HEALTH CARE ACCESS BY TRANSGENDER PERSONS IN SOUTH AFRICA: GENDER-BASED DISCRIMINATION, HUMAN RIGHTS VIOLATIONS, AND THE ROLE OF THE AFRICAN HUMAN RIGHTS SYSTEM

LGBTQIA people, all around the world, experience violence, discrimination, and rights violations almost daily. In the field of human rights and healthcare more specifically, trans people have unique health risks and they face further rights violations, public shaming, and institutional violence when trying to navigate through an essentially cisgender healthcare system. On that account, this research aims to explore transgender persons’ right to access health care (or lack thereof) in South Africa and possible remedies in the African human rights system. The methodology employed consists of a brief review of literature, a qualitative design based on multiple sources, and theoretical reasoning embedded in the larger framework of human rights, more specifically a human rights-based approach to health care. The goal is to employ a somewhat innovative human rights-based approach to health care access and to analyze which international responsibilities the Republic of South Africa has regarding the health rights of transgender persons. Both the advantages and limits of international adjudication and advocacy on behalf of trans people in the African system are also discussed.


INTRODUCTION
Historically, transgender persons 1 have been discriminated against and marginalized in almost all aspects of life in society. Additionally, they face greater barriers when trying to access health care, mainly due to the absence of adequate care for transgender patients in pathology and laboratory medicine, structural and financial barriers, as well as a lack of health care policies, and the inability of healthcare professionals to provide appropriate care for this population (GUPTA et al., 2016;FANTZ, 2014).
In Africa, violence against LGBTQIA persons is a critical area of concern (ARCUS FOUNDATION, 2019), and according to Jobson et al., (2012), transgender persons face further discrimination and invisibility in epidemiological data from African countries, especially in HIV risk determination, even though these populations face higher HIV prevalence rates. In South Africa specifically, a qualitative study performed by  shows that all trans participants interviewed experiencedat different levels -discrimination by healthcare providers based on their sexual orientation and/or gender identity.
In the field of human rights and health care more specifically, even though LGBTQIA people, in general, are susceptible to experiencing discrimination at public health facilities in South Africa , trans people have unique health risks and they face further rights violations, public shaming and institutional violence in all parts of life but especially when trying to navigate through an essentially cisgender healthcare system (GIBLON;BAUER, 2017;LUVUNO et al., 2019).
Moreover, according to Human Rights Watch (HRW) (2011, p. 1): "black lesbians and transgender men in South African townships and rural areas face an overwhelming climate of discrimination and violence despite protections promised them in the country's constitution". HRW conducted 120 interviews in six provinces, which demonstrated that transgender persons face overwhelming discrimination in their daily lives both from individuals and government agents (HRW, 2011). This structural violence reflects directly on the kind of care they receive when navigating the country's healthcare system.
Previous works on the transgender population and health care in South Africa have discussed the issue of accessibility before, as well as service mapping and the quality of care (e.g., LUVUNO et al., 2019;SPENCER et al., 2017;WILSON et al., 2014), but did not necessarily incorporate a human rights-based approach, except from the comprehensive works of Müller (2016; and some other sparse contributions. Therefore, this article is an effort to contribute to the literature on transgender persons' access to health care in South Africa, from a human rights viewpoint. In lieu of possible rights violations, the role of the African human rights system is also discussed, exploring health care access as an international obligation of the state. The judicialisation of human rights in African politics is an emerging theme (BRETT, 2020), with unique nuances. Thus, this research modestly contributes to the expansion of the literature on the judicialisation and international adjudication of the right to health in South Africa more specifically, with possible repercussions to all state parties of the System. Both the advantages and limits of international adjudication and advocacy on behalf of trans people are also discussed.

RESEARCH METHODOLOGY
The methodology employed consists of a brief review of the literature (JESSON et al., 2011) on varied topics related to human rights and transgender health -as well as barriers to accessing and securing adequate health careaccompanied by inductive reasoning that is based on sources and findings of the article.
The research is qualitative (BUSETTO et al., 2020) in its nature, and data is gathered from multiple sources. This article employs, in general, a mix of exploratory and argumentative narratives, aiming to uncover crucial themes related to LGBTQIA health in South Africa.
In addition, the theoretical background of this article is embedded in the larger framework of human rights, more specifically a 'human rights-based approach' (HRBA) to health care (LONDON, 2008) and the international human rights obligations of the state under the African Charter on Human and Peoples' Rights (UN HUMAN RIGHTS, 2018).
Ultimately, the goal is to explore transgender persons' right to access health care (or lack thereof) in South Africa and possible remedies in the African human rights system.

THE STATE OF LGBT RIGHTS IN THE AFRICAN HUMAN RIGHTS SYSTEM
Regional human rights systems are those systems designed to protect and implement human rights in a specific part of the world, as such, they possess particular legal instruments, judicial and nonjudicial bodies, and specific procedures. According to Heyns et al., (2006), regional systems complement the general mandate of the global human rights systemin which the UN plays a major roleand they also allow regional values to be considered when human rights norms are constructed.
Therefore, "regional human rights protection mechanisms constitute important pillars of the international system for the promotion and protection of human rights" (BENEDEK et al., 2010, p. 2).
Generally, a regional human rights system will have its mandate under the auspices of a regional integration body or system that usually has a broader scope than just human rights -in the case of Africa, the African Union (AU); in the Americas, it is the Organization of American States (OAS); and in Europe, the Council of Europe (CoE) (HEYNS et al., 2006).
The African human rights system (hereinafter referred to as the "African System", or just "System") was born from the African Charter on Human and Peoples' Rights, adopted in June 1981.
The African Charter, as described by Evans and Murray (2002) is the regional mechanism for the promotion and protection of human rights on the African continent and has many unique nuances.
Although the System has received its fair share of critiques over the years, both from scholars and practitioners, "there is evidence to support the supposition that the African system that in the past was of very little value now assumed much greater importance given the basic shifts in the continents political economy" (KUFUOR, 2010, p. 3).
In 2016, an important historical milestone was reached by the African System, which marked the 30th anniversary of the entry into force of the African Charter and the tenth anniversary of the operationalisation of the African Court on Human and Peoples' Rights Centre for Human Rights, University of Pretoria, (2016). Another important fact is that all African Union member states have ratified the African Charter, except Morocco. The institutional structure of the System can be seen in Figure 1. It is important to stress that LGBT rights are not a set of "special rights", instead, they are the same universal rights that LGBTQIA people, like others, should be able to enjoy (THORESON, 2014, p. 94) but are often neglected of due to violence and discrimination. The African Charter, which is the cornerstone of the African human rights system, does not mention any explicit reference to sexual orientation or gender identity. This resistance to incorporate the discourse on the human rights of African LGBTQIA persons into the System's agenda is a product -among other things -of the "African morality and traditional values" that allow or even require discrimination against these people; and the anti-LGBT sentiment that is rooted in the majority of African societies (VILJOEN, 2016 However, one cannot overlook some positive achievements within the African regional human rights framework, such as recent applications of the African Charter on behalf of the rights of LGTBQ+ people (see IZUGBARA et al., 2020). The problem is that legal and policy instruments within the System do not explicitly mention LGBTQIA persons and lack clear and effective mechanisms for answerability among member states (IZUGBARA et al., 2020). Despite that, according to Kerrigan (2013, p. 15), the African human rights system still is an important forum for discussion of LGBT rights and gender issues.
Therefore, possibilities and limitations of the advocacy for and judicialisation of LGBT rights in the African human rights system will be discussed further on, focusing on the transgender persons' right to access health care in South Africa.

HUMAN RIGHTS AND THE LGBTQIA COMMUNITY IN SOUTH AFRICA
Concerning terminology: as both categories of gender and sexual orientation can be fluid and encompass a variety of spectrums that represent different identities, the LGBTQIA acronym here utilized is not meant to totalize or exclude anyone, instead, it is viewed as an umbrella term which refers to the community as a whole. The important thing is to deconstruct binary notions around gender and sexuality and unmask "[…] the complicated realities and variety in the realm of social identity" (KANG et al., 2017, p 34), instead of favouring binary systems. Therefore, when one uses the terminology " LGBT" rights, one is simply referring to the transnational advocacy movement on behalf of the human rights of LGBTQIA people (THORESON, 2014); the aim is not to exclude other identity categories, but to employ what Winer (2015, p. 82) classified as "higher levels of generality" in the discourse concerning LGBT rights and international human rights law.
With that said, the quest for LGBT rights in South Africa -and the African continent more generallyis not a new topic, researchers in a variety of fields have already explored the issue from different perspectives. Nyeck and Shepherd (2019) explored the economic consequences of LGBTQIA discrimination in South Africa in the context of LGBT rights and the socio-political sphere. According to them, the Constitution of South Africa is a progressive document with substantive protections that are beneficial for LGBTQIA persons, however, negative attitudes towards this population are still very common. From a legal perspective, Venter (2021) argues that cases discussed in the South African judicial system have been proactively pursued to remedy human rights violations committed against LGBTQIA individuals in South Africa, whilst on the other hand, there is a huge discrepancy between the Earlier, Christiansen (2000) and Massoud (2003) arrived at the same conclusion: that despite a progressive legal change in favour of LGBT rights in the country, there was a gap between progressive laws and South African conservative social attitudes. Therefore, LGBT rights in South Africa remain an unfulfilled promise:

JOURNAL HEALTH AND TECHNOLOGY -JHT ISSN 2764-7625 HEALTH CARE ACCESS BY TRANSGENDER PERSONS IN SOUTH AFRICA: GENDER-BASED DISCRIMINATION, HUMAN RIGHTS VIOLATIONS, AND THE ROLE OF THE AFRICAN HUMAN RIGHTS SYSTEM Erick da Luz Scherf, Maria de Lourdes Alves Lima Zanatta, Marcos Vinicius Viana da Silva, Jose Everton da
The country now has some of the most progressive LGBTQ laws in the world, including full constitutional protections against discrimination. This legal environment is unmatched on a continent where colonial-era laws against gay sex are still commonplace, and where offenders in some nations face the death penalty.
[…] The rights promised on paper in South Africa remain out of reach for many who need them most, particularly those fleeing homophobia elsewhere. For them, a quite different South Africa awaits: morally conservative, hostile to outsiders, and often profoundly violent (DE GREEF, 2019, p. 4;6).
In sum, when talking about LGBT rights in South Africa, there seems to be a consensus around the fact that there is a stark contrast between the written policies and lived experiences of LGBTQIA persons (PILLAY, 2018, p. 2). It is important to highlight that this scenario is even worse in the case of transgender people: according to a recent and comprehensive study by Luhur, Mokgoroane, and Shaw (2021), many transgender persons are not able to obtain legal recognition of their gender (especially those from the poor working class, peri-urban, or rural areas), which often blocks them from obtaining proper legal documents, "[…] essentially prohibiting access to basic services such as health care, education, employment, and travel; receiving social grants; or undertaking essential tasks such as opening a bank account, accessing temporary housing, acquiring a driving license, and voting" (LUHUR; MOKGOROANE; SHAW, 2021, p. 2), among other discriminatory measures such as lack of access to access to bathrooms according to gender identity.
Recently available studies have also focused on the issue of transgender people's access to health care in South Africa, whereas they have indicated the encounter of institutional violence, ignorance, and micro-aggressions by healthcare workers towards trans persons (LUHUR; MOKGOROANE; SHAW, 2021). Going forward, the intention is to add up to this conversation, addressing the delivery of health care services to these populations from a human rights viewpoint. The main argument is that transgender persons' access (or lack thereof) to adequate healthcare in South Africa is not solely a gender or socio-cultural issue, but a human rights issue that should be addressed as such by researchers and the international community, especially when advocating for better health policy outcomes in favour of people who identify as transgender.

TRANSGENDER PERSONS' ACCESS TO HEALTH CARE IN SOUTH AFRICA AS A HUMAN RIGHTS ISSUE
The right to health, or the right to the enjoyment of the highest attainable standard of physical and mental health, in its full name, is not new. It was first introduced, internationally, in the 1946 legal obligation on states to ensure access to timely, acceptable, and affordable health care of appropriate quality as well as to providing for the underlying determinants of health, such as safe and potable water, sanitation, food, housing, health-related information and education, and gender equality." Therefore, the right to health encompasses an array of obligations and components to be followed and provided by the state, including the duty to provide equal and non-discriminatory access to health care (GIORGI, 2012). In addition, the WHO states that (2017, p. 5): "non-discrimination and equality requires states to take steps to redress any discriminatory law, practice or policy."

JOURNAL HEALTH AND TECHNOLOGY -JHT ISSN 2764-7625 HEALTH CARE ACCESS BY TRANSGENDER PERSONS IN SOUTH AFRICA: GENDER-BASED DISCRIMINATION, HUMAN RIGHTS VIOLATIONS, AND THE ROLE OF THE AFRICAN HUMAN RIGHTS SYSTEM Erick da Luz Scherf, Maria de Lourdes Alves Lima Zanatta, Marcos Vinicius Viana da Silva, Jose Everton da
When talking about disparities in health and healthcare access, Baptiste- Roberts et al., (2018) argue that substantial attention has been given to race/ethnic and socioeconomic disparities, but not enough focus was directed towards sexual orientation and gender healthcare disparities, especially in the context of sexual minorities. The concept of "LGBT health" was brought up to address these challenges at some level, which means that LGBTQIA individuals have specific health needsi.e., they are frequently exposed to increased risk of disease that requires specialized, culturally appropriate Transgender persons suffer significant health disparities in multiple arenas. Real or perceived stigma and discrimination within biomedicine and the healthcare provision in general may impact transgender people's desire and ability to access appropriate care. Transgender women (male to female) are internationally recognized as a population group that carries a disproportionate burden of HIV infection, with a worldwide HIV prevalence of 20% […] Although some of these healthcare barriers are faced by other minority groups, many are unique, and many are significantly magnified for transgender persons. 9 care in South Africa, framing the issue in the language of human rights. The issue of access to health care by LGBTQIA persons in South Africa has been thoroughly discussed before by Müller (2016; and Meer and Müller (2017) (amongst others) in terms of health policy and "queer health needs".
According to them, healthcare spaces are overwhelmingly heteronormative and even though LGBTQIA or queer service users indeed challenge the system, "wider efforts are needed to transform the material and ideological space of healthcare facilities through law and policy reform and continuing professional training for healthcare providers" (Meer and Müller, 2017, p. 92). Therefore, the aim is to elaborate on that by exploring how the African human rights system (can or cannot) force health law and policy reform in favour of LGBTQIA people in general, but especially for transgender individuals.
The majority of respondents in a survey reported by Stevens (2012) stated that health workers in South Africa presented either discriminatory or hostile behaviour, or both. In addition, 60% of transgender respondents in the same study appear to have gone through negative experiences in public health facilities (STEVENS, 2012). Therefore, this seems to be the firstand maybe the biggest -barrier to the access of transgender persons to adequate health care in the country: implicit or explicit transphobia and/or gender-based violence (either physical or symbolic) perpetrated by healthcare workers and service providers.  (CHRISTENSON, 1991). It is important to notice that access to healthcare, in general, is challenging in South Africa due to economic disparities, but that SGMs encounter in addition all sorts of institutional and interpersonal violence when seeking medical attention: […] where the vast majority of the population depend on health services in the underresourced and overburdened public sector […] [And] in this highly unequal system, sexual and gender minority people face the general challenges of service and supply unavailability, long waiting times, and a lack of specialized personnel and services, but also encounter homo-and transphobic discrimination and prejudice on top of these other barriers (MÜLLER, 2017, p. 2).
In addition, transgender women in South Africa are disproportionately affected by the HIV epidemic, being at greater risk of acquiring it even at early stages of life such as adolescence 10 (SULLIVAN et al., 2020). The lack of adequate and efficient public health measures to tackle this problem and to prevent these often marginalized individuals from acquiring HIV or to provide them with adequate treatment if they do so can also be interpreted as a health rights violation, in the sense that "[…] a lack of respect for human rights fuels the spread and exacerbates the impact of the disease, while at the same time HIV undermines progress in the realisation of human rights" (OHCHR, 2021, p.

JOURNAL HEALTH AND TECHNOLOGY -JHT ISSN 2764-7625 HEALTH CARE ACCESS BY TRANSGENDER PERSONS IN SOUTH AFRICA: GENDER-BASED DISCRIMINATION, HUMAN RIGHTS VIOLATIONS, AND THE ROLE OF THE AFRICAN HUMAN RIGHTS SYSTEM Erick da Luz Scherf, Maria de Lourdes Alves Lima Zanatta, Marcos Vinicius Viana da Silva, Jose Everton da
3).
Nonetheless, as well argued by Ngwena (2000), only the formal recognition of access to health care as a human right in South Africa under the Constitution as well as international human rights instruments might not be enough to provide people with the full enjoyment of this right. Underinvestment in the state-funded health system, poverty, and other socio-economic inequalities -as well as the discriminatory behaviour above describedalso contribute to poor health outcomes and to the (low) quality of care that is delivered. That is why we propose a human rights-based approach to healthcare access. In that sense, "human rights approaches can include holding states and other parties accountable, developing policies and programs consistent with human rights, and facilitating redress for victims of violations of the right to health" (LONDON, 2008, p. 65). Going forward, both possibilities and limitations to redress measures in the African human rights system will be discussed, bringing forward the role of the System in addressing the health rights of transgender persons in the South African context.

ADVOCACY, JUDICIALISATION, AND NAMING AND SHAMING STRATEGIES IN THE AFRICAN HUMAN RIGHTS SYSTEM
Taking into account the discussion in previous sections, one can affirm that transgender persons encounter several barriers and possible rights violations when trying to navigate through the public, state-funded health system in South Africa. This statement in itself is not necessarily new and has been explored before by other authors. The novelty in what is being proposed here relies on the avenues for accountability and redress for the victims of health rights violations, in the African human rights system specifically. That important portion of the HRBA to health has not been sufficiently explored in the literature on LGBTQIA health and rights in Africa. Thus, a "human rights tripod framework" will be presented which involves: (i) transgender rights advocacy; (ii) judicialisation of health rights; and (iii) "naming and shaming" strategies in the African human rights system. Both possibilities and limitations to this approach will also be discussed going forward.

Advocacy
According to the OHCHR's Manual on Human Rights Monitoring (2011, p. 5): "advocacy involves a wide variety of techniques, including direct or indirect pressure, politeness, humility, showing empathy for the interlocutor, praise and stressing mutual objectives or developing solutions together.
An act as simple as the dissemination of human rights documents can be an effective tool […]." Advocacy then means taking action on behalf of (or alongside) a person, group of people, or community in order to get a certain message across to relevant stakeholders and to seek remedies to suffered injuries, especially in the context of rights violations. As stated in the Manual, human rights advocacy may encompass a wide range of tactics in public education, media work, lobbying, political action, legal advocacy, and monitoring (LORD et al., 2012, p. 2

of Part 3).
We believe that in the context of the health rights violations of transgender persons in South Africa, multidimensional rights advocacy alongside "client-centered" human rights advocacy (HAYNES, 2006) may be the most beneficial strategy for achieving redress measures as well as change in societal and policy structures. In that sense, advocates for transgender rights and LGBT rights, in general, should take into consideration different platforms for activism that should address not only the legal system, but the oppressive schemes built into cultural, economic, and political practices. In that sense, we propose the adaption of Carroll's (2010) six-steps plan for effective LGBT rights advocacy (see Figure 2).
It is important to stress that advocacy put forward by civil society organisations already takes place in South Africa. OUT for example is one of the oldest LGBT organisations in the country and has been involved with advocacy work since 2006 (OUT, 2021). Supported by ActionAid South Africa, the Rainbow Activist Alliance (RAA) "[…] works with more than 450 lesbian and bisexual women to challenge the patriarchal and discriminatory attitudes and perceptions in their communities that fuel violence." (ACTIONAID USA, 2021, p. 11). In addition, when it comes to advocacy for transgender rights more specifically, Gender Dynamix (GDX), established in 2005, "is the first registered Africa-based public benefit organisation to focus solely on trans and gender diverse communities" (GENDER DYNAMIX, 2021, p. 1). The work of these organisations (and the people that compose them) is essential to LGBT rights advocacy in South Africa, and in the whole African continent to a certain extent. In the context of human rights regimes and regional human rights monitoring bodies, both domestic and transnational advocacy mobilization has been indicated as key to fostering human rights compliance and appropriate governmental response to rights violations (MORAVCSIK, 2000;KECK;SIKKINK, 1998). In the African human rights system, local African civil society organisations and networks helped consolidate the mandate of the system and expand its significance (OKAFOR, 2007).
However, still, there is "[…] limited direct access by individuals and NGOs to the Court due to a limited number of States that have accepted the Court's jurisdiction and allowed individuals and NGOs direct access to the Court." (SSENYONJO, 2018, p. 41). Nonethelessdespite the limitations and constraints -advocacy, campaigning, and activism still represent important tools in the task of denouncing rights violations, demanding reparations, and changing harmful policies and practices. Going forward we will explore how advocacy can translate into judicialisation or international adjudication of the health rights of transgender people in the South African context.

Judicialisation
According to the LEXICO online dictionary (2021, p. 1), to judicialise means "[…] make [something] judicial in character; to treat judicially; […] subject to judicial process or decision." In the context of human rights, it mostly means bringing human rights violations to the attention of a judicial body which will then analyse the claims and eventually provide a decision, either binding or non-binding.

STEP 1
Prepare Getting accostumed to international and regional human rights law, standards and obligations With the "reborn" of international law in the post-Second World War scenario, international human rights institutions and regimes have proliferated worldwide. The so-called "language of human rights" has found fertile soil to grow in and "the proliferation of international courts and tribunals in the last two decades has been an important new development in international law" (HERNÁNDEZ, 2014, p. 919). Therefore, the phenomenon of "judicialisation" has become quite common, especially in regional human rights mechanisms but also at the global level, especially within the United Nations system. The term is also widely used especially in the Political Science literature: The judicialisation of politics-the reliance on courts and judicial means for addressing core moral predicaments, public policy questions, and political controversies-is arguably one of the most significant phenomena of late twentieth-and early twentyfirst-century government. Armed with newly acquired judicial review procedures, national high courts worldwide have been frequently asked to resolve a range of issues from the scope of expression and religious liberties and privacy to property, trade and commerce, education, immigration, labour, and environmental protection (HIRSCHL, 2013, p. 1).
The processes of constitutionalisation of rights either at the domestic or international level have also contributed to the possibility of human rights adjudication (NWEZE, 2007). Therefore, Courts and other quasi-judicial bodies play an increasingly important role in developing, implementing, and shaping legal standards and understandings in the field of human rights. According to Hillebrecht (2014, p. 3) "the rise of the international legalization of human rights now makes it possible for individual constituents to sue their governments at international courts like the European Court of Human Rights (ECtHR) and the IACtHR", which is part of the judicialisation trend in human rights practice. In Africa, Brett (2020, p. 1) argues that three main factors have made judicialisation possible in the continent as a whole: " […] new corporate rights norms (including the expansion of indigenous rights), the proliferation of new avenues for legal proceedings, and the development of new support structures enabling litigation".
Judicialisation of human rights has served as a trampoline in many countries to reach rights recognition and realisation, especially in Latin America where the Courts have played an active role in upholding the rule of law and making up for the lack of respect for human rights and democratic institutions and processes (MADEIRA; GELISKI, 2017). Even though there is also evidence of backsliding or deterioration in compliance with human rights (TASIOULAS, 2019(TASIOULAS, , p. 1196, judicialisation still provides avenues for accountability and enforcement of legal rights either in domestic or international institutions and jurisdictions (ANSOLABEHERE, 2016). Judicialisation of the right to health more specifically is also a recurring theme in health law. Although the evidence found is far from convergent on this subject, the main findings are that judicialization of the right to health is crucial to ensure patients access to services to which they are entitled but was eventually denied (BIEL et al., 2016;FERRAZ, 2016;RIBEIRO;HARTMANN, 2016). The problem seems to be that judicialisation of health care and health rights may not translate into beneficial changes for society and the rights of the JOURNAL HEALTH AND TECHNOLOGY -JHT ISSN 2764-7625

HEALTH CARE ACCESS BY TRANSGENDER PERSONS IN SOUTH AFRICA: GENDER-BASED DISCRIMINATION, HUMAN RIGHTS VIOLATIONS, AND THE ROLE OF THE AFRICAN HUMAN RIGHTS SYSTEM Erick da Luz Scherf, Maria de Lourdes Alves Lima Zanatta, Marcos Vinicius Viana da Silva, Jose Everton da Silva
LGBTQIA community in this context, possibly generating negative impacts on equity if the litigation is conducted in an individualized fashion (ANDIA; LAMPREA, 2019).
In addition, judicialisation also depends on the strength of the judicial or non-judicial body and its ability to push for the implementation of its decisions. In the context of the African human rights system, the roles of the African Commission on Human and Peoples' Rights (hereinafter the "African Commission") and the African Court on Human and Peoples' Rights (hereinafter the "African Court") in upholding human rights standards and norms in the African continent has been widely contested. Critics argue that the protective role of the African Commission, its quasi or non-judicial stature, and the nonbinding nature of its decisions are virtually ineffective to realize human and peoples' rights in the African continent (EZENNIA, 2015). Furthermore, when it comes to the African Court, access for individuals and groups to the Court's judicial mechanism is highly limited (EZENNIA, 2015), alongside other limitations imposed by the rule of exhaustion of domestic mechanisms (ONORIA, 2003). In sum, judicialisation in the African human rights system may be difficult in the sense that "[…] access to these [judicial] mechanisms elude most African individuals and groups. As such, their quest to obtain justice through [them] is often defeated" (EZENNIA, 2015, p. 118).

Naming and shaming
"Naming and shaming" is the process through which people, organisations, or third countries publicly denounce the abusive practices and human rights violations of the so-called "shamed" country. This is an emerging concept in the human rights literature and movement, and there is still little empirical evidence of its efficacy or inefficacy. According to Ausderan (2014, p. 93), "although naming and shaming is meant to coerce governments into stopping human rights violations, its track record has been mixed […]." Nonetheless, naming and shaming still is the most used strategy by human rights groups (FRANKLIN, 2015, p. 46). As enforcement of human rights norms and principles highly depends on available information on abuses and violations, publicisation of rights violations and mobilising public opinion seem to be the centre of the task for compliance and accountability: "[…] naming and shaming becomes the primary tool that is available to groups that support human rights against governments that are not already committed to human rights reform. Furthermore, naming and shaming can be used to pressure third-party governments to utilize coercion or sanctions against violating governments" (FRANKLIN, 2015, p. 46). On the other hand, the mere publicisation of human rights violations may not necessarily translate into accountability for the state and redress for the victims. Moreover, due to prejudices yet rooted in many African societies, public opinion might not favour the discourse on transgender rights. Therefore, it is unclear whether or not healthcare providers or government authorities would be successfully "shamed" for violating the health rights of transgender individuals in South Africa.

CONCLUDING REMARKS
Based on the experiences of transgender persons with public health clinics in South Africa, described in previous studies and surveys, this article aimed to explore transgender persons right to access health care (or lack thereof) in the South African Republic and possible remedies in the African human rights system. Discrimination, public shaming, and violence of all sorts were usually encountered by these non-gender conforming individuals when trying to navigate through an essentially cisgender health care system. Thus, even though the right to non-discrimination is present both in the South African Constitution and the African Charter, there seems to be a consensus amongst LGBT rights scholars that there is a huge gap between formally recognized rights and the lived experiences of LGBTQIA persons in that country. This anti-LGBT sentiment has perverted the mind and actions of many healthcare delivers, who serve as gatekeepers that prevent equal access to healthcare by gender and sexual minorities.
This paper addresses a relevant and important question -if and how African regional human rights mechanisms can be employed to address health rights violations of trans persons in South Africa.
It considers the topics of bias and discrimination, violations of human rights, and human rights activism and systems' responses. We proposed that the lack of access to adequate health care services by transgender persons in South Africa be viewed and interpreted through the lenses of human rights.
Transgender people are human and therefore are entitled to the same rights any other human being possesses. However, they are not viewed as equal by their gender-conforming counterparts and are therefore subjected to discrimination and rights violations. Thus, we chose to examine the role of the African human rights system in addressing these abuses, proving redress measures, and preventing future violations from happening. It was identified that the question of LGBT human rights remains residual, to say the least, in the System's human rights agenda but that it might still be an important forum for discussion of LGBT rights and gender issues. Considering that, we analysed mainly three strategies to be employed within the System: (i) transgender rights advocacy; (ii) judicialisation of health rights; and (iii) "naming and shaming" strategies. Some limitations of this research article are that, for example, we were not able to track more queer/LGBTQIA outreach work being carried out by activists in South Africa. Advocacy seems to be an important feature of LGBTQIA movements in South Africa and can provide avenues for challenging transphobic practices in and outside healthcare structures. However, judicialisation and "naming and shaming" strategies -which are common themes in the Western liberal tradition of human rights -do not seem to fit correctly into the South African context. Access to judicial measures by individuals and groups in the African human rights system is still very limited. Equally, naming and shaming health care providers or government authorities for their discriminatory behaviour towards transgender or other LGBTQIA individuals may not be as effective in a society with little if no regard for the well-being of gender and sexual minorities. In addition, health rights litigation may not produce positive effects beyond the individual level and may also result in negative impacts on equity in health care provision. Moreover, we wish we could have further explored past judicial or advocacy efforts within the African human rights system concerning LGBT rights, but that information was relatively hard to come by.
Nonetheless, in sum, the African system's historical lack of effective response to LGBT rights violations in the African continent, alongside weak enforcement instruments, suggests that this may not be exactly the right forum to address the health rights violations of transgender people in South Africa.
In that sense, we encourage future research on this topic to indicate or propose other solutions that are more aligned with the institutional reality of human rights in Africa. Nonetheless, the Courts cannot change a nation, it is only through Education that is sensitive to gender and human rights issues that progress in interpersonal relations can be achieved. Prejudice must be addressed and fought against in the legal system as well but can only be eradicated (or at least reduced) when cultural and socio-political practices are contested and transformed. Legal instruments alone will not likely provide the liberation of transgender people in South Africa and transgender human rights movements might have to combine strategies at other levels of society to achieve equality.

Notes
1. In the context of this research, we adopt the definition of transgender provided by the American Psychological Association (2011, p. 1), as follows: "transgender is an umbrella term for persons whose gender identity, gender expression, or behaviour does not conform to that typically associated with the sex to which they were assigned at birth. Gender identity refers to a person's internal sense of being male, female, or something else; gender expression refers to the way a person communicates gender identity to others through behaviour, clothing, hairstyles, voice, or body characteristics."