The hurdles faced by individuals identifying as queer when seeking for and by healthcare professionals when providing sexual and reproductive healthcare services in South Africa.

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Raikane James Seretlo, Hanlie Smuts, Mathildah Mpata Mokgatle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4157361/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Sexual and reproductive healthcare services and needs (SRHSN) are essential for improving overall health and well-being. Queer people face obstacles not just in obtaining and receiving SRHSN, but also in provisioning of these services by healthcare professionals (HCPs). Methods: In this article we have performed a total of 55 qualitative one-one interviews. Purposive sampling was employed to select all HCPs, and respondent-driven sampling (RDS) was used to choose all queer people. Data was collected in seven district public hospitals and two non-governmental clinics which focused on queer-related healthcare in Gauteng Province, South Africa (SA) and data was analyzed using thematic content analysis. Result: Six main themes emerged from the data demonstrating that HCPs and queer people had similar, contrasting, and different challenges when rendering and receiving SRHSN. These themes include HCPs belief that queer people are afraid, while queer people believe that HCPs have negative attitudes, and are perceived to be gatekeepers. HCPs highlighted being surprised and confused about gender identity, healthcare disparities and familial problems, and highlighted HCPs' incompetence in queer-related healthcare, and queer people engagement as a barrier. Discussion/conclusion: Policies need to be strengthened to address and ensure inclusivity in the healthcare sector and the creation of new creative, including innovative, healthcare solutions to address SRHSN for queer people. This approach has the potential to bridge gaps and address difficulties confronting both HCPs and queer people. LGBT challenges queer people healthcare professionals sexual reproductive healthcare services Introduction Sexual and reproductive health (SRH) refers to both physical and emotional well-being, including the ability to prevent unintended pregnancy, unsafe abortion, sexually transmitted diseases (STD) like human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), and all forms of sexual assault and coercion [ 1 ]. It is therefore important for everyone to have access to high-quality vital health care as the cornerstone of universal health coverage [ 2 ]. However, societies across the globe still have a long way to go, since queer people are still experiencing and facing exclusions and a series of health inequities derived from the stigma and discrimination in the healthcare sector [ 3 – 6 ]. This is despite the fact that the sustainable development goals (SDGs) seek to address issues of inequality, embrace diversity, and ensure health and well-being for all [ 7 ]. Furthermore, these SDGs, notably SDG 3.7, seek to provide universal access to sexual and reproductive healthcare services by 2030 [ 7 ]. Specifically, in SA, queer people continue to face difficult and diverse social challenges such as prejudice, stigmatization, denial of healthcare services, and community rejection [ 8 – 14 ]. There is still a belief that HCPs are the most crucial frontline workers who can help queer people overcome their issues. Some HCPs continue to discriminate against queer people based on their sexual orientation or gender identity, expressing moral judgment and disapproval [ 6 , 10 , 15 ], and imposing heteronormative attitudes [ 16 ]. Again, some HCPs refuse to provide care to queer people [ 10 ], and some HCPs lack information about queer people's identities and health concerns, resulting in poor-quality care [ 10 , 15 ]. These issues around queer people are not only prevalent locally in SA, but across the different continents and countries as well. For example, in sub-Saharan Africa (SSA) queer people continue to face stigma and discrimination, which jeopardizes their health and exacerbates sexually transmitted illnesses such as the HIV epidemic [ 17 ]. Furthermore, a study by Mbeda et. al. [ 18 ] found that queer people reported experiencing healthcare-related stigma experiences, which led to fear of looking for healthcare services and avoidance of seeking, and some said they were denied health services because they were queer. Rosee et. al [ 19 ] found stigma and prejudice as some of the hurdles to healthcare for queer people in SSA, which were exacerbated by the illegality of homosexuality. Furthermore, hurdles to HIV testing resulted in the exclusion of some of queer people from treatment cascades of events and poor sexuality training among HCPs leads to discrimination or denial of treatment for some queer people, notably in government [ 19 ]. Moreover, most of the countries aside from SA, regardless of their level of healthcare advancement and being classified as developed countries, still have challenges in improving queer’s health and well-being. According to a study by Gonzales and Henning-Smith [ 20 ], some queer people like transgender and nonconforming adults continue encountering barriers to health care due to discrimination, insurance coverage, employment, and public policy, as well as an inadequate level of understanding among health care providers about transgender-related health issues. According to Hafeez et. al. [ 21 ], queer people receive low quality care due to stigma, a lack knowledge among HCPs, and insensitivity to their community's particular needs. Westwood et. al. [ 22 ] discovered negative attitudes onto queer people among nurses, demonstrating a toxic nursing culture in an elderly ward, and the person involved in this case study described multiple instances including homophobic and transphobic practice, as well as queer microaggressions, which apparently affected the quality of nursing care. Elliot et. al. [ 23 ] found that queer people have poorer health and bad healthcare experiences. Again, systematic review findings by Alencar Albuquerque et. al. [ 16 ] indicated that the queer people face problems in accessing health services as a consequence of heteronormative views enforced by HCPs. It is critical that the obstacles faced by queer people be addressed as soon as possible in order to reduce any health risks. If these issues are not addressed, queer people will continue to be uncomfortable announcing their identities and concealing signs of sexually transmitted illnesses (STIs) [ 19 ], contributing to an escalating HIV epidemic [ 17 ]. Other additional health challenges that queer people will continue to suffer from are a greater likelihood for substance use, STIs, malignancies, heart disease, being overweight, bullying, separation, disapproval, anxiety, depression, and suicide as compared to the general population [ 21 ], furthermore, they are going to keep experiencing depression and anxiety as a result of homophobic comments by HCPs [ 24 ], and HCPs are going to keep imposing heteronormative attitudes [ 16 ]. Little studies focused on both queer people and HCPs’ challenges experienced in SA had been conducted. Queer people This study fills significant gaps in our understanding of healthcare inequities experienced by both queer people and HCPs. By exploring these gaps, this article aimed to explore the challenges faced by queer people and HCPs when receiving and providing sexual reproductive healthcare services in SA, establishing the way for specific measures and changes in policy that promote inclusive, non-discriminatory healthcare practices, and ultimately enhance the overall well-being of South African queer populations. Methods Study design, population, sampling, and recruitment We performed a qualitative study with individual interviews with participants from seven public district hospitals and one non-governmental organization (NGO) in South Africa's Gauteng Province. The study involved a total of 55 participants (33 HCPs and 22 queer people). Participants in the study comprised of nurses, medical physicians, social workers, clinical psychologists (HCPs), and lesbians, homosexuals, bisexual, transgender, as well as men who have sex with other men (MSM). Purposive sampling was utilized to choose all 33 HCPs, whereas RDS was used to select all 22-queer people. HCPs were sought out during their working hours at their workplaces, whereas for the queer participants, the principal researcher began with staff members on duty at the selected NGO clinic and then asked them to refer other members of the queer people who came to the clinic on the day of data collection. All queer participants received a reimbursement of R250.00 for their transportation. Data collection Data from qualitative interviews were gathered from September to December 2023. We commenced with six pilot study interviews which included three of each study population. The findings of the pilot study were excluded from this article. The pilot study findings enhanced semi-structured interview guide amendment and checking if the questions were answering what was expected and anticipated. In total, we performed 55 interviews in Gauteng Province, SA, from seven district hospitals and one NGO (for public facilities), eight Johannesburg health district office, 20 Tshwane district health services, and five West Rand district health services. We used two selected NGO clinic branches in Gauteng Province for NGO, 13 from the Pretoria branch and 10 from the Kempton Park branch. Participants were interviewed in English, but allowed to respond in their home language, which was largely Isizulu and Setswana; all responses were later translated into English. The principal researcher and a research assistant gathered data, recorded all interviews with an interview guide and a digital recorder. The study's purpose, questions, and objectives were given to participants prior to data collection, and those who decided to participate offered both verbal and written informed consent. Questions that were asked during the data collection for HCPs and queer people, focused on the main aim which was to learn about the challenges both participant groups experienced. For HCPs the questions were “T ell me about some of the major challenges you have experienced when you have to provide/during provision of sexual and reproductive healthcare services to the queer people in your institution , how often to you render SRHSN to queer people , and what do you think are the reasons for queer people to access and utilize SRHSN in your healthcare facility ”. The question for queer people entailed: “ Can you tell me about your experience when you access or/and utilize the services at a public institution and what are some of the major challenges you have experienced when you had to access or/and utilize sexual-reproductive healthcare services and needs as a queer individual at a public institution? ”. Data analysis The principal researcher employed thematic content analysis (TCA) to analyze data, following Ravindran's [ 25 ] four (4) phases. During the study, the researchers immersed themselves in the obtained data; all 55 audio files were transcribed verbatim, and where participants utilized and responded in their home language, the content was translated into English. All transcripts were labeled with the number of an interview, for example, P1 stands for participant number 1 and refers to interview number 1. The primary researcher analyzed the data initially using NVivo 14 based on the research questions, interview guide, and interview notes, while a research supervisor served as an independent coder and a second research supervisor reviewed the final themes as part of the article. To develop a consensual viewpoint, the principal researcher and supervisor examined all the discrepancies in coding interpretations that surrounded the issues faced by both HCPs and queer people. All coded data were examined for commonalities and the emergence of important themes, which drove a subsequent thematic analysis. NVivo 14 analysis revealed six major and linked minor themes. Research ethics Sefako Makgatho Health Sciences Ethics Committee (SMUREC) reference number: (SMUREC/H/291/2023: PG) provided ethical clearance and permission for the project. All participants understood the study's aim, research questions, and objectives and volunteered to participate without coercion. Participants in the study were given both verbal and written informed permission. We used anonymous identities for this work, and all comments were anonymized. Results Table 1 and Table 2 depict the characteristics of study participants and the list of emerging themes respectively. Table 1: characteristics of study participants Characteristics HCPs n (=33) Queer people n (=22) Age, Mean (SD) 4.96 (1.84) 2.86 (.94) Birth gender n (%) Male Female 5 (15.15) 28 (84.85) 19 (86.36) 3 (13.64) Sexual orientation n (%) Straight Lesbian Gay Bisexual Transgender woman MSM 33 (100) 0 0 0 0 0 0 3 (13.64) 8 (36.36) 2 (9.09) 7 (31.82) 2 (9.09) Marital status n (%) Single Married 22 (66.67) 11 (33.33) 22 (100) 0 Education level n (%) No formal education Primary Secondary Tertiary 0 0 0 33 (100) 0 0 10 (45.45) 12 (54.55) Table 2: List of emerged themes. THEMES HCPS QUEER PERSONS HCPs believe that queer people are afraid. Queer believe that HCPs have negative attitudes. HCPs as gatekeepers. HCPs as gatekeepers. HCPs being surprised and confused about gender identity. HCPs being surprised and confused about gender identity. Healthcare disparities and familial problems. Healthcare disparities and familial problems. HCPs' incompetency in queer-related healthcare. HCPs' incompetency in queer-related healthcare. Queer people as a barrier. Queer people as a barrier. The data demonstrated that HCPs and queer people in SA's Gauteng Province face similar, contrasting, and different problems when rendering and receiving SRHSN. Queer people typically reported unfavorable experiences receiving SRHSN in public healthcare facilities. HCPs, on the other hand, conveyed their challenges with a touch of positivism and acknowledged some of the identical challenges mentioned by queer people. HCPs believe that queer people are afraid. HCPs outlined that queer people are scared to come to the healthcare facilities due to their internalized and experienced fears and they tend to distance themselves from the healthcare facilities and not receive services. There were contrary statements between HCPs as some acknowledge that they judge queer people and some stated that they do not judge them. HCPs said that queer people are afraid of being stigmatized. Participants also expressed uncertainty as to why queer people do not come; however, they highlighted that it is possible that queer people are uncomfortable with the people they will meet when visiting healthcare facilities, and that because they have been stigmatized in other healthcare facilities and by community members, they believe they will be everywhere. “I will say maybe it is out of… I don’t know whether maybe it is stigma from where they come or they have a perception that if I identify myself as queer that maybe I am talking to someone who is old, maybe the person will judge me in a negative way” (HCP5, 47yrs. old). “For me I think I would say possibly some of them you find that they are uncomfortable with whoever maybe they are going to be meeting or they are just uncomfortable with how they see themselves, then having to come and explain here. I don’t know. I’m thinking it’s got to do with them or how maybe they are being stigmatised somewhere else. I’m not sure…So, I think people- there is still a lot of stigmas in our communities and unfortunately people are afraid to come to healthcare facilities because of that, because they are going to be discriminated against and that’s something we need to fight” (HCP16, 30 yrs. old). Additionally, HCPs expressed that queer people fear to be judged and discriminated against. HCPs think that some of the reasons queer people do not come to the healthcare facilities is because they are afraid of being judged, rejected, criticised, and discriminated against, as well as being name-called. HCPs further believed that queer people worry about how they will need to look and change their identity when they come to the healthcare facilities. “They are afraid of the judgement, I don’t know…I think what’s hindering them is that they think “Yoh I’m going to go there and I’m going to be judged” or have to change their whole outfit to identify as a person that they are not” (HCP19, 31 yrs. old). “I think they are afraid to be judged. Akere they are used to that, everywhere I go, wherever I go people will be saying “ah, because of you are gay”, and then not knowing that things have upgraded, especially with the sexual assault departments. So, I think they fear judgement and rejection, so you could sense when you talk to them that uh-uh, this person is not free, but the moment then you make a small conversation, you make a small joke, and then they will relax and then they open up, then you are able to provide the service because if we don’t do that” (HCP30, 37 yrs. old). HCPs noticed that some queer people tend to withdraw and isolate themselves, which makes it difficult for them to receive or to be provided a comprehensive healthcare service. “The ones that I got in contact with, I have not experienced any challenges but basically.…they themselves tend to withdraw a little bit because I think they are scared to be free because they were lesbians, yeah!! They isolate themselves when they come to our healthcare facility” (HCP8, 36 yrs. old). Regardless of other HCPs having views and thoughts of queer people being scared, some HCPs acknowledged and agreed that they judge, discriminate, and stigmatize them. This is due to HCPs attitude, unable to understand and accommodative queer people and managerial individuals in the healthcare facilities being even more judgmental to the queer people. “If it's two males now coming to the health facility and then the first question is like oh! are they going to have their own children or are they going to adopt? So, we ask ourselves those kinds of things. They are scared of us because of our attitude as well, and we judge them, yes. Even discrimination, like they say to me, is what are you going to? Do with it. Do you understand? And then we tend to judge them for giving that they are also individuals…. they are normal like us” (HCP1, 40 yrs. old). So, I think because of issues such as stigma and discrimination, although we would want them to have access often or as they need like anyone else, most of them that don't come even if it's post sexual assault. Some of them don't report, or they don't even come for prep. Right? So, because of the stigma and being judged and the discrimination. But those that can actually come access family planning and condoms. And for those that maybe come through the police or the crisis centres, they access the preps. I think it's mostly stigma, honestly, it's mostly discrimination and I think uhm, there is still a lot of resistance to being accommodative and accepting members of the queer community, even in the healthcare sector” (HCP2, 36 yrs. old). “It is difficult you know, we judge them, however, here at the public services, you know, yes, even if they can go and complain, wherever they are going to complain at they are going to be judged even further” (HCP9, 57 yrs. old). On the contrary, other HCPs indicated that they do not discriminate and judge them due to the type of work they do and their profession. HCPs indicated that they treat every patient equally regardless of their gender and sexual orientation and they cannot deny healthcare services to anyone. “It’s like, akere when we- in nursing, in the Health Department we don’t discriminate, we don’t judge, we treat patients equally, whatever I am doing to each and every patient I don’t have to like discriminate or maybe say you are a lesbian. Whatever I am saying to each and every- a patient that comes here with the same problem we are giving them the same services because they are the same people” (HCP12, 42 yrs. old). “You know, as a social worker I’m working under the profession social worker. We are not allowed to judge anyone. I work with whoever gets inside the office and whatever that you mention, it doesn’t matter whether you are lesbian, whether you are gay, remember, that part of individualising people and respecting what the patient or the client wants stands out. I cannot say no because you are a lesbian, I cannot help you” (HCP13, 55 yrs. old) Queer believe that HCPs have negative attitudes. Queer people felt that HCPs disapprove and resent them by making harsh comments, jokes, and gossip statements. Additionally, queer people held that HCPs are judgemental, stigmatising, and discriminating towards them, and as a result, they isolate themselves from public healthcare facilities. Queer people reflected on their experiences in the public healthcare facilities. Some preferred NGOs, because of the safety and love they felt, whereas other indicated that some HCPs judged them and asked them questions why they chose to be homosexuals. As a result, they felt sad and hated themselves. “Yes I used public clinics before, so their service, I can say it was like so- for me it was so fine but the way they look at you, eish they look at you too much, it’s like they make you feel uncomfortable and their looks are judgmental that “Oh is he a girl or boy type” But so far since I went to public clinics like I haven’t experienced like bad things” (Gay, 21 yrs. old). “Sometimes they are judgmental, they call us with names, and it makes me feel so bad, just imagine someone who supposed to help you is the one judging you, one gets bored already” (Transgender woman, 25 yrs. old). “I’ll rather go to an organisation like this and not do it publicly, I come here and do my things because they understand me. But going to a public you get judged, yes, and especially when you ask- like come and talking to a nurse and ask you about your sexuality and you tell them your sexuality then they would come like nurses would be like how come you be gay, this is that. They have those judgemental thoughts, they’ll give you that and they’ll make you like leave that room hating yourself, yes. That’s why I would rather prefer coming to places like this and just do my thing so that no one is going to judge me, all of us we’re all the same” (Bisexual, 32 yrs. old). Queer people highlighted that some HCPs are homophobic, stigmatising, nosy and curious in an inappropriate way once they notice that you are a member of the LGBT community. Again, queer people stated that HCPs would go to the extreme of calling others to gossip or proceed to ask too personal questions such as how they have sexual intercourse. Queer people further indicated that they deserve respect and same equal treatment as everyone else who comes to the public healthcare facilities. “Uhm, some nurses are homophobic obviously so as soon as you get there, sometimes you go there just to test and maybe or you have something like that is not okay with you and then they will now start asking you uhm are you a girl, are you a what, and then you start to say I’m a transgender, transgender what, what’s that and whatsoever, according to my own experience that it has happened to me. So, now I believe that uhm I expect most of all respect and equality with everyone, yah” (Transgender woman, 25 yrs. old). Queer people indicated that one of the reasons they isolate themselves, is due to the fact that they are not accepted in the public healthcare facilities. Isolation is one of their coping mechanisms, protecting their space so that the HCPs stigma does not affect them. “You can’t relate to people who do not like you, then one tries to like have this uhm I don’t know if I can say like a coping mechanism for themselves whereby I say okay this is where and who I am and then I distance myself and not say much to create this working mechanism so that I cannot be affected through the whole stigma outside, actually” (Gay, 27 yrs. old). HCPs as gatekeepers: HCP’s experiences. Based on the responses from the HCPs during the interview sessions, it was noted that they continued acting as gatekeepers and hindered queer people from accessing and utilizing SRHSN in their public healthcare facilities. This theme emerged from the HCPs responses. The majority of HCPs stated that they assumed the gender orientation of queer people by just looking at them as they walked into their consultation rooms and healthcare facilities. As a result, they anticipated that queer people would not require certain services and some linked queer people with certain illnesses such as HIV. Other HCPs classified queer people as looking normal, which then makes them to generalize care of patients. “When you see them walk in, automatically you click your mind that what is she coming to do hear at ANC clinic, she can’t be pregnant, she is butch; but she is pregnant or he is gay he is probably HIV positive, you know those, yah” (HCP11, 25 yrs. old). “Okay, Iyo! It is difficult hey, some other time I saw lesbian client and I wasn’t aware because she is normal, but luckily, she came with the mother. They were reporting sexual assault but when I ask if she is sexually active, she then told me that it was the first because she is a lesbian and I was like shocked also not knowing how handle it, I didn’t know what to say and do further” (HCP30, 37 yrs. old). “The challenge I experience is always having to assume gender, like I normally say like if my mind tells me ai, the behaviour here it looks like she or he might be something else, then I anticipate that he or she is sick because of their sexual practices” (HCP31, 50 yrs. old). Some HCPs believed that their own religious beliefs and cultural practices were the barriers for queer people to come forward to seek for SRHSN. They further stated that they are still cultural and religious beings which in the end makes it difficult for them to advice on other services. “You know, many healthcare professionals when you are speaking about abortion is like you are killing and it is not like that, when you provide these services even myself, they don’t take me serious like I am a Christian. I am a Christian, according to them I am a devil, they think I am doing a disgusting job because I am helping even lesbians who they say they are practicing unholy and dirty things. Gays are doing dirty things, they say God, they think they are the ones who understands better than us. Nonetheless, even lesbians and gays are Christians but if God gave them there-way they are, if someone doesn’t have feelings for a different gender, they have rights to live happily in this world, we deprive them happiness and make them feel bad” (HCP3, 23 yrs. old). “Eish our cultures, like culturally it’s still a taboo, we say how can you get an egg from someone then the ancestors whatsoever, you understand. If now you are getting a strange person’s egg, but this child is going to be yours, those kinds of things. So, culture is still one of the things that come in the way that, I mean, interrupts a process that a lot of people are willing and open to take but now afraid of the culture and the belief system that now stands in the way, it then becomes difficult for lesbians to access IVFs freely” (HCP21, 43 yrs. old). Lack of interest and HCPs being uncomfortable to talk and render services to queer people were observed during the interview sessions. One HCP conveyed that they are not sure of what types of services they should render to queer people, and they are not capable to even conduct physical assessment on them. “I am not sure if they come what I should screen… because let’s say they are presenting with an STI right, Hai, I don’t think I will be comfortable and ready like imagine why would I check their anus? I don’t want to see any trauma there, any legions, any, you know but I don’t think that’s like number one” (HCP11, 25 yrs. old). HCPs as gatekeepers: Queer people’ experiences. Some observations were obtained during the interviews with queer people, related to the fact that HCPs are indeed the gatekeepers resulting in them not being interested in accessing SRHSN. Additionally, queer people stated that HCPs assumes their gender based on how they appear, they reported negative attitudes and treatment from HCPs. However, some queer people stated that they never experienced challenges at all. A significant number of queer people pointed out that HCPs do not ask them about their gender as they just assume, leading to services rendered and offered being wrong. Other queer people stated that HCPs treat them like women without asking what they prefer to be called as this will help them to identify their sexual behaviors. “I don’t know if I should say I was scared, embarrassed or traumatised, I was at the government clinic and a nurse asked me for my pee, you understand, then I went and pee and then when I came back- so I thought maybe she was just testing acidity level in my urine only to find out that she was doing a pregnancy test. Oh well she was not aware that I’m not female, she assumed that I was female. So, she did a pregnancy test and then while waiting for ama-results, she asks me when last did I go to my periods, then I’m like no I don’t get periods, I’m not a girl.” (Transgender woman, 30 yrs. old). “Ai with me, they treated me as a woman, yes I guess it’s that- the only time I felt, I guess, sort of unsafe, I had a girlfriend I think, the first time I had a girlfriend I think I was 17 towards 18, and that’s when I said that was the only time I’ve had an STI and I got that because she was using things that are not yah and I went there and I couldn’t explain why because first of all I’m not having sex with boys, why do I have because she concluded” (Lesbian, 28 yrs. old). Negative experiences, criticism and disapproval were experienced from HCPs by queer people whenever they visited public healthcare facilities. A substantial majority of queer people highlighted that they had unpleasant experiences, felt uncomfortable, forced to take some procedures, and being convinced to fall pregnant by HCPs. “My experience was bad, So, what happened is that I got there and then obviously the admin was doing whatsoever, you give them your ID and then after that I was sitting. So, as I was about to go in, I went in- okay not before, the nurse came and checked my file and then he was like you are not a male, but your file says you are a male, and then she looked at me and be like oh you’re one of and then she left me there. And she went inside, the other nurses came out and then they started looking at me and then are like oh okay [Indistinct] and whatsoever. So that was very uncomfortable because of I had to leave right there” (Transgender woman, 25 yrs. old). “I think challenges would be, I don’t want to say more challenges, but you know how doctors would always like for instance akere I struggle from period pains, and they’ll always say no, but you must get pregnant, I’ll be like no I can’t I’m a lesbian. Then they’ll quickly dismiss that no but if you get- I’m like for me to get pregnant means I need to go for IVF whatever, you know, it’s a whole thing it’s not just me going like a straight person, you know” (Lesbian, 28 yrs. old). Regardless of the majority of queer people experiencing all sorts of challenges when accessed SRHSN, some stated that their experience was great, and they had no challenges at all. Queer people further, praised HCPs for their work. Some queer people reflected that they never experienced challenges because they do not go around talking about their sexuality, and some because they do not look like their sexuality. “Honestly, I don’t think it was challenges, I don’t think we had any challenges. Doctors and nurses are trying to help” (Gay, 24 yrs. old). “I don’t have. I’ve never experienced any stigma or any hate speech or anything. The thing is I’ve never preached, or I’ve never came out to tell people that hey I’m gay. You see, I think my surrounding, even my family knows that my mom, I’ve never explained to my mom or my parents that I’m gay” (Gay, 30 yrs. old). “Okay, I wouldn’t really necessarily speak about it in a sense of being a lesbian woman mainly because I don’t even look like I’m lesbian when I’m walking like on the streets or wherever because I’m feminine representing, I get hit on by men, right, so even when I go to the clinics, they can’t see that I am a lesbian woman” (Lesbian, 30 yrs. old). HCPs being surprised and confused about gender identity: HCPs deliberations. HCPs acknowledged that they are still not understanding the queer gender identity and they will continue asking as they are not used to such identities. As a result, this may present as one of the factors that make queer people not come to the healthcare facilities as they feel uncomfortable when asked for clarity and reasons on their gender identity. “ I think, Yoh…the biggest challenge I have seen was a lady, she came to deliver, I was working in labour ward, she came to deliver, a lady, now this lady came to deliver, when she gets discharged, she is fetched by another lady, and they say this is the father to the baby, but this is a woman. You can see this is a woman, why are they saying this is the father to the baby. They saw my expression and being shocked and they might feel bad and not come back” (HCP11, 25 yrs. old). Ee, only. But when I ask you are you a female or a male, oh wow, oh okay. You will see even their facial expression changing and some of us, remember we are human beings, we are still going to be surprised and be shocked, we will even want to give you counselling as in why are you gay, why are you lesbian? You understand? They still get those questions even if we can hide it, even if… for me I think it’s discouraging for them to say I’m still going to be asked those kinds of questions, so I am not going to go and get the service that I need” (HCP13, 42 yrs. old). HCPs being surprised and confused about gender identity: Queer’ deliberations. Queer people stated that they have observed HCPs being shocked and surprised whenever they are themselves and come across as queer. This has been one of the barriers for queer people to freely access and utilize public healthcare facilities. Queer people further stated that HCPs would ask too many personal questions, encouraging them to resort to private doctors. “So another thing when I got a transfer from the other clinic, my transfer is because of I wasn’t happy the way- about the treatment after all but I- because there was a time my file was written a female name, okay which is not something else I cannot live with, so on my file, I don’t know how did they mix up but then my file came saying I’m pregnant, you know. Then, they came sneaking one by one to come look at me and being surprised and I was surprised too, I stopped going to government clinics” (Transgender woman, 33 yrs. old). “Yah, so most of the time like when I have health issues- maybe when I seek medical attention, I just go to like a private doctor, just like a doctor yah, because I remember I once went to a clinic, its government clinic so when they found out that I was gay, they were surprised than a handsome man like me would be gay, they started asking me how I have sex and decided to test me HIV without counselling, I then decided I will never come back again here” (Gay, 24 yrs. old). Healthcare disparities and familial problems: HCPs discussions HCPs mentioned that some of the challenges that inhibits queer people to access and utilize SRSHN, is because their healthcare facilities are not inclusive. Moreover, other HCPs stated that healthcare facilities have limited resources which might put them at risk of acquiring infections and lack regulations for registering a child of the same gender. Some HCPs remarked that reproductive services are expensive for queer people to afford, and overall, the healthcare facilities are having areas which are exclusive for queer people such as toilets for male and female and lack of privacy for them. “And there are limited resources for them because I'm trying to think if it's two females, then they need those resources to be intimate with. They use their own money. It's not available in government hospitals because people will judge you. Why do you want that toy? Because we think it's too females and then. What? So those resources they use are not available? Yes! So, they need to have money to purchase them. That is why they end up maybe doing wrong things now they end up having infections because they can access whatever resources because they are not cheap as well” (HCP1, 40 yrs. old). “A lot of people are willing to explore, go out there, get the full understanding, but now the issue is also the finances because now if you have to do everything externally so, a lot of people do not have the funds because some of these procedures are costly, they are very expensive when now you have to like a surrogacy whereby the child now has to be conceived through IVF or something and that’s a very expensive procedure” (HCP21, 43 yrs. old). “ The major challenge is our government hospitals, I don’t think they cater them well, reason being if you look at our toilets it’s labelled male, it’s labelled females. There is she coming, it’s a shemale coming to the hospital, feels I’m a man, where does she supposed to go now; there’s a toilet labelled male, there’s a toilet labelled female” (HCP22, 42 yrs. old). “With queer people, even though I never had that before, if I am to have such a patient, I think I wouldn’t know where to refer them to a safe space that will be non-judgmental, so that they can get help because I think that happens quite often” (HCP29, 30 yrs. old). Lack of support from family and relatives were pointed out as one of the reasons that makes it difficult for queer people, regardless of HCPs’ effort to assist them. Additionally, other HCPs highlighted that family members find it difficult to accept and support their queer children but get accepted by other community members. “You know, the only challenge that we have, which I think maybe it becomes a hindering fact of working with an individual, when the family doesn’t want to accept their child. Yah, it’s because of the sexuality and of the adoption matter” (HCP13, 42 yrs. old). “I think the main issue is maybe acceptance from their immediate families or their immediate peers because the same people that I am talking to you about, it was perceived as if they are forcing things, they will say things like why you can’t do it the normal way, you understand. Why can’t you just go the normal way? Why can’t it be like male/female and be normal? So, the main issue that they tend to go through is how will they see us, you understand. Seeing that a lesbian is pregnant, people will constantly ask themselves that how did they do it, why did they even think of doing it like that? Did they ask someone to have sex with them? This leads them not to come look for different ways of having children” (HCP20, 29 yrs. old). “I have only encountered one gay patient. It was long ago. The challenge now was based on that the community- him being- him identifying as a gay person, it was challenging for him because he was now admitted because at home, they also cannot accept him, you know, so it led him to such an emotional distress that he ended up being admitted. it was disheartening to see that. But he was only having challenges with his family, but it was- what I have noticed is that the community has already accepted him” (HCP 28, 27 yrs. old). The observation by HCPs was that queer people are being abused and discriminated against by other community members. Also, other HCPs acknowledged that campaigns of awareness need to start with community members so that they understand that queer people are like any other person, and they need support. “For me right now, as a social worker, when it comes to sexual reproductive health for queer people, I think that’s the one thing that I can think of. They want kids, you know, or maybe it’s the issues as well. We face many issues of the LGBTQI communities being abused, a lot, right? So, maybe it might be that; ‘I have been raped’; ‘I have been abused on’ wherever, at home, or ‘I’m being discriminated against’. that is why I’m here as well, as a social worker to be able to offer that support to say okay, what do you need? How can I give you that support so that we report the abuse that’s happening?” (HCP28, 27 yrs. old). “There’s a lot that can be done but I think we need to start at the communities, talk to people out there like campaigns before they can come to us because again, as I said, queer people can sometimes not be able to come to us because firstly, they feel judged. Our black communities are just so judgemental when it comes to queer people. There’s a lot of hate. There’s a lot of violence towards them and all that, but if we go to them first so that they can feel safer to come back to us, and educate them and- yah, I think spread the information that “hey, come through, we have one-two-three-four” (HCP32, 28 yrs. old). Healthcare disparities and familial problems: Queer’s discussions In the opinion of queer people, public healthcare facilities lack sexual reproductive services due to affordability. Other queer people mentioned that there are delayed services and that they are excluded by being called special cases. “I feel that we are just not being prioritised like other straight people, you know, or maybe is it because we are looking for a specific thing, I’m trans and I need medical attention, this is what I want. Unfortunately, there are limited services to cater us at the public hospitals and clinics, yes” (Transgender woman, 20 yrs. old). “Yoh, I needed IVF or what do you call IUI, it’s like 50K to do IUI or IVF, even that 50K doesn’t even include consultations, doesn’t include blood work, doesn’t include scans, doesn’t even include sperm donor, you know what I mean, I still need all of that. Meaning at the end of it all I would have spent more or less 100K” (Lesbian, 30 yrs. old). “You’ll go to the clinic, and they’ll say oh!! You are part of the LGBTI, okay you’re a special case, we’ll call someone for you, he’s been trained, you understand. Why can’t they all treat us? They don’t train the whole staff, maybe in a department they will train two people. So, they were like you wait for- you’re a special case, you understand” (Transgender woman, 30 yrs. old). Similarly to what HCPs observed, queer people indicated that they tend to be abused and discriminated by other community members and were accepted by their family members. “Firstly, coming out as gay, you know, people will be like Yoh, I don’t want to talk to this one, you know, name-calling, you know those offensive names man. So that’s the first challenge we faced, most of us, in the communities. You are even scared of coming to the clinic because the community members will judge you. So- okay, family wise it was fine because they’ve long accepted me because I think the parents saw from an early age” (Transgender woman, 23 yrs. old). HCPs' incompetence in queer-related healthcare: HCPs’ interactions. Lack of skills, knowledge, experience, and expertise regarding queer-related health matters was observed among HCPs. The bulk of HCPs showed that during their rendering of SRHSN to queer people, they are too empathetic, uncomfortable, do not know how to deal with queer people without making them feel judged and discriminated against. They acknowledged that they were not trained, and some stated that they do not know what types of services to render to queer people. HCPs’ empathy seemed to be blocking them to probe further during history taking when rendering different services to queer people. “I think it’s probably myself where I will be wondering should I ask for details, or should I ask for details or should I ask for this and that. I think it is a question that I will have with myself, and I would always be battling with that. Is it important – the detail – or is it not important, because sometimes you may want to ask a question, but it’s not necessary, so, for me it’s always to ask myself that question, do I have to ask this question or not, or am I just asking out of curiosity? So, it is always to know, and sometimes it is not easy to know whether you can or you can’t; so, I would say that is the issue that I have to always ask myself do I have to ask a question or what I have is enough” (HCP5, 47 yrs. old). “You know, most of my patients, when they come for… especially when she is a lesbian saying sister, you know I just made a mistake, I don’t… because I know how disturbed they are. When they come to me, I do not go much unless the patient starts to open up, when they come here, I just give them information that I have to say you know what guys, these are the services that I am giving you, but remember you need… I have somebody in the hospital that can take you further with whatever you want to open up with. I do not go much in details why because I do not ask the question why” (HCP6, 42 yrs. old). Some HCPs appeared not to be comfortable towards asking queer people questions, they were concerned not to come across as rude HCPs. “The approach. I feel that like if- it will be rude for me just to come up to a person and ask about their sexuality and on how do you have sex, how do I start, or just to ask what is rimming, it’s very difficult I would say, yah” (HCP18, 32 yrs. old). “For me personally I am not working in the department but when I go there, I also honestly felt a little bit of that the uncomfortable, yah, you will feel a little bit discomfort, you know, yah so I think that’s one of the… It’s actually the only challenge that I can think of right now, yah” (HCP9, 57 yrs. old). Not knowing how to address queer people without making them feel discriminated was one of the HCPs challenges which showed that indeed HCPs do lack skills and expertise of handling queer people. “I can’t say their pronouns, I mean that’s something- sometimes it makes us feel- me specifically, I can’t say shy but sometimes I feel like I can’t, I don’t know how to address them, can I say ma’am or sir. Some patients can feel offended, this person just because I’m a male and I have a makeup on it doesn’t necessarily mean you can say- like think that I’m gay or what, maybe I just like wearing this and you come to me think now because oh, a lady, I’m still a sir. Hai, I don’t really know, and I have no information” (HCP32, 28 yrs. old). “The other challenge is I assume a lot like lesbians will be coming in my consultation room and say one, “I am her boyfriend”, yah and it becomes a challenge when we have to intervene into that, because you cannot tell them that you are both equal as females. So, this one I don’t know how we- maybe- again, if we ask them “how do you want me to address you”, in front of everyone; it will be- I will be stigmatising them, yah” (HCP33, 48 yrs. old). Some HCPs were clueless and did not know what they should offer queer people when seeking for SRHSN. Others were uneasy about how their sexual practices might cause health challenges, but still did not know how to prevent those health issues occurring. HCPs continued stating that it is hard to render SRHSN to queer people, but they continue treating them like any other patients who comes to their healthcare facilities. “And then again, regarding their health, remember they practise anal sex, so I think at some point there’s a stage where their muscles loosen, and then they develop some illnesses, I think so, yes. They develop some illnesses. So, I don’t know how we can stop that, how we can prevent that from happening. Hai!! I don’t know” (HCP10, 36 yrs. old). “It’s difficult sometimes to deal with them but the thing is they need help. When I say I give services, the same as I am doing to each and every patient that comes here like services I said before, we are giving them health education, prophylaxis, you see” (HCP12, 55 yrs. old). “I am not even sure, Yoh, that one is a bit difficult because I’m not sure; like if they are transgender, someone who’s a transgender…which is quite tricky when it comes to the queer, LGBTQI community because now when you are dealing with trans individuals, whether a trans man or a trans woman, it’s a whole different ball game, you know. So, yah, then there’s that overlap in between that is sometimes a bit difficult to navigate” (HCP16, yrs. old). Lack of training continue to be a major issue for HCPs, this included training on queer-related matters. Majority of HCPs acknowledged that they do not have skills and knowledge for queer people’s issues, while some HCPs stated that they do not know how to care or render services to queer people because their tertiary curriculum covered only males and females’ content, not queer people health. “I think the other, the other one, is also lack of training actually, amongst the healthcare workers regarding you know how the use of words, the use of correct pronouns, they use, how to treat, you know how to be cautious and caution, yeah, cautious, and also how to be uhm not accommodative, but to actually treats people as they are. So, there is also that I think you know some healthcare workers struggle with, you know, the use of words, understanding some people still consider members of the queer communities as outsiders as attention seeking, as some people who are who have trained in all schools still consider it some kind of a medical condition, something they need to convince someone and treat or so I think what I can think of in terms of challenges is the stigma and discrimination” (HCP2, 36 yrs. old). “The thing is the course that we did is only the female part, but the LGB, the others, we were not involved especially when it comes… because most of my patients, especially males would ask “Sister, why not us, only females”? And I will tell them I do not have any clue or any information or any workshops or any teachings regarding what to be done or how am I going to help you” (HCP6, 42 yrs. old). “Firstly, it’s not being clued up, not being educated or well informed on their sexual orientation, what they are going through, whatever is it that is needed for them at that specific time. Like the patient, for example, who was going through with transition. It’s done at Steve Biko Hospital, and not a lot of us have been there or understand what is happening and all that, and when a patient comes in here, some patients expect you to know because you are a healthcare worker; and if you are not clued up like how, yet you call yourself this person, you are in the medical field, you should be knowing” (HCP32, 28 yrs. old). HCPs' incompetency in queer-related healthcare: Queer’ interactions Queer people highlighted that HCPs ask about sexual activities once they notice they are a member of the queer community. They stop focusing on the reason why queer people came to the clinic in the first place and dwell on who they have sex with and how they do it. “Yah, I remember I was raped, and they took me to the government hospital, and you know that doctor there, the questions he was asking- and he was male, the questions he was asking were very insensitive. So, like okay so the docket says you were raped so this is what I’m going to do to you. Like he explained the whole process and everything. Yoh, and while doing that, questions he was asking like so is it painful, you know, like weird questions. And so how is it, is- now he’s no longer on the rape case, now his asking me on a personal level, so like tell me how it feels to have anal sex?” (Transgender, 30 yrs. old). Queer people reflected that HCPs ask uncomfortable and too personal and invasive questions, leading to queer people lie about their sexuality. Sometimes the questions HCPs ask queer people, they are unable to answer and be free about who they truly are due to fear of judgement. Furthermore, queer people indicated that HCPs do not understand what queer people go through which makes it difficult for them to even explain further. “So, there’s certain questions that they are asking at the government clinics, how do you have sex and is it not painful and why sex with men? I know I can come here as in NGOs because of at the local clinic I didn’t like they ask you questions that makes you feel uncomfortable most of them” (Transgender woman, 33 yrs. old). “Nurses ask too personal questions, for example maybe you have an STI, they ask questions like uhm who are you sleeping with and it becomes difficult like to say oh I’m having sex with a boy because you’re scared of- even if they’re not going to say it but the looks cause probably there’s going to be like maybe another nurse there and whatever but like the looks and whatever now you have to explain how you guys have sex which I didn’t come here for that, I just uhm I came here for- to seek medical attention not to be- understand. So, at the clinics I think the most challenging thing is having to explain to people who don’t really understand, yah they just don’t understand and yah. Some of the questions are quite invasive, yah, so you end up lying even like most of the time I’ll just say I have a girlfriend, yah” (Gay, 24 yrs. old). Refusal of providing services to queer people by HCPs was noted. This might be that HCPs are still not understanding the importance of what SRHSN for queer people could do in terms of protecting them and preventing many illnesses. “I went to the clinic to ask about PrEP because of it was new at that time, they were like no we cannot give you a PrEP, you’re still young and stuff like that. I was like okay, and I was sad that I cannot protect myself from sexual transmitted illness” (Gay, 27 yrs. old). Queer people as a barrier: HCPs discourse. The vast majority of HCPs indicated that even though they are labelled gatekeepers, lack skills and knowledge for queer-related matters, queer people themselves are the hurdles to receive a comprehensive healthcare service. They stated that queer people are unable to open up to them and feel that they should always explain themselves to HCPs about their sexualities. Additionally, HCPs mentioned that queer people utilise private sectors as they feel more safer and HCPs in private sectors are held accountable if treated patients badly. Lastly, various groups of HCPs indicated that queer people are not comfortable when they have to be examined, and some of the queer people do not return for their follow-up care. “The challenges that I have is because they come, they get the service, and they don’t follow up. That is a challenge because I feel like I need to know where they are, what happened to them. Yes, follow-up is a problem for me because some stay far” (HCP6, 42 yrs. old). “I think they use our facilities less. What I have realised about this community, they, I mean that is my perception, the way I observe them, neh, they will rather go to private than to come to public institutions. We are a government public institution, and they don’t come much here. Yes, you will see here and there somebody, you know, it’s sporadic, it’s not like yes there’s an influx, yah, In the private sector you are accountable because there are stakeholders that will really keep you accountable to your acts and your omissions, right, so I think they feel more comfortable there, to go there because they know that should they be judged in any way there will be repercussions or consequences” (HCP9, 57 yrs. old). “Then with others they don’t want to be or like to be undress, looking at them. Others don’t want at all, Yah I think so because it’s like, according to my understanding, like what they are now is what, now they are boys right…you grew up, you changed to be a girl, and then it’s not simple for you to undress for each and every person” (HCP12, 55 yrs. old). “So, I think that’s been the biggest challenge, getting people to open up to say you know what I am queer, I identify this way, and this is my lifestyle, etcetera, and then they just close off, and then you never get that; and it’s also difficult to kind do what you do like to gather the stats, to provide them with relevant services, and to find how we can make our healthcare system more conducive or whatever it may be for our queer population” (HCP14, 28 yrs. old). “You know, what I think is happening now is that it’s becoming a disclaimer, you know. It’s like okay this patient is coming with a disclaimer, they are transgender, disclaimer this and that, and I think that adds to that, you know, but at the same time I think the idea behind putting the disclaimer is to be sensitive and might make them feel uncomfortable to come to the facilities” (HCP17, 24 yrs. old). Queer people as a barrier: Queer’s discourse. Lastly, it was highlighted how difficult it is to be a queer person, which led to many queer people to change how they behave and appear whenever they go to the public healthcare facilities. This was due to the fact that they are afraid to be judged, thus affecting the services they receive as HCPs treat them as heterosexuals. Some queer people stated that not all public clinics and HCPs treated them with an attitude, as they themselves feel uncomfortable of talking about their sexuality. Other queer people, specifically, transgender’s confirmed what HCPs said that they do not want to undress by stating that they feel uncomfortable treated by male HCPs. In addition, they indicated that female HCPs feels uncomfortable to attend to them too. “The way it is difficult to be a gay, I remember there was a time I went with my partner to the public clinic but it was like a long time ago, instead of saying we are dating we said we are friends cause we knew that if ever we said we are dating like the questions are just going to be- they become more interested in how do you guys have sex and whatever, uhm yah. Its taboo [Laughter]” (Gay, 24 yrs. old). “I wouldn’t say the local clinic back at home was the nicest place to go to for PrEP but then yah I- yah, yah, that’s it, I was just not comfortable. They even asked me questions like “why are you taking PrEP and I had to lie that you know I have a girlfriend in Pretoria, that time I didn’t have a girlfriend in Pretoria but then it was not the space for me to say no I’m having sex with men in Pretoria so” (Bisexual, 21 yrs. old). “I would feel uncomfortable to be attended by a male nurse, remember I have to take i-treatment of STI sometimes I need to undress so that I can get the shot, so I feel uncomfortable being attended by a male nurse and at the very same time female nurses are also uncomfortable attending us sometimes, I’m not saying always but sometimes” (Transgender woman, 30 yrs. old). Discussion Our findings show that HCPs detect a common sense of anxiety among queer people seeking healthcare services. Our findings are consistent with previous research indicating that queer people have mental health difficulties such as anxiety [ 12 , 26 ]. Again, drawing on a prior study, homophobic reactions were substantially related to anxiety and sadness, which were linked to stigma or discrimination in employment settings and health care institutions [ 24 ]. HCPs explained that internalized and experienced worries frequently cause queer people to avoid healthcare facilities, with concerns ranging from potential judgment to stigmatization. Researchers agree that queer people have reported discrimination, distrust, and terror in hospital settings [ 6 , 10 , 27 ]. Contrary views within the HCPs community demonstrate a lack of consensus, with some acknowledging judgment and prejudice against queer people, while others claim to treat all patients equally, regardless of gender or sexual orientation. Our study adds to Beagan et. al.’s [ 28 ] synthesis of available knowledge, which found that the majority of participants believed there were no substantial disparities between primary care for queer women and care for all other patients. This indicates that sexual orientation and gender identity were widely regarded as unimportant to care provisioning, as HCPs such as physicians treat everyone the same [ 28 ]. Furthermore, they underlined that they constantly endeavour to suspend any prejudices, remained nonjudgmental with all patients, and avoid becoming "distracted" by aspects of a patient that the physicians themselves find problematic [ 28 ]. However, Seretlo and Mokgatle [ 14 ] found that some primary healthcare (PHC) nurses had a judgmental attitude and were surprised that there were queer patients, associating their sexuality with childhood traumas, whilst other PHC nurses were not judgmental and were willing to serve patients despite their sexuality. Additionally, a Tanzanian study found that certain HCPs actively helped to limiting access to healthcare for men of varied genders and sexualities [ 29 ]. Queer people, according to our research, are concerned about being stigmatized in healthcare settings, fearing judgment, criticism, and discrimination. Again, the research findings highlight a significant disparity in HCPs' opinions regarding queer people. While some admit to making judgments and discriminating against patients, others insist on treating everyone equally. However, queer people regularly reported unfavourable encounters with healthcare providers, such as rejection, hostility, and inappropriate probing. These experiences contribute to queer people's unwillingness to use public healthcare facilities, instead preferring NGOs, where they feel safer and more accepted. Our discussion is framed within the context of multiple studies suggesting that participants, for example, indicated that HCPs told every colleague in the healthcare facility and were humiliated, with some even seducing them [ 30 ]. According to one study conducted among Durban university students, HCPs continue to prejudice homosexual persons and define HIV illness as a gay sickness [ 31 ]. From different angles, researchers in the field have consistently observed that the percentage of primary care providers (PCPs) who had negative sentiments toward queer people differed significantly among studies in the United States [ 32 ]. In Tanzania, some HCPs saw MSM sexual activities as aberrant and referred to them as foolish guys [ 33 ]. Participants expressed uneasiness with the persons they could encounter in healthcare facilities, often as a result of previous experiences with stigma in both hospital settings. These findings is consistent with the findings of Moagi et. al. [ 12 ], who found that stigma and prejudice hampered the health and well-being of sexual and gender diverse people. Furthermore, our findings are consistent with those reported by Ross and Setchell [ 15 ], who found that certain HCPs identified discrimination as a theme, including reports of overt and hidden discrimination, as well as worries of discrimination and the larger community. Similarly, Dean et. al. [ 3 ] state that queer groups have considerable obstacles in accessing sufficient healthcare due to societal stigma. Concerns about how they would be seen, as well as the possibility of having to change their identity to get healthcare services, were recognized as important impediments for queer people. Our findings also demonstrated that HCPs frequently operate as gatekeepers, assuming queer individuals' gender orientation based on looks. This notion, along with cultural and religious beliefs, impedes access to SRHSN. The dearth of inclusive healthcare facilities, as well as familial non-support, have been noted as significant challenges for queer people, resulting in healthcare disparities. Our findings are consistent with a South African study that found that HCPs attributed their moralizing, judgmental, and homophobic attitudes to their Christian beliefs and ideals [ 30 ]. Again, some claim that giving healthcare services to people in same-sex partnerships is difficult because they do not believe in homosexuality [ 30 ]. These studies demonstrate that religious beliefs, cultural traditions, and values impact HCP views toward homosexuality and how queer people are treated around the world. In terms of HCPs competency, our research revealed a significant shortage of skills, knowledge, and training in queer healthcare. Empathy from HCPs, while typically positive, may impede effective communication and service delivery to queer people, highlighting a need for increased education and cultural competence within healthcare institutions. Synthesizing the results from multiple studies, we can conclude that one of the most significant barriers to queer utilization and accessibility of healthcare services is a lack of education, understanding, and competence among HCPs regarding queer people's related health issues [ 10 , 13 , 34 ]. Our findings are consistent with several studies that found an absence of awareness among HCPs about transgender-related health issues [ 20 ], a deficiency of HCP awareness and insensitivity to the unique needs of this community [ 21 ], and a lack of understanding of transgender-specific well-being issues by HCPs [ 15 ]. This study also found that HCPs were confused about queer people's gender identities, which caused discomfort and hampered access to treatment. Queer people, on the other hand, reported being treated unfairly, being asked intrusive questions, and encountering difficulties during physical tests by healthcare providers. This supports the conclusions drawn by Mirza and Rooney [ 5 ], that discrimination in health care settings endangers queer people’s lives through delays or denials of medically necessary care and discourages queer people from seeking health care. Study strengths and limitations Our study investigated and gave a thorough picture of the issues faced by queer and HCPs. Because we included these various participant categories and locations, our study produced more representative information from both parties. Again, our study improved external validity since the findings were more likely to be applied to a broader context within the same province. The final strength is cross-validation of the results, as we saw similar patterns and responses from both participant groups, supporting the study's trustworthiness and credibility. There were some limitations during data collecting as some queer people were underrepresented, such as lesbians, intersex, bisexuals, and MSM. Conclusion Finally, our study's findings shed light on the variety of obstacles that queer people face when accessing healthcare services. Our study further, emphasized the critical need for increased education, training, and cultural competence within healthcare systems to eliminate current obstacles. Additionally, our study advocates inclusive and respectful healthcare for all people, regardless of sexual orientation or gender identity. The development of new innovative healthcare solutions to address SRHSN for queer people may bridge gaps and meet the issues faced by both HCPs and queer people. Abbreviations Healthcare professionals (HCPs), sexual and reproductive healthcare services and needs (SRHSN), respondent-driven sampling (RDS), sexual and reproductive health (SRH), sexually transmitted diseases (STD), human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), sustainable development goals (SDGs), sub-Saharan Africa (SSA), South Africa (SA), sexually transmitted illnesses (STIs), non-governmental organization (NGO), thematic content analysis (TCA), Sefako Makgatho Health Sciences Ethics Committee (SMUREC), primary healthcare (PHC), primary care providers (PCPs), and men who have sex with other men (MSM). Declarations Acknowledgements We would like to express our gratitude to the national Department of Health research ethics committee for granting permission to perform the study, CEOs for allowing us to conduct the study in their facilities, and everyone who agreed to participate in this study. Mr. Kgaugelo Mmalegodi, once more, for his participation and help as a research assistant in this study. Prof. Nombulelo Sepeng for her guidance and support to the lead investigator. Funding The research study was sponsored by the National Research Funding (NRF) for Research Development Grants for nGAP Scholars [grant number NGAP23021680129] and subsidized by the Department of Higher Education (DHET) South Africa through the new Generation of Academics Programme (nGAP). Availability of data and materials The authors disclose that the qualitative data supporting the study's conclusions are included in the article. The original transcripts are not publicly available because they contain information that could jeopardize the privacy of research participants. However, on reasonable request, the corresponding author can provide access. Author’s contributions RJS, MMM, & HS conceptualised the study and developed a research proposal; RJS conducted interviews and developed initial themes during the interview process, RJS analysed the data; MMM functioned as an independent coder to confirm and edit themes; MMM & HS supervised the study, RJS drafted the manuscript; MMM & HS provided critical feedback and revisions to the manuscript. All authors read and approved the final manuscript. Authors’ information 1 RJS is an nGAP Lecturer and PhD candidate at the Sefako Makgatho Health Sciences University. 2 HS is a professor at the University of Pretoria, department of Informatics and working as a head of department and deputy dean, her role in the study is co-supervisor. 3 MMM is a professor at the Sefako Makgatho Health Sciences University, department of Public Health and working as a head of department, her role in the study is supervisor. Competing interests The authors confirm that they do not have any competing interests. 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Medina-Martínez J, Saus-Ortega C, Sánchez-Lorente MM, Sosa-Palanca EM, García-Martínez P, Mármol-López MI. Health inequities in LGBT people and nursing interventions to reduce them: A systematic review. Int J Environ Res Public Health. 2021;18(22):11801. Organization WH. Health in 2015: from MDGs, millennium development goals to SDGs, sustainable development goals. 2015. Müller A. Health for all? Sexual orientation, gender identity, and the implementation of the right to access to health care in South Africa. Health Hum Rights. 2016;18(2):195. Mprah A. Sexual and reproductive health needs Of LGBT. Afr J Reprod Health. 2016;20(1):16–20. Müller A. Scrambling for access: availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa. BMC Int health Hum rights. 2017;17:1–10. Luvuno ZP, Mchunu G, Ngidi H, Ncama B, Mashamba-Thompson T. Evidence of interventions for improving healthcare access for lesbian, gay, bisexual and transgender people in South Africa: A scoping review. Afr J Prim Health Care Family Med. 2019;11(1):1–10. Moagi MM, van Der Wath AE, Jiyane PM, Rikhotso RS. Mental health challenges of lesbian, gay, bisexual and transgender people: An integrated literature review. Health SA Gesondheid 2021, 26(1). Seretlo RJ, Mokgatle MM. Primary Healthcare Nurse’s Barriers and Facilitators to Providing Sexual and Reproductive Healthcare Services of LGBTQI Individuals: A Qualitative Study. Healthcare: 2022. MDPI; 2022. p. 2208. Seretlo RJ, Mokgatle MM. Practice, attitudes and views of right to access of sexual and reproductive health services by LGBTQI among primary health care nurses in Tshwane. Afr J Prim Health Care Family Med. 2023;15(1):3790. Ross MH, Setchell J. People who identify as LGBTIQ + can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey. J Physiotherapy. 2019;65(2):99–105. Alencar Albuquerque G, de Lima Garcia C, da Silva Quirino G, Alves MJH, Belém JM, dos Santos Figueiredo FW, da Silva Paiva L, do Nascimento VB, da Silva Maciel É, Valenti VE. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC Int health Hum rights. 2016;16:1–10. Logie CH, Dias LV, Jenkinson J, Newman PA, MacKenzie RK, Mothopeng T, Madau V, Ranotsi A, Nhlengethwa W, Baral SD. Exploring the potential of participatory theatre to reduce stigma and promote health equity for lesbian, gay, bisexual, and transgender (LGBT) people in Swaziland and Lesotho. Health Educ Behav. 2019;46(1):146–56. Mbeda C, Ogendo A, Lando R, Schnabel D, Gust DA, Guo X, Akelo V, Dominguez K, Panchia R, Mbilizi Y. Healthcare-related stigma among men who have sex with men and transgender women in sub-Saharan Africa participating in HIV Prevention Trials Network (HPTN) 075 study. AIDS Care. 2020;32(8):1052–60. Ross MW, Kashiha J, Misedah L, Mgopa LR, Larsson M, Agardh A, Venkitachalam KK. Addressing the healthcare needs of African men who have sex with men: Barriers to healthcare and promoting HIV and STI treatment in Sub-Saharan Africa. East Afr J Health Sci. 2021;3(1):59–77. Gonzales G, Henning-Smith C. Barriers to care among transgender and gender nonconforming adults. Milbank Q. 2017;95(4):726–48. Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. Cureus 2017, 9(4). Westwood S, James J, Hafford-Letchfield T. He’sa Gay, He’s Going to Go to Hell.': Negative nurse attitudes towards LGBTQ people on a UK hospital ward: a single case study analysed in regulatory contexts. Ethics Social Welf. 2023;17(4):387–402. Elliott MN, Kanouse DE, Burkhart Q, Abel GA, Lyratzopoulos G, Beckett MK, Schuster MA, Roland M. Sexual minorities in England have poorer health and worse health care experiences: a national survey. J Gen Intern Med. 2015;30:9–16. Lamontagne E, Leroy V, Yakusik A, Parker W, Howell S, Ventelou B. Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approach. BMC Public Health. 2024;24(1):1–14. Ravindran V. Data analysis in qualitative research. Indian J Continuing Nurs Educ. 2019;20(1):40–5. Sun S, Pachankis JE, Li X, Operario D. Addressing minority stress and mental health among men who have sex with men (MSM) in China. Curr HIV/AIDS Rep. 2020;17:35–62. Heng A, Heal C, Banks J, Preston R. Clinician and client perspectives regarding transgender health: a North Queensland focus. Int J Transgenderism. 2019;20(4):434–46. Beagan B, Fredericks E, Bryson M. Family physician perceptions of working with LGBTQ patients: physician training needs. Can Med Educ J. 2015;6(1):e14. Mwijage Ishungisa A, Meyrowitsch DW, Mmbaga EJ, Leshabari MT, Moen K. Not a Problem at All or Excluded by Oneself, Doctors and the Law? Healthcare Workers’ Perspectives on Access to HIV-Related Healthcare among Same-Sex Attracted Men in Tanzania. J Int Association Providers AIDS Care (JIAPAC). 2022;21:23259582221121448. Duby Z, Nkosi B, Scheibe A, Brown B, Bekker L-G. Scared of going to the clinic’: Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities. South Afr J HIV Med. 2018;19(1):1–8. Mkhize SP, Maharaj P. Structural violence on the margins of society: LGBT student access to health services. Agenda. 2020;34(2):104–14. Aleshire ME, Ashford K, Fallin-Bennett A, Hatcher J. Primary care providers’ attitudes related to LGBTQ people: A narrative literature review. Health Promot Pract. 2019;20(2):173–87. Mgopa LR, Rosser BS, Ross MW, Lukumay GG, Mohammed I, Massae AF, Leshabari S, Mkonyi E, Mushy SE, Mwakawanga DL. Cultural and clinical challenges in sexual health care provision to men who have sex with men in Tanzania: a qualitative study of health professionals’ experiences and health students’ perspectives. BMC Public Health. 2021;21:1–12. Kurebwa J. Access to Healthcare Services by Lesbians, Gays, Bisexual, Transgender, and Intersex (LGBTI) People in Harare Urban, Zimbabwe. Global Perspectives on the LGBT Community and Non-Discrimination. edn.: IGI Global; 2022. pp. 1–25. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4157361","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":283543507,"identity":"2de87c26-ad46-476e-8567-31e04a35e188","order_by":0,"name":"Raikane James Seretlo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIie3OsWrDMBCA4TMGd7HJqtLWeoUzXk38KhUGeUkgY4YMBoGyJGspZMgruFtHFYOzCLoGMplApxYypkNotRQSqJKOHfRvh+6TBOBy/cPyyhNH4wjiiwTVMVEI6R8I+CeEVRfJqhH4+ZwBnc677Q6zcvmgEfYTyHsWnM+YYHPNAfUqRYV8WG8G6M1a8In6nfSBCRXJBpDwgChshvXNACGqIAALSXudeDnIL6DLt6u9ISVdmFcOFYTUQpJHJopImtN1YO7F5h7Mx3zzCkELwXUn0jtZhKi5TzTypN7wUXPbEkxs5LXcXn/IfkynrbcbjzNKF8VT9z7J8thCfgpPJrNMzu+7XC6X62zfqttamsi62lAAAAAASUVORK5CYII=","orcid":"","institution":"Sefako Makgatho Health Sciences University","correspondingAuthor":true,"prefix":"","firstName":"Raikane","middleName":"James","lastName":"Seretlo","suffix":""},{"id":283543510,"identity":"63b31f29-7ba6-465a-85eb-e4c0b81d8b47","order_by":1,"name":"Hanlie Smuts","email":"","orcid":"","institution":"University of Pretoria","correspondingAuthor":false,"prefix":"","firstName":"Hanlie","middleName":"","lastName":"Smuts","suffix":""},{"id":283543512,"identity":"a55862f0-373b-45fc-a091-41b4a8649f12","order_by":2,"name":"Mathildah Mpata Mokgatle","email":"","orcid":"","institution":"Sefako Makgatho Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Mathildah","middleName":"Mpata","lastName":"Mokgatle","suffix":""}],"badges":[],"createdAt":"2024-03-24 09:44:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4157361/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4157361/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62864795,"identity":"5c263d17-0443-4767-9573-37b3941b6bbe","added_by":"auto","created_at":"2024-08-20 11:20:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":899199,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4157361/v1/2ea3e037-befb-484f-87b7-3250330bc864.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The hurdles faced by individuals identifying as queer when seeking for and by healthcare professionals when providing sexual and reproductive healthcare services in South Africa.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSexual and reproductive health (SRH) refers to both physical and emotional well-being, including the ability to prevent unintended pregnancy, unsafe abortion, sexually transmitted diseases (STD) like human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), and all forms of sexual assault and coercion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is therefore important for everyone to have access to high-quality vital health care as the cornerstone of universal health coverage [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, societies across the globe still have a long way to go, since queer people are still experiencing and facing exclusions and a series of health inequities derived from the stigma and discrimination in the healthcare sector [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis is despite the fact that the sustainable development goals (SDGs) seek to address issues of inequality, embrace diversity, and ensure health and well-being for all [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, these SDGs, notably SDG 3.7, seek to provide universal access to sexual and reproductive healthcare services by 2030 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Specifically, in SA, queer people continue to face difficult and diverse social challenges such as prejudice, stigmatization, denial of healthcare services, and community rejection [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is still a belief that HCPs are the most crucial frontline workers who can help queer people overcome their issues. Some HCPs continue to discriminate against queer people based on their sexual orientation or gender identity, expressing moral judgment and disapproval [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and imposing heteronormative attitudes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Again, some HCPs refuse to provide care to queer people [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and some HCPs lack information about queer people's identities and health concerns, resulting in poor-quality care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese issues around queer people are not only prevalent locally in SA, but across the different continents and countries as well. For example, in sub-Saharan Africa (SSA) queer people continue to face stigma and discrimination, which jeopardizes their health and exacerbates sexually transmitted illnesses such as the HIV epidemic [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, a study by Mbeda et. al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] found that queer people reported experiencing healthcare-related stigma experiences, which led to fear of looking for healthcare services and avoidance of seeking, and some said they were denied health services because they were queer. Rosee et. al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] found stigma and prejudice as some of the hurdles to healthcare for queer people in SSA, which were exacerbated by the illegality of homosexuality. Furthermore, hurdles to HIV testing resulted in the exclusion of some of queer people from treatment cascades of events and poor sexuality training among HCPs leads to discrimination or denial of treatment for some queer people, notably in government [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, most of the countries aside from SA, regardless of their level of healthcare advancement and being classified as developed countries, still have challenges in improving queer\u0026rsquo;s health and well-being. According to a study by Gonzales and Henning-Smith [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], some queer people like transgender and nonconforming adults continue encountering barriers to health care due to discrimination, insurance coverage, employment, and public policy, as well as an inadequate level of understanding among health care providers about transgender-related health issues. According to Hafeez et. al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], queer people receive low quality care due to stigma, a lack knowledge among HCPs, and insensitivity to their community's particular needs. Westwood et. al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] discovered negative attitudes onto queer people among nurses, demonstrating a toxic nursing culture in an elderly ward, and the person involved in this case study described multiple instances including homophobic and transphobic practice, as well as queer microaggressions, which apparently affected the quality of nursing care. Elliot et. al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] found that queer people have poorer health and bad healthcare experiences. Again, systematic review findings by Alencar Albuquerque et. al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] indicated that the queer people face problems in accessing health services as a consequence of heteronormative views enforced by HCPs.\u003c/p\u003e \u003cp\u003eIt is critical that the obstacles faced by queer people be addressed as soon as possible in order to reduce any health risks. If these issues are not addressed, queer people will continue to be uncomfortable announcing their identities and concealing signs of sexually transmitted illnesses (STIs) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], contributing to an escalating HIV epidemic [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Other additional health challenges that queer people will continue to suffer from are a greater likelihood for substance use, STIs, malignancies, heart disease, being overweight, bullying, separation, disapproval, anxiety, depression, and suicide as compared to the general population [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], furthermore, they are going to keep experiencing depression and anxiety as a result of homophobic comments by HCPs [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and HCPs are going to keep imposing heteronormative attitudes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Little studies focused on both queer people and HCPs\u0026rsquo; challenges experienced in SA had been conducted. Queer people This study fills significant gaps in our understanding of healthcare inequities experienced by both queer people and HCPs. By exploring these gaps, this article aimed to explore the challenges faced by queer people and HCPs when receiving and providing sexual reproductive healthcare services in SA, establishing the way for specific measures and changes in policy that promote inclusive, non-discriminatory healthcare practices, and ultimately enhance the overall well-being of South African queer populations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, population, sampling, and recruitment\u003c/h2\u003e \u003cp\u003e We performed a qualitative study with individual interviews with participants from seven public district hospitals and one non-governmental organization (NGO) in South Africa's Gauteng Province. The study involved a total of 55 participants (33 HCPs and 22 queer people). Participants in the study comprised of nurses, medical physicians, social workers, clinical psychologists (HCPs), and lesbians, homosexuals, bisexual, transgender, as well as men who have sex with other men (MSM). Purposive sampling was utilized to choose all 33 HCPs, whereas RDS was used to select all 22-queer people. HCPs were sought out during their working hours at their workplaces, whereas for the queer participants, the principal researcher began with staff members on duty at the selected NGO clinic and then asked them to refer other members of the queer people who came to the clinic on the day of data collection. All queer participants received a reimbursement of R250.00 for their transportation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData from qualitative interviews were gathered from September to December 2023. We commenced with six pilot study interviews which included three of each study population. The findings of the pilot study were excluded from this article. The pilot study findings enhanced semi-structured interview guide amendment and checking if the questions were answering what was expected and anticipated. In total, we performed 55 interviews in Gauteng Province, SA, from seven district hospitals and one NGO (for public facilities), eight Johannesburg health district office, 20 Tshwane district health services, and five West Rand district health services. We used two selected NGO clinic branches in Gauteng Province for NGO, 13 from the Pretoria branch and 10 from the Kempton Park branch. Participants were interviewed in English, but allowed to respond in their home language, which was largely Isizulu and Setswana; all responses were later translated into English. The principal researcher and a research assistant gathered data, recorded all interviews with an interview guide and a digital recorder. The study's purpose, questions, and objectives were given to participants prior to data collection, and those who decided to participate offered both verbal and written informed consent.\u003c/p\u003e \u003cp\u003eQuestions that were asked during the data collection for HCPs and queer people, focused on the main aim which was to learn about the challenges both participant groups experienced. For \u003cb\u003eHCPs\u003c/b\u003e the questions were \u0026ldquo;T\u003cem\u003eell me about some of the major challenges you have experienced when you have to provide/during provision of sexual and reproductive healthcare services to the queer people in your institution\u003c/em\u003e, \u003cem\u003ehow often to you render SRHSN to queer people\u003c/em\u003e, \u003cem\u003eand what do you think are the reasons for queer people to access and utilize SRHSN in your healthcare facility\u003c/em\u003e\u0026rdquo;. The question for \u003cb\u003equeer people\u003c/b\u003e entailed: \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eCan you tell me about your experience when you access or/and utilize the services at a public institution and what are some of the major challenges you have experienced when you had to access or/and utilize sexual-reproductive healthcare services and needs as a queer individual at a public institution?\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe principal researcher employed thematic content analysis (TCA) to analyze data, following Ravindran's [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] four (4) phases. During the study, the researchers immersed themselves in the obtained data; all 55 audio files were transcribed verbatim, and where participants utilized and responded in their home language, the content was translated into English. All transcripts were labeled with the number of an interview, for example, P1 stands for participant number 1 and refers to interview number 1. The primary researcher analyzed the data initially using NVivo 14 based on the research questions, interview guide, and interview notes, while a research supervisor served as an independent coder and a second research supervisor reviewed the final themes as part of the article. To develop a consensual viewpoint, the principal researcher and supervisor examined all the discrepancies in coding interpretations that surrounded the issues faced by both HCPs and queer people. All coded data were examined for commonalities and the emergence of important themes, which drove a subsequent thematic analysis. NVivo 14 analysis revealed six major and linked minor themes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eResearch ethics\u003c/h2\u003e \u003cp\u003e Sefako Makgatho Health Sciences Ethics Committee (SMUREC) reference number: (SMUREC/H/291/2023: PG) provided ethical clearance and permission for the project. All participants understood the study's aim, research questions, and objectives and volunteered to participate without coercion. Participants in the study were given both verbal and written informed permission. We used anonymous identities for this work, and all comments were anonymized.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable 1 and Table 2 depict the characteristics of study participants and the list of emerging themes respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1: characteristics of study participants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCPs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en (=33)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQueer people\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en (=22)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.96 (1.84)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.86 (.94)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth gender \u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e5 (15.15)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e28 (84.85)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e19 (86.36)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3 (13.64)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual orientation \u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStraight\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eLesbian\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eGay\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eBisexual\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTransgender woman\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMSM\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e33 (100)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3 (13.64)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e8 (36.36)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2 (9.09)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e7 (31.82)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2 (9.09)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status \u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSingle\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMarried\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e22 (66.67)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e11 (33.33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e22 (100)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level \u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eNo formal education\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePrimary\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSecondary\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTertiary\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e33 (100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e10 (45.45)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e12 (54.55)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eTable 2: List of emerged themes.\u003c/em\u003e\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTHEMES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCPS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQUEER PERSONS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCPs believe that queer people are afraid.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eQueer believe that HCPs have negative attitudes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCPs as gatekeepers.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCPs as gatekeepers.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCPs being surprised and confused about gender identity.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCPs being surprised and confused about gender identity.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare disparities and familial problems.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare disparities and familial problems.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCPs\u0026apos; incompetency in queer-related healthcare.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCPs\u0026apos; incompetency in queer-related healthcare.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eQueer people as a barrier.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eQueer people as a barrier.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe data demonstrated that HCPs and queer people in SA\u0026apos;s Gauteng Province face similar, contrasting, and different problems when rendering and receiving SRHSN. Queer people typically reported unfavorable experiences receiving SRHSN in public healthcare facilities. HCPs, on the other hand, conveyed their challenges with a touch of positivism and acknowledged some of the identical challenges mentioned by queer people.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCPs believe that queer people are afraid.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHCPs outlined that queer people are scared to come to the healthcare facilities due to their internalized and experienced fears and they tend to distance themselves from the healthcare facilities and not receive services. There were contrary statements between HCPs as some acknowledge that they judge queer people and some stated that they do not judge them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCPs said that queer people are afraid of being stigmatized. Participants also expressed uncertainty as to why queer people do not come; however, they highlighted that it is possible that queer people are uncomfortable with the people they will meet when visiting healthcare facilities, and that because they have been stigmatized in other healthcare facilities and by community members, they believe they will be everywhere.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I will say maybe it is out of\u0026hellip; I don\u0026rsquo;t know whether maybe it is stigma from where they come or they have a perception that if I identify myself as queer that maybe I am talking to someone who is old, maybe the person will judge me in a negative way\u0026rdquo; (HCP5, 47yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For me I think I would say possibly some of them you find that they are uncomfortable with whoever maybe they are going to be meeting or they are just uncomfortable with how they see themselves, then having to come and explain here. I don\u0026rsquo;t know. I\u0026rsquo;m thinking it\u0026rsquo;s got to do with them or how maybe they are being stigmatised somewhere else. I\u0026rsquo;m not sure\u0026hellip;So, I think people- there is still a lot of stigmas in our communities and unfortunately people are afraid to come to healthcare facilities because of that, because they are going to be discriminated against and that\u0026rsquo;s something we need to fight\u0026rdquo; (HCP16, 30 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, HCPs expressed that queer people fear to be judged and discriminated against.\u0026nbsp;HCPs think that some of the reasons queer people do not come to the healthcare facilities is because they are afraid of being judged, rejected, criticised, and discriminated against, as well as being name-called. \u0026nbsp;HCPs further believed that queer people worry about how they will need to look and change their identity when they come to the healthcare facilities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They are afraid of the judgement, I don\u0026rsquo;t know\u0026hellip;I think what\u0026rsquo;s hindering them is that they think \u0026ldquo;Yoh I\u0026rsquo;m going to go there and I\u0026rsquo;m going to be judged\u0026rdquo; or have to change their whole outfit to identify as a person that they are not\u0026rdquo; (HCP19, 31 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think they are afraid to be judged. Akere they are used to that, everywhere I go, wherever I go people will be saying \u0026ldquo;ah, because of you are gay\u0026rdquo;, and then not knowing that things have upgraded, especially with the sexual assault departments. So, I think they fear judgement and rejection, so you could sense when you talk to them that uh-uh, this person is not free, but the moment then you make a small conversation, you make a small joke, and then they will relax and then they open up, then you are able to provide the service because if we don\u0026rsquo;t do that\u0026rdquo; (HCP30, 37 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHCPs noticed that some queer people tend to withdraw and isolate themselves, which makes it difficult for them to receive or to be provided a comprehensive healthcare service.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The ones that I got in contact with, I have not experienced any challenges but basically.\u0026hellip;they themselves tend to withdraw a little bit because I think they are scared to be free because they were lesbians, yeah!! They isolate themselves when they come to our healthcare facility\u0026rdquo; (HCP8, 36 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegardless of other HCPs having views and thoughts of queer people being scared, some HCPs acknowledged and agreed that they judge, discriminate, and stigmatize them. This is due to HCPs attitude, unable to understand and accommodative queer people and managerial individuals in the healthcare facilities being even more judgmental to the queer people.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If it\u0026apos;s two males now coming to the health facility and then the first question is like oh! are they going to have their own children or are they going to adopt? So, we ask ourselves those kinds of things. They are scared of us because of our attitude as well, and we judge them, yes. Even discrimination, like they say to me, is what are you going to? Do with it. Do you understand? And then we tend to judge them for giving that they are also individuals\u0026hellip;. they are normal like us\u0026rdquo; (HCP1, 40 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo, I think because of issues such as stigma and discrimination, although we would want them to have access often or as they need like anyone else, most of them that don\u0026apos;t come even if it\u0026apos;s post sexual assault. Some of them don\u0026apos;t report, or they don\u0026apos;t even come for prep. Right? So, because of the stigma and being judged and the discrimination. But those that can actually come access family planning and condoms. And for those that maybe come through the police or the crisis centres, they access the preps. I think it\u0026apos;s mostly stigma, honestly, it\u0026apos;s mostly discrimination and I think uhm, there is still a lot of resistance to being accommodative and accepting members of the queer community, even in the healthcare sector\u0026rdquo; (HCP2, 36 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It is difficult you know, we judge them, however, here at the public services, you know, yes, even if they can go and complain, wherever they are going to complain at they are going to be judged even further\u0026rdquo; (HCP9, 57 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the contrary, other HCPs indicated that they do not discriminate and judge them due to the type of work they do and their profession. HCPs indicated that they treat every patient equally regardless of their gender and sexual orientation and they cannot deny healthcare services to anyone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s like, akere when we- in nursing, in the Health Department we don\u0026rsquo;t discriminate, we don\u0026rsquo;t judge, we treat patients equally, whatever I am doing to each and every patient I don\u0026rsquo;t have to like discriminate or maybe say you are a lesbian. Whatever I am saying to each and every- a patient that comes here with the same problem we are giving them the same services because they are the same people\u0026rdquo; (HCP12, 42 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, as a social worker I\u0026rsquo;m working under the profession social worker. We are not allowed to judge anyone. I work with whoever gets inside the office and whatever that you mention, it doesn\u0026rsquo;t matter whether you are lesbian, whether you are gay, remember, that part of individualising people and respecting what the patient or the client wants stands out. I cannot say no because you are a lesbian, I cannot help you\u0026rdquo; (HCP13, 55 yrs. old)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQueer believe that HCPs have negative attitudes.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQueer people felt that HCPs disapprove and resent them by making harsh comments, jokes, and gossip statements. \u0026nbsp; Additionally, queer people held that HCPs are judgemental, stigmatising, and discriminating towards them, and as a result, they isolate themselves from public healthcare facilities. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQueer people reflected on their experiences in the public healthcare facilities. Some preferred NGOs, because of the safety and love they felt, whereas other indicated that some HCPs judged them and asked them questions why they chose to be homosexuals. As a result, they felt sad and hated themselves. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes I used public clinics before, so their service, I can say it was like so- for me it was so fine but the way they look at you, eish they look at you too much, it\u0026rsquo;s like they make you feel uncomfortable and their looks are judgmental that \u0026ldquo;Oh is he a girl or boy type\u0026rdquo; But so far since I went to public clinics like I haven\u0026rsquo;t experienced like bad things\u0026rdquo; (Gay, 21 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes they are judgmental, they call us with names, and it makes me feel so bad, just imagine someone who supposed to help you is the one judging you, one gets bored already\u0026rdquo; (Transgender woman, 25 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ll rather go to an organisation like this and not do it publicly, I come here and do my things because they understand me. But going to a public you get judged, yes, and especially when you ask- like come and talking to a nurse and ask you about your sexuality and you tell them your sexuality then they would come like nurses would be like how come you be gay, this is that. They have those judgemental thoughts, they\u0026rsquo;ll give you that and they\u0026rsquo;ll make you like leave that room hating yourself, yes. That\u0026rsquo;s why I would rather prefer coming to places like this and just do my thing so that no one is going to judge me, all of us we\u0026rsquo;re all the same\u0026rdquo; (Bisexual, 32 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eQueer people highlighted that some HCPs are homophobic, stigmatising, nosy and \u003cstrong\u003ecurious in an inappropriate way once they notice that you are a member of the LGBT community. Again, queer people stated that HCPs would go to the extreme of calling others to gossip or proceed to ask too personal questions such as how they have sexual intercourse. Queer people further indicated that they deserve respect and same equal treatment as everyone else who comes to the public healthcare facilities.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Uhm, some nurses are homophobic obviously so as soon as you get there, sometimes you go there just to test and maybe or you have something like that is not okay with you and then they will now start asking you uhm are you a girl, are you a what, and then you start to say I\u0026rsquo;m a transgender, transgender what, what\u0026rsquo;s that and whatsoever, according to my own experience that it has happened to me. So, now I believe that uhm I expect most of all respect and equality with everyone, yah\u0026rdquo; (Transgender woman, 25 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eQueer people indicated that one of the reasons they isolate themselves, is due to the fact that they are not accepted in the public healthcare facilities. Isolation is one of their coping mechanisms, protecting their space so that the HCPs stigma does not affect them. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You can\u0026rsquo;t relate to people who do not like you, then one tries to like have this uhm I don\u0026rsquo;t know if I can say like a coping mechanism for themselves whereby I say okay this is where and who I am and then I distance myself and not say much to create this working mechanism so that I cannot be affected through the whole stigma outside, actually\u0026rdquo; (Gay, 27 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCPs as gatekeepers: HCP\u0026rsquo;s experiences.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the responses from the HCPs during the interview sessions, it was noted that they continued acting as gatekeepers and hindered queer people from accessing and utilizing SRHSN in their public healthcare facilities. This theme emerged from the HCPs responses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of HCPs stated that they assumed the gender orientation of queer people by just looking at them as they walked into their consultation rooms and healthcare facilities. As a result, they anticipated that queer people would not require certain services and some linked queer people with certain illnesses such as HIV. Other HCPs classified queer people as looking normal, which then makes them to generalize care of patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When you see them walk in, automatically you click your mind that what is she coming to do hear at ANC clinic, she can\u0026rsquo;t be pregnant, she is butch; but she is pregnant or he is gay he is probably HIV positive, you know those, yah\u0026rdquo; (HCP11, 25 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, Iyo! It is difficult hey, some other time I saw lesbian client and I wasn\u0026rsquo;t aware because she is normal, but luckily, she came with the mother. They were reporting sexual assault but when I ask if she is sexually active, she then told me that it was the first because she is a lesbian and I was like shocked also not knowing how handle it, I didn\u0026rsquo;t know what to say and do further\u0026rdquo; (HCP30, 37 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The challenge I experience is always having to assume gender, like I normally say like if my mind tells me ai, the behaviour here it looks like she or he might be something else, then I anticipate that he or she is sick because of their sexual practices\u0026rdquo; (HCP31, 50 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome HCPs believed that their own religious beliefs and cultural practices were the barriers for queer people to come forward to seek for SRHSN. They further stated that they are still cultural and religious beings which in the end makes it difficult for them to advice on other services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, many healthcare professionals when you are speaking about abortion is like you are killing and it is not like that, when you provide these services even myself, they don\u0026rsquo;t take me serious like I am a Christian. I am a Christian, according to them I am a devil, they think I am doing a disgusting job because I am helping even lesbians who they say they are practicing unholy and dirty things. Gays are doing dirty things, they say God, they think they are the ones who understands better than us. Nonetheless, even lesbians and gays are Christians but if God gave them there-way they are, if someone doesn\u0026rsquo;t have feelings for a different gender, they have rights to live happily in this world, we deprive them happiness and make them feel bad\u0026rdquo; (HCP3, 23 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Eish our cultures, like culturally it\u0026rsquo;s still a taboo, we say how can you get an egg from someone then the ancestors whatsoever, you understand. If now you are getting a strange person\u0026rsquo;s egg, but this child is going to be yours, those kinds of things. So, culture is still one of the things that come in the way that, I mean, interrupts a process that a lot of people are willing and open to take but now afraid of the culture and the belief system that now stands in the way, it then becomes difficult for lesbians to access IVFs freely\u0026rdquo; (HCP21, 43 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLack of interest and HCPs being uncomfortable to talk and render services to queer people were observed during the interview sessions. One HCP conveyed that they are not sure of what types of services they should render to queer people, and they are not capable to even conduct physical assessment on them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I am not sure if they come what I should screen\u0026hellip; because let\u0026rsquo;s say they are presenting with an STI right, Hai, I don\u0026rsquo;t think I will be comfortable and ready like imagine why would I check their anus? I don\u0026rsquo;t want to see any trauma there, any legions, any, you know but I don\u0026rsquo;t think that\u0026rsquo;s like number one\u0026rdquo; (HCP11, 25 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCPs as gatekeepers: Queer people\u0026rsquo; experiences.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome observations were obtained during the interviews with queer people, related to the fact that HCPs are indeed the gatekeepers resulting in them not being interested in accessing SRHSN. Additionally, queer people stated that HCPs assumes their gender based on how they appear, they reported negative attitudes and treatment from HCPs. However, some queer people stated that they never experienced challenges at all.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA significant number of queer people pointed out that HCPs do not ask them about their gender as they just assume, leading to services rendered and offered being wrong. Other queer people stated that HCPs treat them like women without asking what they prefer to be called as this will help them to identify their sexual behaviors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know if I should say I was scared, embarrassed or traumatised, I was at the government clinic and a nurse asked me for my pee, you understand, then I went and pee and then when I came back- so I thought maybe she was just testing acidity level in my urine only to find out that she was doing a pregnancy test. Oh well she was not aware that I\u0026rsquo;m not female, she assumed that I was female. So, she did a pregnancy test and then while waiting for ama-results, she asks me when last did I go to my periods, then I\u0026rsquo;m like no I don\u0026rsquo;t get periods, I\u0026rsquo;m not a girl.\u0026rdquo; (Transgender woman, 30 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Ai with me, they treated me as a woman, yes I guess it\u0026rsquo;s that- the only time I felt, I guess, sort of unsafe, I had a girlfriend I think, the first time I had a girlfriend I think I was 17 towards 18, and that\u0026rsquo;s when I said that was the only time I\u0026rsquo;ve had an STI and I got that because she was using things that are not yah and I went there and I couldn\u0026rsquo;t explain why because first of all I\u0026rsquo;m not having sex with boys, why do I have because she concluded\u0026rdquo; (Lesbian, 28 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNegative experiences, criticism and disapproval were experienced from HCPs by queer people whenever they visited public healthcare facilities. A substantial majority of queer people highlighted that they had unpleasant experiences, felt uncomfortable, forced to take some procedures, and being convinced to fall pregnant by HCPs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My experience was bad, So, what happened is that I got there and then obviously the admin was doing whatsoever, you give them your ID and then after that I was sitting. So, as I was about to go in, I went in- okay not before, the nurse came and checked my file and then he was like you are not a male, but your file says you are a male, and then she looked at me and be like oh you\u0026rsquo;re one of and then she left me there. And she went inside, the other nurses came out and then they started looking at me and then are like oh okay [Indistinct] and whatsoever. So that was very uncomfortable because of I had to leave right there\u0026rdquo; (Transgender woman, 25 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think challenges would be, I don\u0026rsquo;t want to say more challenges, but you know how doctors would always like for instance akere I struggle from period pains, and they\u0026rsquo;ll always say no, but you must get pregnant, I\u0026rsquo;ll be like no I can\u0026rsquo;t I\u0026rsquo;m a lesbian. Then they\u0026rsquo;ll quickly dismiss that no but if you get- I\u0026rsquo;m like for me to get pregnant means I need to go for IVF whatever, you know, it\u0026rsquo;s a whole thing it\u0026rsquo;s not just me going like a straight person, you know\u0026rdquo; (Lesbian, 28 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegardless of the majority of queer people experiencing all sorts of challenges when accessed SRHSN, some stated that their experience was great, and they had no challenges at all. Queer people further, praised HCPs for their work. Some queer people reflected that they never experienced challenges because they do not go around talking about their sexuality, and some because they do not look like their sexuality. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Honestly, I don\u0026rsquo;t think it was challenges, I don\u0026rsquo;t think we had any challenges. Doctors and nurses are trying to help\u0026rdquo; (Gay, 24 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t have. I\u0026rsquo;ve never experienced any stigma or any hate speech or anything. The thing is I\u0026rsquo;ve never preached, or I\u0026rsquo;ve never came out to tell people that hey I\u0026rsquo;m gay. You see, I think my surrounding, even my family knows that my mom, I\u0026rsquo;ve never explained to my mom or my parents that I\u0026rsquo;m gay\u0026rdquo; (Gay, 30 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Okay, I wouldn\u0026rsquo;t really necessarily speak about it in a sense of being a lesbian woman mainly because I don\u0026rsquo;t even look like I\u0026rsquo;m lesbian when I\u0026rsquo;m walking like on the streets or wherever because I\u0026rsquo;m feminine representing, I get hit on by men, right, so even when I go to the clinics, they can\u0026rsquo;t see that I am a lesbian woman\u0026rdquo; (Lesbian, 30 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCPs being surprised and confused about gender identity: HCPs deliberations.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHCPs acknowledged that they are still not understanding the queer gender identity and they will continue asking as they are not used to such identities. As a result, this may present as one of the factors that make queer people not come to the healthcare facilities as they feel uncomfortable when asked for clarity and reasons on their gender identity. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eI think, Yoh\u0026hellip;the biggest challenge I have seen was a lady, she came to deliver, I was working in labour ward, she came to deliver, a lady, now this lady came to deliver, when she gets discharged, she is fetched by another lady, and they say this is the father to the baby, but this is a woman. You can see this is a woman, why are they saying this is the father to the baby. They saw my expression and being shocked and they might feel bad and not come back\u0026rdquo; (HCP11, 25 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEe, only. But when I ask you are you a female or a male, oh wow, oh okay. You will see even their facial expression changing and some of us, remember we are human beings, we are still going to be surprised and be shocked, we will even want to give you counselling as in why are you gay, why are you lesbian? You understand? They still get those questions even if we can hide it, even if\u0026hellip; for me I think it\u0026rsquo;s discouraging for them to say I\u0026rsquo;m still going to be asked those kinds of questions, so I am not going to go and get the service that I need\u0026rdquo; (HCP13, 42 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCPs being surprised and confused about gender identity: Queer\u0026rsquo; deliberations.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQueer people stated that they have observed HCPs being shocked and surprised whenever they are themselves and come across as queer. This has been one of the barriers for queer people to freely access and utilize public healthcare facilities. Queer people further stated that HCPs would ask too many personal questions, encouraging them to resort to private doctors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So another thing when I got a transfer from the other clinic, my transfer is because of I wasn\u0026rsquo;t happy the way- about the treatment after all but I- because there was a time my file was written a female name, okay which is not something else I cannot live with, so on my file, I don\u0026rsquo;t know how did they mix up but then my file came saying I\u0026rsquo;m pregnant, you know. Then, they came sneaking one by one to come look at me and being surprised and I was surprised too, I stopped going to government clinics\u0026rdquo; (Transgender woman, 33 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yah, so most of the time like when I have health issues- maybe when I seek medical attention, I just go to like a private doctor, just like a doctor yah, because I remember I once went to a clinic, its government clinic so when they found out that I was gay, they were surprised than a handsome man like me would be gay, they started asking me how I have sex and decided to test me HIV without counselling, I then decided I will never come back again here\u0026rdquo; (Gay, 24 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare disparities and familial problems: HCPs discussions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHCPs\u0026nbsp;mentioned that some of the challenges that inhibits queer people to access and utilize SRSHN, is because\u0026nbsp;their healthcare facilities are not inclusive. Moreover, other HCPs stated that healthcare facilities have limited resources which might put them at risk of acquiring infections and lack regulations for registering a child of the same gender. Some HCPs\u0026nbsp;remarked that\u0026nbsp;reproductive services are expensive for queer people to afford, and overall, the healthcare facilities are having areas which are exclusive for queer people such as toilets for male and female and lack of privacy for them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;And there are limited resources for them because I\u0026apos;m trying to think if it\u0026apos;s two females, then they need those resources to be intimate with. They use their own money. It\u0026apos;s not available in government hospitals because people will judge you. Why do you want that toy? Because we think it\u0026apos;s too females and then. What? So those resources they use are not available? Yes! So, they need to have money to purchase them. That is why they end up maybe doing wrong things now they end up having infections because they can access whatever resources because they are not cheap as well\u0026rdquo; (HCP1, 40 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of people are willing to explore, go out there, get the full understanding, but now the issue is also the finances because now if you have to do everything externally so, a lot of people do not have the funds because some of these procedures are costly, they are very expensive when now you have to like a surrogacy whereby the child now has to be conceived through IVF or something and that\u0026rsquo;s a very expensive procedure\u0026rdquo; (HCP21, 43 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eThe major challenge is our government hospitals, I don\u0026rsquo;t think they cater them well, reason being if you look at our toilets it\u0026rsquo;s labelled male, it\u0026rsquo;s labelled females. There is she coming, it\u0026rsquo;s a shemale coming to the hospital, feels I\u0026rsquo;m a man, where does she supposed to go now; there\u0026rsquo;s a toilet labelled male, there\u0026rsquo;s a toilet labelled female\u0026rdquo; (HCP22, 42 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;With queer people, even though I never had that before, if I am to have such a patient, I think I wouldn\u0026rsquo;t know where to refer them to a safe space that will be non-judgmental, so that they can get help because I think that happens quite often\u0026rdquo; (HCP29, 30 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLack of support from family and relatives were pointed out as one of the reasons that makes it difficult for queer people, regardless of HCPs\u0026rsquo; effort to assist them. Additionally, other HCPs highlighted that family members find it difficult to accept and support their queer children but get accepted by other community members.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, the only challenge that we have, which I think maybe it becomes a hindering fact of working with an individual, when the family doesn\u0026rsquo;t want to accept their child. Yah, it\u0026rsquo;s because of the sexuality and of the adoption matter\u0026rdquo; (HCP13, 42 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the main issue is maybe acceptance from their immediate families or their immediate peers because the same people that I am talking to you about, it was perceived as if they are forcing things, they will say things like why you can\u0026rsquo;t do it the normal way, you understand. Why can\u0026rsquo;t you just go the normal way? Why can\u0026rsquo;t it be like male/female and be normal? So, the main issue that they tend to go through is how will they see us, you understand. Seeing that a lesbian is pregnant, people will constantly ask themselves that how did they do it, why did they even think of doing it like that? Did they ask someone to have sex with them? This leads them not to come look for different ways of having children\u0026rdquo; (HCP20, 29 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have only encountered one gay patient. It was long ago. The challenge now was based on that the community- him being- him identifying as a gay person, it was challenging for him because he was now admitted because at home, they also cannot accept him, you know, so it led him to such an emotional distress that he ended up being admitted. it was disheartening to see that. But he was only having challenges with his family, but it was- what I have noticed is that the community has already accepted him\u0026rdquo; (HCP 28, 27 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe observation by HCPs was that queer people are\u0026nbsp;being abused and discriminated against by other community members. Also, other HCPs acknowledged that campaigns of awareness need to start with community members so that they understand that queer people are like any other person, and they need support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For me right now, as a social worker, when it comes to sexual reproductive health for queer people, I think that\u0026rsquo;s the one thing that I can think of. They want kids, you know, or maybe it\u0026rsquo;s the issues as well. We face many issues of the LGBTQI communities being abused, a lot, right? So, maybe it might be that; \u0026lsquo;I have been raped\u0026rsquo;; \u0026lsquo;I have been abused on\u0026rsquo; wherever, at home, or \u0026lsquo;I\u0026rsquo;m being discriminated against\u0026rsquo;. that is why I\u0026rsquo;m here as well, as a social worker to be able to offer that support to say okay, what do you need? How can I give you that support so that we report the abuse that\u0026rsquo;s happening?\u0026rdquo; (HCP28, 27 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026rsquo;s a lot that can be done but I think we need to start at the communities, talk to people out there like campaigns before they can come to us because again, as I said, queer people can sometimes not be able to come to us because firstly, they feel judged. Our black communities are just so judgemental when it comes to queer people. There\u0026rsquo;s a lot of hate. There\u0026rsquo;s a lot of violence towards them and all that, but if we go to them first so that they can feel safer to come back to us, and educate them and- yah, I think spread the information that \u0026ldquo;hey, come through, we have one-two-three-four\u0026rdquo; (HCP32, 28 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare disparities and familial problems: Queer\u0026rsquo;s discussions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the opinion of queer\u0026nbsp;people, public healthcare facilities lack sexual reproductive services due to affordability. Other queer people mentioned that there are delayed services and that they are excluded by being called special cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel that we are just not being prioritised like other straight people, you know, or maybe is it because we are looking for a specific thing, I\u0026rsquo;m trans and I need medical attention, this is what I want. Unfortunately, there are limited services to cater us at the public hospitals and clinics, yes\u0026rdquo; (Transgender woman, 20 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yoh, I needed IVF or what do you call IUI, it\u0026rsquo;s like 50K to do IUI or IVF, even that 50K doesn\u0026rsquo;t even include consultations, doesn\u0026rsquo;t include blood work, doesn\u0026rsquo;t include scans, doesn\u0026rsquo;t even include sperm donor, you know what I mean, I still need all of that. Meaning at the end of it all I would have spent more or less 100K\u0026rdquo; (Lesbian, 30 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You\u0026rsquo;ll go to the clinic, and they\u0026rsquo;ll say oh!! You are part of the LGBTI, okay you\u0026rsquo;re a special case, we\u0026rsquo;ll call someone for you, he\u0026rsquo;s been trained, you understand. Why can\u0026rsquo;t they all treat us? They don\u0026rsquo;t train the whole staff, maybe in a department they will train two people. So, they were like you wait for- you\u0026rsquo;re a special case, you understand\u0026rdquo; (Transgender woman, 30 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSimilarly to what HCPs observed, queer people indicated that they tend to be abused and discriminated by other community members and were accepted by their family members.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Firstly, coming out as gay, you know, people will be like Yoh, I don\u0026rsquo;t want to talk to this one, you know, name-calling, you know those offensive names man. So that\u0026rsquo;s the first challenge we faced, most of us, in the communities. You are even scared of coming to the clinic because the community members will judge you. So- okay, family wise it was fine because they\u0026rsquo;ve long accepted me because I think the parents saw from an early age\u0026rdquo; (Transgender woman, 23 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCPs\u0026apos; incompetence in queer-related healthcare: HCPs\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003einteractions.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLack of skills, knowledge, experience, and expertise regarding queer-related health matters was observed among HCPs. The bulk of HCPs showed that during their rendering of SRHSN to queer people, they are too empathetic, uncomfortable, do not know how to deal with queer people without making them feel judged and discriminated against. They acknowledged that they were not trained, and some stated that they do not know what types of services to render to queer people.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCPs\u0026rsquo; empathy seemed to be blocking them to probe further during history taking when rendering different services to queer people.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026rsquo;s probably myself where I will be wondering should I ask for details, or should I ask for details or should I ask for this and that. I think it is a question that I will have with myself, and I would always be battling with that. Is it important \u0026ndash; the detail \u0026ndash; or is it not important, because sometimes you may want to ask a question, but it\u0026rsquo;s not necessary, so, for me it\u0026rsquo;s always to ask myself that question, do I have to ask this question or not, or am I just asking out of curiosity? So, it is always to know, and sometimes it is not easy to know whether you can or you can\u0026rsquo;t; so, I would say that is the issue that I have to always ask myself do I have to ask a question or what I have is enough\u0026rdquo; (HCP5, 47 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, most of my patients, when they come for\u0026hellip; especially when she is a lesbian saying sister, you know I just made a mistake, I don\u0026rsquo;t\u0026hellip; because I know how disturbed they are. When they come to me, I do not go much unless the patient starts to open up, when they come here, I just give them information that I have to say you know what guys, these are the services that I am giving you, but remember you need\u0026hellip; I have somebody in the hospital that can take you further with whatever you want to open up with. I do not go much in details why because I do not ask the question why\u0026rdquo; (HCP6, 42 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome HCPs appeared not to be comfortable towards asking queer people questions, they were concerned not to come across as rude HCPs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The approach. I feel that like if- it will be rude for me just to come up to a person and ask about their sexuality and on how do you have sex, how do I start, or just to ask what is rimming, it\u0026rsquo;s very difficult I would say, yah\u0026rdquo; (HCP18, 32 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For me personally I am not working in the department but when I go there, I also honestly felt a little bit of that the uncomfortable, yah, you will feel a little bit discomfort, you know, yah so I think that\u0026rsquo;s one of the\u0026hellip; It\u0026rsquo;s actually the only challenge that I can think of right now, yah\u0026rdquo; (HCP9, 57 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot knowing how to address queer people without making them feel discriminated was one of the HCPs challenges which showed that indeed HCPs do lack skills and expertise of handling queer people.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I can\u0026rsquo;t say their pronouns, I mean that\u0026rsquo;s something- sometimes it makes us feel- me specifically, I can\u0026rsquo;t say shy but sometimes I feel like I can\u0026rsquo;t, I don\u0026rsquo;t know how to address them, can I say ma\u0026rsquo;am or sir. Some patients can feel offended, this person just because I\u0026rsquo;m a male and I have a makeup on it doesn\u0026rsquo;t necessarily mean you can say- like think that I\u0026rsquo;m gay or what, maybe I just like wearing this and you come to me think now because oh, a lady, I\u0026rsquo;m still a sir. Hai, I don\u0026rsquo;t really know, and I have no information\u0026rdquo; (HCP32, 28 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The other challenge is I assume a lot like lesbians will be coming in my consultation room and say one, \u0026ldquo;I am her boyfriend\u0026rdquo;, yah and it becomes a challenge when we have to intervene into that, because you cannot tell them that you are both equal as females. So, this one I don\u0026rsquo;t know how we- maybe- again, if we ask them \u0026ldquo;how do you want me to address you\u0026rdquo;, in front of everyone; it will be- I will be stigmatising them, yah\u0026rdquo; (HCP33, 48 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome HCPs were clueless and did not know what they should offer queer people when seeking for SRHSN. Others were uneasy about how their sexual practices might cause health challenges, but still did not know how to prevent those health issues occurring. HCPs continued stating that it is hard to render SRHSN to queer people, but they continue treating them like any other patients who comes to their healthcare facilities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;And then again, regarding their health, remember they practise anal sex, so I think at some point there\u0026rsquo;s a stage where their muscles loosen, and then they develop some illnesses, I think so, yes. They develop some illnesses. So, I don\u0026rsquo;t know how we can stop that, how we can prevent that from happening. Hai!! I don\u0026rsquo;t know\u0026rdquo; (HCP10, 36 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s difficult sometimes to deal with them but the thing is they need help. When I say I give services, the same as I am doing to each and every patient that comes here like services I said before, we are giving them health education, prophylaxis, you see\u0026rdquo; (HCP12, 55 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I am not even sure, Yoh, that one is a bit difficult because I\u0026rsquo;m not sure; like if they are transgender, someone who\u0026rsquo;s a transgender\u0026hellip;which is quite tricky when it comes to the queer, LGBTQI community because now when you are dealing with trans individuals, whether a trans man or a trans woman, it\u0026rsquo;s a whole different ball game, you know. So, yah, then there\u0026rsquo;s that overlap in between that is sometimes a bit difficult to navigate\u0026rdquo; (HCP16, yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLack of training continue to be a major issue for HCPs, this included training on queer-related matters. Majority of HCPs acknowledged that they do not have skills and knowledge for queer people\u0026rsquo;s issues, while some HCPs stated that they do not know how to care or render services to queer people because their tertiary curriculum covered only males and females\u0026rsquo; content, not queer people health. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the other, the other one, is also lack of training actually, amongst the healthcare workers regarding you know how the use of words, the use of correct pronouns, they use, how to treat, you know how to be cautious and caution, yeah, cautious, and also how to be uhm not accommodative, but to actually treats people as they are. So, there is also that I think you know some healthcare workers struggle with, you know, the use of words, understanding some people still consider members of the queer communities as outsiders as attention seeking, as some people who are who have trained in all schools still consider it some kind of a medical condition, something they need to convince someone and treat or so I think what I can think of in terms of challenges is the stigma and discrimination\u0026rdquo; (HCP2, 36 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The thing is the course that we did is only the female part, but the LGB, the others, we were not involved especially when it comes\u0026hellip; because most of my patients, especially males would ask \u0026ldquo;Sister, why not us, only females\u0026rdquo;? And I will tell them I do not have any clue or any information or any workshops or any teachings regarding what to be done or how am I going to help you\u0026rdquo; (HCP6, 42 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Firstly, it\u0026rsquo;s not being clued up, not being educated or well informed on their sexual orientation, what they are going through, whatever is it that is needed for them at that specific time. Like the patient, for example, who was going through with transition. It\u0026rsquo;s done at Steve Biko Hospital, and not a lot of us have been there or understand what is happening and all that, and when a patient comes in here, some patients expect you to know because you are a healthcare worker; and if you are not clued up like how, yet you call yourself this person, you are in the medical field, you should be knowing\u0026rdquo; (HCP32, 28 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCPs\u0026apos; incompetency in queer-related healthcare: Queer\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003einteractions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQueer people highlighted that HCPs ask about sexual activities once they notice they are a member of the queer community. They stop focusing on the reason why queer people came to the clinic in the first place and dwell on who they have sex with and how they do it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yah, I remember I was raped, and they took me to the government hospital, and you know that doctor there, the questions he was asking- and he was male, the questions he was asking were very insensitive. So, like okay so the docket says you were raped so this is what I\u0026rsquo;m going to do to you. Like he explained the whole process and everything. Yoh, and while doing that, questions he was asking like so is it painful, you know, like weird questions. And so how is it, is- now he\u0026rsquo;s no longer on the rape case, now his asking me on a personal level, so like tell me how it feels to have anal sex?\u0026rdquo; (Transgender, 30 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eQueer people reflected that HCPs ask uncomfortable and too personal and invasive questions, leading to queer people lie about their sexuality. Sometimes the questions HCPs ask queer people, they are unable to answer and be free about who they truly are due to fear of judgement. Furthermore, queer people indicated that HCPs do not understand what queer people go through which makes it difficult for them to even explain further.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, there\u0026rsquo;s certain questions that they are asking at the government clinics, how do you have sex and is it not painful and why sex with men? I know I can come here as in NGOs because of at the local clinic I didn\u0026rsquo;t like they ask you questions that makes you feel uncomfortable most of them\u0026rdquo; (Transgender woman, 33 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Nurses ask too personal questions, for example maybe you have an STI, they ask questions like uhm who are you sleeping with and it becomes difficult like to say oh I\u0026rsquo;m having sex with a boy because you\u0026rsquo;re scared of- even if they\u0026rsquo;re not going to say it but the looks cause probably there\u0026rsquo;s going to be like maybe another nurse there and whatever but like the looks and whatever now you have to explain how you guys have sex which I didn\u0026rsquo;t come here for that, I just uhm I came here for- to seek medical attention not to be- understand. So, at the clinics I think the most challenging thing is having to explain to people who don\u0026rsquo;t really understand, yah they just don\u0026rsquo;t understand and yah. Some of the questions are quite invasive, yah, so you end up lying even like most of the time I\u0026rsquo;ll just say I have a girlfriend, yah\u0026rdquo; (Gay, 24 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRefusal of providing services to queer people by HCPs was noted. This might be that HCPs are still not understanding the importance of what SRHSN for queer people could do in terms of protecting them and preventing many illnesses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I went to the clinic to ask about PrEP because of it was new at that time, they were like no we cannot give you a PrEP, you\u0026rsquo;re still young and stuff like that. I was like okay, and I was sad that I cannot protect myself from sexual transmitted illness\u0026rdquo; (Gay, 27 yrs. old). \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQueer people as a barrier: HCPs discourse.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe vast majority of HCPs indicated that even though they are labelled gatekeepers, lack skills and knowledge for queer-related matters, queer people themselves are the hurdles to receive a comprehensive healthcare service. They stated that queer people are unable to open up to them and feel that they should always explain themselves to HCPs about their sexualities. Additionally, HCPs mentioned that queer people utilise private sectors as they feel more safer and HCPs in private sectors are held accountable if treated patients badly. Lastly, various groups of HCPs indicated that queer people are not comfortable when they have to be examined, and some of the queer people do not return for their follow-up care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The challenges that I have is because they come, they get the service, and they don\u0026rsquo;t follow up. That is a challenge because I feel like I need to know where they are, what happened to them. Yes, follow-up is a problem for me because some stay far\u0026rdquo; (HCP6, 42 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think they use our facilities less. What I have realised about this community, they, I mean that is my perception, the way I observe them, neh, they will rather go to private than to come to public institutions. We are a government public institution, and they don\u0026rsquo;t come much here. Yes, you will see here and there somebody, you know, it\u0026rsquo;s sporadic, it\u0026rsquo;s not like yes there\u0026rsquo;s an influx, yah, In the private sector you are accountable because there are stakeholders that will really keep you accountable to your acts and your omissions, right, so I think they feel more comfortable there, to go there because they know that should they be judged in any way there will be repercussions or consequences\u0026rdquo; (HCP9, 57 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Then with others they don\u0026rsquo;t want to be or like to be undress, looking at them. Others don\u0026rsquo;t want at all, Yah I think so because it\u0026rsquo;s like, according to my understanding, like what they are now is what, now they are boys right\u0026hellip;you grew up, you changed to be a girl, and then it\u0026rsquo;s not simple for you to undress for each and every person\u0026rdquo; (HCP12, 55 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, I think that\u0026rsquo;s been the biggest challenge, getting people to open up to say you know what I am queer, I identify this way, and this is my lifestyle, etcetera, and then they just close off, and then you never get that; and it\u0026rsquo;s also difficult to kind do what you do like to gather the stats, to provide them with relevant services, and to find how we can make our healthcare system more conducive or whatever it may be for our queer population\u0026rdquo; (HCP14, 28 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, what I think is happening now is that it\u0026rsquo;s becoming a disclaimer, you know. It\u0026rsquo;s like okay this patient is coming with a disclaimer, they are transgender, disclaimer this and that, and I think that adds to that, you know, but at the same time I think the idea behind putting the disclaimer is to be sensitive and might make them feel uncomfortable to come to the facilities\u0026rdquo; (HCP17, 24 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQueer people as a barrier: Queer\u0026rsquo;s discourse.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLastly, it was highlighted how difficult it is to be a queer person, which led to many queer people to\u0026nbsp;change how they behave and appear whenever they go to the public healthcare facilities. This was due to the fact that they are afraid to be judged, thus affecting the services they receive as HCPs treat them as heterosexuals. Some queer people stated that not all public clinics and HCPs treated them with an attitude, as they themselves feel uncomfortable of talking about their sexuality. Other queer people, specifically, transgender\u0026rsquo;s confirmed what HCPs said that they do not want to undress by stating that they feel uncomfortable treated by male HCPs. In addition, they indicated that female HCPs feels uncomfortable to attend to them too.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The way it is difficult to be a gay, I remember there was a time I went with my partner to the public clinic but it was like a long time ago, instead of saying we are dating we said we are friends cause we knew that if ever we said we are dating like the questions are just going to be- they become more interested in how do you guys have sex and whatever, uhm yah. Its taboo [Laughter]\u0026rdquo; (Gay, 24 yrs. old).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I wouldn\u0026rsquo;t say the local clinic back at home was the nicest place to go to for PrEP but then yah I- yah, yah, that\u0026rsquo;s it, I was just not comfortable. They even asked me questions like \u0026ldquo;why are you taking PrEP and I had to lie that you know I have a girlfriend in Pretoria, that time I didn\u0026rsquo;t have a girlfriend in Pretoria but then it was not the space for me to say no I\u0026rsquo;m having sex with men in Pretoria so\u0026rdquo; (Bisexual, 21 yrs. old).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I would feel uncomfortable to be attended by a male nurse, remember I have to take i-treatment of STI sometimes I need to undress so that I can get the shot, so I feel uncomfortable being attended by a male nurse and at the very same time female nurses are also uncomfortable attending us sometimes, I\u0026rsquo;m not saying always but sometimes\u0026rdquo; (Transgender woman, 30 yrs. old).\u003c/em\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings show that HCPs detect a common sense of anxiety among queer people seeking healthcare services. Our findings are consistent with previous research indicating that queer people have mental health difficulties such as anxiety [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Again, drawing on a prior study, homophobic reactions were substantially related to anxiety and sadness, which were linked to stigma or discrimination in employment settings and health care institutions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. HCPs explained that internalized and experienced worries frequently cause queer people to avoid healthcare facilities, with concerns ranging from potential judgment to stigmatization. Researchers agree that queer people have reported discrimination, distrust, and terror in hospital settings [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Contrary views within the HCPs community demonstrate a lack of consensus, with some acknowledging judgment and prejudice against queer people, while others claim to treat all patients equally, regardless of gender or sexual orientation. Our study adds to Beagan et. al.\u0026rsquo;s [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] synthesis of available knowledge, which found that the majority of participants believed there were no substantial disparities between primary care for queer women and care for all other patients. This indicates that sexual orientation and gender identity were widely regarded as unimportant to care provisioning, as HCPs such as physicians treat everyone the same [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, they underlined that they constantly endeavour to suspend any prejudices, remained nonjudgmental with all patients, and avoid becoming \"distracted\" by aspects of a patient that the physicians themselves find problematic [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, Seretlo and Mokgatle [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] found that some primary healthcare (PHC) nurses had a judgmental attitude and were surprised that there were queer patients, associating their sexuality with childhood traumas, whilst other PHC nurses were not judgmental and were willing to serve patients despite their sexuality. Additionally, a Tanzanian study found that certain HCPs actively helped to limiting access to healthcare for men of varied genders and sexualities [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eQueer people, according to our research, are concerned about being stigmatized in healthcare settings, fearing judgment, criticism, and discrimination. Again, the research findings highlight a significant disparity in HCPs' opinions regarding queer people. While some admit to making judgments and discriminating against patients, others insist on treating everyone equally. However, queer people regularly reported unfavourable encounters with healthcare providers, such as rejection, hostility, and inappropriate probing. These experiences contribute to queer people's unwillingness to use public healthcare facilities, instead preferring NGOs, where they feel safer and more accepted. Our discussion is framed within the context of multiple studies suggesting that participants, for example, indicated that HCPs told every colleague in the healthcare facility and were humiliated, with some even seducing them [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. According to one study conducted among Durban university students, HCPs continue to prejudice homosexual persons and define HIV illness as a gay sickness [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. From different angles, researchers in the field have consistently observed that the percentage of primary care providers (PCPs) who had negative sentiments toward queer people differed significantly among studies in the United States [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In Tanzania, some HCPs saw MSM sexual activities as aberrant and referred to them as foolish guys [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants expressed uneasiness with the persons they could encounter in healthcare facilities, often as a result of previous experiences with stigma in both hospital settings. These findings is consistent with the findings of Moagi et. al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], who found that stigma and prejudice hampered the health and well-being of sexual and gender diverse people. Furthermore, our findings are consistent with those reported by Ross and Setchell [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], who found that certain HCPs identified discrimination as a theme, including reports of overt and hidden discrimination, as well as worries of discrimination and the larger community. Similarly, Dean et. al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] state that queer groups have considerable obstacles in accessing sufficient healthcare due to societal stigma. Concerns about how they would be seen, as well as the possibility of having to change their identity to get healthcare services, were recognized as important impediments for queer people.\u003c/p\u003e \u003cp\u003eOur findings also demonstrated that HCPs frequently operate as gatekeepers, assuming queer individuals' gender orientation based on looks. This notion, along with cultural and religious beliefs, impedes access to SRHSN. The dearth of inclusive healthcare facilities, as well as familial non-support, have been noted as significant challenges for queer people, resulting in healthcare disparities. Our findings are consistent with a South African study that found that HCPs attributed their moralizing, judgmental, and homophobic attitudes to their Christian beliefs and ideals [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Again, some claim that giving healthcare services to people in same-sex partnerships is difficult because they do not believe in homosexuality [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These studies demonstrate that religious beliefs, cultural traditions, and values impact HCP views toward homosexuality and how queer people are treated around the world.\u003c/p\u003e \u003cp\u003eIn terms of HCPs competency, our research revealed a significant shortage of skills, knowledge, and training in queer healthcare. Empathy from HCPs, while typically positive, may impede effective communication and service delivery to queer people, highlighting a need for increased education and cultural competence within healthcare institutions. Synthesizing the results from multiple studies, we can conclude that one of the most significant barriers to queer utilization and accessibility of healthcare services is a lack of education, understanding, and competence among HCPs regarding queer people's related health issues [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our findings are consistent with several studies that found an absence of awareness among HCPs about transgender-related health issues [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], a deficiency of HCP awareness and insensitivity to the unique needs of this community [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and a lack of understanding of transgender-specific well-being issues by HCPs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study also found that HCPs were confused about queer people's gender identities, which caused discomfort and hampered access to treatment. Queer people, on the other hand, reported being treated unfairly, being asked intrusive questions, and encountering difficulties during physical tests by healthcare providers. This supports the conclusions drawn by Mirza and Rooney [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], that discrimination in health care settings endangers queer people\u0026rsquo;s lives through delays or denials of medically necessary care and discourages queer people from seeking health care.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudy strengths and limitations\u003c/h2\u003e \u003cp\u003eOur study investigated and gave a thorough picture of the issues faced by queer and HCPs. Because we included these various participant categories and locations, our study produced more representative information from both parties. Again, our study improved external validity since the findings were more likely to be applied to a broader context within the same province. The final strength is cross-validation of the results, as we saw similar patterns and responses from both participant groups, supporting the study's trustworthiness and credibility. There were some limitations during data collecting as some queer people were underrepresented, such as lesbians, intersex, bisexuals, and MSM.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFinally, our study's findings shed light on the variety of obstacles that queer people face when accessing healthcare services. Our study further, emphasized the critical need for increased education, training, and cultural competence within healthcare systems to eliminate current obstacles. Additionally, our study advocates inclusive and respectful healthcare for all people, regardless of sexual orientation or gender identity. The development of new innovative healthcare solutions to address SRHSN for queer people may bridge gaps and meet the issues faced by both HCPs and queer people.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHealthcare professionals (HCPs), sexual and reproductive healthcare services and needs (SRHSN), respondent-driven sampling (RDS), sexual and reproductive health (SRH), sexually transmitted diseases (STD), human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), sustainable development goals (SDGs), sub-Saharan Africa (SSA), South Africa (SA), sexually transmitted illnesses (STIs), non-governmental organization (NGO), thematic content analysis (TCA), Sefako Makgatho Health Sciences Ethics Committee (SMUREC), primary healthcare (PHC), primary care providers (PCPs), and men who have sex with other men (MSM).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to the national Department of Health research ethics committee for granting permission to perform the study, CEOs for allowing us to conduct the study in their facilities, and everyone who agreed to participate in this study. Mr. Kgaugelo Mmalegodi, once more, for his participation and help as a research assistant in this study. Prof. Nombulelo Sepeng for her guidance and support to the lead investigator.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research study was sponsored by the National Research Funding (NRF) for Research Development Grants for nGAP Scholars [grant number NGAP23021680129] and subsidized by the Department of Higher Education (DHET) South Africa through the new Generation of Academics Programme (nGAP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors disclose that the qualitative data supporting the study\u0026apos;s conclusions are included in the article. The original transcripts are not publicly available because they contain information that could jeopardize the privacy of research participants. However, on reasonable request, the corresponding author can provide access.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRJS, MMM, \u0026amp; HS conceptualised the study and developed a research proposal; RJS conducted interviews and developed initial themes during the interview process, RJS analysed the data; MMM functioned as an independent coder to confirm and edit themes; MMM \u0026amp; HS supervised the study, RJS drafted the manuscript; MMM \u0026amp; HS provided critical feedback and revisions to the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eRJS is an nGAP Lecturer and PhD candidate at the Sefako Makgatho Health Sciences University. \u003csup\u003e2\u003c/sup\u003eHS is a professor at the University of Pretoria, department of Informatics and working as a head of department and deputy dean, her role in the study is co-supervisor. \u003csup\u003e3\u003c/sup\u003eMMM is a professor at the Sefako Makgatho Health Sciences University, department of Public Health and working as a head of department, her role in the study is supervisor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that they do not have any competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbdurahman C, Oljira L, Hailu S, Mengesha MM. 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South Afr J HIV Med. 2018;19(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMkhize SP, Maharaj P. Structural violence on the margins of society: LGBT student access to health services. Agenda. 2020;34(2):104\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAleshire ME, Ashford K, Fallin-Bennett A, Hatcher J. Primary care providers\u0026rsquo; attitudes related to LGBTQ people: A narrative literature review. Health Promot Pract. 2019;20(2):173\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMgopa LR, Rosser BS, Ross MW, Lukumay GG, Mohammed I, Massae AF, Leshabari S, Mkonyi E, Mushy SE, Mwakawanga DL. Cultural and clinical challenges in sexual health care provision to men who have sex with men in Tanzania: a qualitative study of health professionals\u0026rsquo; experiences and health students\u0026rsquo; perspectives. BMC Public Health. 2021;21:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurebwa J. Access to Healthcare Services by Lesbians, Gays, Bisexual, Transgender, and Intersex (LGBTI) People in Harare Urban, Zimbabwe. Global Perspectives on the LGBT Community and Non-Discrimination. edn.: IGI Global; 2022. pp. 1\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"LGBT, challenges, queer people, healthcare professionals, sexual reproductive healthcare services","lastPublishedDoi":"10.21203/rs.3.rs-4157361/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4157361/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eSexual and reproductive healthcare services and needs (SRHSN) are essential for improving overall health and well-being. Queer people face obstacles not just in obtaining and receiving SRHSN, but also in provisioning of these services by healthcare professionals (HCPs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In this article we have performed a total of 55 qualitative one-one interviews. Purposive sampling was employed to select all HCPs, and respondent-driven sampling (RDS) was used to choose all queer people. Data was collected in seven district public hospitals and two non-governmental clinics which focused on queer-related healthcare in Gauteng Province, South Africa (SA) and data was analyzed using thematic content analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult:\u003c/strong\u003e Six main themes emerged from the data demonstrating that HCPs and queer people had similar, contrasting, and different challenges when rendering and receiving SRHSN. These themes include HCPs belief that queer people are afraid, while queer people believe that HCPs have negative attitudes, and are perceived to be gatekeepers. HCPs highlighted being surprised and confused about gender identity, healthcare disparities and familial problems, and highlighted HCPs' incompetence in queer-related healthcare, and queer people engagement as a barrier.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion/conclusion:\u003c/strong\u003e Policies need to be strengthened to address and ensure inclusivity in the healthcare sector and the creation of new creative, including innovative, healthcare solutions to address SRHSN for queer people. This approach has the potential to bridge gaps and address difficulties confronting both HCPs and queer people.\u003c/p\u003e","manuscriptTitle":"The hurdles faced by individuals identifying as queer when seeking for and by healthcare professionals when providing sexual and reproductive healthcare services in South Africa.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-27 08:06:06","doi":"10.21203/rs.3.rs-4157361/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0bb301ad-65a2-491f-b4fd-db41bc38b1ec","owner":[],"postedDate":"March 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-20T11:12:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-27 08:06:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4157361","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4157361","identity":"rs-4157361","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}