Stigma, sexual health, and human rights among women who have sex with women in Lesotho

Abstract

In recent years, gender and sexual minorities have become increasingly visible across sub-Saharan Africa, marking both the progression and violation of their human rights. Using data from a study with sexual minorities in Lesotho, this analysis leveraged the social ecological model to examine relationships between stigma, human rights, and sexual health among women who have sex with women in Lesotho. A community-based participatory approach was used for the mixed-method, cross-sectional study. A total of 250 women who have sex with women completed a structured questionnaire, of which 21 participated in a total of three focus group discussions. Stigma was common within and outside the health sector. Stigma and human rights abuses were associated with increased risk for HIV and STIs. Interventions to address stigma at the structural, community, and interpersonal levels are essential to ensuring sexual health and rights for women who have sex with women in Lesotho.

Résumé

Ces dernières années, les minorités sexuelles et sexospécifiques sont devenues de plus en plus visibles en Afrique subsaharienne, marquant à la fois la progression et la violation de leurs droits fondamentaux. En utilisant les données d’une étude sur des minorités sexuelles au Lesotho, cette analyse a exploité le modèle écologique social pour se pencher sur les rapports entre la stigmatisation, les droits de l’homme et la santé sexuelle des femmes qui ont des relations sexuelles avec des femmes au Lesotho. Une approche participative à assise communautaire a été utilisée pour l’étude transversale et à méthode mixte. Un total de 250 femmes qui ont des relations sexuelles avec des femmes ont complété un questionnaire structuré et 21 d’entre elles ont participé à un total de trois discussions par groupe d’intérêt. La stigmatisation était fréquente à l’intérieur et à l’extérieur du secteur de la santé. La stigmatisation et les violations des droits de l’homme étaient associées à un risque accru de VIH et d’IST. Les interventions pour s’attaquer à la stigmatisation aux niveaux structurel, communautaire et interpersonnel sont essentielles pour garantir la santé et les droits sexuels des femmes qui ont des relations sexuelles avec des femmes au Lesotho.

Resumen

En años recientes, las minorías sexuales y de género se han vuelto cada vez más visibles en Ãfrica subsahariana, lo cual indica tanto la progresión como la violación de sus derechos humanos. Utilizando datos de un estudio con minorías sexuales en Lesoto, este análisis aprovechó el modelo ecológico social para examinar las relaciones entre estigma, derechos humanos y salud sexual entre mujeres que tienen relaciones sexuales con mujeres. Para el estudio transversal con métodos combinados, se utilizó un enfoque participativo comunitario. Un total de 250 mujeres que tienen relaciones sexuales con mujeres contestaron un cuestionario estructurado; de éstas, 21 participaron en un total de 3 discusiones en grupos focales. El estigma era común dentro y fuera del sector salud. El estigma y los abusos de derechos humanos estaban asociados con mayor riesgo de contraer VIH e ITS. Las intervenciones para abordar el estigma a nivel estructural, comunitario e interpersonal son esenciales para asegurar salud y derechos sexuales para las mujeres que tienen relaciones sexuales con mujeres en Lesoto.

Keywords:

• women who have sex with women
• Lesotho
• sexual health
• human rights
• mixed methods

Introduction

Same-sex practices have existed in sub-Saharan Africa since long before European colonial powers arrived and introduced sodomy laws.^1,2 Despite the end of colonial rule, same-sex practices remain criminalized in 38 sub-Saharan African countries; and several countries have enacted even more punitive legislation focused on homosexuality itself rather than sexual practices.^3,4 State-led backlashes began in the 1990s during a time when the World Health Organization removed homosexuality from the International Classification of Diseases and growing numbers of people across the continent began to come out. These backlashes continue, as seen in new laws and constitutional amendments to preclude sexual minority rights in Uganda, Nigeria, Malawi, and Burundi, amongst others.⁵ Backlash has not been limited to legislation, but has also included physical and sexual violence at the hands of the general public and even the police.^6,7

In their recent publication, Born Free and Equal, ⁸ the United Nations Human Rights Commission (UNHRC) asserts that the legal obligations of States to safeguard the human rights of lesbian, gay, bisexual, transgender, and intersex (LGBTI) people are well established in international human rights law and called on States to meet five core obligations including: protection from homophobic violence; prevention of cruel and degrading treatment; decriminalization of homosexuality; prohibition of discrimination based on sexual orientation; and respect for freedom of expression and association. This official UN document builds on earlier work by international human rights experts who drafted key principles on the application of human rights law to sexual orientation and gender identity at a meeting in Yogyakarta in 2006.⁹

Social ecological models describe how interpersonal, community, and structural (law and policy) factors impact individual health.¹⁰ Sexual stigma refers to stigma against sexual minorities,¹¹ and it operates across multiple social ecological levels. It may manifest in overt discrimination and violence (enacted stigma) as well as negative social attitudes and norms, and fears of rejection (felt normative stigma).¹² Stigma requires the exercise of power in order to be enacted,¹³ and the failure to protect LGBTI populations from enacted sexual stigma is an abuse of their human rights. Human rights have consequences for population health. There is a growing literature linking human rights abuses to increased risk for HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM).^14,15 However, despite evidence of vulnerability to HIV and other STIs,^16,17 women who have sex with women (WSW) have been absent from the global discourse on HIV.^18–20 Data linking health and human rights for WSW are rare,²¹ and virtually nonexistent in the African context. Our study addressed this lack of data by examining the relationships between sexual stigma, human rights, and HIV/STIs among women who have sex with women (WSW) in Lesotho.

Methods

Study Setting

The Kingdom of Lesotho is a lower-middle-income country in southern Africa with a national HIV prevalence of 23%, and HIV is the leading cause of death.²² The law in Lesotho is silent on same sex practices between women; however, homophobic violence and discrimination occur. Official reports are uncommon due to fear of further stigmatization.²³ In 2008, a small group of friends formed Matrix Support Group, the first LGBTI organization in Lesotho. They have since grown into an officially registered, national, non-profit organization providing support, education, and human rights advocacy. A community-based participatory approach was used for this mixed method, cross-sectional research. Matrix Support Group partnered with academic researchers in the study design, data collection, and analysis.

Study Population and Sample

Study participation required the ability to provide informed consent in either Sesotho or English. Eligibility criteria included being 18 years of age or older, assigned female sex at birth, and reporting a history of sex with a female, regardless of sexual or gender identity. Most participants were young (mean age 24.2); and 36% were unemployed. Lesbian/homosexual was the most common sexual identity (48%), followed by bisexual (29%), and heterosexual/straight (20%). Only 25% had disclosed their same-sex practices to a health worker; and 45% had disclosed to a family member. While the term WSW has been contested in Western discourse,²⁴ the diversity of sexual identities and behaviours within the study population precluded the use of a single identity label. In consultation with community members, WSW was selected as the most appropriate term to describe participants.

Ethics Statement

Ethics approval was received from the Ministry of Health and Social Welfare in Lesotho as well as the Institutional Review Board at Johns Hopkins Bloomberg School of Public Health. To maximize the confidentiality and safety of participants, no written materials describing the study were distributed nor were written consent forms used. Prior to enrolment, all recruited individuals provided verbal consent. Anonymous codes were assigned to the data for each participant; and no identifying information was collected at any point during the study.

Study Accrual

Participant accrual took place from October – November 2009 in four urban centres: Maseru, Mafeteng, Hlotse, and Maputsoe. Fifteen initial participants came from the membership of Matrix Support Group and functioned as study interviewers. They completed the study questionnaire prior to attending a two-day training that included the purpose of the research, design of the research project, human subjects protection, interviewing methods, and data integrity. Each initial participant recruited 10-15 members of their social networks, then trained those contacts how to recruit others until the desired sample size was reached. In addition to salary, an allotment of 45 Maloti (US$ 6.50) per interview was provided for each interviewer to cover the costs of transportation and refreshments for the participants.

Data Collection

A total of 250 WSW completed a face-to-face structured interview using the study questionnaire. The brief 45-question survey was developed in Lesotho in consultation with LGBTI community members, the National AIDS Commission, the Ministry of Health, UNAIDS, and UNDP. Domains included demographics, sexual practices, sexual health, and experiences of stigma. Each interview lasted approximately 30 minutes.

A subset of survey participants who expressed interest and met criteria were invited to attend one of three focus group discussions (FGDs). Each focus group included 6–8 individuals for a total of 21 participants. FGDs took place in Maseru, Mafeteng, and Maputsoe. These participants were remunerated with 20 maloti (US$ 3.00) to cover transportation costs. FGDs were conducted using a discussion guide developed in consultation with community members. Domains of these discussions included sexual identity, sexual practices, relationship patterns, and social context for WSW in Lesotho. All FGDs were led by a facilitator, drawn from the community, who received additional training in group facilitation skills. Each discussion lasted 60-90 minutes, with an average duration of one hour.

Statistical Analysis

Quantitative data were entered into Microsoft Excel and analysed using Stata 11 (StataCorp, College Station, TX). Means, ranges, and frequencies were calculated. Bivariate analyses included two-sample tests for differences in proportions, ȕ² tests of independence, and logistic regression assessing the relationship between covariates and outcomes of interest.

Qualitative Analysis

Focus groups discussions were conducted in Sesotho, then transcribed and translated into English by a bilingual native Sesotho speaker and research team member. We conducted thematic analysis²⁵ informed by the social ecological framework.¹⁰ First, two separate analysts manually applied topical codes (e.g., stigma) to each transcript (without software). These codes were grouped into themes (e.g., types of stigma) by iteratively examining coded text across the data set. Themes were then assessed in relation to the social ecological framework to develop a thematic map (e.g., family, community, institutional levels); and refined (e.g., organizing different types of stigma across multiple levels) for manuscript presentation.

Quantitative Findings

Prevalence of Stigma

As depicted in Table 1, experiences of stigma were common. Of respondents, 74% experienced at least one form of sexual stigma. The most common form was verbal or physical harassment reported by 52%, followed by blackmail reported by 29%. Additionally, 14% had been beaten because of their sexual orientation. Nine percent reported that they had been raped; however 23% did not answer the question about rape. Of respondents who reported having been raped, 69% knew their rapist, and 31% believed they had been raped because of their sexual orientation.

Table 1 The prevalence of stigma and abuses among WSW in Lesotho

Characteristic	Percent (proportion)
Have ever been raped	8.8% (17/193)
Believe were raped because of sexual orientation or practices	31.3% (5/16)
Knew rapist	68.8% (11/16)
Yes to any human rights abuses related to sexuality (below)	74.0% (151/204)
Due to sexual orientation, in last 3 years:
Lost employment	5.1% (11/215)
Afraid to seek health care services	22.3% (49/220)
Were denied health care services	4.2% (9/213)
Felt health care workers unable to meet needs	23.0% (47/204)
Heard health care workers gossiping	22.5% (47/209)
Felt legal or police discrimination	12.4% (26/210)
Been verbally or physically harassed	52.2% (117/224)
Blackmailed	28.7% (60/209)
Beaten up	14.3% (31/217)

Health care-related stigma was also common. Only 4% of the participants reported being denied health care services; however 22.3% reported being afraid to seek health care services because of their sexual orientation and 23% felt that health care workers were unable to meet their needs. Twenty-three percent had heard health care workers gossiping about them.

Associations with Stigma

Table 2 lists factors associated with experiences of stigma. Participants who identified as lesbian/homosexual had twice the odds of experiencing at least one form of stigma compared to those who identified as heterosexual. Respondents who had ever been married or who had ever had sex with a male partner had 0.4 times the odds of experiencing stigma compared to those who had not. Respondents who had disclosed their same-sex practices to a health worker had 2.5 times the odds of experiencing stigma compared to those who had not. And those who had an HIV test in the previous 12 months had 2.4 times the odds of experiencing stigma.

Table 2 Significant bivariate associations with stigma and abuses among WSW in Lesotho

Any stigma experience	OR (95% CI)
Disclosed same sex practices to health worker	2.5 (1.1, 6.2)
Had an HIV test in the last 12 months	2.4 (1.3, 4.6)
Identified as lesbian/homosexual	2.0 (1.0, 4.2)
Ever married	0.4 (0.2, 0.9)
Ever had sex with male partner	0.4 (0.2, 0.8)
Specific stigma experience
Disclosed same sex practices to health worker
Blackmailed	2.3 (1.1, 4.5)
Afraid to seek health services	2.6 (1.3, 5.5)
Felt health care workers unable to meet needs	3.4 (1.7,7.1)
Heard health care workers gossiping	2.6 (1.3, 5.5)
Lost employment	8.5 (2.1, 34.4)
Felt legal or police discrimination	2.5 (1.1, 6.1)
Been verbally or physically harassed	2.5 (1.3, 5.0)
Diagnosed with HIV
Blackmailed	3.0 (1.0, 8.9)
Afraid to seek health care services	3.7 (1.2, 10.9)
Lost employment	15 (3.3, 68.2)
Felt health care workers unable to meet needs	3.2 (1.1, 9.7)
Diagnosed with STI
Blackmailed	5.1 (1.2, 21.3)
Denied health care	8.9 (1.5, 52.0)
Felt legal or police discrimination	4.6 (1.0, 20.6)
Identified as lesbian/homosexual
Been verbally or physically harassed	2.1 (1.3, 4.4)

An analysis of specific stigma experiences found that disclosure of sexual orientation to health workers was associated with 8.5 times the odds of having lost employment, 2.6 times the odds of being afraid to seek health services, 2.3 times the odds of being blackmailed, and 2.5 times the odds of being harassed. Enacted stigma in employment had the strongest association with self-reported HIV status. Those who had lost employment had 15 times the odds of reporting an HIV diagnosis. Those who had been blackmailed had 5 times the odds of reporting an STI diagnosis; and those who had been denied health care due to sexual orientation had 8 times the odds of reporting an STI diagnosis.

Qualitative Findings

Participants described violence, stigma, and human rights violations across multiple sites: family, community, and institutions. Stigma was associated with actual and perceived sexual orientation, and manifested as felt normative as well as enacted – including sexual, physical and verbal violence.

Family

Interpersonal manifestations of stigma in familial settings resulted in exclusion and often direct violence. The impacts of enacted stigma were often devastating; as a participant in Maseru described:

“the person who found out first was my mother. She kicked me out of her house and said I must never go there.” (P2)

Another participant described a violent reaction when her father caught her having sex with another woman:

“He slapped my face, that chick [sic] went out the window; she left and did say that her dad’s going to hit us; we’d better run away.” (Maputsoe P3)

Others described the isolating impact of felt normative stigma on families:

“The parents will be aware of the type of life their child lives, but because of fearing public shame they end up not feeling comfortable, their friends not able to come around, that thing makes us fight with our mothers. Now my friends don’t come over, when my baby [girlfriend] visits me she says ‘what will people say’. It causes friction between us, that issues for the community ended up being prison doors.” (Maseru P1)

Community

Community norms that stigmatized sexual minorities presented threats and resulted in self-segregation:

“We separate ourselves you see, ‘cause there are meetings where it’ll be said only normal people should come… we’re different meanwhile we’re part of the community. You deserve the same rights as everybody else; they can be stigmatized because of the community, or because of the family, everybody who does something right now - you yourself already have a question mark.”

This segregation was evidenced in public spaces such as toilets and washrooms:

“Girls are chased out of toilets. I have a friend of mine when women see her in the toilet they ask if she’s lost.” (Mafeteng P5)

Another participant described:

“It makes for a hard life. The cleaner called me aside and told me that ‘honestly I’m not comfortable. If you’ve noticed, I bathe when you’re gone; or if I need to pee, I have to wait for you to be gone first. So please give me space so I can do everything’.” (Maputsoe P2)

Participants reported experiencing enacted stigma from community members and peers in multiple forms: verbal, physical, and sexual. A participant described the use of derogatory terms to insult their mental capacity: “some say they’re doing a retarded thing, like stabane [dyke],” (Maputsoe P7) corroborated by another participant:

“that’s my mother who says that. When I said I’m coming to this meeting she said hey that meeting of yours for retards!” (Maputsoe P3)

Other insults reported included: “you’re rubbish, you’re a fakeche [faggot]!” (Maputsoe P3) Name calling was often exacerbated when participants were seen with other WSW: “sitting together, that’s when I first heard that word, fakeche.” (Maputsoe P7)

Threats and fear of physical abuse emerged as a constant concern among participants. Participants discussed feeling threatened at parties by people who knew they were WSW:

“I’ve gone partying, I see a chick. I try talking to her, there’s isn’t even anything there I’m saying to her, so her boyfriend or the people she’s with jump in there, because they know what kind of a person I am. You see, they scare me there: ‘we’re going to beat you up!’ ” (Mafeteng P2)

This fear often restricted movement – “I’m not safe if there’s no one I’m walking with. I wouldn’t walk by myself.” (Mafeteng P2) The convergence of verbal abuse and threats resulted in pervasive fears of violence:

“it’s very dangerous when it’s behind your back not knowing what they’re planning, meaning that actually you don’t live nicely, you don’t know what’s in store for you, today you’re gone tomorrow they tell you that others are not comfortable about your lifestyle.” (Maputsoe P5)

Threats of sexual violence were omnipresent in participant narratives. A participant explained:

“they really like to say, ‘I can rape you’ or ‘if I ever get you at night I’ll rape you’ those kinds of things." (Maputsoe P4)

These threats were directly linked to perceived sexual orientation:

“sometimes in the community they’ll be saying ‘let’s see if you’re actually a boy or a girl, strip let us see you’; they’ll want to strip you, that’s the thing I fear most as a lesbian woman.” (Maputsoe P7)

These threats also targeted female same-sex couples:

“Not only in the home, even outside, a guy can just get on your case, ‘I don’t understand, when I have to screw you both now [because] you’re the ones who are all over each other’.” (Maputsoe P1)

Institutions and Structures

Religion

Discrimination in religious institutions was commonplace and was reflected in community norms. For instance, verbal abuse depicted religious stigma against LGBTI people: “you’re full of demons” (Mafeteng P4) and “she said I’m full of satanic spirit, things like that.” (Mafeteng P2) Another participant narrative illustrated that the very presence of sexual minorities was often perceived as an insult to the church:

“Without knowing when we say a person is a woman who has sex with woman, or is gay what we mean, because sometimes they think it’s someone with evil spirits, they’re doing it on purpose. They’re insulted to the point a person doesn’t want to hear anything.” (Maputsoe P6)

Despite the discrimination and negative messaging in religious structures there was resistance to this exclusion among several participants:

“I was fed up with someone who’d read me the bible and then tell me that it’s against me and yet when you look at that person you find that their actions are much worse than yours even though they call you gay, or whatever they call you. So I went to bible school and found out that actually a person can turn to the bible. So I still go to church I don’t care what they say, when they say amen I take my bag and go.” (Maseru P1)

Participants also discussed challenging stigmatizing beliefs among priests and fellow church members. They resisted judgment and highlighted notions that they were created by God: “we didn’t make ourselves this way” (Maputsoe P1) and could only be judged by God:

“when I’m gone from this world I’ll be judged, and when I answer these past issues of my life I’ll answer alone.” (Maputsoe P3)

Employment and education

Participants discussed stories of WSW losing employment once employers discovered their sexual identity:

“there’s that one whose work ended because of what she is. It started as rumors until it became confirmed that she was sleeping with another girl.” (Maputsoe P1)

These stories also resulted in fear; when asked about something scary that had happened to another WSW a participant responded:

“it’s someone who lost their job.” (Mafeteng P4)

Fear of being discovered as a WSW in schools – suggestive of felt-normative stigma – was also raised:

“afraid cause . . . even at schools you can still get expelled, they could say well now you’re like this, because a lot of people don’t understand.” (Maputsoe P5)

Law and Police

Even though the Lesotho penal code does not address female same-sex sexual conduct, fear of arrests due to criminalization of sodomy was a concern among participants. Fear and displacement resulted from news reports of a woman being arrested for homosexuality:

“I think after that case that was in the papers, majority of us who were in Maseru, including myself and others, even though they were not exposed, we had this fear that, there was a rumor that she’s going to expose those who’re like her [WSW]. We had a fear of staying in Maseru that’s why some of us ended up living in Leribe, because we were scared, even to answer the phone we ended up not answering your phone cause you might come and get arrested or whatever, we were really scared. You were afraid to walk with your partner, thinking what if we get caught.” (Maputsoe P3)

Some participants felt that their sexuality limited access to the justice system. For example, participants were reluctant to seek support for intimate partner violence:

“Sometimes you want support, maybe your person’s violent you see, then you want to go to the police – so what should we do?” (Maputsoe P4)

This was corroborated by another participant:

“Even if she’d hit me when I get to the police and say my person has hit me, they’ll try to blackmail me so that I don’t end up going to court because they don’t understand when you’re both women.” (Mafeteng)

Another participant provided an illustrative example of mistreatment, based on sexuality and gender non-conformity, by the legal system:

“There’s no place for cases for people like us to be dealt with by the law. . . The police degraded me so much so that when I stood in front of the magistrate, appearing there with the lawyer, it became a problem of how this case would be dealt with. They had a problem of which prison they were going to take me to, whether they’d take me to the women or men; I had to be remanded to the magistrate who even told the lawyer that if this person was to be put in prison, the international organization would accuse the country of Lesotho and we’d be the ones involved because there’s nowhere to take her, because anywhere we take her, she’ll be stigmatized; just as the police already have in the charge office.” (Maseru P1)

Legal recognition was highlighted as key to human rights realization. Without it, participants felt they were not fully seen as citizens:

“people of our status who date same sex are not featured at all in the country’s laws, that means we’re not considered as people who exist in the country, that is it’s the same as if we were not there – that there’s only girls and boys who’re dating only.” (Mafeteng P4)

Lack of legal protection also presented barriers to disclosing sexual identity:

“we’re not hiding, but our law still says nothing. Maybe it’s still a threat to us if we were to come out. It’s still a derogatory thing- you won’t know where you’ll go - right now just go to that magistrate.” (Maseru P4)

In response to the lack of legal protection in Lesotho, participants discussed the need for international conventions to protect their human rights:

“in fact our law still says that where our law is silent it should be referred to what the international convention says in those cases.” (Maseru P5)

Another participant reinforced this idea:

“when our law says nothing doesn’t mean the world doesn’t say anything, so we look at what is said internationally – what are the practices.” (Maseru P4)

Solidarity

In the face of human rights violations and stigma, participants highlighted the importance of building networks with other WSW. Solidarity among WSW was described as a means of protection:

“With our friends only, people of the same status who we’re walking this path together. We’re protected amongst ourselves only, there’s no one else who can offer us protection except for ourselves.” (Mafeteng P4)

Another participant described a welcoming environment at a sexual health agency:

“I think they have a lot of understanding because, there was a day when they explained to us about the dangers for our health as in we can think there’s no risk if we sleep with other women rather than men you see so they said, we should go and hear how we can protect ourselves. So I think they’re people who can understand, really people I can talk to. Even when we go to (agency) to go test [for HIV/STI] with my person we’re treated normally, there’s no time when we’re stared at, we just tell them no we’re coming to test and we’re a couple, they’re just happy to see us, so excited they’re starting to see open people.”

This narrative highlights the importance of having centers that explain safer sex to WSW in a non-judgmental manner and also provide supportive counseling programs.

Discussion

Our analyses found widespread sexual stigma, human rights abuses, and lack of protections for WSW across social ecological levels with significant implications for their sexual health. It is clear that WSW in Lesotho did not have access to the core human rights described in the UNHRC Born Free and Equal report. While pervasive sexual stigma and human rights abuses have been well-documented among MSM in sub-Saharan Africa,^26,27 limited literature has examined the social context of HIV vulnerability among WSW.^28–30 This study is one of the first to provide evidence for the relationships between sexual stigma, human rights and HIV/STIs among WSW in southern Africa.

Our analysis brought together the social ecological model for assessing HIV risk contexts¹⁰ with human rights approaches to conceptualizing sexual minority women’s health disparities.²¹ Our findings indicate that sexual stigma takes place at multiple levels, including the family, church, and community, as well as via laws and policies. Even in the absence of de jure criminalization, the widespread belief that female same-sex practices were illegal resulted in de facto criminalization with negative health consequences. Therefore, efforts to improve the health and human rights of WSW must not stop at decriminalization. Addressing felt normative stigma through solidarity, community empowerment, and social support will be critical to translating better laws into better lives for WSW. The qualitative findings suggest that negative stereotypes of WSW as mentally ill predators contribute to stigma. Further research is needed to better understand how stigma is socially constructed in the Lesotho context so as to develop culturally appropriate and contextually relevant interventions that effectively reduce sexual stigma.

Differences in strength of association between HIV/STIs and various manifestations of stigma can help prioritize research and interventions. The strongest association was seen between employment discrimination and HIV. This suggests that employment protection may be a key element of HIV prevention among WSW in Lesotho. Within the health sector, ensuring that WSW have access to knowledgeable, stigma-free sexual health services may reduce vulnerability to HIV/STIs.

In conclusion, this study took an important step toward demonstrating critical relationships between human rights and sexual health among WSW, particularly in sub-Saharan Africa where there is a dearth of data on this population. The findings respond to the emerging body of global literature on the invisibility and marginalization of WSW in the HIV response.³¹ Our study contributes to the dialogue on social drivers of HIV among WSW, as well as community-based and legal strategies to promote sexual health and rights. Future research should develop and adapt contextually relevant multi-level interventions to promote sexual and human rights, and reduce HIV vulnerabilities among WSW.

Acknowledgements

The authors would like to dedicate this manuscript to Bafokeng Kaibe, a fierce Basotho community leader and advocate for human rights. His untimely death during the course of the study was a tragic loss to the community. We are grateful to all the community leaders who participated in the conception, implementation, and analysis of this project as well as to the study participants who shared intimate details of their lives for the purposes of this research. United Nations Development Programme (UNDP) Lesotho provided financial support, and Joint United Nations Programme on HIV and AIDS (UNAIDS) Lesotho provided technical and project management support.