Health care services and challenges among transgender in India

INTRODUCTION

Transphobia is a health issue

Transgender is a term defined as individuals with gender identity is different compared with those who are born with male and female anatomies. Transgender are those people who face rejection initially by even community members and their own family. Because of their different body structure they feel shame, disgrace, exclusion from society, transgender children's are abused, treated by someone unfairly and punished by their own families in hope of changing them as per social norms.^1,2

Transgender category includes transgender male, transgender female, male to female (MTF) and female to male (FTM). It also includes cross-dressers (are the one who wear clothes of the other) gender queer people (they feel they belonged to either both genders or neither gender) and transsexuals. In India, there is wide range of transgender people like Hijras, Aravanis, Kothi’s, Jogatas/Jogappas, Shivshaktis.²

Hijras; is a Persian word translated as eunuch it is used in common parlance for transgender community in India. Aravanis; it is a term used for male transgender who undergo genital modification through SRS (Sex Reassignment surgery) or perform Nirwaan which is a traditional mode of castration. Kothi; is used for those who adopt a feminine role in same sex relationships, but do not live in communes as Aravanis. Jogtas/Jogappas; they are found in Maharashtra and Karnataka are male to female transgender who devote themselves to the service of a particular God. Shivshakti; it is found in Andhra Pradesh, are males who are considered to be married to Gods particularly to Lord Shiva.³

The “Hijras” claim their origin to Mughal era while Kinnars and Aravanis draw their heritage from pre-Mughal Hindu era. While these groups bagged respect and socio-economic security in Mughal era, the criminal tribes act 1871 by Britishers treated these groups as criminals by birth who could possibly kidnap and castrate children .This was the one of the reason that leads to stigmatization and exclusion of these groups from the mainstream society.⁴

Current article mainly focusing on transgender health services and their rights in India.

TRANSGENDER IN INDIA

India for the first time in 2011 had an official count of Transgender as 4,90,000 out of 1.21 billion total population. There are 22,364 Transgenders in Tamil Nadu.⁵ The NACO 2015 study showed that 20 percent transgender experienced some form of physical or sexual violence in the last 12 months preceding the survey.⁶ The NACO study also brings forth associations of excessive alcohol use before and during sex work and transgender people’s inability to properly use condoms. Together, this combination of “gender deviance” as per society, “sex work” and an “HIV infection” triples their stigmatization, discrimination, harassment and exclusion in the society. The result is psychological distress due to rejection from everyone i.e. family, friends, relatives, neighbours, schools, and work places. All these factors are associated with higher rates of post-traumatic stress disorder (PTSD), anxiety, depression, suicidal tendencies and substance abuse among them.⁷

Transgender healthcare system in India

India’s supreme court recognized transgender people as the third gender along with male and female in 2014 for the purpose of safeguarding their rights under our constitution and the laws made by parliament and the state legislature. The rights of transgender persons bill 2014 revised as the transgender persons (protection of rights) bill, 2016 mention the following as Government’s responsibility in relation to providing healthcare to transgender in India; separate HIV sero-survillance centres, free of cost SRS, counselling services, schemes to cover medical expenses and barrier free access to healthcare institutions.⁸ The bill was reintroduced in the parliament in 2019 and finally enacted into a law. Key features of the law are; non-discrimination, certificate of identity, equal opportunity policy for transgender persons, complaint officer, welfare schemes, medical care facilities, National council for transgender persons (NCT), offences and penalties and infrastructural facilities (such as unisex toilets).

HEALTH PROBLEMS FACED BY TRANSGENDERS

HIV

Communicable diseases like STD/HIV are more common among transgender due to lack of adequate knowledge of exposures, hygiene practices, lack of access to health care services. In Worldwide, prevalence of HIV infection are 49 times more in the transgender persons than the general adult population.⁹ In India, National HIV prevalence is 0.31% whereas estimated transgender HIV prevalence is (8.2%) about 20 times higher than the general population, and highest among key populations (Female sex workers, Drug users and Homosexuals).¹⁰ This means that local authorities need to ensure that they have health and social programme that meet the needs of Hijras and has given them the right to vote.¹¹

Mental health

Nearly half of the Hijra participants in one study suffered from psychiatric disorders, ranging from alcohol abuse and dependence to depressive spectrum disorders, but despite the presence of psychiatric disorders in participants, Hijra women are commonly experienced as discriminatory attitudes and institutional difficulties for their basic needs. This attitudes towards Hijra is extremely invasive and destructive for their mental health and leads to sense of loneliness.¹²

Suicidability and non suicidal self harm

A lifetime presence of NSSI was identified in 46.3% of patients and 28.73% reported currently engaging in NSSI (within at least the past few months). Analyses showed that those with a lifetime presence of NSSI had significantly greater general psychopathology, lower self-esteem, had suffered more transphobia, and experienced greater interpersonal problems than those without NSSI.¹³

Tobacco use

Cigarette smoking among LGB individuals in the India. Is higher than among heterosexual/straight individuals. More than 30,000 LGBT persons die each year of tobacco related diseases. Non-smoking lesbian women having more exposure to second hand smoke than non-smoking straight women.

Violence and victimization

Five distinct profiles of Indian TGW were identified based on the type and severity of victimization: low victimization, high verbal police victimization, high verbal and physical police victimization, moderate victimization, and high victimization. TGW in the moderate victimization and high victimization have higher sexual risk than TGW in the low victimization profiles.¹⁴

Impact of exclusion and discrimination

The exclusion and discrimination have major impacts on the lives of transgender persons, dropping out of school earlier, leaving home and family, unable to find regular jobs, have less options than others, being ignored in the community and isolated, mobilization to urban areas, lack of family and social support, migration to other countries (safer livelihood and acceptance ), rejected from religion (especially Muslim and some Christian fundamentalist sects), attempt suicide and decide to follow their parents to marry opposite sex and then divorce.

Problems of homelessness

The major problems for transgender people who are homeless include a lack of housing and services that meet their specific needs. They are living on city’s streets because they were thrown out of their homes for being queer, or ran away to escape an abusive situation. Homeless transgender youth those who without economic support, often engage in drug abuse and sexual behaviour and develop mental health disorders.

Problems of Trans-phobia

Transgender people are more likely to experience intolerance, discrimination, harassment, and the threat of violence due to their sexual orientation, than those that identify themselves as heterosexual. This is due to trans phobia. Negative feelings or attitudes towards non-heterosexual behaviour, identity, relationships and community, can lead to trans phobic behaviour and this is the root of the discrimination experienced by many TG people. Trans phobia manifests itself in different forms, for example physical attacks, discrimination in the workplace and negative media representation. With this background we analysed the various sociocultural aspects of transgender health problem and health seeking behaviour. The following pertinent points needs to be noted: they should be welcomed with open arms in educational institutions, health care systems, work place both public and private and should be treated equally under the law and by the police, they should be provided proper medical facilities which include health insurance and subsidized treatment, for the general public it is important to understand the feelings and mental status of the Transgender community. People try to understand that humans are diverse in nature and last every one is a human being, transgender community has a right to behave and live they are and express their feelings without any fear and the society needs to take off their social stigma towards transgender community and give them a chance to stand equally and participate in together in the community development process.

CONCLUSION

From the above discussion it is clear that foremost priority for transgender health has to be given by Indian authorities to implement the supreme court directives and bring the transgender to the main stream community. Authorities should spread larger awareness campaign in public for the acceptability of the transgender community. Regional schemes like “SWEEKRUTI” implemented by Odissa Government for the promotion of transgender equality and justice is there. But our country is yet to have a pan India programme like “SWEEKRUTI”. Hence specific national health programmes exclusively targeted at the mental and physical health of the transgender community should be implemented by the Government of India at country level.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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