Health care access and utilization among transgender adults in Chennai: a cross-sectional study

Abstract

Background

Understanding regarding the healthcare needs and health seeking behaviour of transpersons is crucial to provide inclusive health care services. This study is an attempt to enhance knowledge about the overall health of the transgender community, analyzing their healthcare-seeking behaviours, the rationale behind their choices, and the barriers they face in accessing healthcare services in Chennai, South India, a large metropolitan city with a significant transgender population.

Methods

This cross-sectional study involved 104 transgender adults recruited through snowball sampling in Chennai, Tamil Nadu. Data were collected using an interviewer-administered questionnaire, developed with inputs from community members, to assess patterns in seeking care for general and mental health complaints, screening for noncommunicable diseases and sexually transmitted infections, and gender reaffirmation procedure. Data was analyzed using JASP (Jeffreys Amazing Statistics Program) and Anthropac software was used for scree plot analysis.

Results

The choice of healthcare was primarily binary between private and government services for major, chronic illnesses and accidents. For minor, major, and chronic diseases transpersons preferred private facilities (45.2%, 61.3%, 66.7% respectively) and for STI screening government facilities (55.4%) were preferred. About 68.3% (71 of 104) of the participants had mental health symptoms in the past year, of those only 18% (13 of 71) sought therapy. Hormone replacement therapy (HRT) is a popular method of gender affirmation among transmen (86.6%). For gender reaffirmation services like HRT and Gender affirmation surgery (GAS), private facilities were preferred (48.21%, 75.7%). government facilities were not preferred for HRT because of non-availability and distrust; and for GAS because of perceived poor quality of services, delay in services, lack of availability and unawareness.

Conclusion

The current healthcare utilization pattern among transgender people shows a preferential use of private facilities and the pattern varies depending on the type of health need. This requires introspection among healthcare policymakers to ensure inclusiveness. Our recommendation is to create gender sensitization modules for health-care workers, encourage private-public partnerships and run awareness campaigns about services offered to increase utilization of government services.

Introduction

The term transgender is used to refer to those whose gender identity differs from that assigned at birth [1]. According to the 2011 census report, 487,803 Indians identified as others, the number of transgenders however is believed to be higher [2, 3]. This minority group has always been a part of Indian society; yet, their existence has been marginalized under majoritarian culture and colonial laws. They have not enjoyed the social security and freedom afforded to cis-gender individuals and are often subjected to prejudice and various forms of abuse.

During the last few years, medical practice has de-pathologized the transgender identity with the removal of Gender Identity Disorder (a condition commonly associated with being a transgender person) from the Diagnostic and Statistical Manual of Mental Disorder (DSM) by the American Psychiatric Association(APA) in 2013, and from the International Classification of Diseases (ICD) by the World Health Organisation in 2016 [4, 5]. Legally, fundamental rights of third gender were for the first time formally recognized by the Supreme court of India in 2014 and the government of India has adopted the Rights of Transgender Persons Act in 2019 [6, 7]. The Act holds the government responsible for ensuring that healthcare services are available to the transgender people [8]. While these acknowledgments are commendable, the community continues to be plagued by the same struggles they faced a decade back like lack of acceptance in mainstream society, inequity in education and the job market, violence, and lack of access to dependable healthcare.

The health challenges that transpersons face today are gender dysphoria, high prevalence of sexually transmitted infection(STI) due to occupational exposure, poor mental health like depression, suicidal ideation, substance use disorders, lack of access to affordable gender transition services and lack of dignified quality health care [9, 10]. Trans-specific healthcare needs include improving health education and awareness for gender affirmation procedures including Hormone-Replacement Therapy (HRT) and Gender Affirmation Surgery (GAS) which helps ease the sense of gender dysphoria [11].

Very few studies exist on the barriers and access to transgender persons’ health in India. A scoping review by Pandya et al. analyzed 67 articles published until Jan 2019 on the health needs of transgender people in India. It showed that 37 of the 67 studies conducted were in major cities in India and only one focused on transgender men exclusively. Forty-three studies focused on sexual health and mental health with a primary focus on the prevalence of HIV/STIs and substance use disorders. Only 4 studies existed on gender transition services [12].

Other studies assessing the mental health of transgender persons show a high burden of depression and substance abuse. A significant correlation between social and gender minority stigma with depression is seen [13]. Studies show a higher risk and incidence of HIV/STI among transgender woman sex workers in comparison to cisgender sex workers in India and globally, and show that small changes in risk-reducing behaviour like condom usage can have a significant decrease in the spread of infection [14, 15]. The lack of a gender-inclusive healthcare system and a clear protocol to address their general and specific healthcare needs has further exacerbated their angst while dealing with gender dysphoria [16].

A qualitative study by Raghuram et al. documents the experience of transgender people’s barriers in accessing routine healthcare services from different regions across India and found that the cis-heteronormative design of health infrastructure, negative experiences due to socio-cultural norms within (including other hospital workers and by-standers) and outside the health system, lack of understanding and knowledge among the physicians on various identities of transgender people and specific health needs result in painful experiences [17]. A lack of knowledge of HRT and GAS among treating physicians, and a lack of sensitization on addressing and treating transgender persons in hospital settings lead to a feeling of isolation among the transgender community [16, 17].

Socio-cultural challenges faced by transgender people like isolation from their biological families, stigma and discrimination faced on a daily- basis, no fixed and regular income, and no health/accident insurance all add to the pre-existing health challenges and worsen their mental health and dysphoria [18, 19]. A Lancet report explains all this via a stigma-sickness slope where the stigma in society leads to marginalization, risky behaviour, and poor social and emotional well-being all resulting in inadequate access and uptake of health services. Concurrently poverty, sex work, and AIDS exacerbate the stigma and the sickness [11].

Transgender persons also face discrimination due to their low socio-economic class, perception of jobs, and HIV status [18]. All this contributes to poor health-seeking behaviour which results in transgender persons preferring home remedies and self-medication until the severity of illness forces them to go to hospitals. A study among transgender people in an urban slum in Mumbai showed that 42% went to the pharmacy, 25% consulted traditional healers another 25% consulted private doctors and very few availed of government facilities for common illnesses and almost all went to private facilities for chronic illness and hospitalization even though 80% had no savings for emergencies [20]. There is inadequate documentation on the reasons for preference for private health care over a more affordable government healthcare facility.

This study is an attempt to fill this gap in research and looks at health of transgender community holistically, by analyzing the healthcare-seeking pattern and barriers to availing government healthcare in basic and routine care, preventive care for non-communicable diseases (NCD) and STIs, mental health services, and gender affirmation procedures including HRT and GAS.

Materials and methods

Study design: This Cross-sectional study design was conducted among the transgender population residing in Chennai. Chennai, the largest metropolitan area in and the capital of the state of Tamil Nadu(TN) was chosen for this study as it is the area with the largest demographic diversity, as well as the highest transgender population density as a result of a large influx of transgender migrants who seek better economic and healthcare opportunities. The 2011 census recorded the number of individuals who gave their gender identity as “other” in Tamil Nadu at 22,364. Out of the 8294 third-gender/other-gender individuals registered as voters, 1157 of them reside in Chennai [3, 21]. This is however not an accurate representation of the actual number of transgender individuals which is estimated to be much higher. This is primarily because of the conflation of data regarding sex and gender. The data about transwomen who have mentioned their identity as female and transmen as male are not captured by either the census data or the voter list. Further many transgender individuals are not open about their identity and the data about them is not captured in any of the official records. Nevertheless, the data indicates that the majority of transgender individuals in TN reside in Chennai. The considerable transgender population in the city can be attributed to the state’s long-standing welfare policies for the transgender community such as first exclusive transgender clinic in a government health facility and transgender welfare cards.

Sample size calculation: The study population was defined as adults who identify as transgender, regardless of whether they hold a transgender identity card. The sample size was calculated using the formulae - N = Zα²pq/d². Assuming preferences for availing any health care services to be 50 (assuming maximum variability). Applying this proportion in the formula for 95% confidence level and 10% absolute precision, the sample size comes to 96 which we then rounded off to 100. A 10% precision was taken since this is a preliminary study.

Questionnaire development: The questionnaire was framed after a thorough review of the literature and supervision and suggestions from the guide (who has experience working with members of the transgender community) and a transgender woman, who is the project director of a Chennai-based NGO catering to the LGBTQIA + community. The English and the Tamil translated questionnaire was further reviewed by 2 subject experts.

Data collection: Data collection commenced after obtaining approval from the Institutional Ethics Committee of Madras Medical College (IEC no- 05102023). A pilot study with 4 leaders including transman, transwomen and gender-fluid transperson was done and changes were made as suggested and the questionnaire was finalized. The pilot study and involvement of community members early on ensured that the questionnaire took into consideration the sensitiveness, sensibilities and cultural practices specific to the community. At every stage of questionnaire development, suggestions from the community were heard, authors of this paper discussed if the question answered the objective and changes made to the questionnaire accordingly. This enabled us to remove repetitive and intrusive questions and add only those that would help in answering the research questions.

Data collection: Data were collected over 2 months between October 2023 and November 2023 using an interviewer-administered questionnaire. Study participants were recruited through a snowball sampling method. Those identifying themselves as transgender individuals, NGOs working for the welfare of the LGBTQIA + population, and allies of the community were approached to refer those known to them. Once 10–15 participants were identified, a date was fixed and participants gathered in the NGO office/commonplace nearest to their locality. Since participants were identified through snowball sampling, the participants were limited to particular Jamath communities (a system of transgender kinship) that were familiar to each other. The transgender community is well connected; however, it can’t be said that the sample covered is representative of all transgender communities in Chennai, and the data collected cannot be generalized.

Ethical Considerations: The study was conducted per the Declaration of Helsinki. Informed consent was obtained from the participants after explaining in the language comfortable to them (English/Tamil) the nature of the study and their freedom to refuse/withdraw from participation. To ensure confidentiality no names were recorded, participants were interviewed only in spaces they were comfortable in and lived openly as transpersons. Additionally, interviews were conducted in separate rooms to ensure privacy. Each participant was compensated for their travel cost.

The questionnaire comprises 6 sections

[1] Demographic and socioeconomic details.

[2] Healthcare utilization pattern and its determinants (Including Minor*, Major**, Chronic illnesses***, STI/RTI**** screening, and accidents/trauma/emergency).

[3] Access to NCD screening and treatment.

[4] Access and Usage of mental health services.

[5] Access to Hormone replacement therapy (HRT).

[6] Access to Gender Affirmation surgery (GAS).

*Minor illnesses were defined as Cold, cough, fever, or any illness that settles within a week with/without treatment (Outpatient department -OPD).

**Major illnesses were defined as Symptoms lasting less than a month and/or requiring hospitalization.

***Chronic illnesses were defined as any illness that requires treatment for more than a month.

****STI/RTI- Sexually transmitted infection and reproductive tract infections.

To determine the factors that influence their choice of healthcare a multiple-choice question was asked and participants were asked to choose from the following options - easy accessibility, affordability, familiarity with physician/facility, community referral, better and faster care, NGO referral, and others. The symptoms of mental health problems like mood swings, bouts of sadness, sleep disturbances, loss of interest, self-harm, and suicidal thoughts were assessed to understand the existing problem of mental health among transgender people.

Data analysis

The data collected were entered in Excel sheets. Data analysis was done using Jeffreys Amazing Statistics Program (JASP) software. Variables, like assigned and preferred gender, education, employment, choice of preferred and receipt of healthcare services, factors determining the choice of healthcare, condom usage and its procurement, screening, treatment, and diagnosis of non-communicable diseases, mental health symptoms, and use of gender affirmation services, frequency were calculated and represented as percentages. For the barriers to availing government health care services for HRT and GAS among transmen and transwomen Anthropac software was used to calculate salience for the free-listed data and scree-plot was obtained using Excel.

Informed consent

This study was carried out with the consent of the participants and the NGO/community space whose premises were used for the interviews. An information sheet with a brief of the study, procedure, benefits, harms involved, and the right not to participate/withdraw and an informed consent form were distributed to the study participants.

Results

A total of 104 participants were interviewed and among the 104, 88 (84.6%) identified as transgender women, 15 (14.4%) as transgender men, and 1 as gender fluid transgender person and the results are summarized in the following sections:

Section 1- Demographic profile of the study population.

Section 2- Healthcare services utilization pattern and its determinants.

Section 3: Access to preventive health care services.

Section 4: Access to mental health services.

Section 5: Access to gender affirmation procedures and barriers to government services.

Section 1- Demographic profile of the study population

Table 1 summarizes the socio-economic details of the study participants. Around 58.7% of those who moved to Chennai from other places moved for easier access to resources regarding gender affirmation procedures, to avoid familial pressure and want of community.

Table 1.

Demographic profile of the study participants

Demography	Category	Frequency	Percentages
Sex assigned at birth	Male	89	85.6%
	Female	15	14.4%
Gender Identity	Transgender women	88	84.6%
	Transgender men	15	14.4%
	Others	1	0.962%
Age (Mean ± SD)		32.5 years	± 9.7 years
Education	Professional Degree	28	26.9%
	Graduate diploma	11	10.6%
	High school	43	41.4%
	Primary and middle school	19	18.2%
	Illiterate	3	2.9%
Financial dependency*	Dependent	14	13.5%
	Independent	90	86.5%
Employment status	Employed	97	93.3%
	Unemployed	5	4.8%
	Student	2	1.92%
Livelihood (n ≠ 97)**	Begging	33	34.0%
	Sex work	17	17.5%
	Salaried job	37	38.1%
	Self-employed	13	13.4%
Economic class*** (n = 90)	Upper class	30	33.3%
	Upper middle class	40	44.4%
	Middle class	12	23.3%
	Lower middle class	8	8.8%
Nativity	Native to Chennai	58	55.8%
	Intra- state migrant	41	39.4%
	Inter-state migrant	5	4.8%
Reason for migration (n = 46)	Work/ Education	16	34.8%
	Surgery/ Medical reasons	18	39.1%
	Social Stigma/ Discrimination	9	19.6%
	Family moved to Chennai	2	4.3%
Live with	Community Group	36	34.6%
	Family	29	27.9%
	Alone	26	25%
	Partner	8	7.7%
	Friends	5	4.8%

*Financial dependency is to assess whether the participant is financially dependent on others for daily living or is independent and takes care of one’s own expenses. ** Study participants are engaged in multiple occupations ***Per capita income was calculated by dividing the individual income by the number of dependents, however since total household income was not asked there is a limitation in the accuracy. For the 14 participants who were financially dependent on others, monthly income was not disclosed, and economic class could not be ascertained hence it was only calculated for the 90 financially independent participants. B.G Prasad scale was taken to measure economic class

Section 2- Healthcare services utilization pattern and its determinants

Figure 1 shows that receipt of care did not always coincide with the preferred choices and there was variability in choice of healthcare depending on the type of illness. Receipt of care reflected where they went for minor illnesses in the past year.

Fig. 1.

Preferred choice of healthcare vs. receipt of healthcare among transgenders in Chennai, South India

*Percentage ≠ 100 since multiple options were chosen by the participants.

Figure 2 shows that the choice was binary between government and private services, except for minor illness and STI/RTI. A pattern of using private over public facilities is seen for all categories of illnesses except for STI/RTI screening.

Fig. 2.

Choice of healthcare for various illnesses among transgenders in Chennai, South India

For minor illnesses, 45.2% went to private and cited ease of access, familiarity, and faster care, 27% went to the pharmacy because of ease of access and familiarity, 26% utilized government facilities for their affordability, and the rest self-medicated or used home remedies. For STI/RTI a unique choice of NGO is seen and 73.2% of those opting for public service did so based on NGO referral.

Table 2 shows the reasons for utilizing the healthcare facility among transgender people. For major and chronic illnesses there’s a larger percentage of transgender persons using public services compared to minor illnesses because of the affordable care in government facilities.

Table 2.

Determinants for the choice of healthcare usage among transgenders in chennai, South India

Reason for choosing the facility	Minor illness			Major illness		Chronic disease		STI/RTI screening			Emergency/accidents/trauma
	Private (n-47)	Pharmacy (n-41)	Public (n-28)	Private (n-19)	Public (n-13)	Private (-10)	Public (n-5)	Public (n-41)	NGO (n-31)	Private (n-6)	Public (n-12)	Private (n-10)
Easy accessibility	15 (31.9%)	23 (56.1%)	5 (17.9%)	6 (31.6%)	1 (7.7%)	3 (30%)	1 (20%)	2 (4.9%)	2 (6.4%)	1 (16.7%)	3 (25%)	3 (30%)
Affordability	4 (8.5%)	5 (12.2%)	17 (60.7%)	-	8 (61.5%)	3 (30%)	3 (60%)	6 (14.6%)	-	-	3 (25%)	3 (30%)
Familiarity with facility	13 (27.7%)	9 (21.9%)	10 (35.7%)	3 (15.8%)	3 (23.1%)	2 (20%)	3 (60%)	8 (19.5%)	5 (16.1%)	1 (16.7%)	1 (8.3%)	1 (10%)
Familiarity with physician	11 (23.4%)	-	1 (3.6%)	6 (31.6%)	1 (7.7%)	4 (40%)	-	6 (14.6%)	-	-	-	-
Community referral	-	-	-	2 (10.5%)	1 (7.7%)	1 (10%)	-	-	12 (38.7%)	1 (16.7%)	-	-
Better and faster care	12 (25.5%)	5 (12.2%)	1 (3.6%)	-	-	-	-	-	-	-	1 (8.3%)	3 (30%)
NGO referral	-	-	-	-	-	-	-	29 (73.2%)	14 (45.1%)	-	-	-
Others	-	-	-	2 (10.5%)	3 (23.1%)	3 (23.1%)	-	1 (2.4%)	-	3 (50%)	5 (41.7%)	3 (30%)

In the case of emergencies or accidents and trauma, 54.5% and 45.5% were treated in government and private facilities respectively reflecting there’s not much difference in the number of people utilizing public and private care. Immediate management following the accident depended on the distance of the hospital from the site of the accident and the type of emergency over the preference of the individual.

Section 3: Access to preventive health care services

Figure 3 shows that 80% of transgender people who are sexually active use condoms to prevent Sexually transmitted diseases. Of the 20% of the sexually active participants not using condoms, 7% stated exclusive partners as a reason for not using condoms.

Fig. 3.

Condom usage among transgenders in Chennai, South India

Figure 4 shows that over 3/4th of those using contraceptives procure the same from NGOs showing yet again the incomparable role of NGOs and CBOs in health education and prevention.

Fig. 4.

Place of procurement of contraceptives among transgenders in Chennai, South India

Figure 5 shows the data for screening and treatment for non-communicable diseases (NCDs) like Diabetes mellitus (DM) and Hypertension (HTN). Of the 83 screened for DM only 66.2% were referred by a primary care physician while for HTN out of 88 only 62.5% had a referral. 20.2% were never screened for DM and 15.4% were never screened for HTN. Among the 8.6% diagnosed with DM, only 88.8% are under regular treatment. Among the 7.6% diagnosed with HTN only 62.5% were under regular treatment.

Fig. 5.

Screening, diagnosis, and management of NCDs among transgenders in Chennai, South India

Of the 31 transpersons eligible to be screened for CA breast only 4 (12.9%) had checked for potential malignancy by self-breast examination. Of the 4 transmen eligible to be screened for CA cervix only 1 (25%) had been tested. In this study, eligibility for CA breast was taken as transgender men who have not undergone mastectomy and transgender women who had ever used HRT. In this study, eligibility for CA cervix was taken as transgender men who had not undergone hysterectomy.

Section 4: Usage of mental health services

Figures 6 and 7 show that 68.3% of the study participants had one or more mental health symptoms like mood swings, sleep disturbances, bouts of sadness, loss of interest, self-harm, and suicidal thoughts in the past year for which only 18% sought therapy. While 10.6% attempted suicide only 3.8% sought care. The reason given for not seeking therapy was that they did not deem it important to seek a professional opinion and got by with the support from their community.

Fig. 6.

Mental health symptoms and access to care among transgenders in Chennai, South India

Fig. 7.

Number of transgenders who attempted suicide and sought professional care in Chennai, South India

Section 5: Access to gender affirmation procedures and barriers to government services

Table 3 shows that HRT is a more popular method of gender affirmation among transgender men (86.6%) than among transgender women (48.8%). 84.6% of transgender men who ever used HRT procured it from a private practitioner, one from a government practitioner, and one from his friend who was on HRT. Among transgender women, this pattern of usage was almost reversed with only 37.2% seeking medical advice before starting HRT and 62.7% procuring HRT from other transgender women on HRT and pharmacies without a prescription.

Table 3.

Usage of HRT among transgenders in chennai, South India

Category*		Transgender women n = 88 n (%)	Transgender men n = 15 n (%)
Ever used hormone		43 (48.8%)	13 (86.6%)
Current hormone use		7 (7.9%)	11 (73.3%)
Prescribed by	Private practitioner	16 (37.2%)	11 (84.6%)
	Not a healthcare worker	27 (62.7%)	1 (7.6%)
	government practitioner	-	1 (7.6%)

* The participant who identified as a gender-fluid transgender person was not interested in any gender reaffirmation procedure and was thus excluded from the data for this section

Figure 8 shows that the most commonly reported barriers for not getting HRT from government facilities among transwomen were lack of awareness and unavailability of the services in government.

Fig. 8.

Barriers to availing hormone replacement therapy (HRT) from a government facility among transwomen in Chennai, South India

Figure 9 shows that the most commonly reported barriers for not getting HRT from government facilities among transmen were non- availability, distrust towards government services, and delay in availing them.

Fig. 9.

Barriers to availing hormone replacement therapy (HRT) from a government facility among transmen in Chennai, South India

Figure 10 shows the status and procurement of gender affirmation surgeries among transgenders. Around 12.5% of the transwomen interviewed did not want the surgery choosing to embrace their gender by clothing/HRT and 23.8% wanted surgery but hadn’t done the procedure because of financial reasons, or family pressure.26.6% of the transgender men who had not yet undergone the procedure cited financial reasons.

Fig. 10.

Status of gender affirmation services among transgenders in Chennai, South India

Fig. 11.

Types of surgeries undergone by transwomen in Chennai, South India

Figure 11 shows the types of surgeries undergone by transgender women. The reasons for the relatively lesser number undergoing vaginoplasty and mammaplasty is due to the high cost of surgery and only a handful of facilities available for these highly specialized surgeries and should not be mistaken as lack of demand.

Fig. 12.

Types of surgeries undergone by transmen in Chennai, South India

Figure 12 shows the type of surgeries undergone by transgender men. The reasons for the relatively lesser number undergoing hysterectomy with bilateral salphingho-oophorectomy is because of the high cost of surgery and only a handful of facilities available for these highly specialized surgeries and should not be mistaken as a lack of demand. Phalloplasty and metoidioplasty were also options given under GAS for transmen. However, none of the participants selected the two options because of a lack of awareness and availability as a surgical option.

Figure 13 shows that the most commonly reported barriers for not getting GAS from government facilities among transwomen were delays and lack of availability of services, poor quality, and lack of awareness.

Fig. 13.

Barriers to availing gender affirmation surgery from government facilities among transwomen in Chennai, South India

Figure 14 shows that the most commonly reported barriers for not getting GAS from government facilities among trans men were poor quality of services, bad reviews from the community, and delays in providing the services in government.

Fig. 14.

Barriers to availing gender affirmation surgery from government facilities among transmen in Chennai, South India

Discussion

This paper is the first of its kind attempt to understand the healthcare-seeking pattern of transgender people and their deterrents in accessing public health infrastructure. The findings of this study are discussed in 5 sections - Demographic profile, healthcare service utilization pattern and determinants, access to preventive services, mental health, and gender affirmation services.

Demographic profile of the study population

Most of the participants were transgender women and literate. However, only 37.5% had obtained/enrolled in diploma/degree courses and 41.4% had a high-school education. The majority 51.5% were employed in what is traditionally considered transgender jobs (begging and sex work), and 38.1% working in a salaried job are predominantly NGO workers. Even participants with a diploma/degree were not employed as skilled professionals because stigma, discrimination, underemployment, and low pay deterred their entry into the organized sector, this was further exacerbated by their Jamath (traditional transpeople kinship structure) directing them into begging/sex work as sometimes it is seen as the traditional job and other occupations pay less, contributing to poor socio-economic growth within the community [22]. The lack of higher education and jobs ensuring dependable income translates to poorer health literacy, lack of health insurance, and paid sick leave. Moreover sex-workers are at an increased risk of HIV and other STIs.

Of those interviewed 34.6% lived in a community group, 27.9% with their biological families and 25% lived alone. The community groups not only serve as support systems in times of financial, social, and medical needs but also are the spaces where the choice of gender affirmation is governed, especially for newer members who are guided for the transformation process though not always medically astute. A characteristic of those living in community groups is that almost all their healthcare choices are similar since they prefer facilities and physicians familiar to them for fear of discrimination and negative attitudes [17].

Healthcare services utilization pattern and its determinants

The health care service utilization differed based on the type of ailment. For minor illness, private healthcare facilities were the most utilized, followed by over-the-counter drugs from pharmacies. Private healthcare facilities were the most used system for major illness and chronic diseases, though there was a significant increase in the number of participants using government services for the same. The reason for utilizing private facilities largely for minor, major illness, and chronic disease was the ease of access and familiarity with the system. If at all public facilities were used, the reason for utilizing their services was affordability, as all public health facilities in the state provide free services and medications.

Other studies point to this trend of avoiding hospitals until other options like self-medication and over-the-counter drugs from pharmacies are exhausted. A study covering 15 states across all socio-economic classes revealed that utilization of public services was low due to poor quality of care and long waiting hours [23]. In addition to the perceived low quality of care, the reason transgender people avoid crowded hospitals, and unfamiliar facilities is due to the longer waiting time, anticipation of judgmental looks, rude remarks, and behaviour of other patients and hospital staff [17]. A study by Prakash et al. showed a similar pattern of preferring treatment from NGO workers and pharmacies over hospitals [24].

For STI/RTI screening NGOs played an important role with 41.8% directly screened by the NGO and 73.2% of those screened in government facilities were referred by NGO workers. Those who were screened in a private facility did so occasionally when the routine screening by the NGO was missed, showing here that a binary choice exists. In case of accidents, trauma, and emergencies the nearest facility to the site of the incident and the type of harm influenced the health care utilization.

Preventive care

Sexual health

Among the sexually active participants, a larger proportion (80%) were using condoms for the prevention of STIs. These numbers are encouraging and are a testament to the success of targeted intervention and community participation- by the transgender people for transgender people. The role of NGOs and CBOs in this regard should be acknowledged. The role of NGOs in increasing awareness and promoting safe sex practices through regular medical camps and routine screening is also evident in the study by Pachuri et al. [9] Under the targeted intervention program by National AIDS Control Organisation (NACO), NGOs and CBOs are recruited to promote safe sex practices through free condom and lubricant distribution, health education and periodical screening for STIs.

One-fifth of the sexually active participants did not use condoms, stating exclusive partners as the reason. They are still at a higher risk of contracting STIs since the partner’s exclusivity cannot be validated.

Diabetes and hypertension

Concerning NCD screening for DM and hypertension, the coverage rate was high among transgender people compared to the overall screening coverage in TN, as evident from the STEPS survey report conducted in Tamil Nadu [25]. The self-reported DM and HTN prevalences among transgender persons were much lower than in the general population. (HTN prevalence – 33.9%, DM prevalence – 17.6%), indicating the lower validity of self-reporting of the disease. The treatment compliance to known DM and HTN was also lesser in the transgender population. A study by Fernandez and Gaitonde showed a high prevalence of risk factors like smoking, alcohol, a diet low in fiber and high in processed food, and obesity among transgender persons putting the community at high risk for NCDs [26]. Considering the high risk of NCDs, and as evident by this study the poor compliance with medications, there is a pressing need for awareness regarding NCD and the benefits of strict adherence to treatment.

Breast and cervical Cancer

CA breast screening by self-breast examination was done by only 12.9% of the 31 eligible. Of 4 eligible for Pap smear for CA cervix screening only 1 had been screened. WPATH guidelines recommend seeing a transgender patient as a whole and providing all services including screening and gender-affirmative treatment right from the primary care level. Among the general population, those screened for CA breast was 17.6% and CA Cervix was 15.6% [19]. There is decreased awareness among physicians and transgender community of the reproductive and gynecological needs of transgender persons [27].

The government of Tamil Nadu has a flagship program dedicated to the screening and prevention of NCDs: MTM (Makkalai Thedi Maruthuvam) which offers home-based healthcare services to ensure a continuum of care. The program includes door-to-door diabetes and hypertensive screening and management, screening for CA breast and CA cervix from the primary healthcare level. However, a study to evaluate the coverage of these services does not provide any significant data regarding transgenders, showing that yet again the community is left behind on essential preventive services and their health remain hidden [28].

Usage of mental health services

According to the National Mental Health Survey 2015–2016, 1 in 20 people in India suffer from depression and 1% of the population is at a high risk of suicide and have suicidal ideation [29]. Among the study participants 68.3% reported a mental health symptom and 10.6% attempted suicide. Other studies are also concurrent with these findings and show a higher burden of poor mental health among the transgender population in comparison to the general population and can be attributed to the lack of family structure or support systems, stable jobs and income, discrimination from society, and the hazards of day-to-day work [20].

On further questioning the reason behind not seeking care for mental health issues, they unanimously answered that they did not deem it important and got through the day with their community support. Further, they did not recognize it as an issue that needed medical intervention.

Gender affirmation practices

Hormone replacement therapy

Seeking medical advice before starting HRT is crucial since the dosage of testosterone or estrogen given to transgender men and transgender women respectively depends on the pre-existing levels of the hormones, liver and renal function tests, and requires close follow-up [27]. Indiscriminate use of HRT could lead to side-effects on skeletal and cardiovascular health and metabolic imbalances [30].

The utilization of public facilities for HRT was nil or minimal. The reasons for such hesitancy to access government facilities for HRT, as cited by transgender women were lack of awareness of such facilities, lack of availability of the drugs in the said facilities, and bad reviews from others. Among transgender men, the reasons cited were lack of availability and delay in procurement of the drugs and poor trust in the services.

Sex reassignment surgery

Among the 63.6% transgender women who have undergone surgery, the majority had undergone bilateral testectomy and penectomy. The reason for the lesser proportion of vaginoplasty and mammaplasty surgeries among transwomen was the increased cost of these procedures and not a reflection of the need. Overwhelmingly these procedures were done in the private sector. The reasons for not availing these services in government facilities were delays in service, lack of availability, poor quality of care, and lack of awareness of the said procedures. Almost one-fourth of transgender women have not undergone GAS due to financial constraints and social stigma and almost 13% of transgender women do not want to undergo surgery as they preferred cross-dressing as a means of gender expression.

Among the 73.3% of transgender men who have undergone surgery, all have undergone bilateral mastectomy and only 2 have undergone hysterectomy with bilateral salphingo-oopherectomy. The relatively small number of participants undergoing hysterectomy with bilateral salphingo-oophorectomy is because of the high cost of surgery and not the lack of demand. Except for a few mastectomies, the rest of the procedures have been done in private facilities. Reasons for not availing of GAS from government facilities were poor quality, bad reviews, and service delays.

Deterrents to availing government services

Surgical procedures help in reducing gender dysphoria. Since these procedures are permanent, a high level of caution is exercised before availing these surgeries. There is a general preference for the same surgeon who has performed for their inner circle. For transgender men, a clean chest that would render them to go shirtless in public is important; for this mastectomy via keyhole procedure is preferred. For transgender women, the size of the implant and the results should complement the pre-existing body type and structure. Government facilities lack these results as there are only 2 sizes of implants available and no keyhole procedure is done.

It is notable that even though the average age of both transgender men and transgender women was around 32 years each, there is a greater percentage of transgender women above 40 years in this study, who sought gender reaffirmation services. About 10 to 20 years ago, HRT was not made part of the government service and there were very few private practitioners with knowledge of the same. Access to these currently available services is better among transwomen as it’s easier for those seen as men in our society to make decisions of their own while the same can’t be said for women.

Conclusion

A panoramic look into the current healthcare utilization pattern shows a preferential use of private facilities over public ones, except in the use of routine STI screening, and where affordability is of concern government facilities are used more. A look into their needs calls for increased health education on gender reaffirmation among the transgender community as well as the healthcare workforce. The biases that deter their access can only be addressed by a top-down systemic change that equips even a primary physician to fulfill all their health needs. This comprehensive account is from 104 transpersons and serves as a guide to modify and frame new policies for the betterment of health.

To combat the deterrents to accessing government healthcare by transgenders, we suggest gender sensitization programs for healthcare workers and support staff, awareness programs at the community level to educate the community on safe and evidence-backed gender- affirmation practices and to advertise services in government health facilities, to encourage partnerships with community run NGOs to act as a conduit for awareness programs and bridge the divide. Hospitals that have undergone sensitization training to be given gender-inclusive tags, to motivate the hospitals and encourage transpersons to access the same. To ensure smooth delivery of services, hospitals have specific protocols for addressing gender affirmation care and other complaints. The protocols should be made with recommendations from the local transgender community, ensuring a constant supply of materials needed for care to avoid wait times. To encourage the use of primary and preventive health-care services training modules on gender sensitization for community workers and partnering with local NGOs to ensure active participation.

For these legal rights to be reflected on the socio-cultural fabric of society, efforts must be made to improve the quality of life with better education, skill building, opening up spaces in the job market, and improving their access to healthcare. Improving healthcare awareness, sensitizing professionals to the health needs of transgender people, providing gender tags to trans-friendly hospitals, and making the trans clinic more accessible are crucial in improving the lives of transgender people.

Future directions

The literature review showed a glaring disparity in research on transmen, while we did include transmen in this study the sample size was not reflective of the population. Future studies focusing exclusively on transmen and ensuring that studies on transpersons, include a significant proportion of transmen would help fill this gap. We recommend time-motion studies on HRT and SRS, to understand in detail why delays in service deliveries occur. Longitudinal studies to track changes following interventions would help better understand outcomes and changes in health-seeking behaviour. Studies to understand health-seeking behaviour in rural areas could help understand the deficits in care and reasons for migration.

Limitation of study

This study covers only the transgender population of a metropolitan city in South India. The findings do not include the challenges faced by the community in rural and or in other parts of India where stigma, lack of availability of gender-affirmation practices, and a smaller transgender community are significant deterrents to availing care. Hence this study cannot be generalized. The smaller proportion of transmen does not reflect the hidden prevalence.

Author contributions

Author SU: Conceptualisation (equal), Data curation (equal), formal analysis, funding acquisition (lead), investigation (equal), Writing- original draft (lead), review and editing. Author GS: Data curation(equal), formal analysis, investigation (equal), Visualisation, Writing- Original draft. Author DKS: Methodology, Resources (lead), Supervision, Validation (lead), Writing- Review and editingAuthor SS: Conceptualisation (equal), Formal analysis (lead), funding acquisition, Project administration, Resources, Supervision, Validation, Visualisation(lead), Writing- Original draft, Review and editing (lead).

Funding

This study was made possible with a grant from the Indian Council of Medical Research (ICMR) under the ICMR-STS (Short-term Studentship) scheme.

Data availability

Data available can be shared upon request.

Declarations

Ethical approval

Ethical committee approval was obtained from the Institution Ethical Committee (No. 05102023) and the study was conducted in accordance with the declaration of Helsinki. The certificate of approval is attached in the related files section.

Consent to participate

Written informed consent was obtained from all participants after an explanation of the nature of the study and their rights was provided. An information sheet was provided for the participants to take home. Both the information sheet and informed consent were obtained in the local language for those who did not speak English.

Competing interests

The authors declare no competing interests.