What stops transgender people going to sexual health clinics?
Transgender people are at a disproportionately high risk of HIV to other population groups and yet often HIV services push them away rather than welcome them in.
A number of factors can prevent transgender people from accessing HIV services, including:
Melody says: “We come across numerous community members on a daily basis stating that they've been denied access to HIV treatment or prevention services. This is mainly because service providers – nurses or doctors – use religion as a frame to discriminate against the queer or the trans community, stating that HIV is a punishment from God to the queer community, and that's why you have it, because you're unholy and these type of things. So that really stops our community from actually accessing services.”
Abhina says: “In India a wide range of transgender-related identities, cultures, or experiences exist – including Hijras, Aravanis, Kothis, Jogtas/Jogappas, and Shiv-Shakthis. Often these people have been part of the broader culture and treated with great respect, at least in the past, although some are still accorded respect even in the present. But this isn’t the case for all transgender people, with many still facing stigma and discrimination, which can lead to social isolation and make them reluctant to seek healthcare services, including HIV services.”
Sazi says: “Often when trans people visit a clinic they will be asked this stupid question of whether they are a man or a woman. And if the staff are surprised by the answer they will call each other because they are amazed, saying this woman with a penis or this man with a vagina! There’s no respect in the way we are treated.”
Abhina says: “Transgender individuals may not be aware of the available HIV services, or they may not know where to access them. This can be due to limited outreach efforts, inadequate health education, or lack of accessible information.”
Sazi says: “It's really sad if you are not empowered and you tend not to get the correct services. With the right knowledge it becomes easier for a person to access medical services and knowing that this is my right to get this or to access this and this is how I need to be treated. We are a minority population, but we still have a voice. We need our community to be better educated about what services they can access and how the services should look like.”
Abhina says: “Transgender individuals often face economic challenges and may not have the financial resources to access HIV services, such as paying for transportation or medication.”
Sazi says: “And sometimes it's because our community is not really financially stable, so they cannot legally transition gender. They cannot medically transition, so their dead names [their name from birth which they have rejected in favour of a name associated with a different sex] are still the names that are on their identity documents.
“So when they will go to a clinic they'll call them by the dead names, which sometimes it's hard when you read as the correct gender. And others are scared to even go because they hear about those bad experiences people are talking about.”
Abhina says: “Discriminatory laws and policies can also prevent transgender individuals from accessing HIV services. For example, certain laws may require identification documents that do not match their gender identity, which can make it difficult for them to access healthcare services.”
How can HIV services be more friendly?
With trans women 66 times more likely to have HIV, and trans men nearly 7 times more likely it is vital that HIV services are made as friendly and accessible as possible.
Sazi says: “The M and E [monitoring and evaluation] tools within public health are not trans friendly and even within LGBTQI community organisation are not friendly because they always want to ensure that they indicate this person is trans.
“And sometimes a transness is an identity of a person, and some other people do not even identify as trans, don't identify as their correct gender, as a woman or as a man, and they don't have the M and E tools that can just get everything out without showing any discrimination against them because, asking something that is irrelevant, like mixing gender and sex becomes even harder.
“Lots of people do not understand what is trans and everybody believes it's just a gay person who is dragging or something … If the M and E tools changes and speaks to humankind or humanity, it becomes easier for even the language around the stuff to change.”
Sazi says: “So breaking all the heteronormative approaches to gender, of saying so you are a man, so you are dating a man. So who's a woman within that relationship … So all of these things need to just be broken down and everything must be just gender neutral whenever accessing services, because whenever we speaking of HIV services is the same criteria for women and men.”
Melody says: “Healthcare providers should firstly have an inclusive intake form that states your preferred name as opposed to your name registered on your identity documents. So that our community members can feel valued and included and not dead named.”
Sazi says: “We need a holistic approach and also not leaving out mental health, linking it with HIV for trans people. Because some people wouldn't even take their medication because of the stigma and others have no one to talk to when they are thinking about defaulting. And they are not being educated about how important it is for them to take their medication.”
Abhina says: “Healthcare providers need training on providing culturally competent care to transgender individuals. This means knowing what questions to ask and what not to ask. It’s also about understanding the issue of combining antiretroviral treatment [ART] with HRT [hormone replacement therapy] medication, which many transgender people use. Many center doctors are unaware of HRT, so they can’t counsel them on ART treatment timings and can result in drug failures. So proper knowledge of HRT and ART drug combinations and side effects is really important.”
Sazi says: “So I believe firstly health care workers lack knowledge on trans issues.
They might be able to assist me with anything that I need, it's just that they don't know anything about it and what hasn't been taught to us, doesn't exist. This has been a trend over the years, so we have been taught that there are only two genders. And when there's only two genders, it's either male or female.”
Melody says: “Gender neutral bathrooms in public spaces would help a lot.”
Abhina says: “We need legal reforms that eliminate discriminatory barriers and improve access to HIV services for transgender individuals in India.”
Examples of poor treatment at HIV services
Bad experiences at health services can be traumatising and may discourage transgender people from seeking care in the future. It is important to create safe and supportive healthcare environments for all individuals, including transgender people, to ensure equitable access to healthcare services.
Melody says: “So a typical example is when you haven't changed your name and your gender mark on your legal documents and the doctor would come in and call you on your name registered at birth. That would also form part of public outing, so then everybody else would know, OK, you present this female, but in actual fact that's a male name.”
Abhina says: “Some transgender individuals have reported being refused care or experiencing discrimination based on their gender identity or expression. In some cases, healthcare providers have used inappropriate language or asked intrusive questions about their bodies or sexual practices. Transgender individuals have also reported being subjected to physical or verbal abuse, including being restrained or forcibly examined without their consent.”
Do you know of any resources to help healthcare workers make HIV services more friendly for transgender people? Let us know by getting in touch at: firstname.lastname@example.org