The Complexities of Trans Women’s Access to Healthcare in South Africa: Moving Health Systems Beyond the Gender Binary Towards Equity

doi:10.21203/rs.3.rs-3237907/v1

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Research Article

The Complexities of Trans Women’s Access to Healthcare in South Africa: Moving Health Systems Beyond the Gender Binary Towards Equity

https://doi.org/10.21203/rs.3.rs-3237907/v1

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published 03 Nov, 2023

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Background: Research in healthcare inequity has shown that health systems are shaped by broader socio-political contexts and biases that shape the institutionalization of healthcare, often leading to significant barriers to inclusive and equitable healthcare access. Health research has, however, overlooked how health systems marginalize gender-diverse persons and sustain health inequities among this population. Trans women, for instance, face multiple layers of exclusion due to their gender identity in health systems that could be considered patriarchal, binary, and cisnormative. Intersectionality-informed research can help challenge these gender structures within healthcare by acknowledging the diversity of identity experiences.

Methods:This study adopts a critical trans politics (CTP) perspective to explore the socio-cultural and political dynamics limiting South African trans women's access to healthcare. Using a critical narrative approach, the research asks:

1) What narratives do South African trans women share about their experiences in health systems?

2) What gendered societal structures, practices, and norms enable or hinder their inclusion in health systems?

Five South African adult trans women between the ages of 22 and 30 participated in semi-structured individual, telephonic interviews that focused on participants' subjective experiences within the healthcare sector.

Results:Trans women are often stigmatized and positioned as outsiders in ciscentric health systems, which uphold traditional gender norms and favour cisgender individuals, while excluding and marginalizing trans positions. Three dominant thematic narratives emerged. First, the denial of trans women’s self-determination reflected in institutional policies and practices that misgender trans women, limited their access to dignified healthcare. Second, the lack of knowledge about gender-affirming healthcare held by healthcare professionals and healthcare institutions led to informational erasure. Third, barriers to accessible and equitable healthcare faced by trans women were compounded by gender, race, and class structural dynamics.

Conclusions:This study sheds light on the challenges faced by South African trans women in accessing appropriate and respectful healthcare, highlighting the need for more inclusive and informed practices in local health systems. In response, a trans-inclusive health equity framework is proposed and its implications for theory, policy, research, and practice are outlined.

Trans women

genderism

cisnormativity

trans-inclusive healthcare

health equity

health systems

Research in healthcare disparities has often neglected to examine the structural mechanisms that maintain the exclusion of trans patients in healthcare. According to Gilson (2003), health systems do not only produce health and healthcare but they are also purveyors of a wider set of societal norms and values. As such, health systems are moulded by broader socio-political contexts (Hay et al, 2019) and biases that inform the institutionalisation of care (Connell, 2012). These biases create considerable barriers to equitable healthcare quality and access (Govender & Penn-Kekana, 2008), reinforcing pathways to conditions of societal exclusion (Heise et al., 2019). Power imbalances in health systems along the lines of gender and sex systemically perpetuate disparities in healthcare for women (Reid & Robson, 2000). They also perpetuate disparities for sexually and gender-diverse persons who carry the burden of contending with biases brought up by complex systems of power in medicine that place cisgender heterosexual persons at the top of the social hierarchy, affording them greater privileges while disadvantaging those who reject the norms of the gender binary (Freeman & Stewart, 2022; Rider et al. 2022). Healthcare becomes organised from a binary ciscentric framework that centres on the experiences, needs, and rights of cisgender healthcare users (Rider et al., 2022). Trans women navigate nuanced layers of exclusion as they carry what Jeane and Janes (2021: p. 1238) describe as “the double bind” of being women and trans. In healthcare, intertwined sources of marginalization are imagined to come from being women in patriarchal medical worlds (Östlin, 2008; Heise et al., 2019) and also queer and trans in binaried, cisnormative health systems (Bauer et al., 2009; Lampe, 2023).

One of the largest trans discrimination studies conducted, with a sample of 6 450 trans study participants based in the United States of America, found that 50% of the sample reported having to teach their medical providers about trans-affirming care (Grant et al., 2011). Of the total sample 48% reported an inability to afford healthcare and 28% reported postponing medical care due to discrimination (Grant et al., 2011). Other studies conducted in Canada (Giblon & Bauer, 2017), Australia and New Zealand (Pitts et al., 2009), and South Africa (Van der Merwe et al., 2020) suggest high incidents of anti-trans stigma in healthcare settings. Being transgender in health systems remains a facilitator of unfair and unavoidable differences, supporting the narrative that health systems are certainly not gender-free.

Intersectionality-informed research practices hold enormous potential for making trans women visible in health research by paying attention to the heterogeneity of identity experience (Koyama, 2000; Boe et al, 2020). First, an intersectionality-informed approach in public health is important for examining the specificities of the social location of trans women in health systems, enabling the development of new trans-centric theoretical concepts that allow scholars and practitioners to understand the structural determinants that engender unique forms of oppression for trans women in healthcare (Baeur, 2014). Second, a more thoughtful incorporation of intersectionality can promote meaningful interventions, such as policy changes, that are specific enough to the population under study (Baeur, 2014).

This study focuses on trans women’s experiences within health systems in the post-apartheid South African context, a nation that remains deeply divided in terms of gender, race, and space (Phaswana, 2021). Research on trans experiences in South African health systems is slowly shedding light on historically marginalized gendered experiences. Campbell and colleagues (2018) report that 82% (n=57) of South African transgender adults experienced social exclusion due to societal stigmatisation of their gender identity, predominantly from family members, and that these experiences were significantly correlated with psychological distress. Within South African healthcare settings studies have found that trans individuals face prejudiced treatment and discrimination (Muller, 2017), rooted in a lack of acknowledgment of trans people as patients within the health system (Luvuno et al., 2019). Luvuno and colleagues (2019) reported that patients who are trans are commonly met with poor prejudicial reception in healthcare institutions. Mbeda and colleagues (2020) suggest that as a result, trans persons are afraid to seek healthcare services. Consistent with this finding, Muller (2017) shows that all trans participants who were interviewed narrated experiences of discrimination by healthcare providers on grounds of their sexual orientation and/or gender identity. Trans women’s exclusion in healthcare is further aggravated by a lack of skilled healthcare workers, policies, and programs addressing the needs of trans patients (Luvuno et al., 2019).

Validating the absence of policy and policy implementation, Spencer et al. (2017) argue that the South African government has not formalized gender-affirming public health systems that can safely facilitate the medical transition of trans persons. Only six South African national government hospitals currently provide gender-affirming care, with waiting lists for gender-affirming surgeries of up to twenty-five years (Spencer et al., 2017). Gender-affirming public health systems and specialized trans units are limited, with only one hospital in the Western Cape currently offering a dedicated Transgender Unit (Wilson et al., 2014), severely limiting trans persons’ access, especially those dependent on state resources. While research has documented the barriers to inclusive care, there is a need for a critical public health perspective that challenges the structural and ideological processes maintaining these barriers and engages with power dynamics in health systems.

This study employs a critical trans politics (CTP) perspective to examine the socio-cultural and political dynamics that restrict trans women’s access to healthcare. CTP seeks to deconstruct and challenge oppressive structures affecting the lives of trans individuals (Spade, 2015). The study focuses on gender as an institutional construct manifested in healthcare policies, practices, and entrenched cultural norms that disadvantage trans women. Concepts such as genderism, cisnormativity, and cissexism are central to understanding and addressing trans marginalization in health systems. Genderism understands gender as a fixed binary composed of man and woman (Jun, 2018), while cisnormativity is the belief that gender is a binary category that naturally flows from one’s sex assigned at birth (Frohard-Dourlent, 2016), and cissexism refers to discrimination and inequality based on gender and sex, affecting trans people who challenge societal gender norms (Serano, 2014). By adopting a critical approach, the study aims to explore the lived experiences of 5 South African transwomen and in so doing uncover institutional barriers to access to healthcare in local settings.

This research draws on a critical narrative approach (Fraser, 2004), using story-telling as a meaning-making tool to facilitate a better understanding of South African trans women’s experiences in health systems. The study aims to understand:

1) What narratives do trans women living in South Africa tell about their experiences in the context of health systems?

2) What are the gendered societal structures, practices, and norms that enable and facilitate the inclusion and exclusion of these trans women in South African health systems?

A critical inquiry explores how individual stories are mediated by broader sociocultural and political contexts, explicitly deconstructing stories to address and question the construction of knowledge, power, and reality entrenched in and through narrative accounts of human experience (Hickson, 2016, Nay & Steinbock, 2021).

Participants

Five South African adult trans women participated in this study, ranging in age from 22-30 years. While the sample size was relatively small, the study focus was on capturing the social context that shapes trans lives, and the sample met this purpose. Trans women in this study are defined as women whose self-defined gender identity does not align with the gender that was socially assigned to them at birth (Stryker, 2013). Participants represented Gauteng, Limpopo and the North West provinces of South Africa. Despite the economic inequalities that persist, Gauteng is a relatively large, urban province with strong infrastructure, economic opportunity, and cultural diversity, while Limpopo and the North West provinces are more rural, less infrastructurally socio-geographic contexts. Some participants were employed, while others were looking for employment. To safeguard the privacy of participants, pseudo-names were used when reporting research findings.

Sampling strategy

The study used a purposive sampling technique. The first author (SS) created a digital poster and published it on their social media platforms – namely, Facebook, Instagram, and WhatsApp. Their social media community was requested to share the posters widely. Interested participants contacted SS directly.

Data collection

Semi-structured individual, telephonic interviews were used to collect data, where questions regarding participants’ subjective experiences within the healthcare sector were explored. The telephonic voice calls were recorded via a Microsoft PowerPoint recording function. The data were transcribed verbatim for analysis.

Data analysis

Fraser’s (2004) phased analytical procedure was used to analyse the data from a critical narrative perspective. The two authors (SS and MC), working independently, immersed themselves in each transcript, noting emerging themes and types of stories. To avoid a narrow perspective, the researchers explored the experiences across different dimensions, including intrapersonal, interpersonal, cultural, and structural aspects. They connected the themes to larger societal structures and systems of power, considering factors such as class, gender, race, sexual orientation, age, (dis)ability, religion, and socio-geographical location. The researchers then shared and compared their analyses. SS then contrasted and reflected on the content, type, and tone of the narratives, and translated the narrative content into a formal written analysis.

Three dominant thematic narratives emerged, which broadly spoke to the positioning of trans women as stigmatized others in ciscentric health systems that maintain and reinforce traditional norms of the gender binary. This positioning favours cisgender positions within healthcare while invisibilizing and excluding trans positions. The first theme highlights the denial of trans women’s self-determination reflected in institutional policies and practices that misgender trans women, limiting their access to dignified care. The second speaks to the lack of knowledge about gender-affirming healthcare held by healthcare professionals and healthcare institutions at large and played out through trans-erasure. The third speaks to the barriers to accessible and equitable healthcare faced by trans women compounded by the collusion of gender, race, and class structural dynamics.

Denial of trans women’s self-determination through (Mis)Gendering: “If they respected me, they would have put me in a female ward.”

Uncovered by the participants’ stories is the refusal of their right to access health systems as women, as their self-determined gender. This is demonstrated through the limited accommodations that are made for their needs and positions as trans patients in cisnormative healthcare settings that operate on the assumption that every patient is and should be cisgender. For example, Lerato said: “If you have to go to the clinic, you will be judged. Sometimes you will be judged by the security at the gate for your gender, how you look and stuff. So, you end up not going to the clinic”. Sam shared a similar experience: “Yes, you will feel excluded the moment you enter the gate. They will make funny jokes about your sexuality, which is totally wrong”. In the same way, Laila conveyed a story of being received with a negative attitude by an administrator when reaching out for healthcare: “They told me… it’s going to be very expensive, so I must go to a local clinic… And then the clerk there [at the local clinic], she gave me attitude.” All these stories reflect how the trans women in this study encountered judgment and ridicule for how they looked and expressed their gender. Participants experienced themselves as unwelcomed at multiple levels in healthcare settings which speaks to a stigmatizing culture within these health systems.

The attitudes and perceptions that the staff members had towards the participants appear to be driven by macro-level societal discourses about transness that create powerful barriers to accessing healthcare. For example, Sam highlights how her gender identity needed to be confirmed as soon as she entered the gates of the hospital: “There is security, right? By confirming your identity, they will see that you are a man”. This practice of confirming identity, especially within sex-segregated medical settings, has important and serious consequences for a woman like Sam, whose gender self-identification does not mirror the gender category she was medically and legally accorded at birth. This is a practice that constrains Sam’s opportunity to receive medical care as an already stigmatized member of society. After the confirmation of Sam’s identity upon admission for the treatment of tuberculosis, Sam was allocated to a male medical ward as per her medico-legal sex designation at birth: “I stayed at the hospital for 2 weeks for treatment due to TB, living with males in the same ward… Remember it’s a public hospital. I didn’t even have the power to ask for a single room or a single ward.”

Cisnormativity, the assumption that every person has and should have a gender that assigns with the gender they were assigned at birth (Bauer, 2009), and gender fundamentalism, the view that entrenches gender as a fixed, innate and dichotomous category (Connell, 2012), become the ideological premise of Sam’s experience of being misgendered in the hospital, where she is addressed and treated using language and designations that do not reflect the gender with which she identifies. In a sex-segregated medical system, stringently divided along rigid gender lines, Sam’s allocation to a male ward demonstrates the perpetuation of an enduring custom of assigning gender and imposing identity in a way that denies individual agency and restricts human rights. Sam specifically mentioned that she did not even have the power to voice her wishes, speaking to a position of social subordination she held in relation to cisgender medical power that held the authority to designate gender.

Mpho had a similar experience, where her gender self-identification was disregarded as a psychiatric in-patient: “I was not staying in the female or male’s room. I was staying in between the female rooms and male wards… Oh, it was so painful. I didn’t feel like I was respected much, that my privacy was respected… Because if they respected me, they would have allowed me to go to the female bathroom and put me in a female ward but they didn’t do that.” In sex-segregated systems such as the hospitals that Mpho and Sam found themselves in, they were required to choose between enduring the indignity of accessing services according to their natal gender or gender assigned at birth and foregoing services entirely. Through these narrative accounts, the South African healthcare system is represented as a social structure set up in ways that assume cissexuality, and in so doing negates patients’ rights to self-identify.

Although the majority of experiences in this study highlight misgendering and consequently stigmatization in pathologizing healthcare settings, there were the occasional experiences of inclusion. For example, Mpho described the power of simple experiences, such as being addressed and treated by medical staff in ways that affirmed her identity: “Some people were not [supportive]. They were, like, “Huh? And then? Some people respected my choice, and they respected everything. They respected me, and they started calling me using feminine pronouns, and I really appreciate that because that really helped with my transition”. Phumeza also shared experiences that constituted being addressed and treated by the people around her in ways that affirmed her identity: “I’ve worked for the company and now I am the patient there, however, the treatment is still the same and I am happy that when I go there, I am actually me and I know what to say there.” These experiences, while infrequent, provide a glimpse of what inclusive healthcare may look like.

(Lack of) Knowledge about gender-affirming healthcare: “You encounter certain staff members that have no idea about being trans.”

Participants’ narratives speak to how healthcare professionals and healthcare institutions largely lack knowledge about gender-affirming healthcare. Trans erasure, whereby trans patients' needs are neglected due to the lack of trans-inclusive policies and practices in healthcare structures (Bauer et al., 2009) was evident in these participants’ experiences. This erasure is a powerful consequence of the failure of knowledge systems to respect, safeguard and acknowledge trans identities, rendering these patients invisible within the health system. Sam shared the following experience: “Let me make an example, if you go to a public health facility, you will find there is someone who doesn’t even know about the transition. So, it starts with the health facilities, the public health around Limpopo is very, very cruel… You encounter certain staff members that have no idea about trans. They don’t have any idea about MSM”. Laila shared a similar narrative of reaching out for gender-affirming hormone therapy and finding out that the healthcare staff was not aware of gender medical transitioning as a legitimate medical procedure: “So, I went to the local clinic and then they didn’t have a clue what it [transitioning] was all about. And then the clerk there, she gave me attitude”.

Both Laila and Sam struggled to find trans-inclusive healthcare environment, where medical and support staff demonstrated specific knowledge of trans health issues. These two experiences of the study participants speak to the denial of their existence as trans patients within healthcare systems. This denial has a direct connection to the denial of their healthcare needs. Laila further reports: “They don’t know about it; they don’t keep it [hormone treatment]. They don’t know how to help you start with the process; whom to refer you to, where you go, how to start and whom to help you”. Laila’s and Sam’s engagement with public healthcare suggests that (even though the information may be present) this information may rarely be incorporated into official healthcare protocols and processes, nor integrated into the educational training of healthcare practitioners in South Africa.

Mpho challenges the South African health system’s lack of provision of gender-affirmative surgeries, suggesting that the public health system does not seem to prioritise their needs as trans identities: “They don’t want to perform surgery on us because they are constantly telling us that they are currently performing more urgent surgeries. They are performing for cancer patients and all that. I don’t know why. It’s an excuse not to help us. I see it as an excuse”. Mpho questions the extent to which public healthcare takes seriously the health needs of trans persons. This is a reasonable charge in light of historical cisnormative practices in medicine that have pathologized trans populations (Kara & Grinspan, 2017). This unavailability of resources possibly speaks to the lack of integration of gender affirmative care into mainstream public healthcare. Particularly, it spotlights the participants’ marginalisation in public medical practice.

Lerato contends that the underrepresentation of gender-diverse healthcare practitioners is also key to their social exclusion in medicine: “I mean, if you are a trans, you should be able to see that this is a trans person. If at the clinic we meet trans women, there should be a trans woman who will deal with the health issues… If there was a trans person at the clinic who would accommodate someone like a trans person, you would feel safer because we are the most vulnerable ones”. Lerato urges for increased representation and visibility of trans healthcare providers. The essence of Lerato’s petition is a concern about the incorporation of trans-inclusive practices and protocols in medical settings that make it easier for trans patients like herself to seek care, self-identify, and have their healthcare needs competently met.

The importance and value of Lerato’s plea is reinforced by Phumeza’s positive experience of a trans-inclusive clinic in her community: “Actually, when I go to the clinic, they just talk to me like a woman. They even say to me if I’m not feeling well. They would say to me [that] if I want to go to the toilet, they can they come with me and all those things. So, I actually, just laugh about the whole situation. I’m glad that we have our own choice clinic… I get my hormonal treatment there and any other clinical services. So, if I have flu, your Gonorrhea or let’s say that any STI/STD of some sort, they are able to help me with that.” Lerato’s and Phumeza’s reflections provide examples of how inclusion in healthcare may look and feel for trans women in South Africa. They emphasise the importance of institutionalising healthcare practices that celebrate gender diversity of healthcare providers that are educated on trans health, administration staff that is informed about how to communicate appropriately with trans patients, and medical infrastructures that are organised in such a way that trans patients are not imposed gender assignments that do not mirror who they are.

iii) Access to transgender-specific healthcare services – race/class/gender intersection: “I wanted to start with my hormone therapy but then I couldn’t because there was the issue of money.”

Participants in the study are not only navigating health systems as women. They also happen to be black and socioeconomically positioned as poor, navigating a post-apartheid healthcare context pervaded with historical racial, class, and gender inequalities. These narratives highlight how primary public medical institutions do not have sufficient resources to provide gender-affirmative care for trans patients. Laila speaks of the inaccessibility of hormonal replacement therapy due to the severe resource limitation of state-funded public clinics: “The only thing is that the resources on this side. It is like we do not have resources. You will go to the clinic and you will hear that they don’t have enough estrogen. It’s not easy at all because sometimes you might have to go and buy yourself with your own money when there are no resources. There are even clinics in the Northern Cape that don’t even keep them in their clinic”.

Due to this lack of resources, the desperation to medically transition and self-actualise pushes women like Lerato to explore alternatives, which are often unsafe. Lerato obtained gender-affirmative treatment through illegal trade without medical supervision: “For a trans woman like me, it’s a lot of needs because I have to go for hormone pills. And I am taking them from the black market because it’s very expensive to consult the doctor and that… So, in Limpopo, you would go for birth control pills at the [public] clinic. And because I have a lot of friends who are [cisgender] girls, they would give me Triphasil pills and they help you develop some boobs. But those ones I was on them, there were a lot of complications. The last time I was on them, my male part wasn’t working properly and I had some terrible cramps. I had to drop them then this other friend said I should go for hormone pills”.

Lerato’s use of professionally unapproved medication led to frightful health complications, which included cramps and the malfunctioning of her penis. Lerato, thus, addresses her inaccessibility to professional and safe healthcare as manifestly driven by the unavailability of resourced public healthcare facilities and the unreliability of public benefit organisations that provide healthcare services often for only a short term: “It’s very difficult for us. We are on a low scale, a very bad scale… You would find that certain organisations would come and provide lubricants and stuff like that. So, after 6 months that organisation is no longer there, and contracts are terminated because there is no longer funding or something like that. So, I would have to go back to my normal… It’s very tiring because we no longer trust anything. So, that’s why I’m saying we’re on a low scale. You go and consult for a few months but after that, you don’t have money so you see it’s a long process”.

Participant narratives highlight experiences of being unable to afford the gender-affirming medical care they needed. The industrialised private medical sector in South Africa is seen in these examples to construct healthcare practitioners as healthcare providers while patients are constructed as consumers. Lerato’s and Sam’s narratives capture the process of seeking medical care as an economic procedure that requires financial capital they often do not have. Lerato explains: “You go and consult for a few months but after that, you don’t have money. So, you see, it’s a long process”. Sam shares similar experiences: “I only worked for only 2 years and 6 months and my contract has ended due to COVID. So I was home, I couldn’t even go for laser therapy, I couldn’t even go, the moment I became broke, I became broke. I wanted to start as soon as possible with my hormone therapy but then I couldn’t because there was the issue of money”. Due to this commodification of healthcare, economically vulnerable trans women are excluded from meeting their healthcare needs.

To the problem of racialised and classed healthcare inaccessibility, trans women like Lerato and Sam, consequently, often find themselves having to travel long distances to access services in the few public hospitals in the country where the government has instituted gender affirmative care. Sam finds that she has to travel across provinces to access gender-affirming care: “You need to go to the Gauteng Province; you need to go to Cape Town. The hormones are very insufficient. You need to go to other provinces to get medical resources”. Space, as a legacy of apartheid segregation, in the narratives of the participants is mirrored as reflecting and reinforcing socioeconomic inequality. Lerato, who lives in rural Limpopo, has to travel to Johannesburg (a journey of almost 400km) to access gender affirmative care: “There is no doctor in Limpopo, you have to go to Wits. I had to go to Baragwanath Hospital and I was put on a waiting list till today… Yes, for the consultation, for the psychologist, everything”.

The economic vulnerability of women like Lerato, who reside in rural communities situated at the socio-geographical and economic margins of society, makes their reach to medical institutions challenging due to the travel costs involved. Due to her limited financial capabilities, Phumeza highlights that she has needed to prioritise her basic necessities, which sometimes comes down to a choice between food and transport costs for healthcare services: “Sometimes I struggle to go to the clinic because I only have one source of income and I have to make sure that it lasts me let me say probably the whole month because I have to buy food, toiletries and everything you know”.

The narratives shared by these South African trans women show how gender is not solely based on assumed natural and universal categories but socially constructed and regulated, even within health systems. The participants' stories highlight a prevailing culture of genderism in medical institutions, where trans women’s participation in the health systems is seen to be constricted by norms surrounding an institutionalized gender binary that does not account for fluidity, difference and the broad spectrum of gender identity (Browne, 2004; Jun, 2018). Participants are faced with medical genderism that problematizes and positions trans women as inferior in health settings while holding them accountable to norms that favour and prioritize cisgender patients. The social structure with its binary systemic view of gender (Farmer & Byrid, 2015) is reproduced in various ways in the delivery and organization of healthcare, leading to the exclusion of trans individuals in South African healthcare settings.

Genderism in the participants' stories was evident through the pervasive interpersonal stigma perpetrated by cisgender staff members. This stigma appeared to be particularly empowered by societal norms and biases within health systems that other and alienate trans patients, within a frame that constructs gender as a binary dichotomy of biologically determined categories of man and woman (Goldman, 1996). Genderism was revealed to underpin a phenomenon of trans-institutional erasure (Bauer et al., 2009, Lebreton, 2013) echoed by participants’ experiences, whereby trans patients' needs were neglected due to the lack of trans-inclusive policies and practices in healthcare structures. Healthcare professionals' use of gendered language that failed to affirm the identities of the trans women in the study as well as sex segregation and the allocation of the trans women participants to male wards that did not match their current self-definition reflected this practice of erasure. This erasure likely adds to significant health disparities for trans individuals compared to cisgender patients. Alongside studies by Luvuno et al (2019) and Mbeda et al (2020) in South Africa, such trans-exclusionary practices have been similarly observed in Canadian healthcare systems (Bauer et al., 2009; Vermeir et al., 2017; Laurin, 2023) as well as in the United States (Mason et al. 2022), Southeast of the United States (Johnson et al., 2020), New Zealand (Parker et al., 2022), United Kingdom (Hibbert et al., 2018), India and Pakistan (Ming et al., 2016; Pandya & Redcay, 2021). Fundamentally, trans-erasure, as an extension of genderism, reinforces the exclusion of trans patients within health systems (Scheim et al., 2022).

The participants’ experiences also reflect a culture of cisnormativity in healthcare, assuming that all patients are cisgender (Kcomt, 2019). As a consequence, health systems generally are unable to provide adequate and sensitive healthcare to trans healthcare users. Cisnormativity leads to and perpetuates trans-erasure in health systems (Bauer et al., 2009). The absence of gender-affirming hormonal therapy in the participants’ local clinics and hospitals speaks to this unique form of erasure, contributing further to the societal marginalization of trans women. In this study, trans women's challenges in healthcare overall arise from existing outside the bounds of entrenched structures of cisnormativity, in which care is regulated from a position that does not have trans patients in mind and, thus, challenges trans women’s ability to receive healthcare that meets them where they are in terms of their needs. These structural patterns result in systematic discrimination of trans women based on their rejection of the gender assigned to them at birth. Despite these challenges, some positive experiences of gender diversity acceptance in medical cultures were reported. Often subtle experiences of inclusion, relayed by the study participants, revealed cisgender institutional power as not immune to resistance and transformation.

The narratives of the predominantly black, poor, and working-class trans women in post-apartheid South Africa highlight the intersecting factors of race, class, and gender that create compounded barriers to healthcare access. The women’s experiences are shaped by a nation with a history of injustices rooted in colonialism and apartheid, resulting in significant socio-economic obstacles to accessing healthcare. The intersection of genderism and capitalism within healthcare - where medicine is seen as an industrial system that constructs healthcare practitioners as healthcare ‘providers’ while patients are relegated to ‘consumers’ (Reeder L, 1972; Collyer, 201–) - led to the social marginalization of some of the participants. Particularly poor and working-class trans women often found themselves unable to travel long distances to access limited gender-affirmative procedures in city centres. These narratives demonstrated how space reflects and reinforces socio-economic inequalities (Cervero, 2013; Gumbo and Moyo, 2020) in trans women’s lives.

This study is significant for its innovative approach in shedding light on the contextual influences of medical genderism, a binary structure of gender that perpetuates the erasure of trans women in post-apartheid South African healthcare. By amplifying the stories and experiences of trans women at the gender margins, the study challenges the assumption of institutional neutrality. It empowers the voices of those who are marginalized and provides a platform for a discursive reimagining of the social world and specifically healthcare from a trans standpoint. Given the historical neglect of trans women’s experiences in public health, the study’s findings are particularly important in exposing and questioning the norms that govern gender in healthcare, as well as its broader sociocultural, political, and historical implications, from the perspective of trans individuals who have long been silenced and side-lined.

In foregrounding the unique experiences of trans women, compelling concerns about the inequitable arrangements of healthcare in South Africa are raised. In working against transgender women’s marginalization in health systems, a trans-inclusive health equity framework is proposed to inform theory, practice, and policy. To truly achieve gender equity, gender-transformative approaches need to be explicit and intentional in including diverse gender identities and presentations in policies, practices, organizational cultures, and data. A trans-inclusive framework would advocate for:

The rigorous inclusion and absorption of trans women in gender programming and feminist practice.
A greater refinement of the concept of gender equity, which has historically excluded the positions of trans women. The framework argues for taking genderism as a social justice issue and a serious feminist concern in public health scholarship. The exclusion experiences of trans women in health systems are observed to be, without doubt, discriminatory and gender-based, violating their constitutional rights to equality and non-discrimination.
The mobilization of a theory of genderism in medicine in the interest of marking and interjecting gendered legalities, administrative processes, policies, discourses, practices, customs, and norms that exclude trans persons in healthcare structures.
The continual questioning and revision of ideas and arrangements of how society maintains the relegation of trans persons to the gender margins. For meaningful social change to emerge, it is necessary to continually name, problematize and destabilize genderist structural processes within systems and across institutions that consistently reproduce gender transgressive bodies as non-normative, out of the ordinary, and unintelligible (Butler, 2004; Francis & Monakali, 2021) in health systems.

When it comes to policy and research, this framework suggests:

A move toward discourse analysis and critical policy ethnography as a central piece in health research for trans patients. This is so to enable a nuanced ground-level analysis of the discourses and policies (Dubois, 2015) in medicine that maintain genderism and the exclusion of trans persons in healthcare institutions.
Discourse analysis and critical policy ethnography shall empower the possibilities for gender structures to be clearly viewed, deconstructed, and interjected; opening up opportunities for inclusive gender reform that solves the practical problems of trans women in medicine.

When it comes to practice, the framework posits that institutionally countering the systematic erasure of trans persons in healthcare contexts is in and of itself, a crucial step toward providing an intervention that supports the health and well-being of trans persons in society. As Bauer and colleagues (2009) have put forward before, there is a need for more resources to be made available to professionally guide attending to the healthcare needs of trans persons. The following are possible recommendations for inclusion, inspired by those penned by Bauer et al. (2009):

Developing intake forms that allow trans patients to self-identify. Through these means, the administration is handled in such a way that it does not restrict self-identification and self-determination.
All healthcare providers and supporting staff should use pronouns and names appropriate for a patient’s gender identity.
For healthcare practitioners to assume that any patient may be trans. In other words, for healthcare practitioners to divorce themselves from the limited assumption that every patient is cisgender.
Developing protocols for assessing, diagnosing, and treating that are not gender-specific or that do not assume all persons are cisgender.
All in all, eliminating sex segregation where possible and providing a safe place for trans patients to access care without entailing a contravention of their ethical right to self-determination in healthcare structures.

Cissexism: discrimination and inequality based on gender and sex, affecting trans people who challenge societal gender norms (Serano, 2014)

Cisgender: describes a person whose current gender self-identification matches the social and legal category of boy/man or girl/woman that the person was assigned at birth (Stryker, 2008; Enke, 2012).

Cisnormativity: a hierarchal system of power that endorses the ideology that it is normal to be cisgender; for a person’s gender identity to align and be congruent with the sex they were assigned at birth (Bauer et al, 2009).

Critical Trans Politics (CTP): a branch of political thought that challenges assumptions of neutrality in institutional structures (Spade, 2015) and addresses the social structures that marginalise those who do not neatly fit into categories of gender (Jourian, 2017).

Genderism: the notion that gender is a fixed binary composed of man and woman categorisations, which are believed to be inherently linked to one’s biological sex category (Browne, 2004).

Trans erasure: the neglect, invisibilisation and exclusion of trans people in broader society, including within healthcare structures that lack trans-inclusive policies and practices (Bauer et al., 2009).

Trans women: women whose self-defined gender does not align with the identity label ascribed to their assigned sex at birth (Stryker, 2007).

Ethics approval and consent:

Ethical approval for this research was obtained from the Rhodes University Human Research Ethics Committee (Reference: 2021-5177-6403), registered with the National Health Research Ethics Council. The research was carried out in accordance with the Declaration of Helsinki and written informed consent was obtained from all participants.

Consent for publication:

Not applicable

Availability of the data:

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

The authors declare that they received no funding for this research study

Authors contributions

SS developed the original conception of the project, research design, data collection, analysis and write-up of an initial draft.

MC contributed to further conceptual development of the project, research design, data interpretation and made substantive revisions to the draft.

Both authors read and approved the final draft and are personally accountable for their contributions.

Acknowledgments

The authors would like to acknowledge the 5 participants who gave so generously of their time and experiences.

Authors information

Siyanda Shabalala is a clinical psychologist currently completing their community service year at the Johannesburg Health District, South Africa. Siyanda is invested in trans liberation and healing. As a clinician, they have a special interest in supporting the mental health of trans people and helping them navigate their complex gender paths through affirming psychological care.

Prof. Megan Campbell is an Associate Professor in the Psychology Department at Rhodes University and a Counselling Psychologist with an interest in the field of gender diversity studies.

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No competing interests reported.

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The Complexities of Trans Women’s Access to Healthcare in South Africa: Moving Health Systems Beyond the Gender Binary Towards Equity

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