When I was an MD resident in the emergency department, I went to attend to a patient with a stroke. As I walked up to the patient, I noticed that she was a 60-year-old transwoman (a person who identified as a woman but was registered with a male sex at birth) with diabetes and hypertension. “She woke in the morning and was unable to move her right-sided upper and lower limbs,” her bystander said to me. Surrounding her were many other trans women who had brought her to seek care.
After explaining that there was a high suspicion of stroke and convincing them to do a CT scan, I walked to the nursing station to enter my notes, where I heard a throwaway comment from a nurse - "Why don't these people just die off instead of coming here and burdening us?" Shocked beyond measure, I just stood there wondering whether this thought would have risen in her mind if the patient who had come with these same complaints was cisgender (a person whose gender identity corresponds with the sex registered for them at birth)
I suddenly realized that even after more than a decade in healthcare, this patient was the first and only transgender patient (a person whose gender identity does not correspond with the sex registered for them at birth) I had encountered. Many healthcare professionals I know have not treated even one person with a trans or non-binary (a person whose gender identity does not fit in the male-female binary) identity. India's transgender population is estimated at 4.8 million by the 2011 census - a count of the number of people who have marked their gender identity as ‘Other’ (a probable underestimation considering the stigma of disclosure and the fact that some transgender people may have marked the gender concordant with their identity), and it appears that their healthcare needs are significantly underserved.
Insights from Research
According to a recent study by Dr. Harikeerthan and colleagues in PLOS Global Public Health, people who do not subscribe to the gender binary face severe discrimination while trying to access health, both within and outside the system. This study attempted to analyze the barriers that transgender people face when accessing healthcare. The uniqueness of the study was the fact that the focus was not just on HIV-related or gender-affirming care but also on health-seeking for general complaints. The interviews conducted in the study with several persons holding transgender and non-binary identities revealed that access to health systems remains dismal.
The authors reported that many transgender people admitted to self-treating their ailments or waiting to seek healthcare until the illness progressed. Some even admitted that they would access healthcare only if they thought they had a life-threatening condition. The most common reason cited for this was the fear of being discriminated against and unfairly taken advantage of.
Similar findings have been previously reported. A study published in 2023 in the Journal of Migrant Health assessed the impact of the COVID-19 pandemic on the health of transgender women. The study revealed that many transgender women decided not to take the COVID-19 vaccine due to fear of hostility in the vaccine centers, thus exposing themselves to the danger of severe coronavirus infection.
"Most people with a trans identity also end up going to a few doctors that they know are safe. They may know these doctors through friends who also go to them. However, they may not be the right specialist doctors for the condition that the patient has. This way, they end up not receiving the right kind of care that they need," adds Dr. Harikeerthan Raghuram.
Another study also suggests that the burden of mental health issues and suicidal ideation is very high among people with transgender identities. Social and financial marginalization also predisposes them to substance use and sex work which worsens their mental health. However, most mental healthcare services too, remain out of reach for transgender persons.
Discrimination in the healthcare systems occurs at various levels including at the mode of transportation used to reach the healthcare facility. In the study by Dr Harikeerthan and colleagues, transgender persons mention being stared at, commented upon, and joked about by all personnel employed at the healthcare facility starting from security guards stationed at the gates, nurses, and ward boys to sometimes even other patients and their bystanders. Outside of overtly hostile language and actions, they also feel subtle body language shifts that express to them that they are unwanted there.
Even after admission, nurses express discomfort in carrying out duties like giving sponge baths, if the patient holds a trans identity. They instead request the bystanders to administer such care to the patient, a transgender activist mentioned in the study by Dr Harikeerthan and colleagues.
A few other transgender folks in the study also expressed having to face gender dysphoria as hospitals addressed them by their deadnames (a name the transgender person was assigned at birth but isn’t using anymore upon transitioning), refused to accept ID cards if they were not gender-conforming, and refused to provide professionals of their preferred gender for examination. Some even complained about being subjected to examination without consent by professionals. A few transgender people who could pass themselves off as cis people chose to do so at hospitals at the expense of their mental health as they felt they were being treated better when they appeared cisgender
Towards inclusive healthcare
I recount to Dr. Harikeerthan, an incident that occurred when we were on rounds and met a patient who decided to disclose their intersex (a person born with both male and female biological traits, an umbrella term which encompasses several biological variations) identity to the treating team. After hearing that, the consultant physician (in front of the patient) suddenly asked to add tests to screen for sexually transmitted diseases to the patient’s evaluation. According to Dr Harikeerthan, people within the trans community are more vulnerable to sexually transmitted illnesses. However being intersex is not being trans, a common misconception among many people. Focused gender sensitivity training is needed to help physicians clarify their own misconceptions and phrase their concerns in a better manner.
"While there have been changes in the MBBS curriculum, gender sensitivity training needs to be a part of the education of a wider range of professionals employed in healthcare - nurses, physiotherapists, occupational therapists to mention a few," says Dr. Harikeerthan. "However in India, doctors are seen as the leader of the team in healthcare, so I expect that the changes made in the MBBS curriculum will also have a ripple effect in ensuring that the rest of the team adopts a more inclusive approach towards a patient with a trans identity", he adds.
Even structurally, hospitals and other centers that focus on health delivery are designed with the gender binary in mind. There may be gender-based separation in queues, restrooms, and wards which causes confusion as well as discomfort for the trans person accessing care. "Eventually a redesigning of these places to make them inclusive is very important, however, a few clinics need to be established now everywhere where transgender people can access safe quality healthcare until those structural and systemic changes can be brought about," says Dr. Harikeerthan.
Solutions are possible - but must be multipronged and require concentrated effort. An expansive curriculum change that begins at the school level is necessary to ensure that all professionals in the healthcare industry are adequately educated on gender and sexuality. Collaboration with transgender advocacy groups and other community members is essential to redesigning hospitals and healthcare delivery areas to make them inclusive. Telemedicine services too can make healthcare more accessible for transgender people without subjecting them to the trauma of navigating a hostile system.
At last, there is a need to increase awareness in the transgender community as well as the medical fraternity about the laws that will punish discriminatory practices by healthcare institutions to safeguard the interests of transgender individuals. With the Transgender Persons (Protection of Rights) Act of 2019, the government of India has recognized the civic identity of individuals belonging to the transgender community. However, there is a long way to go before the practical realization of the community's right to health.
