global Health: The Global Gag Rule from 1984–2018 (Washington, D.C., 2018). See Ilan H. Meyer, “Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence” Psychological Bulletin, vol. 129, No. 5 (September 2003); and Karel Blondeel and others, “Violence motivated by perception of sexual orientation and gender identity: a systematic review”, Bulletin of the World Health Organization, vol. 96, No. 1 (January 2018). 13