Abhina Aher’s transgender friend went to a private skin clinic in South Delhi for laser treatment. When another patient walked in, the doctor asked the friend to hide in the toilet. Aher, who is a transgender activist with the India HIV/AIDS Alliance, a non-governmental organisation in Delhi, said such humiliating experiences are not uncommon. Transgender people report facing worse forms of discrimination – for instance, doctors and nurses have refused them medical care. Even for conditions like fever, doctors have sought to examine a transgender patient’s genitals, Aher said.

Transgender is an umbrella term for people whose gender identity, expression or behaviour does not conform to the sex they were born with. There are about 4.9 lakh transgender people in India. Globally, the discrimination that transgender people face has given rise to the term “transphobia” – a dislike of or bias against transgender people.

A new study seeks to document transphobia among Indian doctors. Researchers from Stanford University and the University of California, Berkeley, in the United States are collaborating with the Civilian Welfare Foundation, a non-profit in Kolkata. The exercise involves interviews with 300 doctors in five major Indian cities with the aim of finding the extent of their transphobia, the reasons for it, and its effect on their communication with and treatment of transgender patients.

The study, which started in October 2016, builds on qualitative studies that looked at discrimination faced by transgender people in hospitals. A consistent complaint of the community is that doctors and nurses schedule their check-ups for odd hours – early morning, lunch time or late at night – when there are few patients in the hospital, said Shuvojit Moulik, who led two such studies in Kolkata. Moulik is also the founder of the Civilian Welfare Foundation and one of the three principal investigators in the transphobia study.

Often, the bias is extreme. A transwoman – a person who is assigned male at birth but identifies as female –who participated in one of Moulik’s studies said that when she went to a hospital after being gang-raped, the doctor asked her, “How can you be raped?” Moulik said the doctor also failed to prescribe Post-Exposure Prophylaxis, an emergency HIV prevention medication recommended to be taken within 72 hours of sexual violence. The National AIDS Control Organisation recognises the transgender community as a core high-risk HIV group.

Denial, ridicule, humiliation

Studies in other parts of the world have shown that bias in doctors can influence their decision-making with regard to their patients from minority communities. Sixteen of the 42 transgender people Moulik and his associates interviewed in 2015 recalled at least one incident where a doctor had refused to examine them.

Shruta Amit Rawat of The Hamsafar Trust, a Mumbai-based non-profit that works on problems faced by the Lesbian, Gay, Bisexual and Transgender community, said a transwoman who had gone to consult a doctor in a government hospital for a fever was scolded for having sex with men. The doctor then proceeded to check on another patient while a nurse wrote out a prescription for the transwoman, keeping a clear distance from her.

The transwoman participated in a study, titled Shakti, that Rawat managed. The study, which is yet to be published, interviewed 18 transgender people in Mumbai to understand HIV-related stigma faced by them in healthcare settings. It also interviewed 132 doctors in 10 Mumbai hospitals to study their attitude toward transgender patients. During the exercise, Rawat found that doctors were not comfortable touching transgender patients and tried to have minimal contact with them. Some doctors also had pre-conceived notions about the sexual lives of transgender people – they believed they were involved in sex work or had multiple sexual partners – which influenced their interaction with them.

Double discrimination

Three years ago, Samira, an HIV-positive transwoman from Kolkata, visited a government hospital for an HIV test. She said the doctor and her assistant laughed at her, saying, “Agar yeh sab bimari tumko nahin hoga toh aur kisko hoga?” (If you people are not infected with such diseases, then who is?”)

According to Aher, the discrimination against transgender people gets worse if they are HIV-positive. “If you are a transgender with HIV, then you face double the discrimination,” she said.

A transgender person displays an anti-retroviral pill used to treat HIV/AIDS in New Delhi. (Credit: Adnan Abidi / Reuters)

Moulik, Rawat and Aher said visits to hospital wards are a cause of distress for transgender people. Most doctors, knowingly or unknowingly, do not ask them which ward, male or female, they might prefer.

Aher said, “Male patients are uncomfortable with our presence or pass sexual comments, and females do not want us around them.” A few years ago, Aher would accompany transgender people to hospitals in Mumbai. She said many of them were made to sleep in the corridors because they were not wanted in both the male and female wards.

Venkatesan Chakrapani, chairperson of the Chennai-based research agency Centre for Sexuality and Health Research Policy, said there have been cases where transwomen undergoing sex change operations have been asked to dress as men so that they could be admitted in the male ward.

Tired of the ridicule and humiliation, some transgender activists have demanded separate wards in hospitals. “I strongly endorse separate wards because of the identity we carry,” said Akkai Padmashali. “We face enormous self-hesitation in male or female wards.”

So far, only the Karnataka government has ordered separate wards for transgender people in hospitals across the state.

Chakrapani said that transgender people must at least be given a choice as to which ward they would like to be admitted in.

Avoidance and self-medication

As a result of the discrimination they face and in the absence of steps to end this discrimination, many transgender people turn to self-medication, alternative medicine and even unlicensed doctors. Private hospitals are not an option for most of them as they are too expensive. Samira said she had not gone back to the Kolkata hospital where she was ridiculed.

Padmashali added, “We tend to ignore our health and self-medication is very high.”

The result is sometimes dangerous as some transgender people may not even want to get better, said the experts. “There is a tendency to inflict self-harm,” said Aher.

Shubha Chacko, a researcher with Aneka, a non-profit in Bengaluru that works with marginalised communities, said, “They internalise the shame.”

Alcohol abuse is common among transgender people. A study found that 37% of the 300 transwomen surveyed consumed alcohol once a week. “It is a relatively high prevalence compared to biological females,” said Chakrapani.

Added Chacko, “It is the biggest failure of a healthcare system if it dissuades people from seeking healthcare instead of encouraging them.”

Reasons for discrimination

Although the reasons for such discriminatory behaviour shown by doctors towards transgender people are yet to be studied in detail, Chakrapani believes there are two broad reasons. First, doctors have not had much contact with the community and have as a consequence formed certain stereotypes about them from society or from their portrayal in cinema. Second, their encounters with the community have been negative – for instance, a transwoman may have demanded money from a doctor at a traffic signal.

Rawat said that while reading the interview transcripts of doctors, she felt their biases were sometimes rooted in culture. She recalled a doctor saying that when he was a child, his parents would often tell him to behave or else the hijras, or eunuchs, would take him away. Some eunuchs in India are transwomen.

Rawat was also surprised to learn that many doctors knew little about transgender people. “They had misconceptions about their anatomy,” she added.

Bhim Singh Nanda, a plastic and cosmetic surgeon with the Sir Ganga Ram Hospital in Delhi, said many of his colleagues labelled transgender people as gay or lesbian.

According to Chacko, “Even if there are sympathetic doctors, they do not know what to do.”

Photo credit: Reuters

Lack of sensitisation

A 2016 paper on transgender health in India and Pakistan published in The Lancet journal says that while the transgender community may have received legal recognition, their access to quality healthcare remains alarmingly scarce. And there are hardly any anti-discrimination laws in place to safeguard equality in healthcare access. The Transgender Persons Bill, 2016, introduced by the Ministry of Social Justice and Empowerment in the Lok Sabha in August 2016, offers some hope. It prohibits denial, discrimination and unfair treatment against transgender people in healthcare facilities. It also asks the government to provide the community with medical care, including sexual reassignment surgery, and a medical insurance scheme. It prescribes imprisonment of at least six months and up to two years for those who harm the health of a transgender person. The bill is expected to be tabled in the Rajya Sabha in the coming winter session.

While the Transgender Persons Bill could take time to become a law, Chakrapani said hospitals should begin to sensitise doctors and develop non-discriminatory policies. Narendra Kaushik, a plastic surgeon who claims the majority of patients at his clinic in Delhi are from the transgender community, said he usually asks them what name he should use to address them. He then uses pronouns accordingly. “This immediately puts them at ease,” said Kaushik, adding that such small steps can make a big difference. “Transgender people should feel safe and welcomed in hospitals,” he added.

Moulik said he hoped the transphobia study would lead to evidence-based intervention in the way doctors and other hospital staff treat transgender people.