Background characteristics of the participants
Of the 60 participants, 33 resided in Mukono district, 56 were aged 18-28 years, 38 had attained secondary education, 55 were single and 18 were Catholic. Thirty-one of the participants engaged in sex work for a living (Table 1).
Table 1: Background characteristics of the study participants
Variable
|
Category
|
Number of respondents
|
District of residence
|
Mukono
|
33
|
Kampala
|
21
|
Wakiso
|
6
|
Age
|
18-28 years
|
56
|
29-39 years
|
4
|
Education level
|
No formal education
|
1
|
Primary
|
10
|
Secondary
|
38
|
Tertiary
|
11
|
Marital Status
|
Single/never married
|
55
|
Married
|
5
|
Religion
|
Catholic
|
18
|
Protestant
|
14
|
Muslim
|
20
|
Pentecostal
|
5
|
Seventh-day Adventist
|
2
|
Other
|
1
|
Main source of income
|
Sex work
|
31
|
Salaried
|
9
|
Casual work
|
7
|
Other businesses
|
13
|
Type of sex work
|
Street-based
|
2
|
Entertainment place-based
|
7
|
Residence/home-based
|
21
|
Other
|
6
|
Living arrangements
|
Home with family
|
14
|
Home without family members
|
21
|
Fellow transwomen
|
14
|
No home to stayat
|
11
|
Theme
|
Subthemes
|
Codes
|
Help-seeking
|
Sources of support
|
Support from key population-friendly healthcare facilities for medical services
|
Seek GBV support from key population-friendly civil society organizations
|
A minority of GBV survivors report to police
|
Seek support from friends and family
|
Nowhere to report incidences of GBV
|
Challenges while help-seeking at healthcare facilities
|
Challenges experienced during help-seeking
|
Health system-related challenges
|
Long distances to healthcare facilities providing GBV support services
|
Gender-based violence in some healthcare facilities
|
Lack of trans-competent healthcare providers
|
Limited GBV services and equipment available
|
Internalized stigma among transwomen
|
Challenges experienced at civil society organizations
|
Exposure to GBV by some managers of some civil society organizations
|
Discrimination of transwomen by some staff at civil society organizations
|
Lack of trans-competent legal personnel in civil society organizations
|
Legal system-related challenges
|
Lack of recognition of transwomen identity by the existing laws
|
Being asked inappropriate questions about experiences of GBV and gender identity
|
Violence perpetrated by police officers and prison inmates
|
Help-seeking following exposure to GBV
Respondents mentioned that they sought GBV support from civil society organizations, healthcare facilities, key population-friendly healthcare facilities, peer educators, and at times family and friends. It was reported that the respondents rarely sought GBV support from the police. The GBV support referral pathways are elaborated in the following subsections.
Support from key population-friendly healthcare facilities for medical services
Respondents who experienced GBV reported that they sought support from key population-friendly healthcare facilities and, on rare occasions, public healthcare facilities with key population programs. Theyoften sought post-exposure prophylaxis (PEP) for HIV, HIV testing and counselling services, and treatment for injuries sustained during the violence.
"Some guy forced me into sex and I got torn. I started bleeding so much and I called my friend for advice. He told me to go to the hospital and explain to the healthcare providers. That is how I first went to facility XXXX. They first gave me an injection and some tablets to reduce pain and afterward I went home." (IDI)
"Besides the healthcare facility, I can't run anywhere else. Even at the police station, I can't go there. After going to the facility, I return home and I stay there with my problems until I get better." (IDI)
GBV support from key population-friendly civil society organizations
Respondents mentioned that they sought GBV support from key population-friendly civil society organizations. Support received was in form of psychosocial support, e.g., counselling, legal support such as mediation with intimate partners, relocation, shelter, and nutrition support. When asked where they seek GBV support services, one of the respondents said:
“When the community where I was living found out I was a transwoman, they beat me up and I ran to PP [key population advocacy civil society organization]. What PP did was to carry out an investigation and when they found out it was true, they relocated me to a safer place.” (IDI)
“There are some transwomen who have been evicted from their homes because of transphobia. So, QQ [LGBT organization] provides shelter and feeding to such survivors.” (FGD)
"Yes, organizations like YY give us some GBV support. I stole someone's husband and I was burnt and badly beaten, but I got full treatment under their support." (FGD)
“And then there is ZZZ and AAA [key population-friendly civil society organization]. These have got clinics which can provide healthcare services to transwomen when they experience violence.” (FGD)
“There are other organizations that have worked hard to save transwomen. Many transwomen report violence such as cases of slapping and beating to these organizations. The executive director of QQ [LGBT organization] together with the one of PP [key population advocacy civil society organization] always help out transwomen because they are paralegals.” (FGD)
“We don’t report to police because QQ [LGBT organization] has helped us gain justice as transgender people. They work on us and ensure that we get the support needed. Even if at times, justice takes long to be realized.”(FGD)
A minority of GBV survivors reports to the police
Only a few of the respondents ever reported instances of GBV to the police. One of the key informants estimated that less than 5% of transwomendid sobecause the police also perpetrated violence which consequently led to stigmatization of transwomen. In addition, respondents also pointed out that they feared reporting cases of GBV to police since they did not believe that transwomen's gender identity existed.
“It is very hard. I think less than 5% of the cases are reported to police because it also stigmatizes transwomen.” (KI)
"For police, you can never [report to them]! I have never seen someone courageous enough to go to the police to report the partner or report anyone who has beaten her. Even though it's a landlord who has beaten a transwoman, she cannot go and report to the police. Usually, the pathway is ‘see the counsellor and then the doctor for medical treatment such as PEP in case you need to.’ But if you mention the word police, they will just say ‘let's leave it!’(KI)
"I can't go to the police. They are still in denial that transgender people exist. They say you are a man; how did you get raped!" (IDI)
Out of all the interviews, only one respondent acknowledged that she reported to the police. The respondent mentioned that the attitude of police officers was now changing compared to the past, and that they concentrate on the cases rather than gender identity.
“Police is now better. Before you would go to the police and the police officers would insult you saying:‘look at this gay fool.’ But nowadays, if you go to the police, they overlook your gender identity and consider the case that has taken you there." (IDI)
Seeking support from friends and family
A minority of the respondents mentioned that they sought support from friends and family in the event of exposure to GBV, particularly in healthcare settings. The survivors often confided in friends, especially transwomen. In addition, some friends helped the survivors to access medication in case they were afraid to go to the healthcare facilities.
“If such a thing [violence] happens, you may run to your friend who is confident and not scared of going to these facilities. She can collect for you the medication if she doesn’t fear.”(FGD)
“I have friends who are also transwomen, so I confide in them. I prefer friends from the trans community because they share the same experience so that makes you more comfortable than speaking to another person.” (IDI)
Whereas a considerable number of respondents sought GBV support from their friends, some felt that some friends would breach confidentiality and spill their secrets.
“If I need counseling, I have my brothers and sisters-in-law that support me. It’s better than going to your friend and they spill your secrets.” (FGD)
Nowhere to report incidences of GBV
A considerable proportion of the respondents opted not to report GBV experiences since they were not aware of where to go and because their gender identity was not recognized by law.
“Some of our employers will use all possible ways to entice you into having sex with them. When you refuse, they rape you before you’re out of the office! At times, you don’t want to have sex, but you have nowhere to report such a case.” (FGD)
“The law doesn’t favour us [transwomen], so we are not recognized. Police officers take advantage of this and mistreat us. We don’t have anywhere to report them.” (FGD)
“I go through all that alone. I have experienced a lot! I started managing alone since my dad disowned me. At some point, I got infected with HIV. The people that infected me are still there and I am here surviving.” (IDI)
Challenges faced while seeking GBV support services from the healthcare facility
Challenges while help-seeking at healthcare facilities
Whereas healthcare facilities were a haven to some transwomen post-GBV, some study participants reported challenges such as limited health services and equipment, long distances to the facility, abuse from healthcare workers, and gaps in the follow-up of the GBV cases.
Long distances to healthcare facilities providing GBV support services
Respondents mentioned that healthcare facilities providing key population-friendly services, including GBV support, were located far away from where they lived. They added that due to the long distances to such healthcare facilities and lack of money, it was very difficult for them to travel just after experiencing violence or while sick. The challenge of longdistance was exacerbated by a lack of equipment such as the proctology machine in nearby healthcare facilities, which forced many transwomen to travel to the only healthcare facility with such equipment.
"We would get the treatment but at times the healthcare facility is located far away. For someone that is already very sick, can't even walk, and has not been working, travel to the healthcare facility may become difficult." (FGD)
"We have mentioned all those transgender-friendly health facilities but the distance also hinders us from getting GBV services. For instance, only KK [key population-friendly healthcare facility] has the proctology machine. Therefore, if you require such services you have to go to KK. So, we request that they put these machines in other hospitals to reduce travel and related costs." (FGD)
Gender-based violence in some healthcare facilities
Respondents reported that the violence they experienced at the hands of healthcare providers while seeking GBV support services discouraged them from visiting healthcare facilities. Specifically, they mentioned inappropriate questions about their gender identity, denial of medical services due to their gender identity, and discrimination as some of the main challenges they faced while seeking GBV support services. Respondents mentioned that some healthcare providers went on to call the police to get them arrested or media representatives to create a news story.
"We would go to those healthcare facilities but we are asked a lot of questions. For instance, we are asked questions like ‘what happened to your anus?’ Then they will tell us to lay on the bed for a check-up and by the time you realize, you’re surrounded by police or media personnel.” (FGD)
Concerning asking inappropriate questions about GBV experience and transwomen's identity, respondents revealed that some healthcare providers asked where and why they had been raped, and how a fellow man can beat them up. To transwomen, such questions were demeaning and traumatizing. This consequently hindered access to and use of available GBV support services in such healthcare facilities.
“When I was raped, at first I didn’t tell anyone. I was in pain and hurt that I had no one to tell. I felt like killing myself. I used to sit on my bed and shed tears. Until I got someone that I shared my problem with and he took me to the hospital for a checkup. Because of what the doctor took me through, I reached a moment and told them that we should just leave the treatment. The doctor was telling me that, “they can’t rape you! How can they rape you? You also went there when you wanted it[sexual intercourse].” I told the person I came with that we should go.” (IDI)
"I have seen some transwomen who have been affected. She is raped, not even raped by one person but gang-raped, and by gang-raped I mean three men and above. You get it. It happens to them. Is she going to go to the hospital? Okay, she is going to go there, and then she is asked ‘where’ she was raped. That question is very rude and demeaning. Do you know what it means? You are raped and when you go to report the case, they ask you ‘where were you raped?’" (IDI)
“Usually when you go to access a service such as counselling, HIV testing or consulting and you are telling the story that ‘I was with my boyfriend and we ended up fighting.’ The healthcare provider will ask you ‘how can a fellow man beat you? That’s so weird.’”(KI)
Respondents revealed that they were at times denied medication once the healthcare providers found out their identity, which made it difficult for them to express themselves while seeking GBV support services.
"They discriminate against us after knowing who we are. Some can't even give you medication. Because of this, we fear to express ourselves to them. A health worker might know the cause of let's say bruises in the anus, and they can refuse to give us help.” (FGD)
Lack of trans-competent healthcare providers
Some survivors of GBV encounteredtrans-incompetent healthcare providers. Some healthcare providers in healthcare facilities used by transwomen were not aware of the transgender identity.
“There is also ignorance about transgender people. When you talk about transwomen, you have to first explain yourself so much. When you talk about GBV, there is no particular service offered or particular point available to take care of transwomen.” (IDI)
Limited GBV services and equipment available
Besides the lack of competent healthcare providers, respondents also mentioned that healthcare facilities lacked medicines and equipment. As a result, GBV survivors were requested to buy such medicines, yet they lacked money. Some respondents mentioned that whereas some healthcare facilities provided GBV services, gaps remained in the follow-up of such GBV cases.
“In most cases, most of the medications and equipment are not available at the healthcare facilities. They prescribe medication and if you have the money, you go and buy. Yet, in most cases, when you decide to go to these healthcare facilities you don’t have money. So, you just stay without treatment.” (FGD)
“The current referral system is not strong. I have sometimes referred transwomen for drugs but they are out of stock or they are not there in the pharmacy.” (KI)
Internalized stigma among transwomen
Internalized stigma evidenced by feeling embarrassed to share GBV experiences with healthcare providers hindered transwomen's access to GBV support services. Some transwomen feared to be seen by their friends while accessing GBV services from known transgender-friendly healthcare facilities. Respondents also mentioned that they found it difficult to confide in healthcare providers because they believed that they didn't understand them since they are not like them.
“As a transwoman, you may have a challenge explaining GBV experiences to healthcare providers. If your partner raped you and you have bruises around your anus, explaining what happened to the health worker is challenging and embarrassing, especially to people who don’t understand us.” (FGD)
“The reason why some of us get infections is that we fear to go to these healthcare facilities [key population healthcare facilities] since they know us. And once they know you, it might be the beginning point of discrimination.” (FGD)
Challenges experienced by transwomen while help-seeking at civil society organizations
Exposure to GBV by some managers of some civil society organizations
Respondents mentioned that the managers of some non-governmental organizations (NGOs) were also perpetrators of GBV. The transwomen were at times subjected to sexual and emotional violence which in the end discouraged them from seeking GBV support services such as obtaining shelter.
“Some of the managers of some NGOs are perpetrators of GBV. I decided to come to this NGO and stay. However, I am tortured but I keep quiet. Sometimes he can say ‘if you want to stay here, you must first have sex with me.’ If you refuse, he starts insulting and abusing you and he tells you to leave his shelter. You end up homeless with no one to support you. He doesn’t give me much help but he says hurtful words.” (IDI)
“Sometimes you may be hungry but you fear asking the executive director for food because you fear to be harassed and chased out of the shelter. I was in a happy family but the conditions were not good and I left. Sometimes he harasses me telling me I am a failure but I just keep quiet and patiently look for money to get capital and start working again.” (IDI)
Discrimination of transwomen by some staff at civil society organizations
Some respondents experienced discrimination by some civil society organizations. Preference was often given to men who have sex with men (MSM) as opposed to transwomen.
"Some organizations startup to help transwomen and they get funding. However, when we go to these organizations, they discriminate against trans persons and instead attend to MSM." (FGD)
"Most of these NGOs help their friends, they used to help us in the past but now that we are many, they select whom to help." (IDI)
Lack of trans-competent legal personnel in civil society organizations
Respondents mentioned that there was a lack of trans-competent legal personnel in civil society organizations and that the available legal personnel did not understand their experiences as transwomen.
“Most legal personnel are straight. They wouldn’t understand us. And they are not in these events or actions with transwomen so they can’t know better.” (IDI)
Challenges faced while seeking GBV support services from law enforcement settings
Lack of recognition of trans identity by existing laws
Respondents mentioned that transwomen were not recognized by existing laws and law enforcers such as the police. This meant that they could not express their gender identity while seeking GBV-related services.
“The law doesn’t recognize transwomen, and police officers are law implementers. You can’t tell them that you are trans yet the trans are not recognized by the law.” (FGD)
The fact that transwomen were not recognized by the law meant that they often ended up being imprisoned while they sought GBV support services from the police. At times, police officers were also perpetrators of GBV. These challenges are highlighted in the following quotes:
"Police officers are also perpetrators of GBV. As I said, you might be attacked in the bar and you go to report. When you reach there [the police] and they ask you ‘why did they beat you?’, if you tell the police who you are [transwoman], it might fuel the police officer to put you behind bars." (FGD)
“I was arrested by police but I could neither express myself as a woman nor as a man. I was scared of expressing who I am. Sometimes they arrest you for another case and they end up charging you for being a transwoman.” (IDI)
Being asked inappropriate questions about GBV and gender identity
Respondents mentioned that they were asked inappropriate questions about their GBV experience and their gender identity whenever they reported a case to the police. Police officers at times asked whether they are female or male, how they got raped, and why they went to a man's place of residence. Transwomen felt embarrassed to tell the police officers that they had sexual intercourse with a man. Consequently, this affected their access to GBV services. This is highlighted in the following quote:
"When you go to the police to report a case of rape, they will ask you:‘are you male or female? How were you raped? Why did you go to see the guy in the first place? What were you going to do there?’ How will you tell them that he is your boyfriend and you were going to have sex with him? Will you say it? Of course not! She [transwoman] will stay home, use warm water, salt and painkillers. Maybe she would go for the [HIV] testing after she is better and there are no more bruises. When she is asked how she got infected she wouldn't be able to tell them. How do you even open up that ‘I was raped by five men yet I am a man and I also have a dick." That's what the society expects you to be, a man, which you aren't." (IDI)
Violence perpetrated by police officers and prison inmates
Respondents mentioned that they did not have confidence in the police since, at times, this exposed them to more violence. Some respondents mentioned that they have been raped by inmates while in prison cells. In addition, some respondents mentioned that, at times, they had been forced to have unprotected sexual intercourse with police officers with the promise of being released from custody. Some respondents who experienced violence in prisons feared to report it due to being ashamed of their experience.
“Some police officers will force you to have sex with them against your will. Some say that ‘I first want to have sex with you and have a feel of how it is before I release you’. They use you without lubricants or a condom and even after sexually abusing you, they end up not releasing you even when you need to test for HIV. You can’t report the abuse anywhere and you don’t even know their HIV status.” (IDI)
"Our fellow prisoners rape us. Remember, when the police officer takes you to prison, they will tell everyone ‘that one is gay.’The prisoners start to applaud the police officer saying ‘ok, bring him in’. They forcefully have sex with you and at times you end up getting injuries. You end up rotting from there and with no treatment in the prison cells. Sometimes, you can't even explain it to the nurses in the prison because they start judging you." (IDI)
"When police arrest you, they first call news reporters, parade you, and accuse you of cross-dressing. By morning you are all over the news and that is why we never go to the police. I hate them!" (IDI)
It was also reported that access to GBV services offered by police was hindered by the corrupt tendencies of police officers. The respondents mentioned that they often ask them for bribes if they wanted to be helped.
"Our main referral place is police especially for cases of fighting and physical violence. However, at the police, they often want kickbacks. Sometimes these police people need bribes, yet sometimes the survivors have no money. In the end, the legal services provided to them [the survivors] are not efficient because of the barriers." (KI)