Abstract
BackgroundSexual orientation and gender identity are social determinants of health for people identifying as lesbian, gay, bisexual and transgender (LGBT), and health disparities among sexual and gender minority populations are increasingly well understood. Although the South African constitution guarantees sexual and gender minority people the right to non-discrimination and the right to access to healthcare, homo- and transphobia in society abound. Little is known about LGBT people’s healthcare experiences in South Africa, but anecdotal evidence suggests significant barriers to accessing care. Using the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, this study analyses the experiences of LGBT health service users using South African public sector healthcare, including access to HIV counselling, testing and treatment.MethodsA qualitative study comprised of 16 semi-structured interviews and two focus group discussions with LGBT health service users, and 14 individual interviews with representatives of LGBT organisations. Data were thematically analysed within the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, focusing on availability, accessibility, acceptability and quality of care.ResultsAll interviewees reported experiences of discrimination by healthcare providers based on their sexual orientation and/or gender identity. Participants recounted violations of all four elements of the UN General Comment 14: 1) Availability: Lack of public health facilities and services, both for general and LGBT-specific concerns; 2) Accessibility: Healthcare providers' refusal to provide care to LGBT patients; 3) Acceptability: Articulation of moral judgment and disapproval of LGBT patients’ identity, and forced subjection of patients to religious practices; 4) Quality: Lack of knowledge about LGBT identities and health needs, leading to poor-quality care. Participants had delayed or avoided seeking healthcare in the past, and none had sought out accountability or complaint mechanisms within the health system.ConclusionSexual orientation and gender identity are important categories of analysis for health equity, and lead to disparities in all four dimensions of healthcare access as defined by General Comment 14. Discriminatory and prejudicial attitudes by healthcare providers, combined with a lack of competency and knowledge are key reasons for these disparities in South Africa.
Highlights
Sexual orientation and gender identity are social determinants of health for people identifying as lesbian, gay, bisexual and transgender (LGBT), and health disparities among sexual and gender minority populations are increasingly well understood
Identifying as lesbian, gay, bisexual or transgender (LGBT)1 is not genetically or biologically hazardous, but societal homo- and transphobia confer risk factors for the well-being of people who identify as LGBT [1, 2]
The framework provides a useful lens through which to analyse access to healthcare for people who identify as LGBT, and links discrimination based on sexual orientation and gender identity to broader discourses around the right to health
Summary
Sexual orientation and gender identity are social determinants of health for people identifying as lesbian, gay, bisexual and transgender (LGBT), and health disparities among sexual and gender minority populations are increasingly well understood. Gender identity and sexual orientation, like other social determinants of health, lead to health disparities and, compared with heterosexual and cisgender socioeconomically matched peers, individuals who identify as LGBT are more likely to face barriers accessing appropriate healthcare [1, 2]. Beyond these societal risk factors, people who identify as LGBT have specific health and healthcare needs in various fields from chronic disease risk, adult and adolescent mental health, violence, sexually transmitted infections, and human immunodeficiency virus infection [7]. Of special concern are mental health disparities: experiences of social exclusion, discrimination and prejudice impact on mental health, and studies from Europe and the United States have shown that people who identify as LGBT have significantly higher rates of depression, suicide, and anxiety disorders than their heterosexual matched peers [8,9,10]
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