A/HRC/41/34/Add.1 47. In 2017, Kyrgyzstan made a commendable step forward by issuing the Manual on Provision of Medical and Social Care for Transgender, Transsexual and Gender Nonconforming Persons, 19 for use by medical professionals at all levels of the national health-care system and at other national institutions. The aim of the manual is to help medical professionals to provide medical and psychological care and assessments, psychotherapeutic and social support and specialized medical care to transgender, transsexual and gender non-conforming persons to maximize their overall physical and mental well-being. It also includes guidance on changing gender expression and making gender-affirming changes to the body, which may involve masculinization or feminization. Importantly, the manual stresses the need to change the gender marker in identity documents to give legal recognition to transgender, transsexual and gender non-conforming persons, and the need to assist them in their social readaptation. 48. While the manual sets one of the most progressive standards in the Central Asian region, it is yet to be fully disseminated among health-care personnel and is yet to be effectively used in health-care centres. Testimonies gathered by the Special Rapporteur indicated that the most pressing challenges related to changing the gender marker in identity documents and addressing the remaining discriminatory attitudes among healthcare personnel. Informal payments may sometimes help to remove the barriers faced by transgender, transsexual and gender non-conforming persons in their access to health-care facilities, although they can rarely afford the high prices that are demanded. 49. The Special Rapporteur reiterates the recommendation made by the Committee on the Elimination of Racial Discrimination in its concluding observations on the combined eighth to tenth reports of Kyrgyzstan to adopt comprehensive anti-discrimination legislation (CERD/C/KGZ/CO/8-10, para. 11). He joins the Committee in welcoming the readiness of the Government to work with United Nations agencies in drafting an anti-discrimination law,20 and further encourages the full implementation of that law. 50. Refugees and minority groups also face difficulties in gaining access to health-care services. Refugees who are recognized by the State hold identity documents issued by the State and one-year renewable residence and work permits. The majority of them have access to their livelihoods, but they can only gain access to public services by paying a rate applicable to foreigners, which is almost 10 times higher than the rate for persons who are not foreigners. These higher payments are not compatible with the 1951 Convention relating to the Status of Refugees, according to which fees should be moderate and commensurate with the fees charged to nationals for similar services (art. 25 (4)). 51. Refugees who are yet to be recognized by the State, but who are recognized by the Office of the United Nations High Commissioner for Refugees (UNHCR), hold UNHCR certificates that are not formally recognized by the State. While they are not expelled from the country, they are not entitled to work or to hold residence permits. They may gain access to health-care services, mainly through costly, informal payments, but they cannot purchase health insurance policies. Their access to health-care services is therefore very limited. 52. The vast majority of refugees, either recognized by the State or solely by UNHCR, are culturally and socially well integrated into society in Kyrgyzstan; they speak the language and have developed personal networks. Kyrgyzstan should strengthen its efforts to find local integration solutions with alternative protection measures and arrangements that effectively protect the rights of all refugees, including their right to physical and mental health. 53. Some ethnic Uzbeks, despite having been born in Kyrgyzstan, may also have to resort to paying the same rate for foreigners in order to gain access to health-care services. The lack of documents among the Uighur and Lyuli communities (Central Asian Roma) also prevents their access to health care. Populations with no State documents may be 19 20 10 Available from www.labrys.kg/ru/library/full/27.html. See www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=22996&LangID=E.