Though Indian texts as old as 3,000 years have documented the history of having transgender people in prominent and important positions, in the contemporary “modern world”, they face social unacceptance, exclusion, and limitations to basic facilities. They are discriminated against getting basic education, job employment, and even healthcare services. The impact is such that there are significant differences in morbidity between transgender and cisgender people. Apart from physical diseases and illnesses, trans people have more mental health morbidity, which includes anxiety, depression, and hyperactivity.
Furthermore, many times, doctors and other healthcare workers treat or want to treat them as cisgender folks without realising or taking into account that it might not be the way the patients identify themselves. Although transgender people are now recognised as the third gender (Supreme Court judgement in National Legal Services Authority v Union of India, 2014), there is still a large healthcare gap that remains to be addressed and closed.
Systemic exclusion from healthcare in India
Gender inequality combined with low socio-economic status leads to poorer health and not just being poor. Health is one of the transgender people’s equality issues. Healthcare systems across the world are failing the transgender community. And the story in India is no different. They are not only refused treatment at several health facilities but are also subjected to verbal abuse. The absence of public and private healthcare insurance for transgender people adds to the burden and excludes them from the regular systems. They are not only underserved but also misrepresented.
On a daily basis, transgender people face exclusion and violence in facilities as basic as water and sanitation. An all-India study by the Freshwater Action Network South Asia and the Water Supply and Sanitation Collaborative Council in 2016 highlighted that transgender persons are unwelcome in both men’s and women’s toilets in public spaces. Left with no option, they are forced to go for open defecation or wait to use toilets when no one is around. This is another major contributing factor to continuous illness. There is a failure to recognise the links and the refusal to tackle them is resulting in incessant poor health standards for transgender persons.
Morbidity in transgender people across India
The prevalence of HIV among transgender people in India is estimated to be 14·5%, which has increased over the past two decades. One of the reasons is that there still is low use of condoms by transgender people in the country. This increases the chances of sexually transmitted diseases. Sadly, most transgender people have no access to treatment for sexually transmitted infections. Apart from a lack of awareness about HIV and AIDS, there is also inadequate information and hence a lack of access to antiretroviral therapies for people in the country. All of this is directly linked to low levels of education and ultimately low levels of health literacy.
Sexually transmitted diseases might be the most prevalent but not the only morbidity issues that the Indian transgender community is dealing with. Non-communicable diseases (NCDs) are on a steady rise. A high proportion of transgender people belong to lower socio-economic strata and are subjected to smoking and alcohol consumption, inadequate fruit intake, and lower physical activity. A 2020 study conducted amongst transgender people in Puducherry showed that the community faces higher vulnerability to obesity, high blood pressure, higher hip-to-waist ratio, and unhealthy dietary practices, which leads to other kinds of illnesses. Other studies have shown that there is a prevalence of diabetes, hypertension, and hypercholesterolemia as well.
Dental care utilisation is another aspect highly neglected for the transgender community. Research in India has shown that there is an 87% dental caries prevalence and 69% periodontal illness among transgenders apart from hormone-related oral illness. Fear of not getting unbiased and non-prejudicial healthcare prevents people from further visiting the dentists and getting the treatments. Without proper treatment plans, transgender folks will continue to deal with more oral health problems.
Fill in the important research gap
In research, there are challenges to tackle, gaps to be closed and opportunities to be grasped. Most research studies conducted in India in this context are regional and have a limited scope. Research at a national level should be prioritised to make sure there is adequate evidence-based healthcare for transgender individuals. These studies are not only important to ensure that the issues are heard but also to address the bias. Apart from that, most studies have shown and highlighted the patients’ (in this case transgender folks) experiences. We need to have perspectives from the medical community as well in order to understand their inhibitions and experiences. Only good and robust data can help in finalising the appropriate indicators and that will help in finalising appropriate medical care for gender and sexual minorities.
Stricter implementation is required for rules such as denial of medical services to any human being on the basis of one’s gender identification. Continuous monitoring with help of all stakeholders including community health workers is necessary. Apart from that, the government needs to ensure that there is appropriate and safe healthcare for all across public hospitals.
We are still way behind in identifying and documenting the risk factors that lead to high morbidity amongst transgender folks in comparison with cisgender people. It is time that we envisage a world where people of all gender identities are able to access evidence-based healthcare and social services. The scant evidence amassed over time through a few research studies points to the need for policy innovation, and systematic and regular interventions in order to address gender exclusion, remove barriers, and support transgender development.
Mahek Nankani is Assistant Programme Manager at Takshashila Institution. The views expressed in this article are those of the author and do not represent the stand of this publication.