Understanding the Socio-Behavioral Dynamics of the Transgender Population in an Under-Resourced Setting in South Africa


By: Dr Shapo Annah Pitsi, Neo Buthuma, Kagiso Mothwa, Tercia Makhaphiedza, and Lebogang Mpete of the Setshaba Clinical Research Site, Soshanguve, South Africa

Background

The transgender population experiences many challenges in society when they identify with and express a different gender that is not congruent to social expectations for their sex assigned at birth. The South African transgender population is no exception to these challenges (Sithole, 2015).

In South Africa (SA), where transgender populations are marginalized, there is limited understanding of the community’s behavioral dynamics. Limited access to socio-economic opportunities, psychosocial support, and healthcare are key issues that impact on the wellbeing of the transgender population. Their vulnerability to infectious diseases such as HIV, set against the backdrop of limited access to healthcare programs, is of particular concern.

The Setshaba Research Centre (SRC), based in the under-resourced community of Soshanguve, Tshwane, South Africa, has been conducting prevention and socio-behavioral studies in this community with a focus on HIV and TB for over 15 years. These studies were primarily amongst cisgender heterosexual participants with limited studies among the marginalized lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) population.

SRC aimed to understand the impact of stigma, increased risk of violence, and economic vulnerability among the transgender population prior to embarking on research studies among this population. As part of community engagement and enhancing researchers’ knowledge of the transgender population, the SRC hosted a participatory consultative workshop in Soshanguve.

Process 

In March 2020, a group of seven participants (4 trans women and 3 cisgender homosexual men) were invited by the SRC through a partnership with the OUT organization that provides support to the LGBTIQ community. The 4-hour long workshop was facilitated by Dr. Pitsi in English based on the participants’ preferred language. All attendees provided voluntary informed consent to be part of the discussions.  Participants narrated their personal experiences, with site staff asking for questions and clarifications. The consultation discussed their responses to questions regarding how they define transgender, safety and disclosure, sexual orientation and behavior, gender transition, healthcare access and utilization, psychosocial support, employment, and interest in clinical trial participation.

Setshaba Research Centre Employees
From the top left: Dr Shapo Annah Pitsi, Sub-Investigator; Neo Buthuma, Transgender participant; Kagiso Mothwa, Community Liaison Officer; bottom center: Tercia Makhaphiedza, Pharmacist; and bottom right: Lebogang Mpete, Participant Engagement Supervisor. Click for high-res version

Outcomes

1. How participants described the transgender population in the community

Transgender was defined by the participants as identifying as a person of a different gender than the sex assigned at birth. One is either trans woman, trans man or gender fluid. However, the respondents reported that locally, it was easier for them to say that they are gay, as that is the term most people understood and are familiar with in their community rather than the term transgender. The vernacular or slang name used to describe them is ‘’Isitabane”, which is a local description for gay people. Participants did clarify that being gay is about sexual orientation while transgender is about gender identity and expression irrespective of one’s sexual orientation. They all mentioned that they knew that they were transgender from as early as their preteen years. Most of them received family support in their ‘coming out’, while others struggled to disclose or did not get support after disclosure. One participant reported that her mom realized that as a kid he liked his sister’s clothes and dressed him in women’s clothes from a young age, which made sense later on when the family accidentally found out their son was trans female. Coming out was unplanned for some attendees, as they did not know how to approach family members and were unsure of how they would be received. It was mentioned that acceptance is easier with immediate family members than with extended family members. Uncles were reported to be the least accepting.

The community was generally receptive of attendees as trans women, with the exception of a few people who insist on addressing them as men (mfana/buti) which are terms used to describe a young man/brother. Pronouns were very important to the attendees, who expressed a preference for using she/her pronouns.

Bullying was experienced at school from peers and teachers alike. This led to some dropping out of school as they were told that they were not wanted, and they felt forced to wear boys’ uniforms per the school regulations. Such discrimination led to several attendees using recreational drugs as their way of coping with the stigma they experienced with regard to their gender identity. One participant ended up as a street kid for 10 years after being chased out of three schools and the family home.

The attendees have chosen a feminine gender expression. They wear women’s clothes and use make-up. They make use of women’s toilets where they are not frowned upon. Gender-specific protocols are observed in social settings; for example, the 4 trans women are expected to dress in funeral-appropriate attire for women which includes covering the head and shoulders, or else they are not allowed to enter a burial site. Given the cultural significance of a male role in this community, it would be interesting to find out if trans men are limited in their male roles.

2. Safety and Disclosure

There seems to be a generational shift with regard to issues of safety when in public. Safety concerns were more prominent in the older participants based on their experiences, whilst younger participants felt they were generally safe.

Disclosing transgender status provides safety while posing risk of victimization at the same time. Violence can erupt following discovery of trans status by a potential sexual partner. As one participant mentioned, it is very important to be upfront, as she knew of friends who were brutally assaulted and killed for not disclosing their status. She mentioned that she prefers to disclose her gender status where there are other people nearby for her protection, in case an assault arises from the disclosure. In some instances, attendees have had to resort to physical violence to protect themselves. Incidences of “corrective rape,” which is when someone who does not conform to gender norms is raped to “cure” them of their homosexuality or transgender identity, were reported. Participants also reported incidences of corrective initiations; where a man is forced to undergo circumcision at a traditional initiation as part of a transitional rite of passage from boyhood to manhood. One trans woman participant reported an incident where she was arrested with fellow trans people at a club, and through it all she was paraded in front of everyone at the police station. Some mentioned that they find it difficult to disclose to everyone as they are afraid of people’s reactions. Others choose to confront incidences of trans hate and transphobia as they believe it is an opportunity to educate others, because they believe that silence perpetuates discrimination. They regard themselves as activists for the LGBTQI community.

3. Sexual orientation and behavior

Sexual orientation is diverse amongst transgender people. The four trans women present engaged in sexual activity with males, including men who do not identify as transgender or gay. There are apparently many married men who have an attraction to trans women. They attribute this partly to curiosity, and the so-called “after nines” who are in the closet about their transgender or gay identity. These men live their lives as married straight men during the day, but come out at night to explore their sexuality and gender identity. Anal sex is practiced since none of them have had vaginal construction surgery. There are different sexual preferences, which need to be disclosed to potential partners: top, bottom or verse (versatile), depending on whether they prefer to be on top, bottom, or either top or bottom during sex.

Promiscuity is common until people find someone they feel like settling down with. Attendees were divided as to whether they engage in risky sexual behaviors more than cisgender heterosexual people do. The general feeling was that they are riskier than heterosexuals, while some believed risky behavior is the same in both groups since it is an individual choice. Transactional sex occurs a lot, which fuels promiscuity. Alcohol was mentioned as a factor driving risky sexual behaviors. Money is needed for maintenance of their lifestyle, which they describe as high maintenance. According to them, they would rather starve than not have make-up or hair weaves. If a man is known to have a lot of money, they will target that man for transactional sex even if they know he has multiple partners.

4. Gender Transition

Participants were aware of only one referral hospital in the province, the Steve Biko Academic Hospital, which offered gender transition services. Most of them expressed the desire for a full transition, i.e. social and physical. One participant reported social transitioning only. She reported that for her it is important to be recognized for her gender identity and did not see the need for physical transition to achieve that. No fears of the hormones, side effects or surgery were reported. One participant was undergoing hormonal transition only, and another two were on hormones and awaiting surgeries. They expressed frustrations with the system with regard to the process. Getting the first appointment at the hospital can take several months. It takes a long time to get approval in the public sector to initiate the transition process, as this involves psychiatric evaluation for a minimum of 6 months prior to appearing before a panel of medical experts (psychiatrist, endocrinologist, plastic surgeon, urologist, gynecologist, and another physician) who assess suitability for transition. Once the process has been initiated, it takes a long time to move from one stage of transition to the next due to long waiting lists, e.g. initiation of hormonal therapy to having surgical procedures done. One participant was in transition for >10 years and ended up being excluded from further transition due to his age and chronic conditions that came with aging.

5. Healthcare access and utilization

All attendees accessed healthcare through public health facilities. Healthcare access was described as not challenging. They freely consult anywhere and felt that their needs were being addressed by healthcare providers. No hostility/discrimination was reported. The usual practice is to disclose that they are transgender to avoid awkwardness during consultations. They were not aware of any private general practitioners who offered hormone therapy for transitioning purposes, and indicated that even if hormone therapy was available through private practitioners, they would not be able to afford these services.

6. Psychosocial support

LGBTQI organizations

Three organizations were reported to be providing support to the transgender community, and it is through these organizations that they are linked to health services including HIV testing, treatment, and prevention; sexual health and STI treatment; and gender transition services. In addition, they organize various events where HIV counselling and testing is always offered by nurses. This is also a platform where they socialize and get introduced to other members of the LGBTIQ community. The use of social media platforms for transgender support or services is not common. They generally use social media to find sexual partners.

Home affairs

None of the attendees had changed their gender identification with the local Home Affairs Department. They were aware of the availability of the service but report being discouraged by the requirements and long process. Some indicated that they do not feel the need to change identity documents. However, they did note the issue of travelling challenges, with one attendee describing how she was delayed at the airport because the ticket was issued for a woman and her identity document indicated she was man. She was not allowed to board the plane until it was corrected. She remarked that she could not imagine what international travel would be like. They felt privileged to live in a country where their rights are protected. Access to other services, such as church and police services, were reported to be without hassles.

7. Employment

Only one of the participants was employed. Reasons for unemployment were reported to be the same as for the general population and not completely related to being transgender. Challenges with getting jobs as a trans person included confusion at interviews, as the identity documents indicate a different gender than their appearance at the interview, amongst others. Some were told at interviews that they could not be offered the job as it required a specific gender due to the type of job, e.g. lifting heavy objects, amongst other reasons. Attendees were financially dependent on their families. Those in stable relationships were financially dependent on their partners. Some engaged in transactional sex for financial support, thus placing themselves at risk of STIs and HIV.

8. Interest in clinical trial participation

Some of the participants were familiar with the clinical trials at our research center, with one being a participant in an HIV vaccine trial. They expressed willingness to participate in clinical trials, especially ones that would address their needs. They felt there was greater need for education on transgender issues at schools and in the community. When asked about biological sampling, they indicated that they did not have objections to blood and rectal sampling. No concerns were raised regarding clinical trials and voluntary participation.

Next steps and Future direction

Going forward, the site plans to engage the local LGBTQI organizations to foster collaborations, to develop an understanding of their social dynamics, and to get more insight into the role they play in the community.  In addition, we aim to obtain input from trans men, trans women and gender fluid individuals to broaden our scope and understanding of these marginalized populations. It is also crucial to include transgender persons in Community Working Groups (CWGs) or Community Advisory Boards (CABs), and to support employment opportunities through networking with NGOs.

The public sector hospitals and social services will be engaged to understand their role in the services offered and processes followed for community members in gender transition. Thus, we will be able to design interventions and conduct studies that will contribute to overcoming some of the community’s challenges and enhance their wellbeing.

Acknowledgements

We would like to acknowledge the transgender women and cisgender men who participated in the workshop for sharing their stories and experiences. A special thank you to contributing co-author Neo Buthuma, a trans female participant in the workshop. We appreciate the site management and staff for organizing and participating in the workshop and to those who contributed to the write-up of the article.

We also acknowledge Dr Athmanundh Dilraj and Neetha Morar for their valuable guidance, input and review of this report.

References:
Sithole, S. 2015. Challenges faced by gay, lesbian, bisexual and transgender (glbt) students at a South African university. The Journal for Transdisciplinary Research in Southern Africa, 11(4):193-219.


Dr Shapo Annah Pitsi is the Sub-Investigator, Neo Buthuma is a transgender study participant, Kagiso Mothwa is the Community Liaison Officer, Tercia Makhaphiedza is the Pharmacist and Lebogang Mpete is the Participant Engagement Supervisor at the Setshaba CRS.