Silent screams: The many struggles of transgender people to access healthcare

A study, 'Experiences of Transgender Persons in Accessing Routine Healthcare Services in India: Findings from a Participatory Qualitative Study,' revealed the difficulties transgender people face while trying to get medical care.

ByChetana Belagere

Published Mar 03, 2024 | 8:00 AMUpdatedMar 03, 2024 | 10:21 AM

The transgender community has very limited access to healthcare. (Commons)

Rajesh surveyed the hospital corridor from the reception. Though it was early in the morning, the hospital was already buzzing with activity. Nurses rushed with files held close to their chests, patients — some strapped to wheelchairs — and those accompanying them navigated the corridor through the crowd, while doctors in scrubs looked more composed and relaxed.

Fear gripped Rajesh (name changed on request), a transmasculine person, as he stepped in with a feeling of entering unchartered territory, his legs weak, and streams of cold sweat trickling down the sideburns despite the morning chill.

He felt as if he did not belong to the place — the odd individual — as he filled out the registration form, fully aware of the stares behind his back. He felt naked, and helpless, and wanted to cower away from the burning gazes of multiple eyes and the not-so-hushed whispers judging him.

Rajesh, however, was determined but he got stuck when the form he was filling out sought his gender — male or female. He was once again facing a world that saw individuals in binaries, refusing to acknowledge the spectrum of gender identities, and preferring to remain cocooned in a time warp.

Also Read: Transgender activist Akkai Padmashali seeks voice for LGBTQIA+ 

Alone in the crowd

The hospital environment did not suit Rajesh, and people like him. It excluded them, their identity — and to a certain extent, their existence.

The waiting area had designated space for ‘men’ and ‘women’, Rajesh noticed as he leaned against a pillar. The washrooms, the most basic of facilities, become a space of anxious discomfort, emblematic of the binary constraints that pervade the medical environment.

The consultation room, a space that should offer solace and understanding, often scrutinised Rajesh’s identity. Questions, intended to diagnose and heal, often veered into personal territory, making Rajesh feel more like an anomaly to be examined than a patient to be treated. The volley of questions, sometimes well-meaning but often intrusive, chipped away their remaining sense of dignity, a reminder of the constant battle for recognition and respect.

Yet, in the face of these challenges, Rajesh’s journey has been one of resilience and strategy. Aware of the discrimination that might come with full disclosure of their identity, people like Rajesh handle these circumstances with care, revealing themselves on a need-to-know basis, protecting their true selves from potential judgment.

This delicate balancing act between concealment and disclosure, testified to their strength, a way to safeguard their dignity in a world not yet ready to accept them as free individuals.

Also Read: Transgender community seeks bigger share of Lok Sabha tickets

Systemic and societal barriers

Rajesh’s story, set against the backdrop of a healthcare system struggling to accommodate the diverse needs of patients, narrated the daily battle of transgender people.

A study, Experiences of Transgender Persons in Accessing Routine Healthcare Services in India: Findings from a Participatory Qualitative Study,” looked into the difficulties transgender people face when trying to get everyday healthcare in India.

Dr Aqsa Shaikh, trans woman, medical doctor and Assistant Professor teaching Community Medicine

Dr Aqsa Shaikh. (Supplied)

The Initiative for Health Equity, Advocacy, and Research (HEAR), Bhopal, along with Sangath, an NGO also based in Madhya Pradesh capital, and the Department of Physiology, University College of Medical Sciences in Delhi and Department of Community Medicine, Hamdard Institute of Medical Sciences and Research conducted the study.

Unlike previous research that mainly looked at specific health services like HIV care or mental health, this study explored the experiences of various transgender identities in getting general healthcare.

The researchers have shed light on the systemic and societal barriers exacerbating health disparities within the community. They interviewed 63 transgender people across the country, including those in South India.

Besides interviews, the researchers also held group discussions involving the participants. The research found that transgender people have been encountering multiple barriers, both within and outside the healthcare system. These barriers, the study found, were rooted in societal norms and prejudices, and they affected transgender people’s health and well-being.

“Access to correct, caring, and compassionate healthcare is everyone’s need and a right. Unfortunately for margianlised groups like trans and gender-diverse individuals, this can mean navigating an endless quagmire that invisibilises or excludes them,” Dr Aqsa Shaikh, lead researcher, said.

Dr Shaikh, a Professor of Community Medicine at Hamdard Institute of Medical Sciences and Research, is a transgender person.

“This needs to change and that change is possible by taking small steps in healthcare provisions to ensure everyone is included. Health For All should not be a goal but a reality,” she asserted.

Also Read: Telangana’s transgender doctors transform the healthcare scene

Before the health system doors even open

The study found that the struggle began for several transgender people well before stepping into a healthcare facility. Their journey was fraught with societal stigma and a lack of familial support, crucial for navigating the already complex healthcare landscape.

“Not just verbal remarks by other people but also by the general body language of people reflected their attitude stigmatising transgender people. For instance, many participants spoke about how people look, stare, laugh, and make them very uncomfortable,” the study report said.

“If you walk on the road, people will identify you as a trans person…a lot of people have myths and misconceptions. They are either afraid of transgender, or they have pity, sympathy,” a  North Indian transwoman, identified only as P66, said.

Supportive family members and the use of correct pronouns could significantly ease their journey, the study found while highlighting the profound impact of acceptance into the healthcare system.

“I have never faced any gender discrimination because my family has always supported me,” P43, a transwoman from Central India, said. Her experience underscored the huge difference the support of family had made.

Another transmasculine person from South India, P16, told researchers that he used the pronoun “they” to refer to transgender people while consulting doctors. “That took some burden off my shoulders,” ‘they’ said.

Community support would also make a lot of difference, gender fluid person P23 from Northeast India added.

Also Read: Only 2% of transgender community can avail health cover benefits

Familiar doctor, the only hope

The experiences shared also showed that the decision to seek healthcare was often clouded by fear and hesitation, triggered by negative experiences and the anticipation of stigma, not just from society but within the healthcare facilities as well.

Even the decision to visit a hospital was made based on whether they knew the doctor directly or indirectly. They avoided hospitals and doctors expect during emergencies.

“I always prefer visiting a doctor based on the recommendations of fellow trans people,” P49, a transwoman from Eastern India, said.

Cis-binormative healthcare maze

The study said that almost all participants interviewed shared at least one negative experience. While some were related to the health system, others were with individual healthcare providers.

The study also found that their experience depended on how ‘visibly trans’ they were earlier. Cisgenders, however, found things easier.

The study also found that their experience depended on how ‘visibly trans’ they were earlier. Cisgenders, however, found things easier. (Flickr)

Despite recent legislative amendments, the community spoke of challenges in getting legal documents that matched their gender identity. Most hospital demanded an identification card for registration.

The study found that a lack of gender concordant identity documents resulted in problems at the registration. One participant said she was asked for ID proof only after the healthcare worker realised that she was a trans person.

“Why do you need ID proof to provide medical treatment? After arguing for 15 minutes the doctor refused to meet me,” transwoman P18 shared her experience.

Nurses reportedly exchanged knowing glances and giggled on seeing male names on identification cards. Moreover, specialties such as gynecology has been normatively designated for cisgender female patients.

“I can’t go to men’s toilet in a saree. If I visit a women’s washroom, my voice gives it away,” transwoman P40 told the researchers.

Another transman said a gynecologist joked that once he transitions completely, he would not be allowed into the gynecology clinic which made him feel uncomfortable and unwelcome.

“Oh, so the next time you come here, you won’t be allowed, because you will then look like a man,” P16 from South India quoted a gynaecologist.

Also Read: Follow SC guidelines, don’t drive transgender persons to courts for certificates

Being ‘visibly-trans’ 

The study also found that their experience depended on how ‘visibly trans’ they were earlier. Cisgenders, however, found things easier.

“I quite like the way that one particular institution has structured the inpatient wards…there is no gender segregation of the washrooms,” P64, a transwoman from South India, said.

The participants suggested that hospitals could segregate sections for every patients — ensuring privacy  – like using curtains or makeshift walls.

Denied treatment, respect

Not even health professions, hospital staff, too, often viewed with contempt. In one case, a hospital watchman reportedly shooed away the trans people.

Transwoman P66 from North India spoke about “untouchability”. “The nurse will not even touch your body because they feel it obnoxious to touch a trans person. So, they used to call me for giving a sponge bath for a trans person. When questioned, they said they were uncomfortable doing such things,” she said.

The lack of sensitivity, financial exploitation and verbal, and sometimes even sexual abuse, the transgender individuals go through several harrowing experience.

Navigating with resilience

Despite challenges, transgender individuals in India have been navigating this complex situation with resilience and ingenuity.

While some adopt strategies to pass as cisgender to avoid discrimination, others resort to self-medication or seek alternative treatments to avoid the healthcare system altogether. The community’s response also varied, with some choosing to educate healthcare providers, while others advocated their rights through legal and policy channels.

The experiences of transgender individuals in accessing healthcare in India highlighted a critical need for systemic change.

“Many doctors wonder why they do not get to see transgender patients in hospitals. Now we know that transgender patients delay or avoid accessing healthcare because of negative experiences they have had in hospitals. We must urgently reform medical education to fix this situation,” Dr Harikeerthan Raghuram, one of the lead authors from Sangath, said.

The recommendations

  • Health professional sensitisation: Update training and education to better understand Transgender and Gender-Diverse (TGD) needs.
  • Eliminate Cis-Bi-normativity: Reduce gender segregation in healthcare to accommodate all identities.
  • Collaborative reform: Work across sectors to address systemic barriers, including legal documentation issues.
  • Diverse inclusion: Tailor healthcare services to the varied backgrounds of TGD individuals and involve them in healthcare roles.