Kolkata: “Why should the burden of specialising in trans-affirming healthcare lie on transgender persons unlike in the fields of gynaecology/obstetrics?” asked Kolkata-based transfeminist, transgender rights and social justice activist, Anindya Hajra.
The burden of healthcare often disproportionately falls upon the affected community, and that’s true for all marginalised communities. The healthcare machinery has historically posed several barriers for vulnerable populations and weakened marginalised people’s negotiation power.
There is a lack of empirical data on the impact of medical gender-affirmation surgeries (formerly called sex reassignment surgeries/SRS) on trans persons’ bodies.
“There should be a commitment towards research on the changes that a transgender person’s body might undergo in the immediate future as well as in the long-term so that we are able to deal with the challenges and work on a future medical pathway,” said Rahul Mitra, founder member of the West Bengal-based LGBTQIA+ social and emotional support group, Transmasculine Initiative to Solidarity, Advocacy, and Resistance (TISAR).
The lack of a robust care network isn’t restricted to gender reassignment treatments alone—the process of gender reassignment involves psychiatric, endocrinological, and surgical components. It continues to haunt transgender persons post treatments and surgeries, compelling them to fall back on informal support systems.
Elderly transgender persons suffer from apathy and neglect, with senior citizens being cut off from psychiatric care, pointed out Hajra.
Studies indicate that most transgender health literature is still limited to substance use and abuse, sexual health and sexually transmitted infections (STIs), although there is a growing interest in documenting mental health as well.
However, there is a lack of empirical data assessing cancer incidence and mortality among transgender persons and little effort has been put into cancer awareness programmes targeting transpersons. Furthermore, when it comes to transgender persons and their sexual and reproductive health rights (SRHR), many believe that the word ‘rights’ either does not exist or is neglected.
Pandemic’s toll
“During the pandemic, customers often refused to wear condoms and instead took advantage of the vulnerability of transgender sex workers by offering them more money, significantly increasing the sex workers’ exposure to risks,” said Dr Santosh Kr Giri, project director, Kolkata Rista which is one of the two Garima Grehs in West Bengal. There are 12 Garima Grehs in India that have been designated to provide access to basic amenities like food, medical care, and recreational facilities to transgender persons.
These were launched by the Ministry of Social Justice & Empowerment under an umbrella scheme called Support for Marginalised Individuals for Livelihood & Enterprise (SMILE) in February 2022.
Kolkata Rista houses transgender persons engaged in the informal labour of begging and sex work. Dr Giri said that during the pandemic-induced lockdown, there was a loss of livelihoods, as it was a difficult time to navigate streets and public spaces.
“During COVID, owing to the absence of transgender wards at government hospitals – with MR Bangur’s three-four beds assigned to transgender persons being the exception – several didn’t disclose being affected by the virus fearing stigma. Moreover, the healthcare crisis of a transmasculine person also stems from the fact that often, doctors do not understand the spectrum of their gynaecological health,” said Mitra of TISAR.
Female-to-male transition (FTM) remains an underrepresented space. “This could also be attributed to patriarchal conditioning and repression of female sexuality, as cis-gendered women are treated as asexual until marriage,” said Avinaba, a Kolkata-based public policy researcher who identifies as queer.
For a transmasculine person, it’s a rite of passage to visit a doctor for sexual and reproductive health, from troubled menstrual health to other stress areas. As Avinaba pointed out, ‘gynaecologist’ in the Bengali language translates to “stree rog visheshagya” (female disease specialist) thereby excluding male/transmasculine sexual health from the spectrum.
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The Transgender Persons (Protection of Rights) Bill, 2019 obligates governments to run medical care facilities, including provision for gender-affirmative surgery, hormonal therapy, and counselling in addition to bringing out a health manual related to gender-affirmative surgery in accordance with the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Profession Association for Transgender Health guidelines (WPATH).
“The only free SRS department at the Institute of Post Graduate Medical Education & Research (S.S.K.M. Hospital) has deplorable hygiene and unfriendly staff. It’s as if they are forced to keep the department open with no real will to do so. Community members often complain of mistreatment,” Mitra pointed out.
The vulnerability of HIV+ transgender individuals is worsened due to food insecurity and a lack of access to nutrition. They also face double the discrimination; the backlash from healthcare centre staff often makes them reluctant to collect the medicine. Kolkata Rista’s helpline receives requests to collect medicines on their behalf.
“The lived experiences of the grassroots sections are often entrenched in a narrative of lack, accelerated by the pandemic-induced loss of livelihoods, worsening their already low health-seeking behaviour,” said Avinaba, who has been conducting research at the intersection of health, labour and identity.
Ghetto-ised, invisibilised
Several stakeholders agree that transmasculine persons continue to be invisibilised in spaces of learning, work, and healthcare.
Mitra said, “Khadyo, bostro, basosthan (food, clothing, shelter) are considered to be essential to living, and we are subjected to moral policing around dressing since childhood leading to an early onset of a cycle of mental trauma.”
Such a ‘gender correction’ project is not limited to schools or spaces of learning but permeates the street, the colony and the home, where the family and the society take it upon themselves to discipline those who do not fit into either of the two heteronormative binaries. “Such negative experiences directly impact the critical years when our peers are busy preparing for their future to enter a competitive landscape of jobs and economic sustenance, while we are left broken,” said Mitra.
“In a society where a psychiatrist is often referred to as pagoler daktar—a doctor treating the mad—several trangender persons are subjected to shock therapy, high doses of medication leaving them drowsy and their nervous system compromised, while others are forcefully taken to mental asylums often under false allegations of drug addiction, where they are further subjected to physical and psychological abuse. Unable to bear the torture, several flee, while some take the final step of suicide,” said Mitra.
A paternalistic beneficiary model
Some question the premise of trans “rehabilitation.” Dr Giri said that often transgender individuals seeking healthcare services at health centres are told to give up anal and oral sex. The use of such dehumanising language reeks of stereotypes and stigma.
In fact, the stigma runs so deep that even if a transgender patient seeks intervention for viral fever, knee pain or a liver ailment, their illness is unnecessarily seen through the HIV lens. And likewise, the most commonly asked “stigmatising question” during the time of medical screening and investigation is ‘who is your sexual partner’.
Avinaba said a “rehabilitation” programme for transgender persons can’t be premised along the lines of women’s empowerment where women make pickles, lentil balls, or papads in self help groups to usually supplement the income of the principal breadwinner, their husbands.
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Not only is the work laborious but also low-paying, and transgender persons employed in informal labour are likely to be earning that already. Secondly, women often foster a sense of sisterhood and community in such groups, and even in this regard, transgender persons already have that sense of community. “Hence, the same narrative wouldn’t fit; we have to come out of that mindset as transwomen are not cisgendered women,” added Avinaba.
Both Dr Giri and Hajra pointed out that “The lens of ‘rehabilitation’ of a transperson is that of “aha re” (pity/ sympathy),”
Hajra said, “ The Garima Grehs are modelled on archaic nari niketan (women’s shelter homes). The attitude is to either discipline or punish.”
Dignity of labour, science versus tradition
Competency-Based Undergraduate Curriculum for the Indian Medical Graduate, 2018 states, “The Medical Council of India visualised that the Indian Medical Graduate, at the end of the undergraduate training programme, should be able to recognise “health for all” as a national goal…”
Globally, there has been a movement in the medical community to make new protocols and best practices to include gender and sexual minority (GSM) individuals. However, despite multiple studies done in this field, a lot about the physiology and pathology of the GSM communities is unknown to the medical fraternity.
One of the reasons for this is attributed to the general reluctance of the LGBTQ+ communities to reach out to medical professionals in case of health issues due to fear of discrimination.
An unresponsive healthcare system leads to an extreme community-based dependance centred around shared sentiments—and means of livelihoods around begging (challa); sex work (khaja); blessings at childbirth and weddings (badhai); launda naach (a popular but dying folk art from Bihar and Bhojpuri-speaking eastern Uttar Pradesh that includes dance, drama, satire, where men imitate women).
“Transgender persons, who are engaged in sex work and begging and do not have access to alternative modes of safe livelihoods and are operating within a stereotyped economic circle.This can be termed as violence and indignity owing to a lack of options,” explained Avinaba. “Overall, the structure of the livelihoods are based on a set of cultural and religious belief systems, backed by superstitions and not science.,” Avinaba added.
Unwilling to be identified, a transgender community member pointed out that sometimes the aspiration of transitioning into a ‘woman’ is so strong that a transgender person may consume oral contraceptive pills like Mala-D, priced at Rs 5, so that they lactate. This can lead to pus formation inducing pain and an ordeal sometimes resulting in death.
Rejection of medical science stems from the systemic lack of validation of transgender persons. “This results in zero health-seeking behaviour and a cocooned hive mentality where members internalise the belief that since they are rejected by society, so what they are doing must be fine,” said Avinaba.
Throwing light on the guru-shishya tradition, Anindya Hajra said that in the State’s active non-participation, the only accessible network is that of the guru ma. It has a layered and long-standing legacy of its own, and has functioned as an internally vetted structure of validation that the larger heteropatriarchal society doesn’t offer
In addition to transgender community leaders, a shift in the overall language and gaze of policies as well as mainstreaming a trans-affirming healthcare system around the intersection of labour, rights and identity, is the need of the hour.
“The idea of steering trans health rights without acknowledging their unique cultural systems and the social dynamics of stigmatised livelihoods will not be able to fully capture the nuances and complexities of trans healthcare needs,” stressed Avinaba.
Alternative economic models can slowly enable transgender persons to access gatekept institutional spaces as well as the modern, technocratic workplace. Moreover, as Sudeb Suvana, an LGBTQ+ rights activist and public policy researcher said, “It’s critical to create role models around livelihood as that significantly increases health-seeking behaviour.”
Suvana runs a transgender-led sustainable farming enterprise in West Bengal’s Baruipur town in South 24 Parganas. The endeavour steers advocacy in earning, staying, and sharing resources and an awareness of rights, pension, gratuity, and health rights. In 2019, Suvana and Avinaba founded Pleqsus India Foundation, with the vision of building an inclusive world for transgender and GSM individuals.
Infrastructural apathy, lack of representation, medicine or nutrition
West Bengal-based Sintu Bagui became West Bengal’s first transgender judge at Serampore Lok Adalat in 2019. “When the West Bengal government introduced the Swasthya Sathi card in 2021, it set up a sex and gender conundrum, with a provision of only sex and no column for gender. Further, one had to link the card with their mother. However, for a majority of transgender persons that’s not an option as they do not stay with their mothers or natal families,” shared Bagui, Secretary of Kolkata Anandam for Equality and Justice, who identifies as a transgender person.
The Transgender Persons (Protection of Rights) Act, 2019 mandated certain healthcare rights for transgender persons. The Transgender Persons (Protection of Rights) Rules 2020, under the Ministry of Social Justice and Empowerment removed one of the clauses that transgender persons had objected to in the 2019 draft of the Transgender Persons (Protection of Rights) Act, which said that a person such as a district magistrate would have to issue a certificate ‘verifying’ a person’s identity. However, there’s a lot that still needs to be done to strengthen trans-affirming healthcare.
Overall, the architecture and design of a healthcare space for vulnerable populations is critical. “For example, the entries and exits are designed keeping the ‘mainstream’ needs in mind, making it challenging for transpersons to navigate those without drawing unnecessary attention to themselves,” Hajra added.
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A transgender health worker at one of the largest government hospitals in Kolkata said that there is nothing designated for transpersons within the general public healthcare machinery. “In case an accident victim happens to be a transwoman who might not have undergone SRS (and was assigned male at birth), then there have been instances of them being admitted to a male ward, with their hair cut off. The occasion becomes a public spectacle; a source of entertainment for all,” recalled the health worker, unwilling to be identified.
Recalling one particularly horrific incident during 2020, Bagui said that a then 24-year-old transgender person from West Bengal who had migrated to Bihar to work as a professional dancer (launda naach) met with an accident on a highway while returning to his native place.
When they were rescued and rushed to a renowned Kolkata hospital, the authorities refused to admit the victim in the absence of a written authorisation from a doctor, as per the hospital rules. The accident led to the victim, the principal breadwinner of the family, losing one leg and being bed-ridden until now. This year during the month of Ramazan, they appealed to Bagui that it’s better they are given poison to end their life as they are unable to bear the pain and the ignominy any longer. During the family’s economic crisis, it’s a fight between food/nutrition and medicine.
In the absence of a social support system, accessing and sustaining healthcare is often dependent upon preferential treatment wherein a survivor is lucky if they are liked by people in positions of power, including enjoying a good doctor-patient rapport. It operates more in the form of a request rather than in a spectrum of rights.
“At another Kolkata hospital, the healthcare staff mocked a transgender patient who had gone to get tested for HIV. Tumi jeta korecho sheta ki theek korecho? (Do you realise what you have done, is it the correct thing to do?), referring to sexual practices,” recalled a health worker, unwilling to be named.
The absence of separate transgender wards and restrooms pose grave risks. “For a transgender person, apart from being a matter of dignity, this can cause severe infection during the postoperative phase, especially for a person suffering from a raw wound being exposed to a female public washroom where sanitary napkins are disposed of in the open,” Bagui explained .
Mitra advocates for separate OPD facilities for transgender persons across functions and departments. “Amra toh manush (we are humans); we demand and deserve respect as human beings. A modern scientific approach could be the only way going forward, ” Mitra added.
The SMILE scheme offers Ayushman Transgender health insurance, wherein each transgender person is entitled to receive an insurance cover of Rs 5 lakh per year. Experts have variously pointed out that while this targets rural poor, it fails to make healthcare accessible to urban poor among the transgender community.
On the other hand, even if there is no explicit policy that restrains people from the transgender community to avail medical insurance cover, there isn’t any active popularisation of schemes or explicit literature existing in the healthcare policy targeting the issues and complexities of trans health either.
Bagui’s own application got stuck even after passing all the documentation screening and interview process. “There is an internalised bias that transpersons are not ‘eligible’; a transgender person must be languishing in hunger and poverty. Why is there no transperson in the board or committee of these insurance companies?” Bagui asked.
At every step, a transgender person is reminded of being “different” even if they don’t perceive themselves to be so. “Tomra maanei jhamela koro; tomra maanei chele chele biye koro (You people mean nuisance; you people means man marrying man).These are some of the everyday verbal abuses that members of the community are subjected to. At every stage and step, our mental health is compromised. We neither belong to home, nor to the world; we are neither accepted by friends nor by society. Hence, we are of none; even not of those whom we love, our so-called loved ones,” said Bagui, adding that the economic agency often lends legitimacy within the family and gives community members bargaining power. “We are often accepted by our families on the basis of the money we are able to make and contribute.”
Diving into the urban-rural paradigm of violence, Kolkata-based queer activist, archivist, researcher and writer, and founding trustee of Varta Trust, Pawan Dhall, cautions against viewing social and medical violence against transgender persons as a rural phenomenon or as a matter of economic convenience. Dhall cites a recent example of a Jadavpur University professor quietly facing violence from the elder brother who was a non-earning member of the family.
Dolly*, a transgender sex worker and a trans rights activist working with Kolkata Anandam for Equality and Justice, recounts that there wasn’t any circular issued during the lockdown specifically for transgender persons. When it comes to trans health, it’s a vicious cycle including natal family violence, societal violence, the healthcare machinery, the police and other authorities.
Body, desire, health
For transgender persons, the trans community spurs a sense of belonging and sisterhood; taali/thirki is a power symbol. “Since transgender persons have been marginalised through the manifestation of a heteropatriarchal power structure, taali is a weapon to reclaim or overturn that power. It’s a protest against the denial of rights,” said Raina Roy, a trans activist and founder of BDS Samabhabona.
The Bengali term Roy uses for describing the act of clapping is “chamkano”, which loosely translates to “to startle”. The act serves the purpose of announcing their presence and disrupting the “decorum” of the status quo.
Gender, body, desire, and mental health are all part of a matrix, said Roy, who has been working as an activist for 20 years. “Today, the LGBTQ+ movement is occupied by a particular class. The NGO-ised approach is that of a top-to-down vertical one, which is driven by the politics of economics.”
In an overarching product-led consumerist healthcare landscape lacking a humanitarian lens, when the issue is that of survival of a transperson, health is most neglected. In fact, there is a negative health status, with many living in denial.
“Why does a transgender person have to consider a partner crisis as insignificant? Because they have to first focus on their survival. But it takes a toll on their mental health. So social rigidity has a relationship with a transgender person’s body, desire, sexual health and mental health. At Samabhabona, we ask these questions,” Roy added.
“A trans person dealing with gender transition surgery might be going through social isolation, or a heartbreak, and not addressing the emotional repercussions is at best a half-hearted clinical approach to censure trans bodies and trans desire, and to medicalise trans bodies through the a heteropatriarchal, transmisogynist and homophobic lens,” reiterated Hajra, who co-founded Pratyay Gender Trust, one of the early community-led collectives in India that became a support space for gender non-conforming and transgender persons facing harassment, stigma and violence for their gender identity/expression in 1998.
Health is a basic right, however, health is intricately related to gender identity, social identity, caste, class, religion, and ecology. Within these discriminatory systems, the overall healthcare machinery has always taken a tokenistic and paternalistic approach towards transgender persons and trans health.
Trans identities do not exist in a social vacuum. Dhall said, “Gender acceptance is rooted in universal attitudes towards gender and sexuality. The onus of upholding the values of ‘bhadralok samaj’(genteel society) has always been thrust upon women; look at the emphasis upon the expression of Bharat Mata as the ‘ideal’ woman. Anything that challenges normativity is a problem with society.”
Undernourished, underwhelming trans health space
Healthcare has to be seen in a continuum, where health-seeking behaviour of marginalised communities has been low and where cisgendered women have been taught to ignore or undermine their problems and pain, especially in the paradigm of sexual and reproductive health rights.
“However, the concentration of prejudices seems to be greater when it comes to trans health. In the absence of information, the apathy of the system doesn’t allow them to assess risk and make informed decisions. The query of ‘how is my health/life going to be affected post-surgery’, how is my body and mind going to be affected after my breasts are removed, is never addressed,” explained Hajra.
Healthcare staff interactions are not textbook interactions. Doctors, in instances of insensitivity, ask transgender patients to take their clothes off, or question them about sex positions when there isn’t any correlation. Largely, attitudinal shifts haven’t taken place, a malaise which is compounded by internalised heteropatriarchal, misogynist, and transphobic biases.
Hajra explained that in the absence of a standard operating procedure and a set of institutional guidelines, gender reassignment surgery is being done in a clandestine manner in a few nursing homes in Kolkata and even Tier II and Tier III towns, ensuring profitability but no accountability. This perpetuates the culture of shame and stigma. Another challenge is unregulated/undetermined pricing. Owing to its obscure and covert nature of operation, this precarity leads to economic exploitation.
The information network that has been internally curated by transgender persons can also be nebulous and nefarious. A transgender person based in Kishanganj, Cooch Behar or Islampur in West Bengal, who has to navigate the complex information/knowledge network, would rather visit Chhapra in Bihar, not Kolkata, owing to mobility.
“In effect, the structural response to gender transition is similar to abortion. Of course, the concentration of prejudice is greater in trans healthcare but parallels can be drawn with regards to the agency of the person. Gender transition is not part of any medical curriculum so trans bodies are akin to being treated as bodies of guinea pigs in laboratories,” said Hajra.
*Name changed to maintain confidentiality.
Sanhati Banerjee is a Kolkata-based journalist.