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“I want to be treated equally just like everyone else” : Working Towards Universal Access to Healthcare for Trans and Gender Diverse People

Bangkok, Thailand, 1st March 2021

To mark Zero Discrimination Day, the Asia Pacific Transgender Network (APTN) is launching its new report, The Cost of Stigma: Understanding and Addressing Health Implications of Transphobia and Discrimination on Transgender and Gender Diverse People. Evidence from a Trans-Led Research in Nepal, Indonesia, Thailand, and Vietnam. This year UNAIDS’s campaign on Zero Discrimination highlights the urgent need to take action to end the inequalities that continue to persist around the world. Everyone has the right to enjoy the highest attainable standard of physical and mental health without stigma and discrimination. 

Yet when it comes to access to healthcare, trans and gender diverse people continue to experience unique gender-based stressors and intersecting discriminations. The Cost of Stigma, the first-ever trans-led research implemented in Nepal, Indonesia, Thailand and Vietnam gathered evidence on the availability, accessibility, acceptability and quality of sexual health and HIV, general healthcare and gender-affirming care services and to gain a better understanding of the barriers trans and gender diverse persons experience. 

Our research found that discrimination remains to be the strongest barrier to access to healthcare services. In all four countries, trans people shared their experiences of discrimination, and how they had delayed seeking necessary general health care because they continued to fear negative and discriminatory treatment. In Nepal, 35% of respondents had delayed seeking health care due to fear of discrimination, and this figure was higher for trans women, sex workers, and older people. In Indonesia, nearly 40% of respondents delayed for this reason, with more sex workers fearing discrimination. The lowest rate of delaying treatment due to fear of discrimination was in Thailand, where only 9% said they had delayed seeking general health care for this reason. However, in Thailand, fear of stigma and discrimination was the most cited reason for avoiding STI and HIV test and treatment, i.e. people who had experienced discrimination accessing HIV services were more likely to have never visited a provider for PEP (95.8%) as compared to those who had not experienced such discrimination (77.9%). In Vietnam, nearly 52% of survey participants had delayed treatment because of anticipated discrimination. In the FGDs, participants reported stigma and discrimination (including use of derogatory and mocking terms) when accessing general health services. Several respondents shared experiences of breach of privacy, ridicule, and lack of knowledge about trans health care. 

“I got a serious injury in my throat and was taken to Bir Hospital, and I was in ladies’ get up. Nobody cared for me for so long though I was in serious condition. After a long time, they took me to the operation theatre and my operation was successful. The news spread around the hospital like a hijra has been hospitalized. Hundreds of people including doctors, nurses, patients and their care provider came to see me as hijra. Even police came for investigation and asked me whether he is male or female in front of my family members. I really felt very bad during that time.”

Research Participant in Nepal


Further, trans people continue to face systemic barriers, including lack of access to health insurance,  to access to healthcare services. Many trans people in Indonesia, particularly waria / transpuan, have been rejected by their families, and therefore have no access to the household’s Kartu Keluarga / Family Card that is needed to register for health insurances, including for access to HIV-related services. In Nepal, research participants reported lack of access to health insurance as a systemic barrier. While Nepal legislated a new public health insurance plan in 2016-2017, data from the Health Insurance Board showed that, by June 2018, the programme was yet to cover 38 districts out of 77. Of the 250 trans people who were interviewed for this study in Nepal, the vast majority (88.8% or 222 participants) reported having no health insurance. Only nine trans people interviewed in Nepal were covered by the national health insurance scheme. In the absence of health insurance, trans people in Nepal have to bear significantly high out-of-pocket expenditure, limiting their ability to access needed health care, including HIV prevention and treatment. 

Significant gaps in the availability of sexual health services, including STI and HIV testing and treatment services, for trans women were identified. HIV and STI services are provided by hospitals, private clinics and community-based organisations (CBOs) in all four countries covered by our regional research. Public programmes with targeted interventions for trans women have a greater focus on testing and treatment and limited prevention services are made available apart from condoms and lubricants. PrEP is available to trans women in three of the countries — Nepal, Vietnam and Thailand.

Limited sexual health services are targeted at trans masculine persons. Our research also noticed that in all four countries, few if any, trans men were accessing HIV-related information or testing. This findings was particularly concerning in Nepal where 16.7% of the trans men who had been tested (three individuals) were HIV- positive. These trends can be attributed to lack of understanding and awareness of trans men’s sexual health and unique needs among policymakers and health programmers, resulting in limited, if any, targeted interventions focused on trans men.

Ensuring Universal, Stigma-free Access to Healthcare for Trans and Gender Diverse Persons: Recommendations for Way Forward

We call on the relevant ministries, medical professionals and healthcare providers, multilateral agencies and donor agencies to take all necessary measures to fully address the stigma-free access to healthcare for trans and gender diverse persons. More specifically, based on the findings of our research, we recommend:

  1. Sensitise public officials in the Ministry of Health and national AIDS programmes on trans people’s specific gender-affirming health needs and the importance of trans competency across all types of healthcare and develop guidelines for non-discriminatory healthcare services, including HIV and sexual health services. 
  2. Build awareness on trans issues and health needs in healthcare settings by developing guidelines and providing training and sensitisation to healthcare professionals and auxiliary staff in healthcare settings, in partnership with trans communities and trans-led local organisations.
  3. Create welcoming, non-judgmental and stigma-free HIV and healthcare settings that ensure privacy and confidentiality and respect the rights of trans people.
  4. Undertake mapping exercises of existing services and needs, and create HIV resources and programmes tailored for the different populations in the trans community i.e trans sex workers, trans drug users, trans men.
  5. Expand clinic timings or provide services at hours that are convenient for trans people. 
  6. Provide complaints mechanisms for when trans rights have been violated in healthcare settings, a process for receiving feedback from trans people, and evaluating and acting on that information in order to improve services.
  7. Sensitise healthcare professionals on supporting the health and well-being needs of trans people, especially youth, and emphasise that ‘conversion’ or ‘reparative’ therapy practices designed to change, repress or ‘cure’ someone from being trans are unethical and harmful.
  8. Reduce stigma and transphobia in society by introducing public awareness campaigns that respect gender diversity and counter outdated views (such as that being trans is a mental illness or that unethical ‘conversion therapy practices’ are a possible remedy).
  9. Recognise the diversity of trans communities, and identify trans people as a priority group with unique needs within health programmes (including those providing nutrition, mental health and addiction services). 
  10. Integrate material about trans-competent health services and gender-affirming care into health curricula across many disciplines (e.g. medicine, nursing, social work and psychology), including as continuing education for the current health workforce.
  11. Conduct additional research on trans peoples’ health needs, and barriers to healthcare, particularly under-researched communities i.e. trans men, trans people who use drugs.

On Zero Discrimination Day, join APTN and our partners in raising awareness about the inequalities that prevent people from living a full and productive life and demanding that governments fulfil their commitments and obligations to end all forms of discriminations. 

¹Fisk, Kylie, and Jack Byrne. The Cost of Stigma: Understanding and Addressing Health Implications of Transphobia and Discrimination on Transgender and Gender Diverse People. Evidence from a Trans-Led Research in Nepal, Indonesia, Thailand, and Vietnam. Bangkok: Asia Pacific Transgender Network (APTN), 2020. Retrievable from: https://weareaptn.org/wp-content/uploads/2021/01/KPRA-Regional_21.01.18.pdf
²“Health Insurance Plan Yet to Cover 38 Districts in Nepal.” The Kathmandu Post, 7 June 2018