3a. Lack of Culturally-Competent Care

 

Amid over 2,200 attacks on Ukrainian health-care facilities (26), there is also a lack of inclusive medical care for LGBTQI+ people. This means that LGBTQI+ Ukrainians go without primary care, as well as specialized gender-affirming health services, such as hormones. Further, since the war, Ukraine has seen a loss of health care personnel, including LGBTQI+-friendly providers. Some doctors have fled, while others are serving on the frontlines. LGBTQI+ individuals worldwide also continue to experience stigma and discrimination when seeking healthcare services (27), and survivor-centered care remains a pressing concern for LGBTQI+ survivors of sexual violence (20).

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Stakeholders and activists express how transgender people face issues accessing essential medicines such as hormones, and this is an issue that recurs “time and time again.” According to an activist in Ukraine:

 

“I think with the trans and intersex populations… a lot of it comes down to medication and having better access to doctors and nurses, and getting access to the medications that they need…”

 

Interruption in access to hormone medication is a particular risk for intersex and transgender refugees. Broadly, hormone medication is not comprehensively included in WHO’s Interagency Emergency Health Kits or in essential medicine lists of civil society organizations during crisis response (20). Interrupted access to hormone medication can be life-threatening for individuals already taking hormone medications (21). Access has been interrupted for trans and intersex Ukrainians during the current crisis, due to pharmacy closures and limited supply (28). While access to hormone medications is vital, there are also protection concerns for refugees outed as transgender (20).

 

3b. Interrupted Access to HIV Prevention and Treatment

 

Ukraine has an especially high HIV rate for Europe, as UNAIDS estimates 260,000 adults and children living with HIV in Ukraine at the time of the invasion (29). Men who have sex with men and transgender individuals (especially transgender women) are especially likely to contract HIV, and HIV-positive individuals at greater risk of harm from COVID-19, as well as other comorbidities (20).

 

Ukraine made substantial progress in HIV prevention and treatment before the war, but the country is now reeling from the war as well as from the U.S. funding pause. Ukraine was the biggest recipient of funding from the U.S. Agency for International Development, and crucial programs for disease prevention, including HIV and tuberculosis, are left unfunded (30). While it is beyond the scope of this white paper to speak to this deadly lacuna, the “America First” policy context is undoubtedly impacting LGBTQI+ people with dangerous implications for disease spread worldwide.

 

3c. Invisible Intersex Issues

 

In Ukraine as well as in host countries, intersex people may face difficulties accessing necessary, appropriately consensual healthcare, leading to unique challenges in the context of the current displacement crisis.

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When children identified as anatomically, chromosomally, or hormonally different from the average infant on the basis of sex characteristics, they are often subject to medical interventions, including surgery and hormonal treatments, aimed at making their bodies more “normal” (31). Since in many cases visible intersex conditions do not seriously affect a child’s health outcomes, these mark a breach of informed consent, where parents are pressured into what are ultimately cosmetic surgeries that can have serious psychological and physical health ramifications (32). Such interventions have been performed in Ukraine since the Soviet Era, and there are no protections against unnecessary, non-consensual medical interventions on intersex people in Ukraine (33). Local intersex activists condemn the practice as harmful (34). This means that intersex refugees from Ukraine may suffer from continuing effects of past medical mistreatment.

 

Environmental stresses may create additional challenges for intersex refugees. Intersex people exhibit higher rates of mental health challenges or psychological than the general population, which may be connected to minority stress and to medical traumas (35). Meanwhile, those with visible variations in sex characteristics may face discrimination and violence in shared housing environments (36).

 

While intersex people may have gender-affirming care needs that overlap with those needed by transgender people, they may also have unique health needs that require specialist treatment or prescription medication. For example, those with certain forms of Congenital Adrenal Hyperplasia may need hormone treatments to maintain basic metabolic functions, with risk of life-threatening adrenal crisis (37). Other conditions may require treatments to maintain lifelong bone density. One intersex activist interviewed noted that while not all intersex healthcare needs may be treated as urgent, stating: “In the end it will turn against you because you will have to pay more for the care later”.

 

Awareness of intersex issues lags, despite a significant percentage of the population (estimated around 1.7% worldwide) having some variation in sex characteristics. In Ukraine in particular, one activist noted that “...intersex is not so popular actually, topic in Ukraine as in Europe.” In Europe, intersex variations are more widely discussed, with European Union-wide initiatives focusing on intersex awareness, official recognition by institutions like the Council of Europe (38), and some countries instituting protections for intersex people (e.g., Greece, Malta). However, many people with intersex variations may thus not be used to openly discussing their differences with others, nor know that they have support when intersex-specific resources are available. Intersex people may use a variety of language to describe themselves, and language barriers can complicate this further.

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Meanwhile, European organizations focusing on intersex are still chronically underfunded compared to other organizations focusing on sexual and gender minorities. In 2021-2022, intersex organizations received around 1% of global funding geared towards LGBTQI+ communities overall, and a single donor (Intersex Human Rights Fund) made nearly half of all grants out to intersex organizations (39). Participants also noted that larger umbrella organizations may compete with them for funding. Ultimately, access to intersex-focused supports emerge as an access gap from a constellation of social and fiscal challenges.

 

Despite these barriers, intersex organizations continued to organize mutual aid and support for intersex Ukrainians displaced by the full-scale invasion. A “second system” mobilized to cover systemic imbalances in the broader provision of healthcare. Larger LGBTQI+ organizations and general refugee-serving organizations were a vital source for grant funding in the immediate months following the full-scale invasion, allowing local organizations to directly support displaced Ukrainians where needed. Medical, financial, and psychosocial support helped refugees to adapt. An intersex organizer noted:

 

“...We basically kind of worked with some doctors, so when people got in touch with us, and they said, 'Oh, my child doesn't have Hormone Replace Therapy,' or 'My daughter needs steroids” or something … then we provide that contact with a doctor.” This second system of support enabled intersex people to access needed therapeutics.