Access to health services: Barriers faced by the transgender population in India

LGBTQ+ identities in the Indian audiovisual advertisements: A content analysis

In the late 2000s, LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and others) identities began to surface in Indian audiovisual marketing campaigns. By 2021, brands had produced at least 105 advertisements featuring LGBTQ+ identities. This research conducts an analysis of these campaigns, examining aspects such as their release date, featured characters, gender identity, sexual orientation, character age, narrative usage, genre, theme, and setting. The study reveals a substantial surge in advertising campaigns since 2018, with brands strategically launching them during Pride Month, Valentine's Day, and Women's Day. Characters embodying gay, lesbian, and transgender identities were most prevalent. Advertisements spotlighting gay, lesbian, or both gay and lesbian characters predominantly emphasised themes of love, featuring youthful characters and urban settings. In contrast, advertisements featuring transgender characters centred on human rights, with older characters and non-urban settings. Based on these findings, it is recommended that the number of LGBTQ+ marketing campaigns should continue to rise, diversifying character identities, ages, and settings while being released throughout the year.

The complexities of trans women's access to healthcare in South Africa: moving health systems beyond the gender binary towards gender equity

BACKGROUND

Public health research highlights the influence of socio-political biases shaping obstacles to fair healthcare access based on gender. South Africa has shown commitment to resolving gender imbalances in healthcare, historically emphasizing cisgender women's challenges. However, research gaps exist in exploring how public health systems perpetuate disparities among gender-diverse persons, like trans women, who face exclusion due to their deviation from cisgender norms in healthcare. Critical, intersectionality-informed health research carries the potential to reveal the diversity of gendered healthcare experiences and expose the systems and processes that marginalize trans patients.

METHODS

This study adopts a critical trans politics perspective to explore the socio-political forces limiting South African trans women's access to public healthcare. Using a critical narrative approach, the research asks: 1) What narratives do South African trans women share about their experiences in health systems? 2) What gendered societal structures, practices, and norms enable or hinder their inclusion in health systems? Over a period of two months in 2022, five South African adult trans women between the ages of 22 and 30 participated in 60 to 90-min long, semi-structured individual, telephonic interviews, focusing on participants' subjective experiences in healthcare.

RESULTS

Trans women's narratives unveiled a culture of medical genderism in South African public healthcare, discriminating against patients whose gender misaligns with societal norms. This culture is represented by the trans women's experiences of their identities being structurally stigmatized and delegitimized when seeking healthcare, reflected in institutional policies, practices, and protocols consistently disregarding and misgendering them. Trans women's systemic erasure was illustrated by the restricted professional knowledge, availability, and adoption of gender-affirming healthcare in a ciscentric public healthcare system prioritizing cisgender needs. The intersection of gender, race, and class dynamics compounded the obstacles faced in accessing healthcare.

CONCLUSIONS

This inquiry underscores the structural hurdles trans women face when accessing suitable public healthcare. It introduces a gender equity framework for trans inclusive healthcare, outlining implications for research, theory, policy, and practice. Toward the goal of embracing complexity and diversity, this framework, for example, promotes the rigorous absorption of trans persons and their healthcare experiences in gender-responsive programming, and encourages the development of a comprehensive understanding of gender equity from an intersectional perspective incorporating the unique needs and rights of trans healthcare seekers. The framework also offers practical guidance for cultivating health systems attuned to gender diversity (such as addressing medical genderism and recognizing the broad spectrum of identity at a policy level).

HIV Testing by Gender Identity Among Sexually Active Transgender-, Intersex-, and Hijra Individuals Reached Online in India

Online outreach may be an important strategy to reach Indian gender minority (GM) populations for HIV testing. However, little is known about Indian GM populations reached online who are sexually active and their HIV testing behaviors. We conducted a secondary analysis of an India wide online cross-sectional survey to assess HIV testing and identify associated factors. The 467 GM respondents identified their gender as transgender women (29.6%), Hijra (5.1%), intersex (37%), or gender non-binary (28.3%). Overall, almost half (47.5%) had never been tested for HIV; among respondents having condomless anal sex, half (50%) reported never testing for HIV. A decreased odds of ever HIV testing was associated with being unsure how to access free testing (compared to being easy; AOR = 0.36, 95%CI 0.20, 0.63) and unaware of comfortable testing sites (AOR = 0.32, 95% CI 0.20, 0.63). Increased odds of testing were associated with identifying as Hijra (compared to transgender women; AOR = 4.07, 95%CI 1.18-16.92) and disclosing sexual behaviors to a doctor (AOR = 3.20, 95% CI 1.91, 5.46). In this GM sample recruited online, HIV testing rates were low. Online interventions are needed to engage individuals with diverse GM identities in India for linkage to accessible and acceptable HIV testing options.

Impact of the COVID-19 pandemic on the mental health of transgender persons in India: Findings from an exploratory qualitative study

Introduction

Transgender persons in India, who are one of the most vulnerable groups, were particularly impacted by the COVID-19 pandemic. Increased risk of COVID-19, challenges with continuing livelihood, uncertainty, and anxiety around the pandemic over pre-existing social discrimination and exclusion pose risk of a mental health impact as well. To investigate this further, this component of a larger study on experiences in healthcare of transgender persons in India during COVID-19 and looks into the question “How did the COVID-19 pandemic impact the mental health of transgender persons in India”.

Methods

22 In-depth interviews (IDI) and 6 focus group discussions (FGD) were conducted virtually and in-person with persons self-identifying as transgender or belonging to ethnocultural transgender communities from different parts of India. Community based participatory research approach was used by ensuring representation from the community in the research team and through a series of consultative workshops. Purposive sampling with snowballing was used. The IDIs and FGDs were recorded, transcribed verbatim and analyzed using an inductive thematic analysis.

Results

Mental health of transgender persons were affected in the following ways. Firstly, COVID-19, its associated fear and suffering combined with pre-existing inaccessibility of healthcare and reduced access to mental health care affected their mental health. Secondly, unique social support needs of transgender persons were disrupted by pandemic linked restrictions. Thirdly, pre-existing vulnerabilities such as precarious employment and underlying stigma were exacerbated. Finally, gender dysphoria was a key mediating factor in the impact of COVID-19 on mental health with a negative and positive impact.

Conclusions

The study reiterates the need to make systemic changes to make mental healthcare and general healthcare services trans-inclusive while also recognizing the essential nature of gender affirmative services and the need to continue them even during emergencies and disaster situations. While this brings out how public health emergencies can exacerbate vulnerabilities, it also shows how the lived mental health experience of transgender person is intricately linked to the way work, travel and housing is structured in our society and therefore points to the structural nature of the linkage between mental health and gender.

Health(care) matters: where do the transgender individuals of Kashmir situate themselves?

While employing a phenomenological perspective, the present study aimed to explore the varied experiences of transgender individuals in Kashmir, concerning their health-seeking behavior, and the constraints they face while accessing healthcare resources on a day-to-day basis in their life world. Participants were recruited through the purposive and snowball sampling strategies and the sufficiency of sample size was determined by data saturation. Data were collected using face-to-face in-depth interviews and analyzed through Colaizzi's procedure of extracting recurrent themes and their interwoven relationships in qualitative research. Three main themes of awareness and the preferences for healthcare, gender identity and persistent stigmatization in care settings, and intra-community support and the resultant caregiving were prominent. Results of the study revealed that the transgender individuals in Kashmir experience inappropriate health-seeking behaviour primarily due to their unawareness regarding health, diseases and public healthcare programs/schemes, financial constraints, social exclusion, improper support and social stigma. They often prefer treating their health issues, mostly through local pharmacies or patent medicine vendors (PMVs), instead of visiting the medical professionals in the organized sector. Moreover, in many instances, they were also found to delay their decisions to seek care or simply decided to remain far from any medical intervention. As a result, the transgender individuals in Kashmir usually experience underutilization of formal healthcare services, which undermines their right to proper health and well-being.

Minority Stress in Emotion Suppression and Mental Distress Among Sexual and Gender Minorities: A Systematic Review

Background:

The existing structural framework of defining gender and sexuality based on heteronormative ideology led to the succession of the notions of stigma, prejudice, and hate towards the sexual and gender minority population. The presence of strong scientific evidence for the negative consequences of discriminatory and violent events has directed the association with mental and emotional distress. This study aims to comprehend the role of minority stress in emotional regulation and suppression among the sexual minority population globally using systematic review of literature through elaborate Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Summary:

The analyses of the sorted literature premised on the PRISMA guidelines revealed that minority stress mediates the emotion regulation processes among the individuals who witness continuous episodes of discrimination and violence leading to emotional dysregulation and emotion suppression. Studies also reported the dominance of various health-risk behaviors such as alcohol addiction, drug abuse, and other forms of intoxication among sexual minority individuals. Increased instances of anxiety, stress, depression, and suicidal ideations were prominent in the findings of the empirical research suggesting an intricate role of minority stress in advancing the faulty emotion suppression and mental health concerns among the sexual and gender minority population.

Key message:

Minority stressors among sexual and gender minority individuals mediate emotion suppression and mental distress.

Diverse Experiences and Coping During the COVID-19 Lockdown and Unlock in India

In response to the coronavirus pandemic, the Government of India imposed a nationwide lockdown of 21 days on May 25, 2020, which was extended thrice to a total of 68 days. Mandatory quarantine could hamper mental well-being, trust in the government, and compliance with guidelines. This study looks in-depth at individual accounts during the lockdown (phase A) and after the “unlock” (lifting of the nationwide lockdown; phase B) using telephonic interviews. Mass job loss and the exodus of migrant workers from major cities highlighted the need to include low-income groups in research; hence, purposive sampling was used. We interviewed 45 participants in phase A and 35 participants in phase B; the latter was drawn from the phase A pool based on availability and willingness. Data were analyzed using thematic analysis. Analysis revealed four themes of participants’ experiences, namely: (1) transitioning from a disrupted normal to a “new normal”; (2) accountability and lack of trust; (3) fear and uncertainty; and (4) perceived lack of control. Within the themes, coping with stressors was observed in six broad categories: (1) distraction, (2) escape/avoidance, (3) positive cognitive restructuring, (4) problem solving, (5) seeking support, and (6) religious coping. Results enabled the drawing of parallels and contrasts between various socioeconomic, religious, and sexual/gender groups and were discussed from the lens of cognitive appraisal theory and coping. The implications of these findings in psychological crisis intervention and policy are discussed, pointing toward the need to allow a collaborative effort and mutual trust to build a resilient society.

Protocol for a scoping review of the use of information and communication technology platforms for the delivery and utilisation of transgender healthcare

INTRODUCTION

In recent years, there has been strong interest in making digital health and social tools more accessible, particularly among vulnerable and stigmatised groups such as transgender people. While transgender people experience unique physical, mental and sexual health needs, not much is currently known about the extent to which they use information and communication technologies such as short messaging service and videoconferencing to access health services. In this paper, we discuss our protocol for a scoping review of the literature about the delivery and utilisation of digitally mediated health services for transgender populations.

METHODS AND ANALYSIS

This scoping review of the provision and experience of telemedicine among transgender people will follow the methodological framework developed by Arksey and O'Malley. The search will be conducted using three online databases, namely PubMed, CINAHL and Scopus, with additional literature explored using Google Scholar to identify grey literature. Relevant English-language studies will be shortlisted after completing a title and abstract review based on defined inclusion criteria. Following that, a final list of included studies will be compiled after a full-text review of the shortlisted articles has been completed. To enable the screening process, a team of researchers will be assigned refereed publications explicitly referring to the provision and experience of transgender healthcare through telemedicine. Screening performed independently will then collaboratively be reviewed to maintain consistency.

ETHICS AND DISSEMINATION

The research is exempt from ethics approval since our analysis is based on extant research into the use of digital technologies in providing healthcare to transgender people. The results of this study will be disseminated through peer-reviewed academic publications and presentations. Our analysis will guide the design of further research and practice relating to the use of digital communication technologies to deliver healthcare services to transgender people.

Information and communication technology-based health interventions for transgender people: A scoping review

In the recent past, there has been a strong interest in the use of information and communication technology (ICT) to deliver healthcare to 'hard-to-reach' populations. This scoping review aims to explore the types of ICT-based health interventions for transgender people, and the concerns on using these interventions and ways to address these concerns. Guided by the scoping review frameworks offered by Arksey & O'Malley and the PRISMA-ScR checklist, literature search was conducted in May 2021 and January 2022 in three databases (PubMed, CINAHL and Scopus). The two searches yielded a total of 889 non-duplicated articles, with 47 of them meeting the inclusion criteria. The 47 articles described 39 unique health projects/programs, covering 8 types of ICT-based interventions: videoconferencing, smartphone applications, messaging, e-coaching, self-learning platforms, telephone, social media, and e-consultation platforms. Over 80% of the health projects identified were conducted in North America, and 62% focused on HIV/sexual health. The findings of this review suggest that transgender people had often been regarded as a small subsample in ICT-based health projects that target other population groups (such as 'men who have sex with men' or 'sexual minority'). Many projects did not indicate whether transgender people were included in the development or evaluation of the project. Relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV/sexual health, in resource limiting settings, and among transgender people of Asian, Indigenous or other non-White/Black/Hispanic backgrounds. While the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people, the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ICT-based interventions for transgender people. Future ICT-based interventions need to be more inclusive and specified, in order to ensure the interventions are safe, accessible and effective for transgender people.

Impact of COVID-19 on Transgender Women and Hijra: Insights from Gujarat, India

Protecting vulnerable populations from the COVID-19 pandemic is a strategic imperative, especially when considering the potential vulnerability it has on a wide range of marginalized communities. Transgender women and hijra individuals who struggle to cope financially, mentally, or physically are vulnerable groups that require attention during the COVD-19 pandemic. Using a qualitative descriptive research design, 12 transgender women and hijra persons participated in semi-structured telephone interviews during India's lockdown phases (1.0 and 2.0) of the COVID-19 pandemic. A snowball sampling technique was used to recruit study participants. Authors identified five themes: knowledge and practice; psychological domain; health conditions; individual and community experiences; and support. Findings offer broad insights into bolstering health concerns and access to healthcare services from public health and human rights perspective. An access to adequate healthcare services is a fundamental human right. The COVID-19 pandemic response without a human rights framework will have a major impact on the progress of the Sustainable Development Goals. Future studies of this population will illuminate unique considerations for healthcare workers while providing care to this neglected group.

Level of Resilience Among Transgenders in Selected Areas of Puducherry, India: An Exploratory Research

Background

Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress, and it is a predictor of mental health status that specifically indicates self-esteem, perceived social support, emotion-oriented coping, and a sense of personal mastery.

The third gender known better as transgender has existed in every culture, race, class, and religion since the inception of human life has been recorded and analyzed. In spite of many advances and reforms, the current plight of transgender is far from being satisfactory. The social integration of transgender with the mainstream community is practically non-existent even today.

Aim and objective

The objective of the study is to assess the level of resilience among transgenders at selected areas in Puducherry, India, and to find out the association between the levels of resilience among transgenders with the selected demographic variables.

Methods

A descriptive cross-sectional study was conducted in the selected areas of Puducherry, India, adopting a linear snowball sampling method after consultation with the Nayaks (heads of transgenders) of the transgender groups, and 100 transgenders were enrolled who fulfilled the inclusion criteria and consented to participate in the research.

Results

About 29 (29%) transgenders were in the age group of 31-40 years, 28 (28%) were in the age group of 21-30 years, 24 (24%) were in the group of 41-50 years, and 19 (19%) were in the age group of 51 and above. In education status, 38 (38%) had secondary education, 23 (23%) had primary education, 20 (20%) had higher secondary education, 12 (12%) had graduation and above, and seven (7%) were diploma holders. Moreover, 54 (54%) were employed, and 46 (46%) were unemployed; 81 (81%) were residing in rural areas, and 19 (19%) were residing in urban areas. The study revealed that 53 (53%) of them had average resilience, 28 (28%) had the least resilience, and 19 (19%) had the highest resilience among transgenders. The minimum score was 28.0, and the maximum score was 52.0. The mean score was 42.50 with a standard deviation of 4.61. The median value was 43.0.

Conclusion

Transgenders exhibit low and average resilience that reflects poor mental health status among them. The educational status was found to be associated with the level of resilience. Proper education among transgenders would help in improving their resilience and betterment of their life.