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Muwanguzi et al. BMC Health Services Research (2025) 25:431
https://doi.org/10.1186/s12913-025-12591-2 BMC Health Services Research
*Correspondence:
Patience A. Muwanguzi
pamuwanguzi@gmail.com
1School of Health Sciences, College of Health Sciences, Makerere
University, Kampala, Uganda
2Humanitarian and Conict Response Institute, University of Manchester,
Manchester, UK
3African Center for Health Equity Research and Innovation (ACHERI),
Kampala, Uganda
4School of Medicine, College of Health Sciences, Makerere University,
Kampala, Uganda
Abstract
Background People who identify as transgender have a gender identity or expression that diers from the sex
they were assigned at birth. Because of this, transgender people may encounter widespread stigma, discrimination,
and violence, including in medical facilities. Understanding how these phenomena manifest during healthcare
interactions is crucial for enhancing health equity for transgender individuals. Therefore, this study explored the
experiences of transgender-related stigma and violence among transgender individuals in Uganda.
Methods The study used a community-based qualitative participatory approach, with transgender women actively
co-generating the data. Six focus groups were held with 33 transgender women in southwestern and central Uganda.
Data were thematically analysed using OpenCode software.
Results Four key themes emerged for the lived experiences of violence and abuse among transgender women
in Uganda. These included: (i) Institutionalized physical violence and violation of bodily autonomy, (ii) Religious
impositions and moral policing, (iii) Dehumanising treatment and objectication and (iv) Systemic discrimination and
denial of care.
Conclusions In conclusion, this study highlights the pervasive violence, abuse, sexual assault and discrimination
reported by transgender women in healthcare settings in Uganda. These experiences not only compromise access
to quality healthcare but also perpetuate stigma and exacerbate health disparities. Addressing these issues requires
comprehensive, trauma-informed care, alongside structural reforms and training for healthcare providers. Ensuring
respectful, arming, and inclusive healthcare environments is essential to safeguarding the rights and well-being of
transgender individuals. Additionally, more studies should evaluate the eectiveness of interventions like healthcare
provider training and addressing social determinants of health to determine the most impactful strategies for
reducing violence.
Keywords Abuse, Healthcare, Sub-Saharan Africa, Qualitative study, Transgender, Violence
Experiences of violence and abuse among
transgender women in healthcare settings
in Uganda: a community-engaged qualitative
study
Patience A.Muwanguzi1,2*, RachealNabunya3 and MosesSabila4
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Page 2 of 12
Muwanguzi et al. BMC Health Services Research (2025) 25:431
Introduction
People who identify as transgender are those whose gen-
der identity does not match the sex with which they were
born [1]. Research from the United States and South
Africa shows that transgender women face unique chal-
lenges and experience multiple forms of violence, includ-
ing physical, verbal, and sexual assault, which can occur
within healthcare environments [2–4]. ese experiences
of violence, can lead to the avoidance of healthcare facili-
ties, denial of services, delays in receiving care, and low
utilisation of essential services such as HIV testing and
post-exposure prophylaxis [5]. is often occurs within
environments that criminalise sexual and gender minor-
ity (SGM) individuals. Studies have shown that SGM
patients encounter marginalisation in healthcare settings
due to a lack of cultural competence among healthcare
providers [6, 7].
e intersectionality and intersectional stigma faced by
transgender women in healthcare settings is a multifac-
eted issue that signicantly impacts their access to and
quality of care. For instance, Naume et al. highlight that
emotional abuse and discrimination in healthcare set-
tings can ignite self-stigma among transgender women,
adversely aecting their self-condence and willingness
to access necessary services, particularly in the context
of HIV prevention and treatment [8]. Similarly, Smart et
al. emphasize that negative healthcare experiences can
lead transgender women to seek nonmedical, sometimes
predatory, care sources, further exacerbating their health
vulnerabilities [9]. ese ndings are corroborated by
Logie et al., who discuss how the marginalization expe-
rienced by transgender women, particularly those living
with HIV, is intricately linked to their healthcare access
and outcomes [10]. Moreover, the intersection of vari-
ous forms of stigma—such as racism, sexism, and trans-
phobia—creates compounded barriers for transgender
women, particularly those of color. Raghuram notes that
in India, the intersectionality of gender, caste, and class
creates unique healthcare access challenges for trans-
gender individuals [11]. is is echoed in the work of
Ogunbajo et al., who identify medical mistrust and nega-
tive healthcare experiences as signicant barriers to HIV
prevention and treatment among Black and Hispanic/
Latinx transgender women in the U.S [12]. Discrimina-
tion against SGM individuals in healthcare is a well-doc-
umented issue, leading to disparities in access to care and
health outcomes [13, 14]. e criminalisation of same-sex
practices can further exacerbate the stigma and exclusion
of SGM persons in various societal systems, including
healthcare [15]. Studies have highlighted biased behav-
iours and discrimination by healthcare providers towards
SGM individuals, ranging from subtle microaggressions
to overt discrimination [16].
Despite global progress in addressing discrimination
and violence based on gender identity and sexual orien-
tation, transgender women continue to encounter perva-
sive stigma, discrimination, and violence, particularly in
their interactions with healthcare providers and institu-
tions [17]. Transgender women in Uganda often face bar-
riers to healthcare access due to discriminatory attitudes
among healthcare providers and inadequate institutional
policies [18]. is marginalisation not only limits their
access to essential healthcare but also exposes them to
increased risks of violence and abuse within healthcare
settings [19]. e intersection of transgender identity
with other marginalised identities, such as education-
level, socio-economic background, and HIV status, fur-
ther compounds the vulnerabilities faced by transgender
women in Uganda [20]. ese intersecting forms of dis-
crimination not only impede their access to healthcare
but also perpetuate a cycle of violence and abuse that
undermines their overall well-being [21]. e experiences
of transgender women in Uganda reect broader global
trends where discrimination, stigma, and violence hin-
der their access to quality healthcare [22]. Additionally,
the legal and cultural context in Uganda presents specic
challenges, as being transgender is illegal and criminal-
ized under the new Anti-Homosexuality Act of 2023 [23].
Considering these challenges, there is an urgent need
for research that critically examines transgender women’s
experiences of violence and abuse while accessing health-
care in Uganda. By shedding light on the multifaceted
barriers they encounter, we aim to inform evidence-based
interventions and policy reforms that promote equitable
healthcare access and address the systemic inequalities
faced by transgender communities in Uganda. erefore,
this study seeks to answer the following research ques-
tions: How do Ugandan transgender women experience
violence and abuse in healthcare settings, and how does
this aect their access to and utilization of health services?
Methods
Research team and reexivity
PAM, RN, LM, and SM work in the medical eld as
health equity researchers seeking to reach underserved
populations with HIV prevention and testing services.
From 2017 to 2019, PAM worked in an HIV clinic and
observed how some health professionals handled trans-
gender women who sought HIV care and prevention ser-
vices. She also observed a decline in transgender women’s
clinic attendance following very unfavourable medical
experiences. Building on that, and together with some
transgender women, they conceptualized this study to
comprehend and describe the stigmatising experiences
through the lens of transgender people. e study’s nd-
ings will serve as a foundation for developing and imple-
menting anti-transgender stigma reduction interventions
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Muwanguzi et al. BMC Health Services Research (2025) 25:431
among Ugandan health professionals. PAM and RN have
qualitative research experience and received training in
gender diversity and sensitivity. ey have both received
training in the protection of human subjects and ethics.
ey have collaborated with transgender communities
and organizations since 2020. e team shared their per-
sonal goals and reasons for conducting the research to
build trust and rapport. ey also discussed their inter-
ests in the research topic and the potential usefulness of
the study ndings. Using bracketing, the researchers mit-
igated potential biases and presumptions regarding the
central phenomenon [24]. None of the co-authors identi-
es as transgender.
Our experience working with transgender communi-
ties indicates they feel more comfortable being inter-
viewed by trusted peers. To support this, we collaborated
with four transgender women identied by community-
based organizations as peer research assistants. e
peer research assistants received two weeks of hands-on
training in interviewing techniques, data collection, and
analysis. e training also covered ethical topics, includ-
ing human subjects’ protection, condentiality, informed
consent, respect, and safety. In respect of their privacy,
they have requested anonymity for this publication.
Study design and setting
is qualitative study used community-based partici-
patory methods with transgender women from central
and southwestern Uganda. ese regions were selected
because they have a high HIV prevalence, at 6.2% and
6.3%, respectively, compared to the national average of
5.5% [25]. is qualitative study is part of a larger project
on reducing gender-identity stigma among transgender
women at risk of HIV. However, HIV status was not a cri-
terion for enrolment, as this paper focuses specically on
experiences of violence and abuse in healthcare settings.
Recruitment and study participants
We collaborated with leaders of transgender-led orga-
nizations in the two districts, which provide safe spaces
for community members to access medical care, shelter,
and peer support. ese leaders helped identify peer
researchers who, in turn, recruited participants based
on the study’s inclusion criteria. e community-based
peer researchers actively sought and informed transgen-
der women about the study and arranged suitable times
for focus group discussions. Participants were recruited
from their homes, shelters, social environments, and
drop-in centers. e discussions took place in safe spaces,
including transgender-led organizations, a hotel com-
monly used for community meetings, and a health facility
oering tailored healthcare services for transgender peo-
ple. To protect study participants’ privacy and uphold the
values of transgender-led organizations, we adhered to a
policy of anonymity and condentiality.
Anyone who self-identied as transgender was older
than 14 years and had experienced violence and abuse in
medical settings was eligible to participate in this study.
Participants were enrolled if they self-identied as hav-
ing experienced violence or abuse in healthcare set-
tings, with the denition of violence or abuse left to their
interpretation.
Transgender individuals face signicant stigma and
physical danger due to the criminalization of their iden-
tity in Uganda. To prevent potential harm to participants
in the study, we developed and implemented a compre-
hensive risk mitigation plan, guided by existing literature,
to ensure their safety throughout the study [26]. Some of
these plans include providing access to legal representa-
tion, anonymizing data, storing data on servers outside
Uganda, holding meetings in safe spaces, and collaborat-
ing with organizations already working closely with the
Ugandan Ministry of Health. Participants were selected
using purposive sampling. About eight (08) people
refused to participate due to concerns about their safety.
Data collection
e peer researchers contacted their community mem-
bers and explained the study’s aims and data collection
procedure. ose willing to participate could choose
between a virtual or an in-person focus group at a des-
ignated “safe space” at their convenience. e peers were
crucial in assigning participants to groups, prioritizing
comfort and privacy. One group consisted of transgen-
der women living in a shelter, another included those
living with HIV, and a third group comprised transgen-
der women who had not publicly disclosed their gender
identity. Additionally, there was a group of transgender
women engaged in sex work, while the remaining two
groups were categorized by age. e age groups were
divided into 18–29 years and ≥ 30 years, based on rec-
ommendations from transgender women. ey believed
younger participants might feel uncomfortable speaking
openly in the presence of older ones, and vice versa.
Transgender women who had experienced violence and
abuse and agreed to share their lived experiences partici-
pated in six focus group discussions (FGDs) [27]. Two
trained peers and PAM moderated the six focus groups.
RN attended all sessions as a notetaker and logistics
coordinator while observing nonverbal cues. Each FGD
lasted about three hours and was conducted in the local
dialects commonly spoken in the study locations. Our
initial goal was to recruit ten transgender women per
group; however, we ultimately secured 5 to 6 participants
per group. is smaller number proved more suitable for
addressing emotionally charged topics, as it allowed for
deeper participant engagement and involvement [28].
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Muwanguzi et al. BMC Health Services Research (2025) 25:431
Data was collected using an open-ended FGD guide
developed by the research team (Supplementary le 1).
is guide included questions and prompts about partici-
pants’ experiences of violence and abuse and how these
experiences aect their trust in healthcare providers and
the health system overall. It also included questions solic-
iting suggestions for improvement. e guide underwent
pilot testing with 5 transgender women from a dierent
region in Uganda. Based on feedback from the pilot test-
ing, several adjustments were made, such as adjusting
the length, adding more prompts, reorganizing the ques-
tions, and modifying some questions to use more inclu-
sive language.
Both PAM and RN were uent in these dialects and
could understand formal and informal language. e par-
ticipants agreed to have the discussions audio recorded.
Data collection stopped when no new information
emerged from the interviews.
Some participants may have been deterred from shar-
ing their personal experiences during the focus group
discussions. is hesitancy could stem from various rea-
sons, such as feeling uncomfortable discussing personal
matters in a group setting or speaking up among strang-
ers. To address this issue, the moderators established
rapport and trust with the participants beforehand to
make them feel more comfortable. Additionally, the peers
played a crucial role in this endeavor.
Data analysis
Immediately following the conclusion of each FGD, ver-
batim transcripts, and eld notes were typed up and
translated into English. OpenCode software was used to
analyse the data employing thematic analysis using Braun
and Clarke’s method [29]. e inductive data analysis
process was exible and followed six key stages: familiar-
ization with the data, generation of initial codes, identi-
cation of themes, renement of themes, denition and
naming of themes, and report writing.
To generate codes and themes, PAM and RN part-
nered with a peer to ensure that the ndings’ meaning
emerged from the data and was corroborated by a com-
munity member, not just the researchers. Both groups
then met to compare their mostly similar ndings. In
cases of slight disagreement, consensus was reached,
with SM serving as the liaison. is method emphasized
a comprehensive, reective, and systematic approach to
analysis, ensuring that the identied themes captured the
richness of the data while maintaining a strong alignment
with the research questions.
Five transgender women who participated in the
study were consulted to review the categories, themes,
and interpretations. is step aimed to verify whether
the ndings accurately reected their perceptions and
aligned with the discussions held during the focus
groups. e team then collaboratively revised any themes
that appeared to misrepresent the participants’ experi-
ences of violence and abuse. Additionally, the transgen-
der women involved in the member-checking process
felt that some categories were worded “insensitively” and
assisted in revising them to use more inclusive language.
Once the participants approved, the researchers created a
textural description of their experiences. Finally, the team
condensed the lengthy description into a few brief, dense
sentences that captured the essential elements of the par-
ticipants’ experiences of violence and abuse [30]. Partici-
pant quotations are presented to illustrate the themes.
To ensure the process rigor, the study was guided by the
four trustworthiness criteria: credibility, dependability,
transferability, and conrmability [31]. e results were
made credible by methods like openness and saturation
[32]. Additionally, the research team developed rapport
with the transgender community. e team leveraged
their prior experience and commitment to health equity,
particularly in underserved populations. Recognizing the
importance of peer-led interactions, the team collabo-
rated with four transgender women, identied through
community-based organizations, as peer research assis-
tants. is approach ensured participants felt comfort-
able and empowered, strengthening trust within the
research process.
Recordings, transcripts, and eld notes created an
audit trail that transparently presented the procedures
and methods, ensuring dependability. ick descriptions
will enable readers to assess transferability to their con-
texts. e researchers’ eld notes and written reections
helped conrm the study’s credibility.
is paper was written following the COREQ guide-
lines [33].
Results
irty-three (33) transgender women participated in the
study, with ve to six participants in each focus group.
Four themes emerged for transgender women’s experi-
ences of violence and abuse in healthcare settings (Fig.1).
e themes include: (i) Institutionalized physical violence
and violation of bodily autonomy, (ii) Religious imposi-
tions and moral policing, (iii) Dehumanising treatment
and objectication, and vi) Systemic discrimination and
denial of care. Please be prepared, as some of the narra-
tive quotes regarding violence and abuse may be dicult
to read.
is section highlights the four key themes that
emerged from participants’ experiences of violence and
abuse within healthcare settings. A nuanced thread of
intersectionality underpins all the themes, which will be
further explored in the discussion section.
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Muwanguzi et al. BMC Health Services Research (2025) 25:431
Institutionalized physical violence and violation of bodily
autonomy
is theme highlights the systemic nature of violence, its
profound physical and emotional impact, and the institu-
tional tolerance that perpetuates such abusive practices.
Participants described experiencing physical assault dur-
ing medical encounters, including being beaten. is
abuse was often rooted in assumptions about their gen-
der identity or sexual orientation, reinforcing barriers to
accessing care and exacerbating their vulnerabilities.
One transgender woman shared:
We were once imprisoned and badly beaten by other
inmates. When we sought treatment at the prison’s
health facility, my friend, who had been assaulted
so severely she became disoriented, was further
harassed by health workers. ey slapped her and
called her a homosexual in front of guards, who
did nothing. e incident was neither documented
nor reported, yet when other inmates are severely
assaulted, investigations are conducted. (Participant
7, FGD 03)
Another participant reported that healthcare providers
inict pain and intentionally harm transgender people,
particularly through anal examinations.
I went to a government hospital for a severe urinary
tract infection. e health worker insisted on an anal
exam, which I didn’t think was necessary, claiming it
could be the cause of the infection for ‘people like me’.
When I refused, she called two men who beat me. I
didn’t receive any treatment for the infection, I just
bought medication from a pharmacy. (Participant 4,
FGD 04)
Another transgender woman described feeling trauma-
tized and violated when the health worker conducted
examinations without using any lubricant.
…. they brought in a female health worker to per-
form an anal examination, but instead, she inserted
her two dry ngers roughly into the area. e experi-
ence was traumatizing, and I couldn’t walk properly
for a week afterward. (Participant 6, FGD 01)
Religious impositions and moral policing
is theme captures the imposition of religious beliefs,
and moral judgments by healthcare providers as forms of
abuse that stigmatize, distress, and alienate transgender
women in healthcare settings.
Fig. 1 Transgender women’s experiences of violence and abuse in healthcare settings in Uganda
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Muwanguzi et al. BMC Health Services Research (2025) 25:431
Religious imposition and forced conversion
Participants highlighted instances where health-
care workers imposed religious beliefs on them, often
attempting to “convert” or “correct” their gender identity.
ese actions included preaching, praying, and attempt-
ing to “cast out demons,” which were perceived as deeply
stigmatizing and discriminatory. ese practices com-
pounded the participants’ experiences of marginalization
and had signicant implications for their mental health
and access to care.
One participant shared how presenting as her preferred
gender often led to denial of care:
“Many times, health workers refuse to provide care
when we go to the health facility, presenting as our
preferred gender. is feels stigmatising and violates
my rights. It’s like nurses are telling me to revert to
my former self. I don’t want to go back to that. is
situation aects my mental well-being and puts me
in a bad state of mind.” (Participant 6, FGD 01).
Many participants indicated that they avoid certain pub-
lic health facilities because healthcare workers engage
in preaching and praying during medical encounters.
ese actions were perceived as an infringement on their
liberties.
“Hey man, let me tell you, Jesus loves you. He came
to die for people like you.” I asked her, “Are you a
medical worker or a pastor?” She replied, “I will do
both.” I left the facility speechless. As I exited, she
stood atop the stairs, preaching very loudly, and
everyone turned to look at me as if I were a sinner.
(Participant 2, FGD 05)
One participant reported that the health worker went so
far as to try to cast out demons from her. ey likened
this persistent questioning to a form of unwarranted con-
version therapy, further compounding their distress.
I’m concerned about unfriendly healthcare work-
ers because they are unprofessional. ey often
seemed clueless when I approached them for help
and started lecturing me instead. One time, a nurse
began casting out demons when I went to her station
for a blood pressure check. I thought they were there
to help the sick, not to preach. (Participant 3, FGD
04)
Moral inquisitions and judgements
e participants reported that during every healthcare
encounter, health workers consistently questioned why
they were transgender and why they could not revert
to their assigned sex. e participants felt that these
judgmental questions reected a fundamental misun-
derstanding by the health workers about the nature of
gender identity, which cannot simply be altered.
Participants recounted instances of health work-
ers exhibiting stigmatizing behavior, including intru-
sive questioning, unnecessary exposure of injuries, and
derogatory comments about their lifestyle.
“She asked me to explain how I got the injury and
called two more nurses. She had me repeat the story
when they arrived and kept lifting the sheet to show
them the injuries. en, she made comments about
sin and sexual immorality while treating me.” (Par-
ticipant 1, FGD 04).
Such actions violated their dignity and reinforced feel-
ings of judgment and discrimination within healthcare
settings.
Dehumanising treatment and objectication
is theme highlights the multifaceted nature of the
abuse experienced by the study participants. e ndings
are organized into two sub-themes: psychological and
emotional abuse, and sexual harassment and abuse.
Psychological and emotional abuse
Participants recounted incidents where healthcare work-
ers subjected them to public ridicule, drawing unneces-
sary attention to their identities. For instance, healthcare
sta often called colleagues to “see” them, turning their
presence into a spectacle. Such encounters not only
violated participants’ dignity but also instilled fear and
exacerbated feelings of alienation within healthcare envi-
ronments. One transgender woman shared her distress-
ing experience.
I’ve struggled for a long time to feel comfortable with
who I am. Whenever I go to the hospital, the rst
person I see always calls others to come and see me.
When I exit the doctor’s examination room, I nd
many other sta and patients have gathered and are
waiting to see me. Sometimes, I’m scared they will
gang up on me. (Participant 5, FGD 02)
is theme also encompassed instances where healthcare
workers forced patients to disclose their gender identity
or sexual orientation, eectively “outing” them in front of
others without their explicit permission or consent.
Once at a health facility, I overheard one of the
nurses telling her friends, “Can you imagine this cute
lady is a man? ese are the homosexuals.” ey all
turned to look, not realising I was right behind her.
It was awkward when she saw me. Being outed like
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Muwanguzi et al. BMC Health Services Research (2025) 25:431
that to people who aren’t informed can be tough.
Imagine if it happened to my neighbours, who don’t
know I’m transgender because I keep that part of
myself private. ese situations can have a big
impact on us. (Participant 6, FGD 02)
Participants expressed dissatisfaction with healthcare
providers’ intrusive questions about their sex lives and
inappropriate comments on their gender identity and
sexuality. ey felt that cisgender individuals are not
subjected to similar inquiries and found these questions
embarrassing and traumatizing. As a result, they were
discouraged from returning to these facilities, knowing
they would face further interrogation.
ey ask questions like: Does it hurt? How do you
manage it? Why did you choose this path? "What
did you do to become like this?" or "Don't you want
children in the future?" You might nd yourself won-
dering why they're so interested in these aspects. I
didn't come here to discuss children, so why are you
so curious about that? (Participant 01, FGD 05)
ey ask irrelevant questions, like how you have
sex, how you could get HIV, or how your body parts
became sick. It’s frustrating to return to the facility
when they ask such intrusive questions, like whether
you’re the one having sex or being involved in it, as
if it’s any of their business! (Participant 01, FGD 03)
Participants shared experiences of verbal abuse and dis-
criminatory communication by healthcare workers,
including shouting, demeaning language, and public dis-
closure of their health status. ey felt targeted, as such
treatment was not directed toward cisgender individuals.
One participant recounted:
“When you visit a health worker, they often rudely
refer you to someone else who also can’t help. Your
le is brought out, and your name is read aloud,
revealing you’re there for HIV medication. At times,
you’re treated dierently from other clients.” (Partici-
pant 2, FGD 05).
Others described being addressed with derogatory lan-
guage, causing signicant humiliation:
“When I was leaving, the nurse shouted, ‘Let those
homos get out’ in front of everyone. We were so embar-
rassed. ey refused to give us medication even though
we were sick and in pain.” (Participant 3, FGD 04).
ese experiences underscore the pervasive verbal hos-
tility and discriminatory behaviour that marginalized
groups face in healthcare settings, contributing to feel-
ings of exclusion and mistrust.
Sexual harassment and non-consensual sexual acts
Transgender women in this study frequently reported
incidents of sexual harassment by healthcare providers,
ranging from invasive questions about sexual practices to
non-consensual sexual acts during medical procedures.
Participants reported experiencing harassment through
unsolicited sexual advances from health workers and
violations during bodily assessments conducted without
their consent, which they perceived as forms of sexual
violence.
Several participants shared experiences of non-con-
sensual sexual acts with the health workers at the health
facilities. One participant recounted.
I once suered from a certain condition, and I went
to the health worker for proctology. So, when I went
and disclosed, the doctor examined me, and during
the examination, he inserted something cold and
hard in my anal region and started asking me if
that’s how I have sex and if it felt good. at was sex-
ual abuse from a health worker, and I did not have
anyone to report it to. (Participant 4, FGD 05)
Some of the participants reported that male healthcare
workers made unsolicited sexual advances. One trans-
gender woman narrated.
e man examining me said that because I wanted
to become a woman, he’d teach me ‘how to be a
woman’. I felt upset because my identity isn’t about
my sexuality—it’s just who I am. I felt so powerless,
this was a person who was supposed to help me.
(Participant 3, FGD 06)
Systemic discrimination and denial of care
is theme underscores the structural barriers and
explicit biases that undermine access to quality health-
care for transgender individuals. Participants consistently
reported discriminatory practices, including healthcare
providers refusing treatment or delivering substandard
care. Healthcare workers were frequently dismissive or
hostile, making unfounded assumptions about patients’
sexual orientation and, in some cases, blatantly refusing
care.
One commonly recurring issue was the denial of essen-
tial health services, including emergency care and HIV
treatment and prevention. Many described being denied
emergency services or essential medications, such as
HIV prevention or antiretroviral therapy (ART), solely
because of their gender identity.
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Muwanguzi et al. BMC Health Services Research (2025) 25:431
I had an accident on [……….] and went to the near-
est treatment facility, [……….], but it was closed
when I arrived. I was directed to the public hospital’s
emergency section. When I got there, I was bleeding
heavily. A nurse approached, asked for my name,
and then called the doctor. She said to the doctor,
“ese are the ones.” e doctor seemed confused
and asked, “Which ones?” e nurse replied, “e
homos.” I felt embarrassed. ey gave me a tetanus
shot but never attended to my injuries. I lost a lot
of blood and had to go to another facility for proper
care. (Participant 3, FGD 05).
Another participant did not take antiretroviral therapy
(ART) rells because of the way the health worker spoke
to her.
“Even the homosexuals get HIV!! I won’t work on
them.” After that incident, I never went back. I
even lost the courage to return for my medication.
I became so fed up that I stopped taking my ART
because I was afraid to go pick it up. (Participant 1,
FGD 04))
While yet another transgender woman was denied access
to post-exposure prophylaxis (PEP), and another was dis-
couraged from HIV testing.
I went to a health facility for PEP, but they refused
to provide it, saying they don’t serve KPs [key popu-
lations] like me. I did not go to another facility and
did not take PEP. I have not yet taken another test to
know if I am still negative (Participant 6, FGD 04).
Some participants also recounted instances where health
workers demanded bribes before providing treatment,
further compounding these systemic injustices.
I visited a health facility where a health worker
asked me for money before doing any work on me
and this was at a public facility. I’m not sure if they
ask everyone or just transgender people like me, but
I think this might be a common experience for trans-
gender individuals because they know it is dicult
for us to get healthcare. (Participant 2, FGD 01)
Discussion
Four key themes emerged for the lived experiences of vio-
lence and abuse among transgender women in Uganda.
ese included: (i) Institutionalized physical violence
and violation of bodily autonomy, (ii) Religious imposi-
tions and moral policing, (iii) Dehumanising treatment
and objectication and (iv) Systemic discrimination and
denial of care. Intersectionality emerges as a critical lens
underpinning the ndings of this study, highlighting the
complex interplay of multiple forms of oppression expe-
rienced by transgender women in healthcare settings.
Intersectionality theory explains that dierent forms of
oppression are interconnected and work together to cre-
ate and uphold a system of power maintained by social
structures and institutions [34].
Physical violence, as reported by participants, illus-
trates how gender identity intersects with societal
and institutional biases, creating environments where
abuse and discrimination are not only pervasive but
often normalized. These experiences are further exac-
erbated by structural factors such as legal criminaliza-
tion and social stigmatization, which deepen barriers
to justice and perpetuate cycles of violence. This aligns
with findings from other healthcare settings [35–37].
Such violence ranged from overt aggression to subtle
forms of mistreatment and discrimination. Partici-
pants described instances of assault, harassment, and
even torture when accessing healthcare services [36].
These acts, perpetrated by healthcare providers, staff,
or other patients, often led to fear, intimidation, and
reluctance to seek care [35, 36]. A significant issue
is the institutionalization of such violence, which is
compounded by limited avenues for reporting abuse
and systemic barriers, including legal criminalization
and societal discrimination. Advocacy and structural
reforms at policy levels are critical to addressing these
foundational issues. Without systemic change, efforts
like healthcare worker training or stigma-reduction
interventions will have limited impact [38].
Instances of verbal abuse, service denial, and breaches
of condentiality underscore the compounded vulner-
abilities faced by transgender women. e intersection
of gender identity and societal norms fosters an environ-
ment where discriminatory behaviours, such as “outing”
patients or gossiping about their gender identity, under-
mine their dignity and trust in healthcare systems. is
multifaceted marginalization often forces individuals to
avoid formal healthcare, highlighting the intersectional
impact of social stigma, systemic discrimination, and
institutional shortcomings [39]. is “outing” caused
feelings of violation and discrimination [40, 41]. Studies
from various countries, including Brazil, the US, Colom-
bia, Korea, and Mozambique, highlight similar issues,
such as denial of transgender-specic care, discrimina-
tory behaviour, and condentiality breaches [42–48].
e emotional toll of such treatment drives many trans-
gender individuals to avoid formal healthcare systems,
often turning to unsafe, nonmedical alternatives [9].
Research by Casey et al. revealed that one in six LGBTQ
adults avoids healthcare due to anticipated discrimina-
tion [49]. is avoidance perpetuates health disparities,
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 12
Muwanguzi et al. BMC Health Services Research (2025) 25:431
emphasizing the need for trauma-informed, culturally
competent, and stigma-free care.
Transgender individuals are disproportionately aected
by sexual violence, including rape, unwelcome sexual
comments, and unwanted advances [2, 50, 51]. Sexual
violence and its aftermath further reveal how intersect-
ing identities, including gender identity, socioeconomic
status, and occupational vulnerabilities (e.g., sex work),
amplify risks. Participants in this study shared how
healthcare access was complicated by harassment, soci-
etal stigma, and fear of legal repercussions. ese fac-
tors create barriers to seeking care and negotiating safe
practices, particularly for those in contexts like sex work
[52–54]. e resulting emotional distress often leads
to maladaptive coping mechanisms, such as substance
abuse, further impacting health outcomes [55]. Address-
ing these issues requires systemic healthcare reforms,
including trauma-informed care and culturally compe-
tent provider training [56].
Additionally, the role of healthcare providers’ personal
beliefs highlights the intersection of individual biases
with institutional practices, contributing to the denial
of care and inequitable treatment. Such discrimination
not only impacts physical health but also exacerbates
mental health challenges such as anxiety and depres-
sion, reinforcing the importance of intersectionality in
understanding and addressing these disparities [57]. Dis-
crimination rooted in these beliefs manifested as refusal
of care, biased treatment, and lack of understanding of
transgender-specic health needs [58]. Comprehensive
training programs emphasizing professional competency
and arming care are essential to counteract these barri-
ers and foster inclusivity [59].
Finally, the denial of HIV care reflects how gender
identity intersects with systemic healthcare inequities,
resulting in delayed treatments and heightened health
risks. In this study, some participants missed antiret-
roviral treatments (ART) or post-exposure prophylaxis
(PEP), risking their health and increasing HIV trans-
mission [60]. One participant avoided follow-up HIV
testing after being denied PEP, highlighting the dan-
gers of discrimination in healthcare. To mitigate these
risks, healthcare providers must create supportive
environments addressing the unique challenges faced
by transgender women. Community-based initiatives,
such as peer support and drop-in centers, have dem-
onstrated effectiveness in providing stigma-free HIV
care [61]. Furthermore, robust policies protecting
patient confidentiality and preventing discrimination
based on gender identity are critical to building trust
and improving health outcomes.
By applying an intersectional lens, this study under-
scores the urgent need for inclusive policies, structural
reforms, and community-based initiatives to address the
multifaceted barriers transgender women face in access-
ing equitable healthcare. rough this lens, the nd-
ings advocate for a holistic approach to fostering health
equity, grounded in an understanding of the intercon-
nected forms of oppression that shape transgender wom-
en’s experiences.
Strengths and limitations
e study’s strength lies in its detailed documentation of
transgender women’s experiences of violence and abuse
in healthcare settings in Uganda, initiating an impor-
tant discussion through the lens of intersectionality. To
increase transferability, we involved transgender women
from both urban and rural areas. is approach allowed
us to explore the experiences of transgender individu-
als in various settings and gain a more comprehen-
sive understanding of their perspectives. Additionally,
we identied common themes in their experiences by
including participants from diverse geographic locations.
One limitation of the study was the absence of a specic
theoretical framework for data collection, particularly
given the pervasive themes of intersectionality and inter-
sectional stigma throughout the study. Future research
could benet from being guided by an intersectionality
theoretical framework to explore and address these com-
plexities better.
Conclusions
In conclusion, the experiences of transgender women in
healthcare settings, as revealed in this study, highlight
the pervasive and multifaceted nature of violence and
abuse they face. ese women endure a range of viola-
tions, from sexual assault and institutionalized abuse to
dehumanizing treatment, religious impositions, and out-
right denial of care. e themes identied underscore the
signicant barriers transgender individuals encounter in
seeking and receiving healthcare, often exacerbated by
deeply ingrained societal and institutional biases. e
ndings call for urgent reform within healthcare sys-
tems to ensure the protection and dignity of transgender
women, emphasizing the need for comprehensive train-
ing for healthcare providers on trauma-informed, arm-
ing care. Additionally, addressing the structural and
systemic issues that perpetuate discrimination, and vio-
lence is essential for improving the health outcomes and
overall well-being of transgender individuals. Ultimately,
fostering an inclusive and supportive healthcare environ-
ment is not only a matter of equity but also a fundamen-
tal human right.
Future qualitative studies should capture the nuanced
experiences and coping mechanisms of transgender
women who have encountered violence. Furthermore,
additional research should evaluate the eectiveness of
suggested interventions, such as healthcare provider
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 12
Muwanguzi et al. BMC Health Services Research (2025) 25:431
training and initiatives targeting social determinants of
health, to ascertain which measures are most successful
in reducing violence.
Abbreviations
ART Antiretroviral therapy
DIC Drop-in-center
DSD Dierentiated service delivery
FGD Focus group discussion
HIV Human immunodeciency virus
IEC Information education and communication
KP Key population
LGBTQ+ Lesbian, Gay, Bisexual, Transgender and Queer +
MSM Men who have sex with men
PEP Post-exposure prophylaxis
SOGIE Sexual orientation
STI Sexually transmitted infection
TG Transgender
Supplementary Information
The online version contains supplementary material available at h t t p s : / / d o i . o r
g / 1 0 . 1 1 8 6 / s 1 2 9 1 3 - 0 2 5 - 1 2 5 9 1 - 2.
Supplementary Material 1.
Acknowledgements
The authors wish to express their gratitude and acknowledge the following
organisations: Transgender Equality Uganda (TEU), Kuchu Shinners Uganda,
Trans Youth Initiative Uganda ( TYI-UG), Rainbow Shadows Uganda, Tomorrow
Women in Sports Foundation (TWISF), Initiative for Rescue Uganda, Rights
for Her, Anna foundation, Come Out Post Test Club-Uganda (COPTEC), Trans
advocacy initiative (TAI-UG), and Freedom in Harmony.
Authors’ contributions
PAM Concept and design, acquisition, analysis, interpretation of the data, and
manuscript drafting. RN Concept and design of the manuscript, supervision,
data collection, analysis, and drafting of the manuscript. SM Manuscript
design, qualitative expertise, and critical revision for important intellectual
content. All the authors gave nal approval for the work to be published. All
authors agree to be accountable for all aspects of the work to ensure that
questions related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Funding
Research reported in this publication was supported by the Fogarty
International Center, the National Institute of Mental Health, and the Oce of
AIDS Research of the National Institutes of Health under Award Number D43
TW010037. The HIV, Infectious Diseases, and Global Health Implementation
Research Institute (HIGH IRI) at Washington University in St. Louis provided
additional funding.
The funders had no role in study design, data collection and analysis,
publication decisions, or manuscript preparation. The contents are solely the
authors’ responsibility and do not necessarily represent the ocial views of the
supporting institutions.
Data availability
The datasets used and/or analysed during the current study are available from
the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The Makerere University School of Health Sciences Research Ethics
Committee approved the study (Ref. Number: MAKSHSREC-2022-257). Prior to
participation, each participant was asked to provide written informed consent.
This study was conducted in accordance with the ethical principles outlined
in the Declaration of Helsinki and other applicable international and national
ethical guidelines.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 2 September 2024 / Accepted: 17 March 2025
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