Health status and health seeking behaviour in transgenders in Kakinada: a community based cross-sectional study

INTRODUCTION

According to TG persons act, 2019 TG person is defined as a person whose gender does not match with the gender assigned to that person at birth and includes trans-man or trans-woman, person with intersex variations, genderqueer and person having such socio-cultural identities as kinner, hijra, aravani and jogta.¹ TG people have unique needs and seek specialized healthcare that is often unavailable to them.

TG persons (Protection of Rights) Act that came into effect in 2019 (and subsequent rules in 2020) articulated the rights of TG people in several sectors (e.g., education, health, workplace) and what can be done to improve welfare of TG persons.⁵ In India, the TG community faces challenges in accessing healthcare, education, housing, jobs and livelihoods. Majority of the community have to face stigma, discrimination, and violence in their daily lives-often forcing them to remain on the peripheries. They have been invisible, staying away from public discourses, social movements, mainstream media that often overlook their needs and their voices.

The 2030 Agenda for the Sustainable Development Goals (SDGs) embody a powerful commitment to “leave no one behind” and ensuring a life of dignity for all, including LGBTQ people. Without inclusive development, they wouldn’t sustain the progress that have been made on the SDGs. The inclusion of LGBTQ people will not only benefit them but will also help them contribute to these goals. Since the majority of the research in this TG population concentrated primarily on STDs and HIV, its obscured attention to their health status and treatment-seeking behavior for conditions other than HIV/AIDS. The TG community has either been overrepresented or underrepresented in research as a result of this single-minded focus. Because TGs deviate from traditional gender roles, they are subject to stigma and discrimination in society, making it crucial for public health practitioners to understand their health status and treatment seeking behavior. The current study was carried out with an objective to assess the health status and health-seeking behaviour among TGs.

METHODS

A cross-sectional descriptive study was carried out in TGs living in an urban area of Kakinada in December 2022 to January 2023. As per records of the community-based organization (CBO) working in the area, around 324 TGs residing in Kakinada. A sample of 160 TGs who were selected through snowball sampling. Members of the CBO who belonged to the TG community helped to initiate contact with a group of TGs, who in turn assisted in contacting other TGs. Data was collected with pretested semi structured questionnaire (pilot tested). Information was obtained on diet, lifestyle, substance abuse, health problems faced, and health services utilised, direct and indirect expenditure on illness, mode of payment and savings for health including a section on demographic and socio-economic characteristics. All health problems mentioned in the study were self-reported. Hence, information about HIV and STD was recorded only when the respondents disclosed such details openly during the interview. Informed consent was taken from each respondent who participated in the study and strict confidentiality of their identification was maintained throughout the study. Data was collected using a pretested semi-structured questionnaire. Data was entered and analysed in MS Excel with descriptive statistics.

RESULTS

The mean age (standard deviation) of study subjects is 24.35 (5.81) years age range between 18 to 49 years. Majority of them are Hindus (62.5%) and 56.9% are literates. 86.9% of the study subjects are staying in rented houses. Their main source of income was sex work and begging (Table 1). 57.5% were underwent gender reassignment surgery. 71.9% of them are living with gurus.

On enquiring about the periodic HIV/VDRL screening status, 88.8% were screened for HIV/ VDRL in past 6 months. Of which 3 were tested positive for HIV and 1 tested positive for syphilis. Alcoholism (63.1%) followed by tobacco chewing (47.5%) and smoking (9.4%) were more prevalent among them.

Odd work timing was observed among study subjects based on their profession. Only 52.5% were having breakfast in the morning. Odd sleeping pattern was observed among them usual time for bed was 2 am and wakeup time was 12 pm. Majority (61.9%) were taking junk food daily. 44.4% were taking fruits >5 times a week.

On doing anthropometric measurements, it was observed that 43.1% were obese (BMI ≥30 kg/m²). 77.5% were complained of gastritis, it was because of improper dietary habits. All study subjects gave history of suffering from STIs at least once in their lifetime, 11.9% were experienced STDs in past 1 year. 6.9% were tested positive for HIV and were on regular ART. Various morbidity profiles were listed in Table 2.

Regarding first point care, about 58.8% are contacting outreach worker, 16.9% are going to local pharmacy, 13.15 were going to Government hospital and 11.3% were to private hospital (Figure 1). Multiple reasons were given for not using free government facilities which included-inconvenient OPD timings (46.3%), long waiting timings (24.4%), distantly placed labs (18.8%), stigma (6.9%) and indifferent attitude of health care staff (3.8%).

On asked about the knowledge about the services provided by the government, all knew about the financial assistance of 1500 Rs/month but only 18.1% are getting benefit from it. 50.6% were have Aadhar, 35% have savings bank account and 21.3% have ration card.

DISCUSSION

With the passage of the transgender persons (protection of rights) act in 2019, attention is once again being paid to TGs in India. It provided government welfare programmes, education, social security, health care, and a national council for transgender people. It also recognised the identity of TG people.

The majority of the study participants in our study were from a demographic that was economically productive. They were literate and living in rented housing because there were more employment opportunities in cities. The participants' main sources of income were begging and prostitution. Together, stigmatisation, marginalisation, poverty, and abuse raise the morbidity burden among them. These circumstances frequently cause long-lasting stress, depression, and anxiety, which pushes people towards addiction. Gastrointestinal issues and hypertension/diabetes were the most prevalent chronic and acute morbidities, respectively, among them. The outreach worker was the preferred point of care among the study participants.

The majority of study participants, who range in age from 20 to 27, have a mean age of 24.35 years. In their study, Jerajani et al found that TG people were mostly between the ages of 21 and 25.² Additionally, IBBA research among trans people in Tamil Nadu revealed a related result. The majority of the study's participants, 56.9% were literate.³ While Narayanan et al reported a literacy rate of 87% among transgender people.⁵ Anjela et al reported a 69% literacy rate among transgender people.⁴ The fact that the current study was being conducted in a city where the majority of the study subjects had immigrated to at a young age may be the reason why the literacy rate in this study was lower. Renters make up 86.9% of the population. This showed their dire economic conditions, which may be harming their health. Few study participants stayed alone or with their partner for sex, while the majority of participants stayed with their guru. Khan et al reported that 63% of the participants were lodging independently in their study, which was different from other settings.⁶

The participants' main sources of income were begging and sex work. Similar results were reported by Khan et al. and Prabawanti et al. in their studies.^6,7 They were forced into occupations that put them at risk for STIs due to a lack of discrimination in the workforce and stigmatisation by the cisgender population.^8,9

High rates of addiction were found in our study's participants. According to Baqi et al research TG people abuse drugs at a rate of 45% and smoke cigarettes at a rate of 63%.¹⁰ People who identify as TG must battle social stigma, prejudice, and discrimination every day, which made them more likely to experience poverty, abuse, and violence. Overcoming these realities frequently results in ingrained stress, depression, and anxiety that push people towards addiction.

Diabetes was the most prevalent chronic morbidity among study participants, while skin conditions were the most prevalent acute morbidities. Similar findings of a higher prevalence of diabetes among TG people were published by Justine et al.¹¹ Diabetes was listed as one of the top three diseases affecting transgender people by Garnero et al.¹² The increased prevalence of risk factors for noncommunicable diseases, such as sedentary behaviour and addiction, may be to blame. Every study participant experienced STI symptoms at least once in their lifetime, with burning urination and pain being the most frequently reported signs. Similar findings of 100% history of STI among transgender people as compared to only 6.9% among the general population were published by Ebensrtejin et al.¹³

Only 11.3% of TG patients received care in private facilities. As a first line of defense, 58.8% of patients contacted an outreach worker. It demonstrated their confidence in outreach field staff. When asked about the challenges they faced when obtaining health services, they cited difficult OPD hours (46.3%) and lengthy wait times (24.4%), indicating that 70.7% of them had scheduling issues. This opened opportunities for telemedicine in the TGs field.¹⁴ The participants saw a need for improved access to healthcare as being exclusively community-based health care delivery. The gap between cis and trans genders widens as a result. Education and inspiration are required to make the trans community more inclusive. According to Rizvana et al society ignored TG people despite the government having passed numerous bills and schemes to ensure their social equality in the community.¹⁵ This was because society lacks awareness of transgender people. Multi-specialty TG clinics have been established by the government and are open on specific days of the week which led to an increase in TG people using public facilities.

It was essential to integrate this previously marginalized group into society. Connecting them to the national skill development mission run by the Ministry of Skill Development and Entrepreneurship for skill development and upkeep could be one approach to assisting them in achieving economic independence. To prevent addictions among them, IEC and BCC strategies need to be actively promoted. Giving TGs the ability to assert and negotiate effectively, particularly when it comes to the continuous and consistent use of condoms with all partners, would aid in reducing the prevalence of STI.

To close the healthcare gap, a community-based health services delivery model should be developed for this community that combines primary healthcare with focused intervention projects. The most important thing is to raise their level of awareness of the various government services and programmes that were available to them. Despite the fact that transgender people are now legally recognised as belonging to the third gender, there is still room for improvement in the way the general public and medical professionals view them. This would go a long way towards integrating them into our society on a regular basis.

CONCLUSION

Public health initiatives to end health inequalities should routinely take TG people's perspectives and needs into account. Access to health services for vulnerable genders is another important issue. To improve the health of this community, the healthcare system as a whole must adopt a more accepting attitude because their fear of stigma prevents them from utilising even basic healthcare needs. The inclusiveness promoted by universal health coverage will help each of these people's health statuses improve.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. India Code. Fact sheet: Transgender Persons (Protection of Rights) Act, 2019. Available at: https://www.indiacode.nic.in/handle/123456789/13091?sam_handle=123456789%2F1362. Accessed on 1 March 2023.
2. 2. Shinde S, Setia M, Row-Kavi A, Anand V, Jerajani H. Male sex workers: are we ignoring a risk group in Mumbai, India? Ind J Dermatol Venereol Leprol. 2009;75(1):41-6.
3. 3. National Summary Report – India (July 2011), Integrated Behavioural and Biological Assessment (IBBA), Round 2 (2009-2010). New Delhi: Indian Council of Medical Research and FHI 360. ISBN 1-933702-81-8
4. 4. Bayer AM, Garvich M, Díaz DA, Sánchez H, García PJ, Coates TJ. Just getting by: a cross-sectional study of male sex workers as a key population for HIV/STIs among men who have sex with men in Peru. Sex Transm Infect. 2014;90(3):223-9.
5. 5. Narayanan P, Das A, Morineau G, Prabhakar P, Deshpande GR, Gangakhedkar R, Risbud A. An exploration of elevated HIV and STI risk among male sex workers from India. BMC Public Health. 2013;13:1059.
6. 6. Khan AA, Rehan N, Qayyum K, Khan A. Correlates and prevalence of HIV and sexually transmitted infections among Hijras (male transgenders) in Pakistan. Int J STD AIDS. 2008;19(12):817-20.
7. 7. Ciptasari P. HIV, sexually transmitted infections, and sexual risk behavior among transgenders in Indonesia. AIDS Behavior. 2011;15(3):663-73.
8. 8. Kumta S, Lurie M, Weitzen S, Jerajani H, Gogate A, Row-kavi A, et al. Bisexuality, sexual risk taking, and HIV prevalence among men who have sex with men accessing voluntary counseling and testing services in Mumbai, India. J Acquir Immune Defic Syndr. 2010;53(2):227-33.
9. 9. Sandy EJ, Jody H, Mara K, Lisa M, Ma’ayan A. 2015 U.S. Transgender Survey (USTS). Inter-university Consort Polit Soc Res. 2019;5(22).
10. 10. Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon A. Seroprevalence of HIV, HBV, and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan. Int J STD AIDS. 1999;10(5):300-4.
11. 11. Defreyne J, Bacquer DD, Shadid S, Lapauw B, T’Sjoen G. Is type 1 diabetes mellitus more prevalent than expected in transgender persons? a local observation. Sex Med. 2017;5(3):215-8.
12. 12. Garnero TL. Providing culturally sensitive diabetes care and education for the lesbian, gay, bisexual, and transgender (LGBT) community. Diabetes Spectr. 2010;23(3):178-82.
13. 13. Javier J. Sexually transmitted infections among transgender individuals and other sexual identities. Medicina. 2009;69(3):327-30.
14. 14. Gamariel F, Isaakidis P, Tarquino IAP, Beirão JC, O’Connell L, Mulieca N, et al. Access to health services for men who have sex with men and transgender women in Beira, Mozambique: A qualitative study. PLoS One. 2020;15(1):0228307.
15. 15. Fernandes S, Jadhav H. A study to access morbidity profile and health-seeking behavior among transgender persons in a metropolitan city. Int J Med Sci Public Health. 2020;9(10):589-93.