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Journal of Migration and Health logoLink to Journal of Migration and Health
. 2023 Nov 3;8:100204. doi: 10.1016/j.jmh.2023.100204

COVID-19 pandemic and transgender migrant women in India: Socio-economic vulnerability and vaccine hesitancy

Arun Kumar Acharya a,⁎, Jennifer Bryson Clark b, Sushree Subhalaxmi Behera a
PMCID: PMC10654218  PMID: 38028887

Abstract

In India, transgender women, often referred to as hijra or kinnar, remain a marginalized group and encounter interpersonal and structural barriers that subject them to social exclusion, discrimination, lack of access to education and health care, and fewer job opportunities compared with the general population. During the COVID-19 pandemic these disparities were heightened and the livelihood of transgender migrant women were severely hit and disrupted, causing further financial and physical hardship. The present study aims to explore the socio-economic vulnerability faced by these women during the pandemic and the factors that contribute to vaccine hesitancy in order to assist government officials and policy makers in the formulation of more inclusive policies for transgender people. Results indicate that the pandemic has adversely impacted their livelihood as most of them depend on sex work and begging. In order to fulfil their daily needs during the lockdown, they have borrowed loans from multiple sources with a higher interest rates and remain in debt. On vaccination status, only seven out of 43 transgender migrant women have taken one vaccine dose, and the rest are not willing to visit vaccine centres because of societal stigma and discrimination including from healthcare personnel. The study reported that these migrant women suffered intensified social stigma, verbal hostility and transphobia attitudes from healthcare professionals whihc caused panic, fear, anxiety and depression among them, and thus they evade these spaces for further consultation or to obtain any other services. Many of them have decided not to take the COVID-19 vaccine in order to stay away from hostility. Further, the lack of trust in medical professionals is also one of the principal concerns leading to vaccine hesitancy among transgender migrant women. Thus a systemic inclusive healthcare services policy is required to address the factors that may influence the vaccine acceptance among transgender women in India.

Keywords: Transgender migrant women, COVID-19 pandemic, Stigma, Discrimination, Vaccine hesitancy and India

1. Introduction

Transgender is a term used to describe people whose gender identity does not conform to that typically associated with the sex they were born as or assigned to at birth (Mayer et al., 2008). In India, the transgender community is referred to as hijra, kinnar or Chhakka (having both masculine and feminine characteristics), Maichiya (male with feminine characteristics) and other slang terms. In colonial times, transgender people, then commonly known as eunuchs, were categorized as habitual offenders or natural-born criminals under the Criminal Tribes Act of 1871 and were punished for their cross-dressing practice. Historic persecution not only rendered transgender people invisible in the public sphere but also laid the foundations of a transphobic society. The transgender community remains marginalized and encounters interpersonal and structural barriers that subject them to social exclusion, discrimination, and a lack of access to education, medical facilities, and job opportunities (Deb, 2020; Ganju and Saggurti; 2017; Goldie and Chatterjee, 2021).

A growing body of literature describes how the 69-days complete lockdown in India restricted the physical movement of people during the pandemic disproportionately and affected the livelihood of millions of daily paid workers, especially of transgender migrants more profoundly leaving them at heightened risk of hunger and further poverty (Deb, 2020; Acharya and Patel, 2021; Pandya and Redcay, 2021). Approximately 2 million transgender people have been disproportionately affected in India during the COVID-19 lockdown, largely due to the fact that the livelihood of transgender women depends entirely on daily wages including begging, street entertainment, and sex work . The lost livelihood opportunities due to the lockdown have exacerbated marginalization and unemployment further (Banerji, 2020).

From June 2020 onward the lockdown was gradually lifted, however, transgender women in India continued to suffer much distress due to continued shutdown of many public places, the continued restriction of movement of the general public, and the non-availability of the COVID vaccine, which prevented any hope of returning to their traditional way of life. The Government of India started the COVID-19 vaccination programme during the month of January 2021 and since then 100 million people have been vaccinated with at least one dose. However, the statistics shows that only 48 % women in general1 and 5 % transgender women out of 4.88 million have been vaccinated.2 Some media reports indicate that the transgender population group is less likely to be vaccinated, because of gender dysphoria more than to social class3.

Discrimination against transgender women is well documented. Bradford et al. (Bradford et al., 2013), Ming et al. (Ming et al., 2016), Grant et al. (Grant et al., 2011) and James et al. (James et al., 2016) identified that the discriminatory behaviour by healthcare professionals ranges from a denial of services to physical, verbal, and sexual abuses that discourages the transgender population from accessing available healthcare services, including either avoiding or delaying receiving these services. Even before the COVID-19 pandemic, numerous studies around the globe, including India, have highlighted the intolerance and negative attitudes including stigmatization and marginalization due to their transgressive gender identity in their daily life (Thompson et al., 2019; Ganju and Saggurti, 2017; Kalra, 2012; Reddy, 2005).

A study by the United Nations Development Programme (United Nations Development Programme (UNDP) 2010) on transgender women in India, indicates that some members of society ridicule gender-variant people for being ‘different,’ often escalating to incidences of outright hostility. The COVID-19 pandemic has exacerbated negative attitudes toward transgender women and thus prevented them from accessing healthcare services including the COVID-19 vaccine. Studies on the effect of COVID-19 pandemic on transgender women are scarce, and as of date, few studies have been written on how transphobia and normative social standards have played a role in COVID-19 vaccine hesitancy. Thus, the principal aim of the paper is to explore the socio-economic vulnerability faced by transgender migrant women during the pandemic and analyze the factors behind vaccine hesitancy among them in India. In this research authors defines “vaccine hesitancy” as; delay in the acceptance or refusal of vaccines despite the availability of vaccination services.

2. Transgender women in India

In 2014 the Government of India recognized transgender as a separate gender for the first time in the country and named it the “Third Gender”. The reorganization in terms of identity, helped transgender people gain the right to vote, own property, and claim a formal identity through a passport or other government identification, and secure government services such as food subsidies, education, employment, and health [(United Nations Development Programme (UNDP) 2010; Chakrapani et al., 2004; Humsafar Trust 2012)].

The Transgender community in India, known as hijras numbers up to a total 4.8 million as per 2011 census (in the state of Odisha the total number of transgender people is 20,332)4 and occupy a unique role in society. Traditionally there is a universal acceptance of transgender people in Hindu society and it is believed that transgender women have the power to confer fertility. However, their traditional role of begging and dancing at weddings has currently declined with increased urbanisation and changing social structures, resulting in many being pushed into sex work in towns and cities as a means of survival (Sahastrabuddhe et al., 2012; Setia et al., 2006). Studies have also identified that transgender women are, not only ignored, but are often ostracized from society and face numerous barriers that limit access to education, employment and health care (Ganju and Saggurti, 2017; Humsafar Trust 2012; Jayadeva, 2017). They also face physical and verbal abuse, forced sex, extortion and arrests on false allegations by the police (United Nations Development Programme (UNDP) 2010).

Transgender women are among the most marginalized and vulnerable communities in India, they face multilayered discrimination resulting in miserable living conditions (Chakrapani, 2016). Living as a transgender person is an experience filled with trauma and tensions and they often bullied or dismissed (Chakrapani, 2016; Philip, 2018). Ganesan, Elangovan and Murugaiyan (Ganesan et al., 2013) describe that these women are stigmatized and discriminated against from their family to the larger society. They are often thrown out of the family and are ridiculed, abused, and harassed by society at large. They are humiliated in educational establishments and healthcare centres and in all public and private places, additionally, there is a wide misconception that transgender people are untouchables, insufficient and unfit, which adversely impacts their mental health (Ganju and Saggurti, 2017; Humsafar Trust 2012; Sahastrabuddhe et al., 2012; Jayadeva, 2017).

Studies conducted by Chakrapani et al., (Chakrapani, 2016) and Saraswathi and Praveen (Saraswathi and APraveen, 2015) affirmed that transgender women in India suffer incongruent treatment in healthcare centres with many health care service providers considering them a mentally ill group. This flagrant disregard for transgender people by the government, policy makers and health professionals has resulted in a denial of access to welfare services that contravenes to their basic human rights. As such, the socio-cultural exclusion including the lack of healthcare support experienced by transgender community renders them unable to sustain themselves. In addition, the societal negotiation to position and render sexuality status to transgender persons different from male or female identities hinders access to healthcare system including the COVID-19 vaccine.

During the pandemic systemic discrimination against the transgender community has continued and can be seen on the government's own COVID-19 vaccine registration form on the official COVID-19 vaccine portal of the government of India (CoWIN). CoWIN does not offer a transgender category in the gender section, instead the application boxes include male, female, or “others” The site's choice to employ the word "others" is confusing and renders the transgender community invisible since all official government IDs, since 2014 utilize the correct term "Transgender Persons". Also, the CoWIN form insists on the provision of photo ID proof which the average trans person does not have access to, and a smart phone which many transgender people do not have creating further marginalization.

3. Methodology

In 2018, the World Bank and the Odisha Higher Education Department jointly established the Centre of Excellence on Regional Development and Tribal Studies and one of the objectives of this centre is to analyze the migration and livelihood patterns of the people of Western Odisha, India. As a part of this project, we studied the socio-economic vulnerability faced by transgender migrant women during the COVID-19 pandemic and vaccine hesitancy among them in Western Odisha. During the months of June and August, 2021, the authors conducted 43 face to face semi-structured interviews in Sambalpur City, Odisha (see Map 1) among transgender migrant women. All the respondents have migrated during the last five years from nearby districts such as Bargarh, Bolangir and Sonepur, they run away from violence and discrimination faced in their families and peer groups in search of peaceful life and better livelihood opportunities.

Map 1.

Map 1

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Enumerated transgender migrants women in Sambalpur district, Odisha, India.

For the present study, a transgender migrant woman was identified through author's personal contact and recruited for the research study. After the completion of interview the first participant was asked to connected author with other transgender migrant women and participants were given 100 rupees ($1.50 USD) as compensation for their time of collaboration. Using snowball sampling strategies a total of 43 transgender migrant women were interviewed. Although authors contacted nearly 90 migrant women from transgender community but they were not interested to participate in the study. All the interviews were conducted at the respondent's respective houses by the researchers. The interview scheduled included both quantitative and qualitative data information. The first section of the questionnaire included socio-economic and demographic information of transgender migrants and the second section included questions on socio-economic vulnerabilities during COVID-19 and reasons behind vaccine hesitancy. Each interview was last for about 30-40 minutes.

3.1. Ethics statement

Keeping the human objects in mind for this research, the authors followed the declaration of Helsinki (DoH) by the WMA (2013) regarding the ethical and safety procedure during interviewing of the transgender women, maintaining confidentiality and anonymity. The principal investigator obtained approval from the Institutional Review Board (IRB) of the home institution (Sambalpur University, India) on 01.03.2021 (Approval number 41A/PGA). It should be noted that, while the participants agreed to be interviewed, we obtained their consent and repeatedly explained to them the purpose of our study and subject to be discussed. We never asked their names, avoided any questions could be interpreted as discrimination, and did not question their sentiments or judge their decisions or character. Moreover, all informants were also told before the interview that they were in no way required to answer all of the questions if they did not feel comfortable, and if during the interview they feel timid or uncomfortable to continue, they can discretely end the interview.

3.2. Data analysis

In this study both the quantitative and qualitative fieldwork information were analysed in the following two ways. The quantitative information such as socio demographic data, measures taken to safeguard on COVID-19, the impact of COVID-19 on economic and social life, and reasons for COVID-19 vaccine hesitancy were analyzed using SPSS version 22 software. The quantitative information was evaluated using descriptive statistical method such as the frequency distribution of the data. Secondly, the qualitative information was analyzed using Critical Discourse Analysis (CDA). Here we examined transgender migrant women's words (discourses) including the prosodic features (differences in pitch, loudness, tempo, emphasis, and rhythm), paralinguistic features (pauses, gaps, restarts, body language, facial expressions), and kinetic signals (hand gestures, head nods, etc.). We analysed the discourses to see how, during the COVID-19 period, various social actors, including those working in the medical field, stigmatised and discriminated against transgender migrant women. This qualitative information was examined together with the quantitative information to shed light on the magnitude and seriousness of the problem and thus assess its future implications. In the paper pseudonyms are used to protect women's identity.

4. Results

4.1. Socio-demographic characteristics of transgender migrant women

A total of 43 transgender migrant women were interviewed and the majority (53.5 %, n = 23) of study participants were in the age group of 26-30 years. Thirty-six participants (83.7 %) had studied up to primary school and then discontinued school, and seven of them (16.3 %) never attended any formal education (see Table 1).

Table 1.

Socio-demographic characteristics of the study's participants.

Sample characteristics n (%)
Current Age
18-25 years 08 (18.6)
26-30 years 23 (53.5)
More than 30 years 13 (30.2)
Education
Illiterate 07 (16.3)
Up to Primary (dropout) 36 (83.7)
Caste
Scheduled caste 26 (60.5)
Scheduled tribe 02 (04.6)
Other backward class 11 (25.6)
Other 04 (09.3)
Occupation
Sex work (only) 04 (09.3)
Begging (only) 01 (02.3)
Dancer 01 (02.3)
Daily wage labour (only) 01 (02.3)
Sex work and Begging 36 (83.7)
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Source: Fieldwork, 2021

On caste composition, 26 transgender migrant women (60.5 %) were from Scheduled Caste (SC), and the rest of the participants were from Scheduled Tribe, Other Backward Class and General Caste. Traditional Indian society is divided into five main categories of castes: Brahmins, Kshatriyas, Vaishyas, Sudras, and Dalit. However, to provide equal representation of disadvantaged groups in education, employment and politics, the Government of India re-categorised the castes into four broad categories in official statistics— Scheduled Caste (SC), Scheduled Tribe (ST), Other Backward Class (OBC), and General Category (GC), which includes the 'upper' castes. On occupational pattern, majority (83.7 %, n = 36) of these migrants said both sex work and begging are the primary professions, however, some participants also described solo sex work, begging, dancing and labour work as their occupations (see Table 1). It was observed that all the respondents below the age of 30 participated in sex work, as clients prefer young and teenage woman for sex and do not hesitate to pay more for a young woman compared to an elder one.

4.2. Knowledge about COVID‑19

All the 43 interviewed transgender migrant women were well aware of COVID-19 and their major sources of information were television and social media principally WhatsApp and Facebook. For example, Malti a transgender woman said: “......I received all information on COVID on my WhatsApp and facebook. During the lockdown when we were closed inside the home, social media was the only source of information on COVID-19 for me..... Every day, I used to get information from my group (Sambalpur Transgender Bindia) related to COVID.....” (Malti, 18 years). On the signs and symptoms of COVID-19, participants were able to list correct symptoms. All participants said the primary and common symptoms of COVID-19 are fever, difficulty in breathing and cough. Additionally, some participants also reported vomiting, diarrhoea, severe headache, muscle pain and loss of taste or smell as signs of COVID-19 infection (see table 2).

Table 2.

Measures taken to safeguard on Covid-19 by the study's participants.

Sample characteristics n (%)
Social distancing 43 (100.0)
Mask when going outside 43 (100.0)
Avoid handshake 43 (100.0)
Avoid touching objects and infected persons 35 (81.4)
Washing hands regularly 32 (74.4)
Wearing gloves 18 (41.9)
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Source: Fieldwork, 2021

On measures taken to safeguard against COVID-19, all studied participants stated that social distancing, mask use, and avoiding handshakes are the principal preventive measures used as safeguards. Some transgender women (all school attended) responded that avoiding touching of objects and infected persons, washing hands regularly, and wearing gloves at all times can protect from contagion of virus (see Table 2). Rakhi a 25 year old transgender migrant woman educated upto the 4th standard of primary education said: “although none of the government agencies has dropped a message how we (transgender) have to take care during COVID, but from the circulated information (on WhatsApp & facebook), I think social distancing and use of mask can protect us from the Corona virus infection... and this I follow....”.

4.3. Impact of COVID-19 on livelihood

The COVID-19 pandemic has severely affected the financial stability and livelihood opportunities of the transgender community, which is facing socio economic hardships during these unprecedented times. Such is the situation of the interviewed transgender migrant women in Sambalpur city. Participants said they had lost their principal source of income due to uncertainty and a lack of job opportunities. Similarly, 38 participants (88.4 %) said their working hour has been reduced due to the pandemic and 26 participants (60.5 %) had lost their savings (see Table 3). Manjari, a 34 year old transgender woman said: “I used to earn about 800-1000 rupees every day by sex work and begging, but all these have stopped during lockdown and my earning has dropped to zero. Now I have started working again, but not getting good numbers clients as they are afraid to get contact with COVID. My principal clients were truck drivers and now days when I am offering sex at a lower price, they still hesitate..... my income reduced significantly. Without sufficient earning I could not pay the house rent, so I was forcibly evicted from my rented room and now I am seeking shelter at my friends’ room. I had little saving, it also finished.... do not know how to live ahead and meet my needs.....”

Table 3.

Impact of Covid-19 on economic and social life of study's participants.

Sample characteristics n(%)
Less income 43 (100.0)
Unstable Job 43 (100.0)
Reduced working hours 38 (88.4)
Loss of saving 26 (60.5)
Starvation 40 (93.0)
Debt 39 (90.6)
Homeless 11 (25.6)
Difficultly in purchasing antiretroviral drugs 07 (16.3)
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Source: Fieldwork, 2021

On other economic and social impacts on transgender migrant women, as observed in Table 3, many participants suffered from hunger and starvation (n = 40, 93 %), borrowed money (debt) (n = 39, 90.6 %) from other sources, became homeless (n = 11, 25.6 %) and have difficulty to get antiretroviral drugs (see Table 3). Radha an 18 year old transgender woman said: “.....Most of us earn money on begging or sex worker, but the pandemic has put an end to these activities. We are facing massive challenges to get food, with no income, we are starving. Although government is providing food... I am not interested to go those places as I have to stand in queue... COVID has pushed us in an anguish and bad situation and we have not even a place to live and a source of income amid this crisis. The government should help us otherwise we will stage a demonstration....”. Moreover, many transgender migrant women mainly of Schedule caste and Schedule tribe do not poses government identity proofs such as an Aadhaar card, driving license, passport, permanent account number, ration card, or voter identity card and are therefore, excluded from various social security schemes of the Central and State governments.

4.4. Impact of COVID-19 on general health

During the interviews, all respondents were asked how the COVID -19 pandemic has affected their health in last two months (at the time of interview), the majority of participants expressed more than one factor that has caused a further reduction in the quality of life. The biggest impacts are mental stress and depression as 100 % (n = 43) of the participants noted that they have experienced some form of depression due to the pandemic (see Table 4). For example, Rani a 24 year old transgender migrant woman said: “When COVID spread in India, it affected more the trans community. Members of the community used to earn 500 to 600 rupees each day before the pandemic but during the second wave, this income vanished completely. As there is no work or income it was hard to buy daily needs which causes gradual mental stress. Every day, I moved around the city and periphery areas to get some money through begging.... but it was very less, not even 100 rupees. I am HIV positive and need medicine (antiretroviral drugs) everyday. With this little money how can I manage my life......”. Similarly, Buli a 28 year old transgender migrant woman said: “I feel like I am going to die of stress and depression. My living partner, who was working as wage labour, has no job at present and this made him very aggressive. The financial crisis has worsened our relationship as we both cannot earn. I am tired of life, and COVID-19 has put me into trouble”.

Table 4.

Impact of Covid-19 on general health of study's participants.

Sample characteristics n (%)
Mental stress 43 (100.0)
Depression 43 (100.0)
Anxiety 38 (88.4)
Loss of sleep 40 (93.0)
Loss of weight 40 (93.0)
Feeling isolated 16 (37.2)
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Source: Fieldwork, 2021

In addition, nearly 38 participants of all age groups (88.4 %) experienced anxiety, 40 women (93 %) have lost weight (see Table 4). In this regard, Jaguni, a 26 year old trans woman said: “Before COVIDCOVID-19, my way of living was totally different. I was working as sex worker in few Dhabas (roadside restaurant in India). They are on highways, generally serve local cuisine, and also serve as truck stops) and my earning was good. But as the virus spread the Dhaba owners didn't allow me to operate there. It suddenly affected my life style and changed my eating practices. With no income now I eat rice and stir fried potato only. I am running cashless; all savings are used-up…. I am in extreme need of money and worried about the future. These things have caused me to lose weight. However, it is not only the food, the constant stress and lack of sleep also caused weight loss. I am feeling very fragile internally.......”.

Similarly, some younger participants also reported a feeling of isolation (n = 16, 37.2 %) as Malti, an 18 year old trans migrant woman said: “The COVID has put us in prison... earlier we could move all the places.. but now it is not possible... whenever we visit mall or any public places for begging, people watch us in a very suspicious eyes.... many times they are so obsess with isolating us and also say we are the diseases carrier...., it hurts my dignity..... I feel despair and no longer continue to be alive.... it is very depressive situation and I feel totally isolated staying at home 24 hours. Very disgusting situation......”.

4.5. COVID-19 vaccine hesitancy

During the interviews transgender migrant women were asked about their vaccination status, of the total 43, only seven women have taken first dose of COVID-19 vaccine and the majority (36 women) have not been vaccinated despite the fact that the vaccine is freely distributed by the Government of India. When asked for the reason of vaccine hesitancy, various reasons were cited. Most participants (n = 36, 100 %) expressed fear of discrimination and stigma at healthcare centres which caused them not to visit the vaccine centre, and 34 women (94.4 %) said they were not interested in being vaccinated due to harassment and the transphobic attitude of health care professionals (see Table 5). They suffered double and triple harassment compared to others for being transgender and migrant woman and sometime it also became so harsh when they belongs to Schedule Caste and tribe. Laila an 18 year old a Dalit caste (Dalit are also called Harijan or untouchable in low-caste in traditional Indian society. Officially they known as Scheduled Caste) transgender migrant woman described: “....during the COVID-19 pandemic period, once I visited district hospital for a check-up, at that time the doctor asked me sit outside her cabin..... after waiting for 30 to 40 minutes a nurse came out from the (doctor's) cabin and said; “Harijan (Dalit) Hijras” are not allowed to cabin. She continued and said: you people are virus carrier and you may infect all medical staffs with Coronavirus, leave this place immediately.....”.

Table 5.

Reason of Covid-19 vaccine hesitancy of study's participants.

Sample characteristics n (%)
Vaccine taken
Yes 07 (16.3)
No 36 (83.7)
Reason for vaccine hesitancy
Fear of discrimination and stigma at the healthcare centre 36 (100.0)
Harassment and transphobic attitudes 34 (94.4)
Fear of being rejected 30 (83.3)
Discomfort with health care professionals 30 (83.3)
Afraid of becoming sick 21 (58.3)
Fear of side-effects 18 (50.0)
Do not have Identity proof 02 (5.5)
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Source: Fieldwork, 2021

Similarly, 30 (83.3 %) participants said they fear of being rejected and denied vaccination in the healthcare centre and do not feel comfortable with healthcare professionals (see Table 5). For example Nauri a 26 year old a Scheduled Tribe transgender migrant woman described: “......visiting district healthcare centre or other medical centre of the city is just like hell and traumatic experience.... Doctors including nurses and paramedical staffs behave us strangely.... as if we have come from other planets... we have already rejected by the family and community, so visiting again hospital for the vaccine not easy for me. I do not feel comfortable the way they look and talk with us... their behaviour is very inhuman and it gives lots of mental stress... so better not to get vaccine.... if I fall ill, let it be......nobody care us.........”.

Several of these migrant women (n = 21, 58.3  %) also live in constant fear that if they get vaccinated they may become sick, and many of them felt that the COVID-19 vaccine has many side-effects such as hair loss, weakness, death and sexual impotence and thus they do not want to receive the vaccine (see Table 5). Radha an 18 year old transgender migrant woman said: “.......I do not want to take vaccine........ do not know how it reacts in my body.... many people said that vaccine caused high hair fall and many have fallen sick...... I also received a message in my WhatsApp on possible side effects of COVID-19 vaccine such as fatigue, fever, body pain, infertility, irregular menstruation and sexual impotent.... I work as sex worker and if vaccine make me impotent (sexual), how can I survive?.... also if I fall ill who will take care of mine..... I live alone and do not have any relatives... I am also scared to death of getting this vaccination, so better not to take a chance by getting vaccinated; probably I might survive......”. Moreover, two migrant women from transgender community (5.5 %) replied they do not have identity proof to take the vaccine (see Table 5).

5. Discussion

Transgender women have been recognized in many cultures and societies from ancient times to the present day. Every society comprises individuals who do not fit into the culture's dominant sex/gender categories persons born inter-sexed, those who exhibit behaviour or desires deemed appropriate for the “opposite” sex/gender, or those who, while conforming outwardly to culturally normative gender roles, experience themselves in fundamental conflict roles (Ahmad, 2018). The transgender women constitute a marginalized section of Indian society and thus face legal, social as well as economic difficulties. The structural inequalities and social stigma disempower transgender women due to the labelling and negative generalized attitude towards them, and cause an inability to secure government services such as food subsidies, education, employment, and health services including the COVID-19 vaccine.

The COVID-19 lockdowns in India have further distressed the social, healthcare and economic outcomes of transgender people. The transgender community has been uniquely and negatively impacted by the pandemic, and in the absence of gender affirming healthcare, welfare or social support measures, the transgender migrant women are solely reliant on public and community oriented jobs such as begging and sex work. The pandemic has rendered many migrants in the transgender community unable to sustain themselves pushing them into further poverty and starvation. In order to fulfil their daily needs during the lockdown, the only recourse has been to take out loans from multiple informal lenders with extremely high interest rates, and many have experienced further homeless. As Bhattacharya (Bhattacharya, 2020) described many transgenders cannot access a bank loan as many of them are illiterate, or migrants and do not have proper valid documents and thus becoming vulnerable to further exploitation and debt bondage.

Vaccine hesitancy is not a new phenomenon especially among migrants and is not limited to COVID-19 vaccine; studies have noted a worrying trend in general vaccine hesitancy in recent years (Lazarus et al., 2021; World Health Organization 2021) and various experts have pointed out that vaccine hesitancy has become a significant factor among migrants and sexual minority populations (Garg et al., 2021; Harrison and Wu, 2020; Wang et al., 2020; Harapan et al., 2020; World Health Organization. Report of the Sage Working Group on Vaccine Hesitancy 2021). In the Indian context, the present study has highlighted barriers to healthcare access and a lack of awareness about the benefits of the COVID-19 vaccine as the fundamental factors behind vaccine hesitancy. Many participants described how their gender identity including their belongingness of Schedule Caste or Tribe caused discrimination and stigma and thus they were reluctant to access public healthcare facilities to get vaccinated. Transgender people have been traditionally mistreated at medical facilities by healthcare professionals so accessing these places and systems has always been a traumatic experience (Parveen, 2020; Deb, 2020).

The transgender community in India is prone to systemic structural violence from many segments of society. Discrimination, harassment, and a lack of access to social institutions have an effect on transgender women and result on hesitation of entering to public spaces including markets, hospitals, and schools (Meher and Acharya, 2022). Moreover, the transphobic behaviour caused double or triple layers of discrimination in health care settings, for example because of having a different gender identity, being a woman, being a migrant and belonging to a lower caste or tribe. This discrimination explained by transgender women have deep historical and systemic roots and its among the factors affecting the universal vaccination process. In the present societal context, transgender people are often seen as a matter of curiosity in the Indian health care system by medical professionals. As Choudhary (Choudhary, 2021) described, transgender women often report discrimination at hospitals and public places because of their non-conformity. Moreover, as health care professionals are curious about the transgender identity, they exploit them in the process such as forceful and un-necessary examination of their genital parts including, use of derogatory remarks such as hijra, kinnar, AIDS carrier, etc. This indicates the intensified social stigma, verbal hostility and transphobic attitudes of healthcare professionals cause panic, fear, anxiety and depression among these women and thus they avoid these spaces for further consultation or to obtain any other services. Therefore, many transgender migrant women have decided not to take the COVID-19 vaccine in order to stay away from hostility.

As Clark et al. (J et al., 2018) mentioned, although the world is moving in the right direction to accept the transgender community, most nations still hesitate to acknowledge the community on a cultural level. In the Indian context, on one side it is believed that transgender women have some sort of spiritual power, and on the other side they also considered as mentally ill person, this dual or triple discrimination and structural stigma contributed to long-term violence. Although, the study is based on small sample size, the findings of the research reflect that these migrant women have unique healthcare needs, and vaccine hesitancy within this specific population is not well-explored. By focusing on transgender migrant women, the study shed light on an understudied and marginalized group, leading to more inclusive public health interventions. Also by utilizing both qualitative and quantitative research methods, present research gain a deeper understanding of the reasons behind vaccine hesitancy among these migrant women. Quantitative data can provide numerical trends, while qualitative data can provide a rich narratives and personal perspectives about vaccine hesitancy.

6. Limitations of the Study

This study has certain limitations. First, the sample was limited to 43 transgender migrant women. Although we tried to find a larger number of transgender migrant women for greater representation, owing to the lack of a wide network comprising key informants, it was not possible to do so. Therefore, the findings of this study should be interpreted in the context of the study. Second, the study focused on transgender migrant women only, issues affecting transgender men were not addressed due to their invisibility. Despite these limitations, the study sheds some light on socio-economic hardship faced by these women in India and the principal factors behind their vaccine hesitancy. It offers a springboard for further analysis and research.

7. Conclusion

Recently, the Government of India has implemented various welfare programmes and policies to mainstream the transgender community and protect transgender women from stigma, discrimination and structural violence such as the Transgender Persons (Protection of Rights) Act 2019, the Transgender Persons (Protection of Rights) Rules, 2020 and National council for Transgender Persons. The State Government of Odisha has also implemented umbrella programme “Sweekruti” to protect transgender people's rights and provide fair justice. However, in the case of COVID-19 vaccination out of 4.88 million transgender people only 5 % have been vaccinated. The lack of trust in medical professionals by the transgender community is one of the principal concerns for vaccine hesitancy, thus a systemic inclusive healthcare services policy is required to address the factors that may influence vaccine acceptance among transgender migrant women in India.

Moreover, transgender women perceived systemic stigma, discrimination, oppression, and structural health inequities during and after COVID-19 pandemic and these behaviour modifiers among healthcare professional and society as a whole can positively influence vaccine acceptance. Also non-discriminatory and inclusivity practices workshops and awareness programs can be organised for the healthcare practitioner to better understand this marginalised community. Along with that peer to peer information sharing among the transgender community will help them to be informed about various benefits available to them. Similarly, it is in the public interest for India to make a more concerted effort to create public services accessibility for the transgender community and in the context of the COVID-19 vaccine, efforts should include targeted vaccine drives organized exclusively for transgender people. It is essential to promote vaccination as a social norm with a human rights approach to motivate transgender migrant women to get vaccinated.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

We would like to thank Odisha Higher Education Program for Excellence and Equity (OHEPEE), Government of Odisha, India for financial support through World Bank.

Footnotes

1

https://dashboard.cowin.gov.in/ (Accessed on 16.11.2021)

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