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

Abstract

Abstract 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.