Popular Netflix show, Pose, with its string of awards and prestigious nominations, has done more than just introduce us to new, diverse acting talent. The show, with its historymaking assembly of the largest transgender cast ever, has also shone the light on what has been a largely marginalised section of our society: the transgender community.

Transgender people are defined as those whose personal identity and gender does not correspond with their birth sex. In South Africa, the Alteration of Sex Description and Sex Status Act (2003) means that our constitution allows one to change the sex description on their birth record, under certain conditions.

A study by the Williams Institute found that about 0.6% of US adults identify as transgender. However, the size of the transgender community in South Africa is not known. Germaine de Larch is a non-binary transgender person who works at Pan Africa ILGA, a human-rights organisation with a focus on LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, and asexual) issues.

He says: “There are no official or even unofficial statistics [for the number of South African people identifying as transgender].” Tish Lumos, programme co-ordinator of sexual orientation and gender identity advocacy at the University of the Witwatersrand, says people can come out as transgender at any age, from toddlers to middle-age people.

As with many people in the LGBTQIA+ community, transgender people experience a number of social problems, difficulties, and barriers to accessing many resources and services.

One such challenge is access to adequate healthcare. Admittedly, access to decent, affordable healthcare is an obstacle many South Africans face. But when you compound these issues with discrimination, gatekeeping, and the unavailability of basic treatments and services, these problems become magnified in the transgender community, which is also often misunderstood and marginalised.

Jonathan Bosworth, a counselling psychologist with a special interest in the LGBTQIA+ community, says access to healthcare for trans people is a fundamental problem in South Africa. “When transgender individuals access healthcare services, their gender identity becomes the focus rather than actually the flu or a broken foot or whatever it is. I think that can be quite traumatising or further stigmatising for gender-diverse people.”

Bosworth says the problem of accessing healthcare as a transgender person is two-fold. Transgender individuals seek healthcare on two levels: the basic level of treating day-to-day health conditions that all people experience; and the level of accessing trans-specific healthcare, such as gender-affirming surgery and hormone replacement therapy (HRT).

When it comes to public hospitals, only Chris Hani Baragwanath in Soweto, Steve Biko in Pretoria, Groote Schuur in Cape Town, and Helen Joseph in Johannesburg offer trans-specific healthcare services.

In other public-sector facilities, services may be offered on an ad-hoc basis. Even then, accessing these services is dependent on whether you live close to these facilities and the length of their waiting lists.

The 25-year waiting list at Groote Schuur for transgender women to have bottom surgery ― reshaping the male genitals into the form and function of female genitalia ― attests both to the need, and the limitations in the public sector to assist transgender patients.

People can also access transgender healthcare at private doctors, but this is dependent on their ability to afford private medical aid. Even then, medical schemes won’t cover all the costs associated with transitioning. Healthcare practitioners who act as gatekeepers are one of the biggest problems transgender patients face.

Lumos went to five different doctors before they found one that would prescribe testosterone — not because it was dangerous to their health, but because their identity as a transgender individual was being questioned.

Many trans patients who have fought the constant battle of access to healthcare are currently experiencing yet another crisis in the healthcare sector. Local stocks of Depo-testosterone (Depo T), the cheapest and most popular form of hormone replacement therapy (HRT) for intersex individuals, non-binary people, and trans men, ran out weeks ago. This is a huge problem as it is a chronic medication.

Medical doctor, author, and activist Anastacia Tomson says Depo-T is the most accessible and commonly used form of HRT in South Africa, which means the shortage is a big problem.

“Withdrawing HRT can lead to severe psychological and emotional distress, can worsen gender dysphoria, and can lead to physical effects like the return of menstruation and redistribution of body fat,” Tomson says.

Elliott Kotze is a transgender psychologist and researcher. Kotze has been unable to inject himself with Depo-T for the past few weeks, which has caused dysphoria, a depressed and anxious state.

“For me, [it] is an intense discomfort with my body, specifically those parts and functions of my body that designate me ‘female’ in the public eye. I experience it both as emotional distress and physical discomfort (sometimes it feels like fire ants are crawling across my chest),” he says. “For many of us, myself included, dysphoria precedes suicidal ideation and self-harm — it is quite literally life-threatening,” he says.

Tomson, who is transgender herself, says it can be difficult and costly to switch to other forms of testosterone and that long-term withdrawal can lead to a reversal of masculinisation.

The shortage started at the end of last year and some people have not had a shot of Depo-T for months.

Pharmaceutical company Pfizer has said there is no stock due to unforeseen circumstances and that it will have stock by the end of March.

There is no guarantee, however, that this will be the case. Kotze says some public hospitals still have stock, so he’s going to try to access Depo-T via them. He says this is a bit of a gamble, however.

“I don’t know how the professionals I encounter will behave towards me once they know I’m trans; whether they have any experience in dealing with trans patients; and, if they don’t, whether they will take my knowledge seriously when I inform them of my healthcare needs.”

Lumos says: “It’s not necessarily an investment in the perfect body as some cisgender people [whose personal identity and gender corresponds with their birth sex] might phrase it: it’s an investment in yourself.”

Kotze sums up what the stockout fundamentally means for the trans community. “When hormones are not available for our treatment, it disrespects the arduous process of coming out, accessing healthcare, transitioning, and the great losses we suffer as a result.”

Know your terminology

NON-BINARY is a way of describing a gender identity that does not fall into a strictly male or female category. For many people, there is more diversity in terms of sex and gender and they may identify as neither.

A PERSON’S GENDER IDENTITY refers to their internal sense of themselves as male, female, or as a different gender. SOMEONE WHO IS TRANSGENDER does not identify with the gender identity traditionally assigned to their sex at birth. Rather, they feel they are born into the wrong body. This may lead someone who identifies as a trans male, for example, to seek to change their female anatomy to match their internal male identity.

GENDER-AFFIRMING surgery may include top surgery to have breasts removed or augmented, or bottom surgery for gender reassignment.

HORMONE-REPLACEMENT THERAPY (HRT) is part of an ongoing, long-term transitioning process that involves the need for either a testosterone or oestrogen prescription from a healthcare practitioner to supplement the body’s lack of the desired hormone production.

TRANSGENDER PEOPLE may identify as male or female, but may also identify as non-binary. People who are non-binary may choose to use gender-neutral pronouns and it is common courtesy to ask a transgender person which pronouns they prefer