deterring effect on key populations users, who lose confidence in the facility, and are less Identity matters, not only biology. Moreover, identity matters to biology. And this is relevant likely to return for other services. to health workers who aim to provide quality services. Service-users need to be able to speak freely about who they are to describe and discuss the symptoms, the behaviours, Four areas define this “small set of high-demand services”: the concerns that lead them to seek care. Without that complete picture, service providers i. Services that acknowledge and affirm the sexual and reproductive health needs of women cannot make an accurate diagnosis that facilitates quality care. who have sex with women: availability of protective barrier methods (eg. finger cots; dental dams); appropriate cervical cancer screening methods (eg. sensitivity to and caution in the Sexual rights are extensions of human rights and include the right to quality sexual health; use of speculums); ability to have private, non-group, pre-HIV test couples counselling; to a safe and satisfying sexual life with a partner or partners of choice; to self-determinism, consulting questionnaires that use inclusive language. control and agency in matters of sexuality, reproduction, bodily integrity and gender ii. Trans-specific healthcare, including protective barriers that provide for lesbian or bisexual identity; to access to services and information that make it possible to appropriate these women and trans men (dental dams, finger cots, female condoms, gloves); availability of rights. Achieving good sexual and reproductive health is indivisible from good sexual and hormones and knowledge about the interactions of hormones with other drugs such as reproductive rights. ARVs; provisions for psychosocial support and mental health that include gender, sexuality and partner counselling; binders and knowledge about their effects on breast cancer; While this formulation suggests that advancing human rights in a suppressive and information about gender-affirming surgery for which the government makes provision for oppressive society is necessary to facilitate better health outcomes, the reverse is also true: intersex people, but not for trans people. that better rights might be achieved, across the universal spectrum of rights, in the course of iii. Drug shortages most relevant to the treatment of sexually transmitted infections, conscientiously strengthening delivery of sexual and reproductive health programmes and specifically benzathine penicillin and Podophyllin indicated in the treatment of genital warts. services. iv. Access to STI management and treatment as a stand-alone programme, not as a secondary/referral service following HIV-related testing and treatment. In oppressive socio-political environments, where certain citizens are victimised by having their sexual identities invisibilised, invalidated, delegitimised or criminalised, it is especially 6. Good sexual and reproductive health are indivisible from good sexual and reproductive rights. important that health service-providers not reinforce that institutionalised culture of violation. It is clear from what has already been discussed, and from what will be discussed in other marginalised and suppressed community in society – observe other fundamental rights in sections of this report that where sexual identities and diversity are affirmed in the design the way services are delivered: and delivery of services to key populations, demand, access, uptake and utilisation of services increase. Identity – sexual orientation, gender identity, gender expression – is not incidental to seeking If “good” public health services, in general, are where people feel respected and treated with dignity, then it is essential that health-providers trying to reach key populations – an already 7. In social and political environments where sexual rights are denied, other rights require greater recognition! healthcare and services. Where identities and rights are suppressed, denied or invisibilised – • the right to privacy; where gay men do not feel confident to talk about an anal infection because it reveals their • the right to information; orientation; where a trans woman presents at a facility as a straight man in order to receive services free of fear and discrimination; where lesbian women lie about their domestic partner in response to a presumptively heterosexual series of questions – health outcomes suffer. PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 13