Barriers and facilitators of post-violence help-seeking behavior among 21–49-year-old transgender women in Phnom Penh: A qualitative study

Abstract

Background: Transgender women are disproportionately affected by gender-based violence (GBV). However, little is known about how they respond to GBV.

Aims: This study aims to understand transgender women’s response to GBV and identify barriers and facilitators in accessing healthcare and legal aid after experiencing the violence.

Methods: We conducted a qualitative study between February to March 2020 in Phnom Penh, Cambodia. Data were collected through in-depth interviews with 20 transgender women aged between 21 and 49 who had experienced GBV or knew a peer who had experienced GBV. Thematic analysis was conducted for the coding process, and an inductive approach was used to develop a coding frame.

Results: All participants had experienced at least one form of GBV in their lifetime, and most participants had experienced multiple forms of GBV. However, most of them did not seek any services from healthcare providers, law enforcement officers, or assistance for healthcare and legal aid from non-governmental organizations (NGOs). Participants reported the following barriers to access to GBV services: anticipated stigma, the internalized stigma, which resulted in shame and low self-esteem, a lack of knowledge on NGOs’ services that can assist with healthcare and legal aid, the perception that mental health services were unavailable, a lack of social support, enacted stigma by the police, and the perceived healthcare cost. The participants reported social support and knowledge of NGOs’ services as facilitators of access to GBV service. Social media and NGO staff were reported to be preferred sources of information. Participants wanted more effective law enforcement services, comprehensive healthcare catered to the unique transgender women’s needs, and non-discriminating service providers.

Discussion: Interventions to address GBV and improve the health outcomes of transgender women should involve creating an enabling environment for help-seeking with the partnership between NGOs and different sectors and building social support.

Introduction

Gender-based violence (GBV) disproportionately affects transgender women all over the world. GBV is violence directed against a person because of the person’s gender (European Commission, n.d.). It can be in the form of physical, sexual, psychological, or economic violence (European Commission, n.d.). GBV also includes human rights violations, such as denying healthcare services and arbitrary detainment by the police (United Nations Population Fund et al., 2015).

GBV increases the vulnerability of transgender women to both physical and mental health issues. Transgender women are a key population who are 49 times more likely to have human immunodeficiency virus (HIV) than other adults of reproductive age (Baral et al., 2013). GBV contributes to their increased risk of HIV and sexually transmitted infections (STIs) (Baral et al., 2013; Maman et al., 2000; Nuttbrock et al., 2015). Causal pathways include limiting employment opportunities, leading to engagement in transactional sex and limiting access to HIV prevention programs, and affecting the ability to negotiate condom use (Baral et al., 2013; Maman et al., 2000; World Health Organization (WHO), 2014). Transgender women also have a higher prevalence of depression than the general population (Mustanski et al., 2010; Yadegarfard et al., 2014). A prospective study in New York found that GBV on transgender women was predictive of depressive symptoms with hazard ratios that ranged from 3.01 to 3.23 (Nuttbrock et al., 2015). In addition to depression, GBV increases vulnerability to anxiety and suicide (De Santis, 2009; Ganju & Saggurti, 2017; Wilson et al., 2016).

In a cross-sectional study of 1,375 transgender women in Cambodia, the prevalence of GBV in the past 12 months was 23.6% for physical abuse and 39.3% for sexual violence, and 24.8% reported fear of being arrested by authorities because of their transgender identity (Yi et al., 2018). The study also found that 45% of the participants had depressive symptoms, and participants who had depressive symptoms were significantly more likely to report GBV experiences (Yi et al., 2018). The same study revealed the HIV prevalence of 5.9% in the transgender population, which was 20 times higher than that of the general Cambodian adult population (Chhim et al., 2017).

Social and economic exclusion caused by GBV can also impede transgender women’s access to healthcare services as it negatively affects their inclination and ability to access them (Reisner et al., 2016; Winter et al., 2016). Moreover, anxiety disorders caused by repeated exposure to GBV can result in additional barriers to seeking healthcare (UNFPA et al., 2015). Their inability to access preventive, diagnostic, and treatment services often results in poor health outcomes (Reisner et al., 2016; World Health Organization (WHO), 2014; Winter et al., 2016).

GBV in transgender women is thus a public and global health issue. Addressing GBV involves preventing violence and providing support services for transgender women who have experienced violence (World Health Organization (WHO), 2014). However, in most countries, the response to GBV is inadequate. It is often underreported and improperly investigated and prosecuted (International Labour Organization et al., 2015). While GBV impedes access to post-violence healthcare, specialized post-violence services are few in most settings, particularly in low- and middle-income countries (UNFPA et al., 2015). Studies on how GBV on transgender women is being addressed and the post-violence help-seeking behavior of transgender women in Cambodia are scarce. Hence, we conducted this study with two main objectives: (1) to understand the help-seeking decisions that transgender women make after having experienced GBV and (2) to identify barriers and facilitators that determine their access and receipt of healthcare services and legal aid. This study’s findings would help us understand the obstacles transgender women face when seeking help and recommendations for policy and practice to address them in resource-limited settings.

Materials and methods

This study was exploratory and qualitative with an epistemological stance that was interpretative. Semi-structured interviews were conducted between February and March 2020 at Men’s Health Cambodia (MHC) in Phnom Penh. MHC is a local non-governmental organization (NGO), providing HIV, sexual and reproductive health, and legal aid services to men who have sex with men and transgender women in Cambodia.

Sampling

This study used a snowball sampling technique to recruit transgender women participants, a marginalized, hard-to-reach population. An MHC transgender woman staff informed others in the transgender women community about the study. Each participant enrolled in the study recommended a subsequent participant who met the inclusion criteria and was willing to participate in the study. We included individuals in the study if they: 1) were assigned male at birth and self-identified as woman, 2) were Khmer-speaking, 3) were at least 21 years of age and not older than 49 years old at the time of screening, 4) were able and willing to provide informed consent, and 5) had experienced GBV or known a peer who had experienced GBV. The exclusion criterion was a lack of consent for audio-recording of the interview.

Interview guide

The formulation of questions in the interview guide was guided by existing literature on GBV experienced by transgender women (Ervasti, 2015; Evens et al., 2019; Ganju & Saggurti, 2017). The interview guide was first developed in English and then translated into Khmer, Cambodia’s national language. We collected the following information: experiences with GBV, post-GBV actions, barriers and facilitators when seeking help, perceived benefits of help-seeking, perceived seriousness of GBV in transgender women community, perceived harms to physical and mental health that GBV can cause, and their recommendations on the types of services that would help them receive the support they need after experiencing GBV. We also collected socio-demographic data of the participants. The interview guide was piloted on one transgender woman before commencing data collection.

Data collection

Twenty audio-recorded, one-time, face-to-face, individual interviews were conducted in Khmer by a trained counselor (S. Eang). The interviewer provided the study information to participants before obtaining their verbal consent to audio-record and conduct the interviews. Then, the counselor collected their socio-demographic data and explained the definition of GBV before commencing the interviews started. Each interview lasted between 30 to 60 minutes, and each participant received US$5 to compensate for their time and transport. Fieldnotes with observations were documented by the Principal Investigator (PI) for each interview.

Data analyses

Recordings of the interviews were translated and transcribed in English. Transcripts were coded using QSR NVivo 12 software. We discussed possible cultural nuances in the translated transcripts. An inductive approach and thematic analysis were used for the coding process. (Braun & Clarke, 2006; Green & Thorogood, 2018). In the earliest coding stage, line-by-line analysis, a technique from grounded theory, was used to fragmentize the data. As analysis progressed, themes and sub-themes were derived. These were refined after discussions between investigators and colleagues. No new ideas or themes emerged during the analysis of the last few interviews. Hence, we determined that thematic saturation had been reached and ceased the participant recruitment.

Reflexivity

We explained the study background and protocol thoroughly to the interviewer before the interviews started. The PI was present for all interviews. As the PI did not understand Khmer, the interviewer paused at intervals during the interviews to briefly summarize what was being reported. These intervals were kept at a minimum, not interrupting the conversation flow between the interviewer and interviewees. Interviewees often expressed the impact of GBV on their mental health and frequently mentioned the lack of knowledge of available services as a barrier. Thus, questions that probed about participants’ knowledge of mental health services and preferred sources of information were some of the questions that were added to interviews.

Ethical considerations

The National Ethics Committee for Health Research (NECHR) of the Ministry of Health, Cambodia (015 NECHR) and the National University of Singapore Institutional Review Board (S-19-337) approved the study protocol and materials. Verbal informed consent was obtained from all interviewees. Participants were informed that they could withdraw from the study at any time or decline to answer any question if they felt uncomfortable with it. Interviews were conducted in a private room by a trained counselor who could counsel participants if they experienced distress while discussing traumatic experiences during the interview. We maintained confidentiality by removing all personal identifiers from study materials.

Results

Participants had an average age of 30.4 years (range 21 to 49 years). Table 1 shows the sociodemographic characteristics of participants. Most participants had attended or completed secondary education, and 75% reported not having a regular source of income.

Table 1.

Socio-demographic characteristics of participants.

Socio-demographic characteristics	n (%)
Age group
21-30	12 (60.0)
31-40	5 (25.0)
40-49	3 (15.0)
Education level
Primary or lower (0-6 years)	5 (25.0)
Lower secondary (7-9 years)	7 (35.0)
Higher secondary (10-12 years)	7 (35.0)
University or higher	1 (5.0)
Frequency of expression as female
All the time	8 (40.0)
Often	3 (15.0)
Sometimes	8 (40.0)
Rarely	1 (5.0)
Had regular source of income	5 (25.0)
Current occupation
Hairdresser/beautician	6 (30.0)
Sex worker	4 (20.0)
Seller	3 (15.0)
Non-Governmental organization staff	2 (10.0)
Other	5 (25.0)
Number of transgender women friends in social network
Does not use social media	4 (20.0)
0–19	2 (10.0)
20–49	8 (40.0)
50–100	3 (15.0)
>100	3 (15.0)

Participants described their and their friend’s experiences of help-seeking during interviews. The police, healthcare workers in public and private facilities, and staff in community-based non-governmental organizations (NGOs) were commonly reported as formal sources of help. Family, friends, and neighbors were commonly reported as informal sources of help. All participants had experienced at least one form of GBV in their lifetime, and 90% reported having experienced multiple forms of GBV at different times. However, 70% of participants did not seek any help after experiencing GBV. All participants said that GBV was unacceptable and that the law should punish the perpetrators. Most participants recognized the negative consequences of GBV on their physical and mental health.

We present our results under four main themes identified during the transcript analyses. The first theme discusses the anticipated and internalized stigma felt by the participants after GBV. The second looks at how the participants’ knowledge of available services influenced their help-seeking. The third examines the effect of social support on their help-seeking decisions. Lastly, the fourth theme discusses organizational factors that affect seeking and receiving help. In this paper, all quotes from the interviews with respondents will be identified by their interview number, age, and occupation. All participants referred to themselves as ‘TG’, which stands for transgender.

Impact of anticipated and internalized stigma

Anticipated stigma

Participants discussed their reasons for not seeking formal and informal help for GBV. Anticipated stigma was identified as a key barrier. Almost all participants stated that anticipated stigma, the fear and expectation of a stigmatizing experience (Overstreet & Quinn, 2013), was a reason for not seeking help. For some, the anticipated stigma was due to their experiences of discrimination from the general society. As one participant shared:

“We would be afraid by ourselves that they would discriminate against us. We used to hear the words that others said badly about TG. They said don’t trust those TGs.” (I-16, 31 years, flower seller)

Participants also described the anticipated stigma due to their previous negative encounters with the police and healthcare workers. Most of these negative experiences involved the police. One participant recounted the following:

“That’s why when I faced the problem, I hesitated to seek support from those policemen. Police officers used to insult us. Some police officers chased us violently even if we told them that we were waiting for our friends. They then drove our friend’s motorbike to the police office.” (I-1, 21 years, works in a massage parlour)

A few participants shared the perspective that they could only seek the police’s help if they knew the identities or location of their perpetrators. The perception that the police would only help when bribed was another barrier to help-seeking shared by a third of the interviewees. One interviewee replied the following when asked about the difficulties of seeking help:

“If I filed a complaint to the police, the problem would be bigger, and I would spend a lot of money… I need to spend to the police to process the case. I used to file a complaint at the police office, and I spent money on it.”(I-10, 22 years, dancer)

Internalized stigma

Most respondents appeared to have endorsed and accepted the negative societal attitudes toward themselves (internalized stigma) (Overstreet & Quinn, 2013). This was evident in reports of feeling shame and not wanting others to know about their experiences with GBV. One respondent had experienced sexual violence by a neighbor after she and her friends had followed him from Phnom Penh to a province. She explained the following when asked about why her violent experience was not reported to the police or shared with family:

“I felt scared and shy. I thought it’s because of us too that we followed (the neighbour) to the province, so (the neighbour) can do.” (I-15, 25 years, beautician)

Internalized stigma also appeared to cause low self-esteem and low self-efficacy to challenge discrimination. Despite stating that getting beaten was ‘crossing the line’, participants who experienced physical GBV reported that they did not make a police report as they perceived their injuries to be minor and did not want to make a ‘long story’. One participant who had a bleeding nose and bruises after being beaten by strangers noted the following:

“ First, I didn’t want to make a long story. Secondly, I thought it’s just minor violence.” (I-10, 22 years, dancer)

Knowledge of available services

Lack of knowledge of services that can assist with healthcare and legal aid

After experiences of GBV, many participants felt that they needed assistance to access and navigate healthcare and legal aid but did not know where to seek such assistance. A participant whom men had gang-raped shared the following:

“I: Why didn’t you go to healthcare at that time?

R: It’s because I didn’t have money and didn’t know where to go too.

I: Why didn’t you report to the police?

R: I didn’t know the perpetrator, so I didn’t know how to report to the police.” (I-3, 41 years, sex worker)

Participants shared that their lack of knowledge on available supporting services was a barrier to help-seeking. As one participant stated:

“It’s hard because I don’t know where to contact, and if we want to get the help, we need to have some money for them.”(I-18, 38 years, sex worker)

Services provided by NGOs

Respondents who sought an NGO’s help after experiencing GBV reported positive experiences. Services they sought mainly involved advocacy with police and linkages to healthcare, mostly to test for HIV. An interviewee who sought the help of an NGO after being beaten, verbally abused, and detained by the police reported the following:

“When the police arrested, the NGOs helped to release us. They were so helpful to help TGs…helped to coordinate with health care and…advised me to go by myself because my name already registered” (I-20, 38 years, sex worker)

Most participants who had learned about the HIV services provided by the NGOs said that they would seek these services if they experienced future sexual GBV. However, one participant indicated the perception that more healthcare services were needed for victims of sexual GBV. Despite knowing about the HIV health services available at NGOs, she shared that she would not seek such services if she experienced future sexual GBV. She explained with the following:

" Because it helps to offer only offering medicine and other sicknesses, not sexual abuse. I think they don’t help me who suffered sexual abuse.” (I-3, 41 years, sex worker)

Mental health services availability

Almost all participants noted how their mental health was affected to different degrees by their experiences of GBV. A respondent, who had experienced physical, sexual, and psychological GBV, shared the following:

“It affects my mental health. It makes me so scared of people. It seems like I have a mental health problem and always want to hide in the house. I don’t want to go anywhere.”(I-12, 49 years, trash collector)

Despite the effects of GBV on their mental health, none of the participants sought mental health services after their GBV experiences. Most participants did not associate the availability of mental health services with public or private hospitals. Many reported that they did not know where to seek such services.

Preferred sources of information

Most participants stated that they preferred to get information about helping services via social media and NGOs through peer educators and outreach workers. One participant explained the advantage of sharing information through the NGO network:

“Like some groups (of transgender women), they don’t use a network, if we spread out the information in the community, we can make them know. Spreading the information from the network, it’s good.” (I-19, 35 years, beauty salon staff)

Television was also a popular source of information for participants.

Importance of social support

Most participants stated that they had confided in their friends after at least one experience of GBV. Few participants reported confiding in a relative or a neighbor.

Friends as a source of information

Participants reported friends to have provided information on the need to seek healthcare and legal aid. One respondent, who confided in a friend after being raped by a group of men, shared the following:

“My friend advised me to go to health care to do a blood test because those perpetrators would have many partners.” (I-16, 31 years, flower seller)

Peers were also sources of information on finding support services like NGOs for healthcare and legal aid.

Emotional and legal support

Participants reported friends to be a source of emotional support after experiences of GBV. As one participant shared:

“I: You said your friend gets beaten after sex; did she seek any helping service?

R: She didn’t go for any helping services. We all just sat together and then each of us goes home. That’s all.” (I-17, 25 years, outreach worker)

Friends, relatives, and neighbors were also perceived as sources of support required for filing a police report. As one participant noted:

“If violence happens again, I would go for legal services. I’d go to the police office and ask my relatives to help fill the complaint form.” (I-7, 22 years, hairdresser)

A lack of support

Many respondents stated they could not seek help from their relatives or neighbors as they anticipated stigmatization. When one respondent was asked why her experiences of GBV were not discussed with family members with whom she lived, she explained the following:

“My family also discriminated against me. Others discriminate against me, and my family does too. I hide from everyone. I just tied up my long hair and wore a hat and dressed in a man’s jacket to not let them see me look like a girl.” (I-14, 30 years, sells coffee)

A few participants discussed how their fear of discrimination from people in their community affects their healthcare-seeking decisions. One participant observed:

“Sometimes TGs don’t want to go to public health care because there would be many people from the community and those who look down on us. So TGs who have the money go to private health care.” (I-19, 35 years, beautician)

Some participants reported that they experienced discouraging reactions from family and friends when discussing their GBV experiences. As reported by an interviewee:

“They said all of you go out and seek those men on the street that’s why they fight you” (I-17, 25 years, outreach worker)

Organizational factors that affect seeking and receiving help

Enacted stigmatization

Enacted stigma refers to discriminatory behavior against the stigmatized (Frank et al., 2018). Many participants recounted experiences of enacted stigma by the police when GBV was reported. Enacted stigma by the police presented itself in the form of inaction. One participant shared the experience of her friend, who was also a transgender woman:

“She was beaten and got injured. She wanted the one who beat her be arrested, but it was impossible. The case was closed. If she told the organization (NGO), it might be better.” (I-14, 30 years, coffee seller).

Another form of the enacted stigma involved victim-blaming by the police, as described by an interviewee:

“I reported to them about another police officer that beat me, while I was just standing at the park, and then they replied you deserved beating because you stand there and make the mess.” (I-8, 42 years, sex worker)

Cost and distance of healthcare

A third of the interviewees said they found healthcare expensive and did not seek healthcare after experiencing GBV due to the anticipated cost. Participants also reported that they anticipated discrimination from healthcare workers if they did not have sufficient money. As one participant noted:

“They don’t pay much attention to us when we don’t have money. They keep us waiting for them for so long.” (I-3, 41 years, sex worker)

Some participants reported that having a healthcare facility near their home made it easy to seek help. When asked about healthcare accessibility after experiencing GBV, an interviewee stated:

“The healthcare centres are near my place, so it’s easy.” (I-15, 24 years, beautician)

Services in need

Most participants expressed a need for more effective policies and legal actions. They requested to be protected by the law without discrimination. As an interviewee shared:

“I want them to protect us. I want justice. Police to protect us and not to protect those who hurt us.” (I-12, 49 years, trash collector)

Another participant spoke of police harassment:

“I want freedom, no police chasing and arrest us. I want equal rights and (not) look down and discriminate against us.” ((I-20, 38 years, sex worker)

A few interviewees reported that a hotline for help-seeking would be beneficial. Participants also stated that they wanted non-discriminating, comprehensive healthcare with services for mental health; testing and treatment for HIV, STIs, and other conditions; physical checkups; and thorough consultation with healthcare professionals. One respondent stated that she wanted a service catered to victims of sexual violence. A quarter of the interviewees said that they would like to have free healthcare available. Respondents also mentioned employment opportunities and assistance in securing jobs as essential supporting services for help-seeking after violence. A few participants also stated the need for clinics that were catered solely for transgender people. One of them said:

“Establish like a clinic because many TGs have weak health, and they get sick easily…the government health care providers are uncomfortable to go.” (I-19, 35 years, beautician)

Discussion

This qualitative study explored the barriers and facilitators transgender women in Phnom Penh encountered when seeking help after experiencing GBV. Participants recognized that GBV was unacceptable, and the law should punish the perpetrators. They were aware of the effects of GBV on physical and mental health. However, most participants did not seek help. Figure 1 summarizes the linkages of key findings in this study. Anticipated stigma, internalized stigma, and a lack of knowledge of available supporting and mental health services presented barriers for help-seeking. Participants who knew and sought services provided by NGOs reported positive experiences. Friends were an essential source of information and emotional support. Social support was perceived to be important for making a police report, and the lack of it discouraged help-seeking. Enacted stigma by the police and healthcare costs were barriers, while having a healthcare facility near home was perceived as a facilitator for help-seeking.

Figure 1.

Summary and linkages of key findings.

Several factors made seeking and receiving police assistance, legal aid, and healthcare an uphill task. The first was anticipated stigma. In addition to the pervasiveness of stigmatizing attitudes in society, participants also expressed anticipated stigma caused by their negative past experiences with service providers. Past discriminating behavior from service providers, including bribery and street harassment by the police, had resulted in distrust and fear of service providers. A research study in Cambodia by Schneiders and Weissman (2016) described similar findings, with about a third of their key population respondents reporting recent verbal harassment by the police. Approximately 8 to 10% reported having paid money to avoid harassment and arrest or get released from the arrest. Besides, 27% of the respondents in their study were afraid of accessing healthcare and legal services (Schneiders & Weissman, 2016).

After experiencing violence, participants reported feeling shamed and did not want others to know what happened to them. Feelings of shamefulness were also echoed by transgender women in other countries who had experienced GBV (Evens et al., 2019; Ganju & Saggurti, 2017). Stigma internalization, internalizing the devaluation of the transgender identity, can manifest in shame (Bockting et al., 2020). Internalized stigma has also been negatively associated with self-esteem (Austin & Goodman, 2017). Participants exhibited low self-esteem and self-efficacy to challenge violence as they reported an unwillingness to go through the tedious process of seeking police help. A similar association between stigma internalization and low self-efficacy has been described in an Indian study (Ganju & Saggurti, 2017). While participants in this study recognized that GBV was unacceptable, similar studies have found that some transgender women who experience violence accept it as a part of their life and do not seek help as a result (Evens et al., 2019; Ganju & Saggurti, 2017).

The inability to afford healthcare was also a barrier to help-seeking. Transgender women often live in poverty due to unemployment and other forms of economic marginalization caused by social discrimination (Winter et al., 2016). In this study, three-quarters of the participants reported not having a regular source of income. Participants felt that they had to have enough money when seeking healthcare to prevent discriminatory behavior by healthcare workers. At the same time, one difficulty in going to public healthcare facilities that had payment schemes benefiting the poor (Asante et al., 2019) was the anticipated stigma from community members whom they might meet there.

In this study, experiences of GBV affected the mental health of transgender women. However, they did not seek mental health care after experiencing GBV. The study participants did not know where to receive mental health care and generally did not perceive its availability in public and private healthcare facilities. In the 2014 Cambodia National Lesbian, Gay, Bisexual, and Transgender (LGBT) Community Dialogue, participants noted the lack of mental health services for LGBT people (United Nations Development Programme & United States Agency for International Development, 2014). Participants in that dialogue also recounted previous negative experiences with mental healthcare professionals who lacked expertise in LGBT issues and reported receiving unhelpful advice from counselors in their youth (UNDP & USAID, 2014).

Moreover, fear of public and professional discriminatory behavior has been documented as a barrier to accessing mental health services in Cambodia (Aberdein & Zimmerman, 2015). In addition to GBV, factors, such as loss of family and peer support due to gender transition, fear of inability to have an intimate and loving relationship, and social and economic marginalization, contribute to depression and other mental illnesses experienced by transgender women (Health Policy Project et al., 2015; Yi et al., 2018). Mental healthcare professionals must respond to their unique needs without discriminating against them. Transgender women have also been reported to value trans-competent care (James et al., 2016; Smith et al., 2014) and look for explicitly trans-inclusive facilities (Tettamanti, 2018). Anticipated stigma and the lack of mental health services catered to the unique needs of transgender women are probable reasons why mental health services were not perceived to be available in healthcare facilities.

Facing the challenges of help-seeking and experiencing shame and low self-esteem from internalized stigma may lead to a low self-efficacy to seek help and a feeling that they needed assistance from family, friends, and neighbors and support services offered by NGOs. Respondents who sought help from NGOs for advocacy with the police and linkages to healthcare reported positive experiences. This finding corroborates WHO’s guidelines, which detail that a community-based approach to service delivery can improve reach and acceptability for key populations (World Health Organization (WHO), 2014). The lack of knowledge of such supporting services proved to be a barrier to help-seeking. Social media, outreach workers, and peer educators were reported to be preferred sources of information. Similarly, another study involving female entertainment workers in Cambodia, an HIV key population, found that they were keen on receiving health information on their mobile phones and accessed their social media accounts daily (Brody et al., 2017).

Friends were an essential source of emotional and legal support after the experiences of GBV. Also, many participants perceived that help could not be sought from relatives and neighbors as they anticipated stigmatizing behavior. This finding supports other studies that found that transgender women often seek emotional and instrumental support from members of their social circle, particularly their transgender friends, due to the lack of familial support (Factor & Rothblum, 2007; Nemoto et al., 2011; Pinto et al., 2008). Thus, the health of transgender women can be influenced by their social networks (Clark et al., 2018). Social support is also important for the holistic wellness of transgender women, particularly their mental health (Budge et al., 2013; Nemoto et al., 2011; Pinto et al., 2008).

Similar to other countries (Evens et al., 2019; Ganju & Saggurti, 2017), many participants in this study, who sought help from the police, experienced stigmatizing behavior in the form of police inaction and victim-blaming. Police inaction increases the vulnerability of transgender women to GBV as it creates a context where violence against them is the norm and would go unchallenged (Ganju & Saggurti, 2017; World Health Organization (WHO), 2014). In addition, the police’s inaction and victim-blaming contribute to the anticipated stigma and internalized stigma felt by transgender women (Overstreet & Quinn, 2013). These findings suggest a need for the healthcare and law enforcement sectors to create an enabling environment for help-seeking so that GBV can be addressed for the well-being of transgender women. According to the World Health Organization (WHO),) (2014), service providers creating an enabling environment is essential for addressing GBV.

Implications for policy and services

Partnerships between different sectors linking advocacy, healthcare, and human rights are essential in addressing the needs of transgender women (Reisner et al., 2016). First, comprehensive health services should be made available and provided by trans-health competent, non-discriminating health professionals. The services include mental health services and post-violence care such as medico-legal documentation and post-exposure prevention and should be made explicitly trans-inclusive. Thus, integrating these services with the existing community-based HIV services that target transgender women would be cost-effective (Yi et al., 2018). Moreover, integrating the health services would allow better communication between different health professionals allowing for better care of transgender women (World Health Organization (WHO), 2012a).

There is also a need for sensitization training and training of the police on the human rights of transgender women and promoting accountability for rights-based policing (World Health Organization (WHO), 2013). Policies and mechanisms to report human rights violations such as GBV and discrimination by the police or healthcare providers are needed (World Health Organization (WHO), 2014). Community-based organizations can serve as a third party to help report complaints (World Health Organization (WHO), 2014). More initiatives, like the Police Community Partnership Initiative (PCPI) in Cambodia, which encouraged the police to link key populations to the necessary services instead of detaining them, can be set up (Schneiders & Weissman, 2016). In Cambodia, funding for non-communicable diseases, including mental health, remains limited. It limits the availability of mental health services. Stigma related to mental health exists in the Cambodian context. Transgender women have the additional burden of facing stigma related to their gender identity. Mental health services that are non-discriminating and catered to their unique needs are even more limited. These challenges make it difficult for transgender women to access gender-sensitive services.

Participants in this study appreciated the services by NGOs compared to those provided by the authorities. Community-based NGOs can have hotlines that link victims of GBV to trained peer counselors who can help them access legal, health, and psychosocial services (World Health Organization (WHO), 2012b). In this study, social media, outreach workers, and peer educators were the preferred sources of information for transgender women. These platforms can be used to inform transgender women about the available services. The Mobile Link project in Cambodia aimed to connect female entertainment workers with HIV services using text and voice messages, which would link them with outreach workers (Brody et al., 2018). Similarly, social media can connect transgender women with outreach workers and peer educators, who can inform them about and help them access available post-violence services. Participants also mentioned the influence of their friends on their help-seeking behavior and the lack of family support. NGOs can form support groups for transgender women to compensate for the loss of familial support and give them opportunities to network and build their social support (Nemoto et al., 2011; Torres et al., 2015). These support groups can also be a source of empowerment for transgender women who have accepted GBV to be part of their lives.

Study limitations

This study has a few limitations. Firstly, it focused only on transgender women aged 21–49 years living in Phnom Penh; hence, the generalizability of the findings to transgender women younger than 21 and older than 49 living in other parts of Cambodia is limited. Second, there is the possibility of recall bias, especially when participants described early experiences of GBV. Recall bias was minimized by having an experienced interviewer who used prompts effectively and gave participants sufficient time to recall their past experiences. Third, recruitment originated from an NGO; thus, recruited participants might have more contact with NGOs than transgender women in the general population. We addressed this limitation by comparing study findings with other sources of information to check for data convergence to support the study findings. Fourth, GBV is a sensitive subject, and participants may not have felt comfortable discussing their GBV experiences in detail. Having an interviewer who was a trained counselor helped address this limitation as he developed a rapport and made respondents feel more at ease and open to sharing.

Conclusions

This study found that transgender women in Phnom Penh often do not seek healthcare and law-enforcement services after experiencing GBV. This study also indicates that multiple individual, interpersonal, and organizational factors intersect to make help-seeking an uphill task for transgender women. Thus, GBV on transgender women often goes unchallenged, and transgender women do not receive the healthcare and protection services they require after experiencing GBV. Addressing GBV on transgender women is important for improving their health outcomes and overall well-being. Partnerships between community-based NGOs and the healthcare and law-enforcement sectors can be created to establish integrated, transgender women-tailored interventions to create an enabling environment for help-seeking. Interventions to build social support are also needed as it is a key facilitator for help-seeking.

Funding Statement

Saw Swee Hock School of Public Health, National University of Singapore, supported this study as part of the first author’s Master of Public Health programme and through UHS-SSHSPH Integrated Research Programme (USIRP).

Conflict of interests

The authors declare that they have no conflicts of interest.

Ethics approvals

The National Ethics Committee for Health Research (NECHR) of the Ministry of Health, Cambodia (015 NECHR) and the National University of Singapore Institutional Review Board (S-19-337) approved the study protocol and materials.

Informed consent

Verbal informed consent was obtained from all participants in the study.

Data availability

Data are available upon reasonable request. Data used for this study can be accessed upon request from the corresponding author (SY) at ephsyi@nus.edu.sg.