Providing STBBI services to trans people: Beyond kindness, what truly matters?

It is around 11 p.m. and I am getting an urgent call from a friend who is a community member and a refugee trans woman living with HIV. She is telling me that she cannot get the urgent treatment she needs at the hospital and that the front desk misgendered her many times and frowned upon her broken English. Later, I learned that different clinics denied and delayed her HIV and hormone replacement therapy (HRT) meds for different reasons like lack of insurance or language barrier.

Another community member who is nonbinary, assigned female at birth, was constantly questioned at a sexual health clinic about birth control, Pap testing and vaginal health, even though the patient refused many times to talk about their body in that terminology and those were not the services they came in for.

On another occasion, a friend who is a gay trans man shared with me that he was invited to join a medical study that offers free PrEP and doxy-PEP at a sexual health clinic, only to be further denied as a participant when they learned he is trans. As a result, he ended up not getting the medications for free as promised because of the research criteria.

These three people from different walks of life share the common experience of many trans and non-binary people trying to access sexual health services in Canada. As a refugee trans woman myself, I had to learn to advocate for my health many times to access services and to educate providers. Apologies if I break any illusion of cis allyship, but kindness and respecting pronouns are the least one can do. Contrary to what the title of this article presumes, lack of kindness and failure to respect pronouns remain among the gaps in gender-affirming STBBI care in Canada, even though they are the bare minimum baseline. Especially if you are a transfemme of colour, a newcomer trans person or Two-Spirit, the challenges in access are interlayered.

Our work in gender-affirming provision of services and knowledge is multidimensional. It requires the collective and coordinated actions of all stakeholders, from frontline workers in clinics to researchers, backbone organizations, facilitators and educators.

Let’s take note of some key points to make our HIV/STBBI work more gender-affirming:

Frontline work

• Use preferred language in forms and communication. For example, If I am calling my girl d*ck a “princess wand”, please join the fun and say it that way! The language trans people use to describe their bodies and identities can be different from what providers are used to in cisnormative nomenclature.
• Your perception of trans bodies provides us with limited knowledge: Trans people don’t need an anatomy lesson about the sex binary on every visit to a provider. Our bodies reflect the complexity of human nature —regardless of whether or not we are on HRT or have undergone surgery— and so do our needs. Ask us what we need first.
• Being trans is only a single aspect of our sexual health needs: Being trans and non-binary, especially being a newcomer trans woman of colour, is materially difficult. Coming from a lower economic class, being a refugee, not knowing the language or system navigation, being street-connected or being a sex worker also shape the trans experience and are among the social positions that many trans people in Canada share. Even some of the health system wins achieved by the HIV/STBBI community can pose challenges for marginalized trans communities. It is important that our practice be guided by a vision that addresses the social determinants of health specific to trans clients.

Institutional work

• We need to meaningfully engage Two-Spirit, trans and non-binary (2STNB) people in issues and knowledge sharing: It is essential to have set principles around gender-affirming approaches in our work. This can look like internal organizational guidelines on gender-affirming approaches in clinics, universal design principles for intake forms and washrooms, or processes of making safer spaces for 2STNB people. This can also look like creating resources around systems navigation and initiating HRT prescription protocols for trans patients. 
• More data is needed, but it has to be ethically acquired: Although there is an obvious need for trans public health and clinical data so that we get more informed on our issues, it is essential to acquire it ethically. Another important point is that not only quantitative data but also trans narratives and other types of data should be integrated into evidence-based approaches.
• Hire and integrate more of us in STBBI work: Trans work is way too versatile and interconnected to be in silos. The knowledge of 2STNB people is endless when it comes to providing new and rich ways of offering STBBI prevention and care.

As we are approaching the International Trans Day of Visibility (March 31), let’s try to find ways to integrate holistic and intersectional gender-affirming approaches into our work and institutions. Intentionality, humility and compassion truly matter in any service or knowledge provision for trans and non-binary people, particularly nowadays with rising anti-trans and anti-immigrant sentiments. We need a radical change to transform not only how we treat 2STNB people but also the way we practise our service and knowledge provision, which cater to cisnormative understandings of the human body and public health.

Last but not least, as part of my work at the Ontario HIV Treatment Network (OHTN) and Trans Women and Gender Diverse People HIV/STBBIs Health Research Initiative (TWIRI), I have many more resources to share about gender-affirming HIV/STBBI service provision and I love connecting folks to each other. Feel free to reach out to learn more!

Asya Gunduz is the founder of LubunTO, a queer organization for immigrants from Turkey and Northern Kurdistan. She also works at the OHTN as the lead, trans and gender diverse people HIV prevention and health promotion and is co-chair at TWIRI. Besides her efforts in community building through LubunTO, she volunteers on the board of Community-Based Research Centre (CBRC). Contact Asya here.