Chapter 22: Health Needs and Service Delivery Models for Transgender Communities in Low- and Middle-Income Countries

INTRODUCTION

This chapter focuses on transgender and gender diverse (TGD) communities in low- and middle-income countries (LMIC) and explores both key differences in the communities compared with higher resource areas as well as issues that are similar across settings. Data suggest there are no fewer TGD people in LMIC compared with higher resource countries, and their health care needs are similar. However, given pervasive and intersectional stigma, it is harder to conduct research about and provide health care to TGD in LMIC. Therefore, there are less data on TGD, their health, and effective service models in LMIC. Nevertheless, providers and implementers must consider stigma and discrimination when designing and delivering evidence-based and high-quality services. This chapter discusses some of the roles of intersectional stigma and violence, including stigma related to gender, sexual behavior, and HIV/AIDS; then highlights issues of sexual health, infectious disease, mental health, and substance use that are particular to TGD people in LMIC. The chapter then discusses service models for affirming health care for TGD people and concludes with a case study about TGD health care for individuals in Lebanon.

Intersectional Stigma and Violence

Worldwide, TGD individuals are at a disproportionately high risk of experiencing discrimination and violence due to sexual- or gender-related stigma. Stigma is a decrease in social value as a result of deviation from the values and social norms of a community.¹ Members of society may stigmatize TGD people who do not conform to mainstream cis- and heteronormative standards, and may also commit discrimination or violence against TGD people. Health behaviors, such as seeking care or continuing a treatment plan, are also strongly influenced by the intersection of anticipated, perceived, and enacted stigma.² Health services can also be restricted due to discriminatory inclusion and exclusion policies.³ Stigma generates discrimination and violence at the individual, interpersonal, and societal level. Stigma also influences physical and mental health outcomes and can disrupt or inhibit access to resources. Discrimination as a result of stigma can include name-calling and insults, such as accusations of sex work or HIV-positive status. It can also include being threatened, physically or socially, or harassed. Stigma and discrimination can be strong social determinants of health and effect one’s psychological well-being through both self-esteem and interpersonal relationships.⁴ As an example, in a study of Latin American transgender women, at least 50% of respondents reported being denied employment, housing, and access to restrooms; detained by law enforcement; and rejected by family members.⁵ In this section, we discuss how TGD individuals in low- and middle-income countries are at risk of experiencing stigma due to gender identity and gender expression, sexual behavior, and actual or perceived HIV status.

Gender-Related Stigma

While gender identity is an aspect of the internal sense of self, gender expression, roles, and expectations are socially constructed. Expressions, roles, and expectations therefore vary across societal ...