Transgender and gender-diverse (TGD) people need access to appropriate and affirming healthcare that validates their identities so that they can overcome health disparities.
An article in the South African Medical Journal, titled "Gender-affirming care in South Africa: A cross-sectional survey of transgender and gender-diverse people in the Eastern and Western Cape provinces, South Africa" provides a comprehensive analysis of the experiences of, and need for gender-affirming care and HIV services for transgender and gender-diverse individuals in these provinces.
The article is the culmination of a research project led by Lynn Bust from the Desmond Tutu Health Foundation, based within the University of Cape Town's (UCT) Faculty of Health Sciences (FHS), and includes contributions from a team of researchers.
TGD people often face difficulties in accessing care, due to discrimination within the health system, and limitations in the provision of gender-affirming care. The aim of this study was to describe TGD people's access to and need for social, legal and medical transition, including psychosocial care, hormone therapy and surgery, as well as HIV services.
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"The study was conceptualised from shared lived experience of discrimination in healthcare services."
The study recruited a diverse sample of TGD people across races, ages and locations. A cross-sectional quantitative survey design was utilised, with 150 TGD individuals recruited via convenience sampling in the Western and Eastern Cape. Interviews were conducted using structured questionnaires. The results revealed a vulnerable population, with substantial levels of housing insecurity and unemployment, and poor access to medical gender-affirming care.
"There is a lot of value in gender-affirming care than just validating one's gender identity. If you have an identity document that matches your appearance, you are much more likely to be employed," Bust explained. "The majority of authors on this study are queer, and the study was conceptualised from shared lived experience of discrimination in healthcare services."
Limited access
She continued: "The paper highlights the huge gap between people's desire and need for gender-affirming care and actual access to those services. Looking at the data, there are a lot more people who have been able to socially transition and access non-medical gender-affirming practices which usually cost less and are more accessible. However, when it comes to legal transition and medical gender-affirming care, which includes hormones, surgery and psychosocial care, then the access drops significantly."
Sources of access to medical gender-affirming care are limited primarily to tertiary health institutions in the public sector in South Africa, with many services no longer provided by primary care clinics run by NGOs dependent on unpredictable international donor funding. Of particular concern is the limited availability of gender-affirming surgery, with a 15-20-year waiting list in the public sector.
In the private sector, medical aid does not generally fund gender-affirming care. This leaves TGD individuals with very limited access to gender-affirming surgery unless it is paid for out-of-pocket in the private sector, which is unaffordable for most people, especially TGD populations, who have a very high reported level of unemployment.
Collaboration
"Further barriers to accessing healthcare for TGD people include discrimination by health facility staff, lack of knowledge of healthcare providers, lack of availability and denial of services, financial barriers, internalised stigma and anxiety from TGD people about accessing services, as well as broader social inequalities that impact access to health services," Bust explained.
To improve access to comprehensive gender-affirming care services and create health systems inclusive of TGD people, partnerships between healthcare providers, health departments, legal institutions and TGD communities are essential.
"We have seen some steps in the right direction which have been taken by the Department of Health."
"There is a huge gap between research and policy in practice," she noted. "For us at the Desmond Tutu Health Foundation, we have seen that there have been some steps in the right direction which have been taken by the Department of Health, and with the sweeping United States funding cuts, we have been able to source funding to provide a temporary gender-affirming care service for people who were previously receiving this care by USAID-funded NGOs in Cape Town. We are also working directly with the Western Cape Department of Health and Wellness to ensure continuity of this care once our programme comes to an end."
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The expressed need for comprehensive support for gender-affirming care, including legal transition, psychosocial support, hormone therapy and gender-affirming surgery, along with the reported difficulties in accessing care, highlight the necessity for multidisciplinary teams to collaborate to provide better access to these essential services.
Study highlights:
Of the 150 respondents, 74.0% were people assigned male at birth (AMAB) and 26.0% were people assigned female at birth (AFAB).
Demographics showed a vulnerable population, with 18.7% with housing insecurity and 66.0% unemployed.
Respondents reported low levels of access to psychosocial care (45%), hormone therapy (32%), legal transition (4%), and gender-affirming surgery (3%).
Of the respondents who had not legally transitioned, 71.4% wanted to. Most respondents who had not accessed medical gender-affirming care services expressed a need for psychosocial care (77.1%) and hormone therapy (68.6%).
