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