Dr Anastacia Tomson outlines the barriers to adequate, safe and informed health care for transgender people.
Transgender populations are neglected by a number of areas in society but especially or very prominently the health care system. This is a population group that has very specific needs, not complicated needs, just specific needs, and those needs are underserved. That means it is exceedingly difficult for a trans person to access gender-affirming care.
- In the first instance, there’s a lot of gatekeeping, a lot ignorance on the part of staff, there are a lot of social factors like being undermined or condescended to, or deadnamed or misgendered. Deadnaming occurs when someone, intentionally or not, refers to a person who’s transgender by the name they used before they transitioned or while they are transitioning.
- The demand for medications trans men, trans women and non-binary folk use often, is often underestimated. As far as the hormones they need are concerned, these are used by cisgender people too, either cisgender women experiencing menopause or cisgender men who have erectile dysfunction or for androgen decline in aging men (male menopause, basically), but they tend not to use them in the kinds of doses and quantities transgender people require them.
- The more transgender people we manage to identify and provide access to care for, the more rapidly the demand on pharmaceuticals grows, and that demand needs to be adequately acknowledged and addressed in order to ensure that the supply does not run out. The fact of the matter is that the amount of Depo-Testosterone we have had available until now is probably quite inadequate considering that a large proportion of the population is still not accessing the kind of care that it needs.
- When it comes to trans women, the forms of estrogen that are available to them are very outdated and very unsafe. Premarin (which is the most used hormone, particularly in the public health sector) has a much higher risk of clot formation which is the most significant side effect associated with feminising hormone replacement therapy than any other medication available.
- Gender-affirming care is seen by many as elective and cosmetic. This is the reason medical aids will not pay for it.
- We don’t have national guidelines on how to manage the medical or surgical care — gender-affirming care — for transgender people. That means that care is only available in specialised facilities, commonly Grootte Schuur in the Western Cape and Chris Hani Baragwanath and Steve Biko in Gauteng, outside of which expertise is limited to a handful of practitioners who may or may not be working in public sector clinics — and it’s luck of the draw as to whether you are able to find them — and a few private practitioners.
- It also means that everyone is doing something different. Government clinics are handing out Premarin because it’s what they have in their pharmacies. Some people get certain blood tests done at regular intervals, some people don’t. Some people are subjected to more rigorous scrutiny and gatekeeping, before getting access to their treatment, while others are treated on an informed consent model, which is much more in line with latest best international practice. But this doesn’t happen everywhere.
- A transgender person entering the healthcare system does not know what kind of experience they’re going to have before they go in. Are they going to be deadnamed and misgendered? Are they going to be laughed at in front of all the clinic staff and all the other patients? Are they going to get to see a doctor, and if so, when?
- When they do see a doctor is there going to be doubt cast on who they are? Will they have to prove themselves, meet some antiquated set of standards in order to get access to the care?
- Once they get access to the care, is it going to be the latest and best care available, or is it going to be outdated medication that carries severe side effects, and is that medication even going to be available or is it going to be out of stock from the pharmaceutical company?
- In the public sector there is a 25-year waiting list for gender-affirming surgery. Some centres are not doing procedures that are cutting edge, they’re using very old techniques that might have side effects like urinary incontinence or loss of sexual function or sensation, and are completely ignoring the need for allied healthcare, for speech therapists, or for psychology for instance.
- Pychological assessment might form part of that initial evaluation, in that gatekeeping approach, but it’s not used to support people, it’s used to keep them from accessing the treatment. Psychology should be an adjunct to gender-affirming care, so that trans people have the psychological support they need, not only as a screening tool to stop them from having access to care. This happens in both private and public sector.
- The requirements to get the gender marker on your ID document changed at Home Affairs is a complex process that can take up to 18 months, because they want you to have had medical or surgery gender reassignment. They don’t define what they mean by that, but Home Affairs uses this as an excuse to reject doctors’ letters out of hand. There have been instances where Home Affairs have said a letter from a psychiatrist doesn’t count because a psychiatrist is not considered to be a medical doctor, which is nonsense. Psychiatrists are medical specialists.
- It is very difficult to gain access to the medical treatment that you need without an ID. When you go to the clinic, you have to present your ID, but your ID is outdated, and you need the medical treatment in order to update it.
- For the most part, transgender people have had to be their own doctors, own researchers and their own research subjects. Many people in the healthcare system have very little idea about how to care for us.
“There are so many barriers. You have to have this dynamic, systems-orientated view of it to see that the health system is failing us, but so is home affairs, tertiary education — because our doctors don’t know how to manage trans patients adequately — so is basic education. It all ties in. You have to see the interconnectedness. You can’t fix the healthcare system without fixing the other systems.
“We have a problem now in that we don’t have the masculinising hormone used by so many people, but if and when that problem is sorted out, it doesn’t mean that trans health is sorted out. This might be a catalyst for a bigger movement and a bigger conversation. And that conversation needs to go forward.
“We need to keep our attention focused and mainstream society needs to have this conversation. We need people to understand what the difficulties are and how easily they’re fixed. All it would take is some attention, effort and compassion from the systems and those running them.”