One could almost see Regerlee Letsapa smiling as she declared on the other side of the sometimes patchy WhatsApp call: “I have made a year now on hormones.” A transgender woman, the 31-year-old started her hormone replacement therapy in May 2019 after years of what she describes as “a lot of difficulties”.
“Before I was on hormones … I couldn’t come to terms with who I am. Things were not going well with myself. I didn’t know what to do. I was even considering suicide. But in the end I did make a turnaround and told myself I need to seek help. So I went to the psychologists here in Kimberley I could get help from [and they] referred me to an endocrinologist at Bloemfontein Universitas hospital.”
From her home in the township of Galeshewe in the Northern Cape, Letsapa would make the two-hour journey to the facility for her prescription, which lasts six months. But her appointment scheduled for the first week of May was postponed to September because of the outbreak of the Covid-19 pandemic.
“I think I will not meet September,” Letsapa said, referring to her dwindling supply of hormones. “I am supposed to be taking 2.5mg a day, but I’m rather taking 1.25mg to try and make it stretch. So I’m not taking my usual dose. But even so, it will only last a few weeks. The thing is, I am sad about it. Really. I’m worried.”
Letsapa is in a position in which many transgender people throughout South Africa currently find themselves, particularly if they are poor and living in rural areas or provinces that do not offer gender-affirming healthcare.
The transgender health and advocacy organisation Gender Dynamix (GDX), a non-governmental organisation (NGO), defines gender-affirming treatment as “medical treatment and procedures such as cross-gender hormones, gender-affirming surgeries etc, which a transgender person can choose to undertake in order to make their bodies congruent with their gender identity”.
Not all transgender people feel the need to undergo gender-affirming treatment. But for those who do, the incongruence between their physical and real genders can lead to gender dysphoria – a conflict between their physical gender and the gender with which they identify. This, in turn, can lead to depression, anxiety and suicide.
Bad situation made worse
In South Africa, gender-affirming treatment is only available in Gauteng, the Western Cape, Eastern Cape, Free State and KwaZulu-Natal. “What happens is that, ordinarily, people from rural areas or provinces where gender-affirming care is not available would travel to the cities to access it,” said Anil Padavatan, GDX’s health advocacy coordinator. “But because basically everything in the healthcare system has been upended to deal with the Covid-19 crisis, accessing doctors and just getting information has been very difficult for a lot of people.
“The lockdown has really made the existing problems of access to gender-affirming healthcare even worse. All surgeries have essentially been cancelled for now, to be rescheduled at a later stage. So you can imagine the psychological impact of that – where you once had certainty and then had that certainty taken away.”
Padavatan gave an example: “A friend of mine was due to start hormone therapy … but then the lockdown was announced. He had a choice then of being locked down in Gauteng, where he would be able to access the medical treatment but be for a prolonged period without his family, or go into lockdown in another province with his family.
“He chose to be with his family … and he is experiencing a great deal of ongoing gender dysphoria. He has a very upbeat personality, but this has really knocked him because he has been through so much to get to the point of getting ready to start treatment. Everything was on track and now it is back to uncertainty.”
At 48, Padavatan, who jokingly describes himself as “like, the oldest trans man in South Africa”, has first-hand knowledge of the importance of being able to access this kind of treatment. “I had recurring episodes of depression basically my whole life. It started when I was a teenager. I’ve been on hormone treatment for a year now and, since starting it, this is the first time in my life where I’ve felt that depression completely lift.”
Switch the channel
In an attempt to prevent other trans people from suffering the mental health effects of not being able to access hormone treatment, GDX is calling for a broader adoption nationally of telemedicine, especially now, during the lockdown, but also in the future.
In a 2010 report by the World Health Organization, telemedicine is defined as the delivery of healthcare services “where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation”.
The report noted that telemedicine benefits communities that traditionally have been underserved, such as those in remote or rural areas with few health services and staff. It also holds “important socioeconomic benefits for patients, families, health practitioners and the healthcare system, including enhanced patient-provider communication and educational opportunities”.
Mindful of the lockdown’s negative impact on medical facilities in South Africa, Padavatan said: “With the number of [Covid-19] cases due to increase, hospitals will be really busy and dealing with emergency cases. Healthcare facilities are also high-risk areas for people to possibly contract the virus. In this situation, you don’t want people going into healthcare facilities unnecessarily. On the other hand, we don’t want people not being able to access healthcare.”
Fortunately, he said, some doctors have been able to set up telemedicine services and do online consultations, but they are few and far between. One of them – and “one of the heroes in all of this” – is Johannesburg-based general practitioner Dulcy Rakumakoe, who is also the CEO of the Quadcare group of medical centres. “From the outset, our practice has been about offering quality healthcare to everyone,” she said.
“I’m queer myself and I’ve seen what issues of access to healthcare looks like from the time I was a student. I saw how, as a lesbian, you would go to a doctor and how you would be treated once you disclose what your sexuality is – where sometimes the focus of the doctor changes completely from what you came for to your sexuality, even if it is not related to what you are there for, you know?”
Breaking down resistance
Prior to the outbreak of the coronavirus locally, offering telemedicine services was “something we had thought about, but the biggest issue was the regulations from the Health Professionals Council of South Africa [HPCSA] frowning upon telemedicine”, she said.
In a statement issued by the regulatory body in March, it relented somewhat and said that while “the National Department of Health’s e-Health Strategy South Africa … specifically refers to telemedicine as ‘a tool that could bridge the gap between rural health and specialist services’ … the HPCSA does not regard telemedicine as a replacement for normal ‘face-to-face’ healthcare but an add-on meant to enhance access to healthcare for South Africans who are disadvantaged and outside of the health services reach such as specialists”.
“I think the Covid-19 era has forced even the regulators to relook at [their restrictions] and open things up a bit more,” said Rakumakoe, who now does online consultations at R200 per session, down from the regular price of R300. Once the consultation is completed, the necessary prescription is sent “either to the patient or directly to a pharmacy of their choice”.
This, said Rakumakoe, is “a very much needed service, especially if you think about what Covid-19 has taught us about the spreading of infections when we are in close proximity to one another. So if people can find other ways of accessing services without physically going to a facility, it will also help a lot in managing the spread of some infections or illnesses.”
Padavatan added that GDX’s fledgeling push for the broader adoption of telemedicine will take considerable buy-in from others. “Obviously, as a small NGO, we can’t do this on our own. We are looking for funding and partners to see how we can set this up, firstly, as an emergency response.
“But secondly, even once we have managed to get the Covid-19 pandemic under control and it’s not a massive factor anymore, we will still be sitting with the problems of access we have been facing for all these years as the trans community.”
It is, however, not only trans communities that are likely to benefit. Said Padatavan: “We see this as a potential way of really relieving the burden on all state clinics and hospitals.”