Trans and gender diverse people face multiple barriers accessing UK sexual health services

Trans and gender diverse people often expect poor treatment at UK sexual health clinics and actively look for signs of inclusivity before accessing services, according to recent qualitative research. Simple steps could ensure more inclusive, welcoming environments.

Background

In the UK, trans people remain a highly marginalised group: facing high levels of stigma, exclusion, discrimination and violence. This results in both social challenges, such as unemployment and homelessness, and health challenges, such as an increased risk of substance use disorders, anxiety, depression and suicidal ideation. The number of people reporting a trans identity in UK primary care records increased fivefold from 2000 to 2018. While barriers accessing healthcare generally have been well documented for trans people, less is known about specific barriers when accessing sexual health services.

Globally, trans people are more likely to acquire HIV, with trans women being the most affected key population. In the UK, prevalence data for trans and gender diverse people have been inconsistent, with 2021 data suggesting a similar prevalence to the general population. However, trans and gender diverse people are less likely to access sexual health services in the UK than cisgender people and tend to have negative experiences when they do – this could lead to growing sexual health disparities for these groups.

The British Association for Sexual Health and HIV (BASHH) have acknowledged this and have developed expert recommendations for trans inclusive sexual health services. They recommend system-wide changes, such as gender-neutral registration forms, waiting rooms and toilets. Additionally, they emphasise the need for clinic staff to attend diversity and equity training focused on trans inclusivity. Clinically, they suggest that a person-centred approach be taken, with an emphasis on tailoring STI testing to individual sexual practices and risks.

However, these recommendations lack specific user perspectives from trans and gender diverse people accessing sexual health services, creating the need for this study. For this reason, Dr Tom Witney from University College London and colleagues conducted the study published in Sexually Transmitted Infections. 

The study

Researchers carried out virtual one-on-one interviews with 33 trans and gender diverse participants and conducted small virtual focus groups with an additional 26 participants living in the UK between 2022-2023. Participants were recruited via community-based organisations and using social media.

Among the 53 participants who shared demographic information – this was optional, so as to encourage participation – there was a wide age range from 17-71, with the largest group being aged 25-34 (45%). Most were White (82%), followed by Mixed Race (9%), with smaller numbers of Black and Indian participants. Over a quarter of the sample identified as bisexual (26%), followed by queer at 23%, with 15% identifying as pansexual, 13% as gay men, 11% as heterosexual and 6% as lesbian (more than one category could be selected). This was a well-educated sample, with 70% having attended university. Only 17% of the sample were not employed or studying at the time of the study. Most were based in urban areas (85%).

There was a range of terms used for how participants identified their gender identity. While some opted simply for man or woman, others included trans in the description. In some instances, this was expressed as transmasculine or transfeminine. Other participants opted for terms that were not limited to a binary, such as genderqueer or non-binary. Terms such as ‘transsexual’ were used more rarely. In terms of pronouns, he/him was preferred by 31% of participants, with 27% using she/her and 22% opting for they/them.

While the research team all identified as cisgender, the research project was guided by an expert steering group, including representatives of trans community organisations and sexual health clinicians. Additionally, they sought input from trans patient and public involvement representatives throughout the research process.

The following themes were expressed by participants.

Multiple barriers result in feelings of exclusion

Often, participants expected to be treated differently at sexual health clinics. Within a system mostly structured for cisgender people, trans or gender diverse people found that they did not fit anywhere neatly. In some instances, this feeling was driven directly by denial of care, or poor experiences in other National Health Service (NHS) settings, such as gender-affirming services – where there are lengthy waiting lists. Overall, participants did not expect sexual health services to be inclusive.

“It’s scary by definition. The fear is that you are going to be treated badly. You’re going to be treated as something different rather than just an individual with those concerns, those problems, you know.” – Interviewee (she/her)

Participants felt that clinic staff viewed trans identity as a ‘problem’ requiring specialised intervention, or that they attributed sexual health problems to trans identity.

“If we disclose our trans status when seeking sexual healthcare, we will immediately be denied, like before anything else. It’s either, ‘You’re too complicated to deal with, you need a specialist,’ or ‘Hmm, yes, you do have raging thrush and do you think that that’s probably because of your hormones and you should de-transition about that.’” – Interviewee (he/him)

The fact that some guideline recommendations, such as for PrEP, are specifically gender-based also caused a great deal of frustration. Here, participants expressed a sense that assumptions were made about their anatomy and sexual practices:

“I had a great deal of trouble accessing PrEP because they don’t offer PrEP to heterosexual cisgender women and it took me quite a while to convince them, on the phone, that that was not me… the service is not accessible in that way unless you fit their expectations.” – Interviewee (she/her)

“It’s very ‘these are the body parts a man has, and these are body parts a woman has.’ And if you’re trans, you’re going to have to ask for something different.” – Interviewee (he/him)

Simple changes would create more welcoming services

Participants shared concrete suggestions to make sexual health services more welcoming to trans and gender diverse people. These included clinics showing signs of friendliness, such as displaying trans flags:

“It’s nice to see [the trans pride flag] but you see it, and you think, OK, this organisation probably isn’t going to be transphobic. And I think just people being explicit about their trans inclusivity because, sadly, you know, simply having a generic Pride flag or saying we’re LGBT supportive, that’s not really the comfort anymore that it necessarily should be.”

In a context of increasing exclusion and hostility towards trans people, a few participants made the distinction between signs of generic gay inclusivity and specific trans inclusivity.

Clinic staff were asked to make linguistic changes, such as gender-neutral greetings and giving their pronouns when introducing themselves.

“That’s the difference between me feeling comfortable and uncomfortable. I don’t think the average man or woman is bothered whether they get called sir or madam at a clinic. Just say hello, that’s it.” – Interviewee (she/her)

“I find [it] easier when the other person introduces their pronouns. That makes that ‘OK now I can’ because I often am scared that these health providers will have their own biases.” – Focus group participant (they/them)

Physical space changes would also lead to greater feelings of comfort when accessing the sexual health services. Participants shared how they found gendered waiting areas disconcerting, as well as gender-specific toilets. Additionally, inclusive options such as non-binary could be added to registration forms to signal openness to diverse genders.

Participants had mixed feelings about whether there should be standalone trans and gender diverse sexual health services, or whether current services should become more inclusive. While the sense of familiarity provided by standalone services would be a plus, there were concerns expressed over possibly becoming targets of transphobia or increased waiting times, as with gender-affirming services:

“Having specific clinic times set aside for trans-people so that you’re not waiting in a room and worried about other people looking at you and going ‘Who’s that?’” – Interviewee (they/them/he/him)

“In an ideal world, everything is just sexual healthcare, and it's normalised for everyone. If you have more specialised trans and gender diverse clinics, maybe you have some lovely people lurking outside that want to harass anyone that goes in.”  – Focus group participant (she/her)

Sexual health staff need be more trans inclusive

The final theme related to interactions with sexual health clinic staff – and how these overwhelmingly dictated how comfortable trans and gender diverse people felt within clinics. This theme also revealed specific steps that staff could take to become more trans inclusive.

Participants expressed an expectation of good care, without invasive questions and inappropriate curiosity. They also did not want staff to be overly delicate in interactions, arising from a fear of causing possible offence. This could lead to unnecessary delays and highlight difference instead of minimising it.

“I guess it’s trying to remember that you can kind of just speak to people normally […] I get that it comes from a place from not wanting to upset me but then I almost find it frustrating because I’m like… this conversation is just taking longer!”  – Interviewee (he/him)

“Just that you have that connection with [staff] – you can just relax in the situation and you don’t feel they’re going to find you odd, or not really understand you, or you’re just not on the same page […] And an openness, like a curiosity but not like an over curiosity but like… kindness and understanding.” – Focus group participant (they/he)

Some participants had personal preferences for terms used to refer to body parts, such as using ‘front hole’ instead of ‘vagina’. This extended to asking about types of sex and sexual partners – doing so in a way that did not make any assumptions about the presence or absence of specific body parts, or sexual practices based on identity.

“If I put in that I was a man and that I had sex with men I would get a throat swab, a bum swab, and a pot to piss in – there was no way for me to communicate that I needed the [vaginal] swab not the pot… eventually they’d figure it out… and they would just hand me back a single swab…” – Interviewee (he/him)

Some participants highlighted positives, such as the fact that most staff already know how to deliver sensitive person-centred care as part of their skillset – they simply need to apply this to trans and gender diverse people.

“You don’t have to build from the ground up in terms of knowing how to get people to talk about their bodies and their health problems.” – Interviewee, (he/him)

Conclusion

“This study found that trans and gender diverse people often expect that sexual health services are not designed to meet their needs and they look for signs when judging if a service is inclusive,” the researchers concluded. “It also found that a person-centred approach to consultations, along with basic awareness of trans and gender diverse people’s sexual health needs, can help to meet common expectations of good care. These findings highlight how simple changes can improve trans and gender diverse people’s experience of services… These findings support the BASHH expert recommendations for inclusive sexual health services. They highlight the need for services to actively engage to reach a population with potentially greater sexual health needs who are disengaged with services.”