Queering health care
Clio Koopman | Amandla 64| June, 2019
Access to health care is a perfect example of who is important in South Africa and who is not. In unequal South Africa, private health is accessed by 16% of the population. 4.4% of GDP is spent on that 16%, while 4.1% is spent on the 84% of the population who use public health care. This means that working class South Africans pay a poverty premium for access to health care.
LGBT people are faced with the intersection of poor health care with discrimination, homophobia and transphobia. Recent South African studies have shown that LGBT patients experience high levels of discrimination from health providers. The South African Department of Health’s 2012–2016 National Strategic Plan for HIV, STIs and TB showed that transgender people are one of the most at risk populations for HIV, STIs and TB. It is easy to deduce from this that working class queer people are the most at risk of illness and disease.
Metal illness grows
The issue of mental illness in South Africa is a growing crisis. The effects of colonisation and apartheid have caused generational trauma and mental ill health, which goes undiagnosed and untreated. The urban crisis, an extension and result of these systems, continues to perpetuate the cycle of mental illness, specifically in communities that are impacted the most, i,e black, working class people.
LGBT people face constant discrimination, from all institutions and aspects of life. Homophobia is so deeply embedded in South African rhetoric and ways of being that it cannot be separated from any institution or provision of service. LGBT people are not only the most at risk of communicable diseases, but also mental illness, as a result of attitudes of hatred, and non-acceptance.
Treatment for mental illness is seen as a luxury, and often limited to middle and upper middle class communities. Mental health treatment is no exception to general health care, as far as discrimination against queer people is concerned. Mental health care is meant to heal and tackle intricate, deeply embedded issues of homophobia and internalised homophobia. One would think this would be non-discriminatory and non-biased. The reality for queer people, however, does not echo these assumptions.
“They treat us like we’re not there” – Queer bodies and the social production of healthcare spaces, written by Talia Meerand Alex Mülle contains sentiments from queer people around the provision of health care in South Africa, or lack thereof in the case of queer health. This was one respondent’s experience of therapy “[After learning about my sexual orientation] the psychologist read me some scriptures from the bible; and she told me ‘you know what, just pray’”.
Mental health issues in the queer community are treated as a consequence of the “wrongdoing” of being queer. Christian rhetoric that you can “pray the gay away” influences health care professionals, as much it influences a lot of South Africans.
No transgender provision
Health provision for transgender individuals is virtually non-existent. Hormone replacement therapy and gender reassignment surgery are impossible to access. Groote Schuur Hospital in Cape Town is the only hospital in South Africa that offers free gender reassignment surgery. It has a waiting list of 27 years, with four surgeries done every year. There is one private medical aid scheme that covers this surgery.
In addition, as one respondent to a study pointed out, “There is no queer protection, like the safety pack [HIV and STI prevention material distributed by a local NGO, consisting of dental dams, gloves, condoms and lubricant]. I would love to see a dispenser at a clinic.”
All of this sends a very clear message to queer and trans people in South Africa: “We do not care about your health or health needs”. The lack of access for transgender people to appropriate health care is supported by the idea that South Africa is already overstretched when it comes to health care. So the sentiments of South Africans are ‘How can we provide frivolous services such as gender reassignment surgery when we cannot provide “basic” health care services?’
Lesbian HIV untreated
HIV in the lesbian community continues to go unattended to. Studies have shown that 10% of lesbians in South Africa have HIV. Because of the assumption that lesbians do not have “real” sex, and therefore cannot contract STIs, there is little awareness and attention paid to the growing epidemic of HIV in their community. This also means that little is done to intervene in HIV and STIs. There is no effort from health care facilities to provide safety measures for sex, or alternatives to heteronormative sex education.
This extends much further than health care provision. Sex education in schools is taught through an extremely heteronormative lens. This perpetuates the idea that queer people do not need to learn about sex and sexually transmitted diseases, because they do not engage in “real” sex.
Gay men blamed for HIV
The opposite applies to gay men. 26% of gay men in South Africa are HIV positive. Common rhetoric in South Africa is that gay men “brought” or “caused” HIV. This has caused South Africans to harbour hatred towards this community. This has heightened awareness and focused attention on HIV in gay communities. But the attention is not matched by intervention in the high prevalence of HIV in the gay community. The question is, does the attention and awareness of HIV in gay communities come from a place of concern, or from a place of blame, using gay men as the scapegoat for HIV in South Africa?
The queer black body has over time become either hyper visible or invisible. When we think about health care, it is important to take history into account, and think about examples of how Africans were made to be experiments, through eugenics during colonialism. The legacy of objectifying and analyzing the black body continues to govern how we position ourselves in the health care system.
It is impossible to separate how black queers experience medical treatment from the experience of their white counterparts. The legacy of Apartheid continues to govern the way black queer people navigate the healthcare system, and generally the world. Because of hierarchical structures imposed on black communities in South Africa, it has become unsafe for black queers to access both affluent spaces and working class spaces. This legacy goes further than Apartheid, to colonialism. Its influence is that South Africans have come to deem homosexuality as unAfrican.
The question is, how do we access health care, without being subjects of historical moments? How do we carve out an autonomous identity? The answer to this question needs to come from healthcare practitioners and South Africa in general, as well as black, queer South Africa.
On an ideological level, there needs to be a huge shift in what health care providers imagine queer people’s health needs are, and why queer people are entitled to access to quality health care. This can only come from people interrogating their perception of the imagined “queer experience”. This requires openness from health care professionals and a willingness to put in effort to unlearn flawed ideas around queerness.
On a more practical level, there are very easy, small steps to make healthcare more inclusive. For example, provide inclusive STI and HIV prevention material at all clinics and compulsory sensitivity training, specifically around queerness.
More long term solutions would be to change paperwork to be inclusive of gender deviant identities, to make queer inclusive sex education mandatory in schools and to insist on medical students doing practical work which involves procedures such as gender reassignment surgery, so as to grow the amount of qualified health professionals who can perform these operations.
LGBT+ organisations are currently doing important work to combat exclusive health care practices. This comes in the form of immediate intervention in two main issues: mental health and HIV and STIs. These hit the queer community especially hard, due to contextual factors. There are various LGBT+ shelters offering support and safe havens for queer people, as well as psychiatric support. Because queer people do not have access to adequate health care, LGBT+ organisations have to focus on immediate issues, and therefore cannot help being reactionary. It is important to interrogate where long term action should come from to ensure better health care for queer people, and whether all the responsibility should sit on the shoulders of LGBT+ organising groups, struggling with funding and overcapacity because of the system failing.
There is much work to be done. It needs to come from the health sector. There needs to be a greater sense of accountability and acknowledgment of the failure to address the needs of queer people. Only from there can solutions start to be discussed.
Clio Koopman is a young trans man originally from Cape Town. He started an organisation focused on making workplaces more transgender inclusive. He is an activist, a campaigner, a writer and a fighter.