Either way, this is an issue to be addressed in the delivery of services so that patients feel “Someone might understand who you are, or they’re trying to understand. But you still see both safe from judgement and stigma, and informed in order to make choices about their “that look” and you withdraw from giving your information. Most of the time I go there as own health and care. someone else. The services they offer me are not appropriate to me as a transwoman. I go as a man. And then not even a gay man. A straight man.” Amongst trans women: “Hormonal therapy is only available to cis women. I went to the clinic and asked for an “Health services are very generic, or they have a clear priority on “MSM” from that perceived injection, but the nurses can’t prescribe anything there, and they’re in any case only available HIV-risk angle. But nothing for trans health. Screening for cancer, for instance, is available at special facilities.” for biologically born females only.” Sexuality and gender-affirming health services are a critical enabler of service uptake by “They have no knowledge of trans people. We are virtually invisible. But we’re the most members of key populations. And, in as much as gay and bisexual men present a more vulnerable, especially transwomen. If you go to the facility, you’re discriminated. If you get favourable perspective on the acceptability of the health facilities, they are also subject to raped it’s hard to report when you’re seen as a man, and the belief is men don’t get raped. pressure to comply with a heteronormative standard. It’s hard to go back to the facility. You’ll sit in your house, rot, die.” “At one point when I was being interviewed by the counsellor, I was asked ‘when was the “At PSI, if we send a transman to the clinics, they record “female”. And when we ask for last time you had sex...with a girl’”. protective barriers for transwomen, we’re told ‘you are covered under MSM’. They didn’t know I was a transwoman. I was told to sit in a queue with ladies going for a pap smear. I “Within our political environment, with the situation here as it is, I still don’t feel completely got to the counsellor and had to explain why I couldn’t get a pap smear. A trans man went safe to fully disclose everything. The questions can be too personal, especially about your for cervical cancer screening; told he could not be at the women section and was made to partners. So, you lie. You want treatment and services, so you lie. You say your partner is not leave.” around. Or you tell them you have a wife who works out of town.” “Doctors assume gays get anal warts and prescribe [Podophyllin]. This can be painful to “They still use that standardised questionnaire with us. But it should be more open-ended, apply. One of our members – a trans person – went to the clinic complaining of a condition not so heterosexual.” and, without confirmation, was given that medication. It was just assumed she was a gay man, so she must have anal warts. She applied it for a month, but there was no change. She In the analysis of acceptability, five other themes emerge, more universal and systems- went back to the clinic, and they told her she had been misdiagnosed.” related in nature, and not specific to a sexual orientation or gender identity: “In Zimbabwe, trans people who are on hormones often obtain those hormones from the 1. Sensitisation is no substitute for representation. Cisgender, heterosexual health black market. If we need to go on ART, we are presented the choice by nurses to either stop providers – however sensitive and empathetic – are not as relatable as members of the the hormones, or not take ARVs.” community. Reducing stigma as a barrier to accessing care requires a more visibly diverse “Being a gender non-conforming person I’m already confusing to even the LGBT community. If I go there to the facility and explain I don’t want to be recorded under any gender binary! It’s easier to just go as a cis-woman, but it’s not who I am.” PERCEPTIONS, PERSPECTIVES and inclusive facility environment. “There are no trans people on the staff to speak to, someone who can really relate to me. It would be so nice to be able to see a trans person at the clinic as a counsellor. Because even a very sensitive and sensitised person would not be able to understand fully certain things. They just don’t share your experience. Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 34