All posts for the month December, 2013

Lack of access to transgender healthcare in South Africa. What funders should know……

Published December 9, 2013 by transfeminists


I am honoured to have been invited to a funding dialogue in Berlin, December 2013 and I am happy to share this presentation with you.

Though South Africa is classified as a developing country, the political, economic and social conditions for South Africans are still very much in line with third worlds standards. The brunt of South Africa’s previous apartheid regime can still be felt today. The regime, based on racial segregation played a huge role in the inequalities that South African’s still feel today. Those inequalities are no more visible than in the LGBTI community. Some members of the LGBTI community have managed to create a fairly good existence for themselves in a post apartheid South Africa. Sadly, this is not the reality for most transgender people in South Africa. When hate crimes are perpetrated, in most cases they are committed against those who express visible gender diversity. The black transgender women from impoverished communities almost always serve as the primary target in this regard.

What does this have to do with transgender health? The inequalities that play itself out, especially in the transgender movement of South Africa, are based on the inequalities that were created through the apartheid regime. A system whose mission was not just to racially segregate South Africans, but also further entrench gender inequalities. This is to say that in the hierarchy of power, it is the white cis-gender man who, at the top of the hierarchy assumes a self-imposed position of power, while it is the black, illiterate trans woman from the so-called homelands, that is positioned at the bottom of this hierarchy. This is a population of women that come through our programs on a daily basis, and we continue to work hard at addressing this dynamic.

There is no doubt in my mind that this unhealthy power dynamic still plays itself out, even 20 years later in South Africa’s ever maturing democracy. These are dynamics that influence the ways in which transgender folks access mainstream health and well-being services. Needless to say that those services are non-existent to black trans folks in rural areas. Most trans people of colour in South Africa does not have the privilege of boarding a flight to Bangkok in order to access gender reassignment procedures. The ways in which trans persons of colour in South Africa access gender affirming treatments is unequal in relation to the ways that trans folks with privilege access the same treatments. Our organisational efforts at creating safer spaces, including access to gender affirming care, are located within this context. After all, the high HIV infection rates are amongst trans women of colour. The same can be said for the intolerable levels of violence, the lack of development opportunities and a number of other obstacles.

On access to health care in South Africa

  • Most trans persons access health through the public health care system.
  • Trans specific services exist only in two centres in South Africa, one in Cape Town, and the other in Pretoria. Needless to say, it is difficult for rural trans people to access these services.
  • At both centres there exists a 26 year waiting list
  • Very little theatre time is dedicated to gender reassignment surgery since it is not as seen as urgent in relation to other surgeries.
  • Hormone treatment is available but difficult to access even for those in the urban centres. This is because there is no streamlined service and cases are handled on an individual basis, rather than as being part of a standard service package
  • More FTM patients are helped since some of the surgical procedures are offered as general surgeries like hysterectomies and mastectomies are offered within the gynaecology departments of both these centres in contrast to MTF for whom breast augmentation, is classified as cosmetic surgery in South Africa

Challenges in accessing health care for trans persons in South Africa

  • Self-medication remains a huge problem among especially trans women.
  • Little to no research exist on the HIV vulnerability of bodies post sex reassignment surgery.
  • Little to no research exist on the cross drug interactions between certain hormone treatments and ARV’s
  • Rural transgender people’s access to gender affirming treatment is disproportionately affected in relation to those in the urban centres
  • The concept of validative sex among trans women is ever increasing. This is problematic in the context of HIV vulnerability.
  • Looking at issues in isolation is problematic. My race, my gender, my homelessness, my HIV positive status is all one struggle. Integration of these intersectionalities should be key in the HIV response.
  • Harmful traditional practices remain challenging. The cultural obligation to go through cultural circumcision drives many trans women into sex work because by refusing to go through the ritual, they lose access to family resources and a sense of belonging.
  • Religious fanaticism is challenging to trans people in South Africa because many religious and cultural institutions feel these concepts are new and that they are imported from the West
  • Some trans people find it difficult to access ARV’s without the change of gender markers in their identity documents because some have medical records in their old names and/or id numbers

Strategic opportunities for advocacy on trans health issues in South Africa at the moment

South Africa is having their national elections for president in 2014. This is an opportune time to advocate a more comprehensive public health package.

There is an ongoing conversation on re-engineering public health and this offers room to advocate for better services for trans people.

We are giving two presentations on the upcoming ICASA conference where we can talk about the unique health, and HIV needs of transgender women, removed from an MSM intervention.

After a long and hard effort, the ECAC has recently called on us for conversation on the unique HIV needs of transgender women.

There is a tripartite alliance of organisations who established SATHRI to advance transgender health in South Africa

The most recent contraception policy guidelines mention the needs of LGBTI persons in terms of accessing contraception in South Africa.

The Groote Schuur transgender clinic has domesticated some guidelines of the WPATH standards of care version 7 and we continue to disseminate this to primary health care practitioners.

S.H.E has contributed to the Key Populations Guidelines for HIV management in public health sector.

Where do we go from here?

  • As a first step, we need to develop language around trans terminologies. We need to develop literature in vernacular languages of trans people.
  • We need to create, strengthen and maintain safe spaces and support groups for transgender people.
  • Biomedical research on the vulnerabilities of trans people (women) should be on the research agenda.
  • Donors fund advocacy and that is a great thing but while we are advocating for the inclusion of trans people in government services, trans people continue to be negatively affected. We need to start thinking about service provision models for trans organisations
  • Core funding is essential to creating health and well-being spaces for trans organisations. I can’t advocate for other trans people when I am experiencing many shortcomings myself







PRESS RELEASE Transgender Day of Remembrance – 20 November 2013

Published December 4, 2013 by transfeminists

Friends, it has been so long since we have written something on our blog. This is our press release for the Transgender Day of Remembrance for 2013.


Purposefully politicizing our sexual and reproductive health rights! State actors perpetuate violence against transgender women. Health is a human right….now more than ever!

S.H.E speaks from a feminist platform in articulating this strategic message to the South African, and other regional state actors, communities and other stakeholders in observing the 15th International Trans Day of Remembrance on 20 November 2013.

S.H.E, as a collective wants to highlight and address the violent actions (and sometimes the lack of appropriate actions) by our governments. The sad reality is that these actions go undocumented and they are unspoken of because the media would rather report on the sensationalist events accompanied by graphical pictures of scars, blood and murder. This plays off against the background of high prevalence of HIV because of an inappropriate government response. Trans* women globally, are plagued by high HIV prevalence, but more so on the African continent, and this is simply because we are not fully recognised by our leaders. A recent research report indicated a 19% HIV infection rate among transgender women globally. Needless to say, there was no data from the African continent.

“In South Africa and other parts of the African continent, our sisters die in large numbers as a result of the HIV burden. This will not change until we are recognised first, epidemiological counts of HIV among trans women are conducted, and effective evidence-based programming developed, that takes into account our unique needs as trans women, and far removed from the MSM (men having sex with men) response. The conflation of trans women with MSM statistics is fundamentally flawed and poses a threat to the health and well-being needs of transgender women”, says Leigh Ann van der Merwe – coordinator of S.H.E.

Transgender people are listed as a key population for the HIV intervention in the current National Strategic Plan on HIV, STIs and TB (2012-2016), yet there is no program(s) addressing the HIV burden in this population. There remains a large disparity between the political commitment on the provision of (health) services, and the lived realities of people on the ground. Outside of the health focus, safety and security remain a threat for African transgender women. Transgender women’s psychological and physical well-being comes under great threat when they are locked up in male cells in prison. They become vulnerable to rape and other forms of physical and/or psychological abuse, which in turn, has serious implications where HIV/Aids are concerned.

The focus, should however, not just be on government to deliver health and other services. The traditional leadership of especially the Eastern Cape Province have a very big role to play in advocating for the human rights of trans women. The issue of cultural circumcision is a contentious issue with the cultural obligation of all those born male-bodied to undergo cultural circumcision. This is a very controversial issue in light of government’s encouragement of circumcision as an HIV prevention strategy. Sadly, this intervention is based on a one-size-fits-all approach. Says Zaza Kwinana: “the obligation to undergo cultural circumcision in my culture goes beyond the snipping of the foreskin, it is the passage into manhood, the very notion that I reject as a self-identified trans* woman. As a sex worker, who does not have access to hormones and gender reassignment surgery, there are serious implications in the context of HIV/Aids”.

There are simply not enough accountability mechanisms on government concerning the sexual and reproductive health rights of minority groups. For this reason, we have to purposefully and strategically politicize our sexual and reproductive health rights context. On this transgender day of remembrance and into the lead up to the sixteen days of activism for no violence against women and children, we are appealing to the South African government, as well as other leaders on the African continent to initiate meaningful dialogues on sexual and reproductive rights for minority groups. There needs to be strategic efforts at understanding the ways that HIV affect particular groups and programming must be informed by such efforts. We fully share the ICASA conference’ sentiment on getting down to zero, now more than ever!

For more information on this statement, please contact:

Leigh Ann van der Merwe, S.H.E coordinator

Tel: +27(0)43 7220750

Mobile +27(0)73 8110789


Anele Klasmani, S.H.E Programs Officer

Tel: +27(0)43 7220750


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