Evidence of interventions for improving healthcare access for lesbian, gay, bisexual and transgender people in South Africa: A scoping review

Background The lesbian, gay, bisexual and transgender (LGBT) populations have unique health risks including an increased risk of mental health problems, high usage of recreational drugs and alcohol, and high rates of infection with human immunodeficiency virus (HIV). Healthcare workers’ heteronormative attitudes compromise the quality of care to the LGBT population. Aim The objective of this study was to provide an overview of documented evidence on South Africa interventions aimed at improving healthcare access for LGBT individuals using a systematic scoping review. Setting This is a secondary literature review. Methods An electronic search was conducted using the following databases: EBSCOhost, PubMed, Cumulative Index to Nursing and Allied Health Literature, and Google Scholar. Abstract and full article data were screened using inclusion and exclusion criteria by two researchers. Data extracted from the eligible studies were analysed using thematic analysis. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool, version 2011. Results Seventeen articles of the initial 151 hits were selected for review and an additional five files were identified through bibliographical search. Most studies had small sample sizes and focused on sexual health, targeting gay men and men who have sex with men in urban areas. Lesbians and bisexual women were not prioritised. Discussion It emerged from the review that LGBT issues were not covered in the healthcare worker curriculum. Further it was noted that there is a paucity of data on the South African LGBT population, as sexual orientation does not form part of the routine data set. The findings of this review indicate gaps in the literature, practice guidelines and policies in LGBT healthcare in South Africa.

representation. 12 Sexual orientation signifies the enduring pattern of sexual, romantic, physical and/or spiritual attraction. The terms lesbian, gay, bisexual and transgender are defined as follows: Lesbian denotes a woman attracted to other women; gay denotes a man who is attracted to men; bisexual denotes a person who experiences sexual, romantic, physical attraction to both men and women. 12,13 Transgender is an umbrella term used widely to refer to a diverse group of individuals whose gender identity and expression diverge from culturally defined categories of gender, or denoting gender that does not conform to societal gender norms. 14,15 Studies indicate that sexual and gender minorities face stigma, neglect and harassment in the hands of HCWs, who justify the poor treatment of the LGBT population using political, moral or religious beliefs to explain their behaviour. 16,17,18 Consequently, the LGBT populations avoid healthcare facilities because they perceive health spaces as unsafe. 19 In addition, this results in the LGBT populations experiencing increased risk of morbidity and mortality from preventable infections and cancers as they forgo health checks because of the hostility. 20 Furthermore, the LGBT populations are reported to have an increased risk of alcohol and substance abuse, as well as mental health disorders, and are disproportionally affected by HIV infection. 21,22,23 South Africa's National Strategic Plan on HIV, STIs and TB 2017-2022 recognises the LGBT populations as at high risk for acquiring HIV. 24 The documented risks among the LGBT populations are not properly addressed nor managed. 16 The main barriers contributing to this gap in quality care is that the HCWs are taught little or nothing about the unique aspects of LGBT health pre-and post-service. 6 This is evident in the incompetency and lack of understanding of LGBT sexual health among the South African health workforce. 3,16 Research on the South African LGBT population is sparse; the majority of research in LGBT populations is conducted in developed countries and thus does not align with the South African context. 8,19,25 Finally, there is a lack of accredited courses on sexual health in South Africa. 6 Currently, data on South African LGBT populations are limited. 26,27 For example, sexual orientation and gender identity data are not collected in population surveys or the national census. 9,28 The paucity of data on LGBT populations makes it difficult to plan evidence-based LGBT-targeted health programmes and to properly estimate the required resources for such programmes. 29 This calls for introduction of an innovative, inclusive and respectful approach to collect data on sexual orientation and gender identity in the health care facilities. This will prevent misclassification, which can result in inappropriate medical care, and advise. Approaches such as inclusion of sexual orientation and gender identity information in the health surveys and census data to learn more about the demographics. 30 Privacy may be maintained by using electronic data collection tools that will allow individuals to remain anonymous. The aim of this study is to map evidence of interventions for improving healthcare access for the LGBT populations in South Africa in order to identify areas for primary research and to help guide contextspecific health policy development and practice guidelines for LGBT populations.

Research question
Is there evidence relating to LGBT health interventions in South Africa?

Objectives of the review
The objective of this review was to map the literature reporting on LGBT health interventions in South Africa.

Identifying relevant studies
To identify studies relevant to the mapping of interventions that seek to improve LGBT health access in South Africa, we conducted a comprehensive literature search on articles published between 1996 and 2016. Various databases (EBSCOhost, PubMed, Google Scholar and the Cumulative Index to Nursing and Allied Health Literature [CINAHL]) were searched using the following key terms: lesbian, gay, bisexual and transgender health; sexual and gender minorities; LGBT in South Africa; LGBT and health in South Africa.
Two reviewers were responsible for the search and collectively designed the data-chronicling form, shaped according to the population, interventions, comparison and outcome (PICO) criteria. The search was limited to articles written in English and to studies based in South Africa. In the search, primary research studies, systematic reviews, letters and guidelines that address LGBT health issues in the South African context were included. The articles were then scanned for additional studies that were not identified by the search.

Study selection
A comprehensive search of literature on the EBSCOhost, PubMed, Google Scholar and CINAHL databases was done based on our PICO inclusion and exclusion criteria. Literature search results were loaded to the EndNote (version 7) library. Two independent reviewers screened the titles and the abstracts against the inclusion criteria. All the titles and abstracts that met the inclusion criteria were selected, and full text reports were drawn. The reviewers screened the full reports for eligibility and meeting the inclusion criteria. The study selection process tracked the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (see Figure 1). 32

Data extraction
The reviewers utilised a data-chronicling form to determine text words, variables and themes for inclusion and extraction to answer the research question (see Table 1).

Keyword search
Boolean expressions (including and/or) were employed in combinations of the following keywords and phrases: lesbian, gay, bisexual and transgender health; sexual and gender minorities; LGBT in South Africa; LGBT and health in South Africa.

Data collating, synthesis and summarising results
Six steps were undertaken to enable data collating and synthesis and to summarise the results of the scoping review. Firstly, researchers carried out thematic content analysis of the included studies using NVivo. Secondly, the two researchers independently coded the studies on LGBT people to find evidence of themes in literature on LGBT health.
Thirdly, once the coding was complete the researchers met to synthesise the results and the codes, linking them to the scoping review objectives. Fourthly, data chartering was conducted, which involved documenting demographic data about the studies, the authors, study methods and design, including the number of participants and study setting. Fifthly, coded articles were themed on the topics and the focus covered in relation to the interventions relating to healthcare access for the LGBT populations. Finally, researchers met to collectively interrogate the studies and review how the identified themes linked to the aim of the review.

Ethical considerations
Ethical clearance was not required as this study used secondary desktop data.

Results
The initial search resulted in 151 references, with an additional five files found through scanning references of the extracted studies. Figure 1 provides an overview of the search and selection process. Ultimately, 17 articles were selected for this review. Table 2 gives an overview of the articles and the key findings using the following headings: author and year of publication; study methods and design; study population; aims of the study; key findings including recommendations.
Of the 17 references, three were systematic reviews, 33,34,35 two were qualitative studies, 5,20 three studies used quantitative methodology 8,37,38 and two triangulated the results using mixed methods. 42,43 An additional five studies were identified that were editorials, 7,17,39,40,41 and there was one grey literature article published on an organisation website. 4 Most studies focused on sexual health (n = 6), with specific focus on men; there was only one study on women having sex with women (WSW) and one on transgender women. The sample sizes ranged from 22 to 1045. All the quantitative studies were based on respondent reports, and none of the studies were longitudinal.
The Mixed Method Appraisal Tool (MMAT) was used for quality assessment of the included studies. 44,45 In this study, all relevant studies were appraised in terms of methodology and quality using the MMAT checklists from appraisal outcomes, and motivation for decisions was kept for audit purposes. A second reviewer was asked to perform an independent appraisal of the selected studies.

Analysis
Three main themes emerged from the scoping review: the South African terminology of LGBT, South African HCW skills, data and policies.

South African terminology: Lesbian, gay, bisexual and transgender, men who have sex with men and women who have sex with women
Most of the studies (n = 7) did not categorise the participants as lesbian, gay or bisexual, according to sexual orientation,   Investigate healthcare experiences of lesbian and bisexual women in Cape Town, to understand how they experience healthcare, where and how they access sexual health information and the recommendations they may have for the healthcare facilities to be more inclusive.
Mixed results were found: women who accessed care at private facilities reported good interactions with HCWs, while those using government facilities were stigmatised and subjected to religious teachings. Homophobia or heteronormativity in the private sector was attributed to individual clinicians, while in the public sector it was attributed to the health system; all groups noted lack of sexual health information targeted at sexual minorities, healthcare facilities must provide more inclusive sexual health resources as this will improve the visibility of LGBT people in health facilities. Lack of HCW skills on sexual health also emerged.
The participants suggested that HCWs should be trained on LGBT and comprehensive sexual health training and additionally have targeted patient education information and protective devices for safe sex. The women felt it would beneficial to have LGBT HCWs.
Muller (2013)  Only 10 academics, of the 93 who responded, taught LGBT-related topics for medical students. There was no structured curriculum to teach LGBT issues within all health disciplines. The knowledge, attitudes and practices of the medical students were not explored as part of the lessons. In disciplines such as the allied health professions and nursing, LGBT issues didn't feature in their curriculum at all. It is of concern that even in the post-basic nursing curriculum, there was no content on LGBT health issues. Despite covering LGBT issues in the MBCHB curriculum, there was no formalised practical approach to assess the skills of students on LGBT issues.

Recommendations:
LGBT-related topics need to be incorporated into the health worker curriculum in order to equip students to provide competent care to LGBT patients. The study aimed to highlight the disregard of WSW in the South African HIV response, through a survey of PLWHA same-sex behaviour.
The results indicated that 11% (72) of the HIV-positive women surveyed reported sex with another woman, and 21 of the 72 indicated they were married to men. A proportion of the 72 women further indicated they engaged in both vaginal (44%) and anal (22%) sex without condoms. The above responses confirmed that although the women occasionally or regularly had sex with women, they also engaged in sex with men. Sexuality transmitted infections were reported by 76% (55) of the women.

Recommendations:
Research organisations should conduct large-scale research that can be used to influence modification in public policy on the responses and programmes to cater for WSW's risks for HIV and AIDS.   34 ; MSM population in the studies indicated they were attracted to both sexes. In a study by Sandfort and associates, 12.2% of 1045 participants indicated they were attracted to both men and women. 37 Similarly, in the study by Cloete among 75 HIV-positive women, 21 of the women stated they had sex with women but were either married or in long-term heterosexual partnerships with men. 36 Dlamini and associates argue that in the South African context, people who engage Gender nonconforming individuals (n = 80) The study aimed to learn about the sexual health and practices of transgender people with the purpose of informing the development of new interventions or the adaption of existing evidencebased interventions to meet the unique HIV prevention needs of transgender populations.
Transgender people face barriers because of stigma, discrimination, abuse and unprofessional behaviour of HCWs when accessing healthcare services in SA public health facilities. Participants noted lack of skills and knowledge of HCWs in relation to LGBT health needs. The participants indicated that HIV risk factor health messaging was not relevant to their needs and noted a scarcity of safer sex protective devices (condoms, lubricant and pre-exposure prophylaxis) in state facilities. The transgender participants tabled various sexual practices with partners, including transactional sex and sex under the influence of alcohol and drugs. It also emerged that the transgender participants may be bisexual, homosexual or heterosexual. Recommendations: Healthcare workers should be trained on sensitivity towards the transgender population to be able to provide affirming health services. Further, the informational materials provided by HCWs in health facilities needs to be adjusted to cater for all individuals and take into account diversity of gender presentation; HCWs must be sensitive and use appropriate pronouns to demonstrate respect.
Note: Please see the full reference list of the article for more information.
LGBT in same-sex relations do not necessarily identify as gay, as they will still have heterosexual relations, get married and have children in keeping with social norms. 46 In South Africa, black people are not labelled according to sexual desires, as the expectation of procreation and marriage is paramount; same-sex sexual activity is ignored as long as there is marriage and reproduction to maintain the family name. 47 Thus, the LGBT label may not essentially be appropriate in defining the South African MSM and WSW and gender non-conformity; rather the terms MSM and WSW are more suitable. The definition of these terms is important for HCWs to bear in mind when taking sexual history, to enquire about sexual behaviour and partnerships rather than the LGBT label. 4 When a sexual history is taken from a transgender patient, sexual orientation should not be linked to the gender assigned at birth, nor gender identity, but must be confirmed with the particular transgender individual, to be able to assess the risk factors and offer relevant safer sex resources and messaging. 4,48 Reproductive and contraceptive care must be part of the services offered to the transgender population, as there is a risk of unplanned pregnancy in transgender men engaging in unprotected receptive vaginal sex with men. Literature reports on unplanned pregnancies among transgender men, even while on exogenous testosterone. 49 Absent from the studies are WSW and women who identify themselves as lesbians; little attention is paid to their HIV risk. The main focus is on MSM, yet there is evidence that WSW are also at risk of being infected with HIV and also face increased risk of mental illness, obesity and substance abuse. 36 The National Strategic Plan (NSP) for HIV, tuberculosis (TB) and sexually transmitted infections (STIs) is also silent on WSW and women who identify as lesbian. The absence of WSW in the literature may be a result of societal homophobia and patriarchal views and an effort to correct same-sex behaviour in women. 30,36 Four studies were on the transgender population; one study examined sexual health needs in grey literature, commissioned by a non-governmental organisation, which focused on the transgender population, and one literature review described the transgender woman. 4,7,35,39 Two other documents found were editorials, highlighting lack of facilities for the transgender population. In the South African context, there are limited facilities to cater for the transgender population, 4,7 which is subjected to stigma and discrimination not only in the public health sector but also in the private sector, as most medical aid companies exclude transgender care services and deem them cosmetic. 39 International studies indicate that transgender women are at high risk of HIV, with a possibly similar situation in South Africa. 14,50 Transgender individuals may have an increased risk of HIV infection because of a range of factors including poor access to employment, thus partaking in transactional sex. 14 Further, transgender women may engage in unprotected receptive anal and oral sex, as this could be understood as affirming their female gender; conversely, this practice increases their risk of contracting HIV. 14,51 South African healthcare worker training on lesbian, gay, bisexual and transgender issues Results indicate that South African HCWs are not equipped with training to deal with LGBT health issues preservice and in service 8,40 ; as a result they lack sensitivity and exhibit various degrees of homophobia towards LGBT populations. This leads to the LGBT populations being isolated. Homophobia is defined as rejection, fear and irrational intolerance of same-sex individuals. 52 The LGBT population reports being subjected to religious teachings, verbal abuse, micro-aggressions and sometimes being denied care by HCWs. 5,16,20 The poor treatment of LGBT populations alienates them from accessing healthcare facilities, and they tend to attend health facilities only when complications have set in and it becomes an emergency. 4,17 Nonetheless, if LGBT people do attend health facilities on a regular basis, it is highly possible that they do not disclose their sexual orientation; as a result they are treated as heterosexual, thus missing the opportunity to care for specific risk factors and related health screening. 20

Lesbian, gay, bisexual and transgender policies and guidelines for care in South Africa
The South African constitution has proclaimed the right to healthcare for all South African citizens. 1 The South African healthcare system has not developed polices and practice guidelines to support LGBT people within the public health sector. 34 Specialised relevant healthcare services that target the needs of LGBT populations are limited; available resources are constrained, limiting health access to the LGBT populations. 5,6 Data on the LGBT utilisation of health facilities is limited, because data is not collected as part of the Department of Health data set, nor is it collected as population data. 9 Thus prevalence of HIV among the South African LGBT populations is not documented, because sexual orientation data is not collected on large-scale, population-based HIV prevalence surveys and censuses. 35 The few studies conducted on LGBT populations in South Africa have small sample sizes and were conducted in urban areas, disadvantaging the LGBT population in rural areas. 5,27,41 The lack of data on South African LGBT populations means that designing programmes and developing related policy guidelines is a challenge. 29 Documents such as the NSP for HIV, TB and STIs do identify LGBT, lesbian, gay, bisexual and transgender.
the LGBT population as being at risk; an improvement is noted in the 2017-2022 plan, outlining supporting strategies to mitigate the risks identified. 53 Figure 2 is a self-developed diagram representing the key themes. The LGBT populations have poor access to health services because of lack of information and skilled HCWs. Lack of data contributes to a paucity of policies, and stigma and discrimination by HCWs alienate LGBT individuals from health services.

Discussion
The South African government has developed a constitution that is exceptional as far as human rights are concerned, granting rights to all South African citizens, including minority groups such as the LGBT population. However, implementation of the proclaimed rights has been found wanting.
Interventions are required, such as education of HCWs on LGBT care at an early stage of their careers and reinforcement at regular stages, to prepare HCWs to treat patients with professionalism and in a non-judgmental way. 8,40 Further, healthcare interventions must focus not only on the diagnosis and treatment of illness but also on health promotion to empower LGBT clients to become advocates for their healthcare. 11 Evidence indicates that HCWs are not well trained to deal with LGBT health issues, resulting in a lack of professionalism, demonstrated in poor attitudes towards the LGBT populations. In a study conducted in Kenya, a multidisciplinary team of HCWs was taken through 2-day sensitisation training on LGBT health issues followed by group discussion. Pretraining evaluation was conducted on knowledge and attitudes towards the MSM population.
Post-training evaluation was carried out after 3 months and results reported improved knowledge of LGBT issues, correlated with reduced homophobic scores. 55 This is an indication that improved health knowledge of HCWs on LGBT issues is likely to improve attitudes towards the LGBT population. Once HCWs are skilled on LGBT health issues, they are likely to conduct research and develop evidencebased care related to the South African LGBT population. 16,54 It is apparent that there is a need to develop LGBT terminology relevant to the South African context and settings in view of the cultural nuances, inclusive of the rural population. The appropriate terminology will facilitate proper history taking and allow development of relevant sexual health messaging. The LGBT populations are grouped in this scoping review, yet it is a diverse population with specific health needs and risk factors. It is important to study each subgroup individually. 29,55 The scoping review indicates a paucity of information and interventions for WSW and transgender populations. More studies are required to understand the risk of WSW in acquiring HIV; this group needs focus in research, as their exclusion in HIV research suggests they are not at risk of HIV. 5 In worldwide studies the transgender population is identified as being at high risk of HIV infection and are duly mentioned in the NSP as part of the high-risk group. 24,51,53

Limitations of the study
The literature is limited to studies published on South African LGBT populations and in English; studies in other languages have been omitted. Studies that may report on health-related LGBT issues in search engines outside of the health field were excluded. Only studies on LGBT issues from South Africa were used, possibly missing relevant issues relating to the LGBT population.

Conclusion
The results of this scoping review indicate there are limited interventions targeted at the LGBT population. Failure to include sexual and gender minority health as part of the South Africa HCW training curriculum contributes to the neglect of LGBT issues, thus unconsciously limiting the production and circulation of knowledge on the sexual and gender minority population, as HCWs are not socialised to the LGBT population as they enter the various health professions. 6,16 Research has shown that early career exposure of HCWs to LGBT patients increases clinical confidence and results in better patient experiences. 18,56 Another possibility is that the key opinion leaders and policymakers have deliberately suppressed the production of knowledge and discussion of LGBT issues within the health system, to endorse the hegemonic view that instils the notion that all patients are heterosexual and cisgender. 18 This renders a subset of society invisible, unseen and unheard; if they do speak up, they are often disregarded or punished at a macro level through lack of data and provincial policies and at LGBT, lesbian, gay, bisexual and transgender; HCW, healthcare worker. micro facility level through HCW and population microaggression. 20,34,57 There is a pervasive societal argument that sexual and gender minority is un-African, thus silently punishing those who transgress this view and relegating them to the margins. 46,58 It is documented that LGBT populations experience a high risk of HIV acquisition. 26,27,34,36,59,60,61 Despite the known risks, there is limited data on LGBT health and health policies to guide care, and this creates difficulties for the development of programmes that target the specific LGBT populations, as well as monitoring and evaluation of such programmes particularly in the areas of HIV care and prevention. Furthermore, there is a need for research on LGBT health, with all the subgroups studied independently as their needs and risk factors are diverse. 55 Additionally, a qualitative study on HCWs is recommended to gain understanding of what drives the observed behaviour and attitudes towards LGBT populations. Engagement of LGBT populations on their experiences, views and expectations from the health services would be valuable to guide practice.
It is important to include data on the sexual orientation and gender identity of patients who utilise the healthcare facilities; this will aid in planning and programme development, particularly for STI health programmes.