Barriers to Gender-Affirming Care, Health Care Services, and Experiences of Health Care Provider Bias Among Transgender People in Nigeria

Abstract

In the current study, we explored barriers to accessing gender-affirming care among transgender and gender-diverse (TGD) people in Nigeria. Between February and September 2021, we conducted focus group discussions with 25 adult TGD individuals residing in Nigeria. We found (1) a lack of trans-competent health care providers, (2) high medical costs, (3) limited access to accurate health information, (4) experiences of transphobia, and (5) a lack of trans-specific programming. Health care services that cater to the unique needs of TGD people in Nigeria are needed. (Am J Public Health. 2025;115(8):1231–1235. https://doi.org/10.2105/AJPH.2025.308057)

In sub-Saharan Africa, the health of transgender and gender-diverse (TGD) populations—individuals whose current gender identity or gender expression do not align with their birth-assigned sex—remains largely understudied.^1–3 In Nigeria, sexual- and gender-minority (SGM) communities experience stigma, violence, and discrimination, which might hinder access to health care services. Previous work has demonstrated that access to gender-affirming care (GAC) improves the mental health and well-being of TGD populations.^4–7 However, the health care experiences of the TGD population in Nigeria remain understudied.

STUDY OBJECTIVE

To characterize barriers to accessing GAC among TGD in Nigeria, we carried out a qualitative study that explored (1) barriers to GAC services, (2) health care experiences of TGD populations, and (3) health care providers’ (HCPs’) bias.

RESEARCH QUESTION

What are the barriers to accessing GAC, including negative experiences in health care settings and HCP bias, among TGD in Nigeria?

PARTICIPANTS, SAMPLE, GEOGRAPHIC LOCATION, SETTING, AND YEAR OF STUDY

Between February and September 2021, we conducted three focus group discussions with 25 TGD individuals. The participants, recruited through convenience sampling, resided in Abuja (n = 17) or Lagos (n = 8), Nigeria.

METHODS

The study inclusion criteria were (1) being aged 18 years or older, (2) identifying as TGD (having a current gender identity that differs from birth-assigned sex), and (3) residence in either Lagos or Abuja. Recruitment was conducted in collaboration with two nonprofit organizations that provide health and advocacy services to SGM communities in Lagos and Abuja. Health outreach workers, key opinion leaders, and community activists shared study promotional materials with the target population during programming events (HIV testing outreach, peer educator sessions) and by sharing with members of their social network (via text message, phone calls, and social media posting). They provided study contact information to potential participants. Recruitment strategies utilized for SGM communities in the United States, such as clubs and bars, cannot be deployed in this setting because of the illegality of such establishments in Nigeria.

To maintain confidentiality, we obtained verbal informed consent from all participants before study enrollment. All focus group discussions were conducted in the private offices of the partner organizations. After conducting a detailed literature review and consulting with academic researchers, we developed a focus group guide capturing several thematic areas. The discussions were digitally recorded and lasted about 1.5 hours. Participants received 5000 Naira (US $10).

All interview transcripts were transcribed verbatim by a Nigeria-based transcription company. We utilized a qualitative content analysis approach to analyze the transcripts (NVIVO 12).⁸ First, a study team member (A. O.) read 20% of the transcripts and created an outline of preliminary emergent themes. We defined themes as codes with similar patterns of response. Next, a draft codebook was developed and circulated to the study team for review, who provided iterative feedback until a refined codebook emerged. Next, one team member (A. O.) coded all transcripts. We utilized the consolidated criteria for reporting qualitative research (COREQ) checklist to ensure the systematic application of qualitative data analysis and summary of our findings.⁹

KEY FINDINGS

The majority (52%) of participants were aged 25 years or older, 80% were transgender women, and 20% were transgender men. While 76% had at least a high-school diploma, 96% had a monthly income of 50 000 Naira (US $100) or lower. Most (68%) were single, 40% were unemployed, and 24% had unstable housing.

A synopsis of the emergent themes is discussed here, and representative quotes are provided in Box 1.

BOX 1—

Illustrative Quotes From Focus Group Discussion With 25 Transgender People in Abuja and Lagos, Nigeria, Conducted in February‒September 2021

Theme and Subtheme	Illustrative Quote
Barriers to gender-affirming health care services
It is difficult to find competent and accepting health care providers (HCPs) to assist with the gender-affirmation process.	“I have challenges, because with taking hormonal pills, with the research I did online, you can’t just place yourself on hormonal pills yourself, you have to … there is a protocol like, a consultant that you need to talk to, because they will have to check your liver, your kidney… .” (26-year-old transgender woman) “Some transgender women might be HIV-positive, you know, if you are HIV-positive and you still want to take hormonal pills you will have to seek for a consultant, to check maybe this hormonal pill … you have to balance both; it can be a lot.” (30-year-old transgender woman)
Transgender individuals are often forced to seek their own information and self-administer their own hormones.	“You can chat up [people] online through social media about something like hormones, but they don't give you like a specific dosage or how to actually self-medicate?” (32-year-old transgender man) “When I got information about the drug, it was online. I was always conversing with other trans girls outside the state, so they were telling me ‘use this, use that’ … I just kept searching.” (25-year-old transgender woman) “With the hormonal therapy, I am presently on hormones … and I am self-medicating because nobody will want to prescribe anything for you.” (24-year-old transgender man)
Hormone therapy is expensive.	“As a trans person, it's not easy getting hormone therapy in Nigeria, a bottle of the pill cost about 46,000 Naira [about $95]. I have trans friends that have started their hormonal therapy and sometimes tell me that they've spent a lot of money trying to get their pills, they have GoFundMe to fund all of that.” (22-year-old transgender woman)
Experiences within the health care setting as a transgender community member
There is a lack of health care service options for transgender individuals.	“As a trans-identified person, zero [health care centers], but for MSM [men who have sex with men], there are abundance of health care services and all of that but, as a trans-identified person, zero.” (30-year-old transgender man) “The doctors found out about you like they have to strip you of your clothes, and they found out, what are you going to do about that?” (26-year-old transgender woman)
Health facilities often misgender transgender individuals.	“I’ve gone to care in that facility, they don’t want to accept my gender, that I’m a trans woman… . It’s the same community organization, which supposed to be for us, and a staff working there will sit me down and start telling me, my life that I’m living is bullshit, I don’t get it.” (30-year-old transgender woman) “If I wanted to get health care services, I just claimed to be a gay man, which is cringeworthy to begin with.” (22-year-old transgender man)
Health centers lack the appropriate medications needed by transgender populations.	“After going to hospital and them not having the medication that I needed, I have to go and take natural herbs.” (27-year-old transgender woman)
Positive health care experiences occur at community-based organizations (CBOs).	“Well. In general hospital it’s zero for me, yes … it’s zero for me, but when it comes to CBOs, they are not homophobic, they're not transphobic, so they are fine, at least.” (26-year-old transgender woman)
Health care provider bias
There is unequal access to hormone therapy based on gender identity.	“My understanding is that most of these drugs are multipurpose drugs; they don’t have one use. They [HCPs] don’t give the drugs to people who want to transition; they give it to men who are struggling with testosterone issues.” (29-year-old transgender man)
Individuals experience prejudicial treatment from health care providers.	“When you go to the hospital, you see someone that is trained to not look at you but to only look at what brought you here. Once they see you, they already judge you from your head, your shoes. They have misplaced priority and don’t have the emotional intelligence to deal with this issue.” (32-year-old transgender woman)

Barriers to Gender-Affirming Health Care Services

Three key themes emerged in barriers to accessing GAC: (1) difficulty finding competent and affirming HCPs to assist with the gender-affirmation process, (2) transgender individuals often being forced to seek out information and self-administer hormones, and (3) hormone therapy being expensive.

Participants described knowing that GAC, specifically hormone therapy, should be prescribed, administered, and monitored by a trained medical professional, but widespread transphobia in Nigeria made it difficult to find HCPs who were willing and able to provide these services. While some participants expressed some knowledge about the clinical requirements to administer GAC, others noted how transphobia permeates Nigerian society and inhibits access to GAC, specifically hormones.

Participants discussed the dearth of accessible information on hormone therapy. As a consequence, because of limited health information and a stigmatizing health care environment, participants turned to social media as a source of information. While some participants mentioned engaging with people on the Internet about hormone therapy but not getting enough information about hormone dosage and how to self-administer, others built an online community of transgender women to deepen their knowledge about hormone therapy. A few participants described having gained access to hormone therapy. These individuals often self-administered because of HCPs’ inability to provide GAC services. One participant commented on the dangers of self-administration and the potential for overdosing because of limited information and lack of medical guidance.

Participants noted the high cost of hormone therapy as a major barrier and that many people are forced to pay for these medications themselves or resort to crowdfunding platforms (e.g., GoFundMe) to raise money.

Experiences Within the Health Care Setting

Four key themes emerged regarding navigating the health care system for other non-GAC health services: (1) lack of health care service options for transgender individuals, (2) health facilities often misgendering transgender individuals, (3) health centers lacking the appropriate medications needed by transgender populations, and (4) having positive health care experiences at community-based organizations compared to traditional health care settings.

Participants described the lack of options for general health care services tailored to the unique needs of TGD people, especially compared to sexual-minority men who have access to more tailored services. There were also some expressed apprehensions about seeking health services at facilities that serve the general public. One participant discussed the fear of their transgender identity being discovered during a medical examination.

Several participants relayed experiences of nonaffirmation, such as being intentionally misgendered and being incorrectly classified as a gay man by HCPs. It was especially hurtful when these comments came from staff members at facilities expected to be inclusive and accepting of the SGM community. One participant recalled being forced to misgender themselves to receive health care services.

Another participant mentioned seeking out alternative medicines because of health care centers not having the appropriate medications. Lastly, some participants reported having a more positive health care experience at community-based organizations that specifically serve SGM communities.

Health Care Provider Bias

Two key themes emerged in participants’ experiences of bias among HCPs: (1) unequal access to hormone therapy based on gender identity, and (2) experiences of prejudicial treatment from HCPs.

Participants indicated that accessing hormones for health issues was easier for cisgender people with endocrine problems compared with transgender people seeking these hormones for GAC. Participants also discussed experiencing prejudice from HCPs attributable to their reason for presenting at the medical setting or their outward appearance.

EVALUATION, TRANSFERABILITY, AND ADVERSE EFFECTS

This first-of-its-kind study, to our knowledge, shone light on the barriers to health care access experienced by TGD people in Nigeria, which might be applicable to similar countries across sub-Saharan Africa. This study also highlights the possibility of developing TGD-specific health services by organizations that have primarily served the SGM community but largely excluded TGD groups. In addition, future studies should investigate the longitudinal effects of limited access to GAC on the health and wellness of TGD populations in Nigeria and across the African continent.

SCALABILITY

The development, testing, and scaling of interventions aimed at addressing health disparities among TGD in Nigeria is desperately needed. Specifically, we need to design and conduct randomized controlled trials investigating the efficacy of different health care delivery models (e.g., traditional health care setting, peer-to-peer, telehealth) and sensitivity training to address health disparities among TGD people in Nigeria.

PUBLIC HEALTH SIGNIFICANCE

To our knowledge, there are no programs within any major hospital systems in Nigeria specifically catering to the unique health care needs of TGD people. A recently published study exploring access to HIV services among TGD individuals in Nigeria found a lack of transgender-inclusive and gender-affirming HIV services, which perpetuated experiences of stigma and discrimination.¹⁰ There is a dire need for accessible, competent, and comprehensive gender-affirming health care services—including social, psychological, legal, and medical services. It is also important to consider the potential for self-administered GAC because of limited access to hospital-based care and the potential negative consequences that have been found, including both inadequate hormone concentrations¹¹ and excessive hormone dosing.¹²

Given the inevitable public backlash and potential for increased violence against TGD Nigerians in response to a TGD-centered hospital or clinic, community-based organizations that serve sexual minority men should expand their service offerings to include TGD-specific health care. Program offerings should include case management, gender-affirming primary care including HIV prevention and care services, and social and mental health service programs.¹³ Specifically, SGM health organizations should explore offering free or low-cost GAC to TGD populations in Nigeria, as cost is a major barrier. In addition, advocacy for policy change must co-occur with health promotion programs for this community. Most importantly, these programs should employ TGD individuals as staff members and hold regular staff training in cultural sensitivity and effective communication with TGD clients.