The Impact of COVID-19 on Economic Well-Being and Health Outcomes Among Transgender Women in India

Abstract

Coronavirus disease 2019 (COVID-19)–related lockdowns in India have disrupted the meager sources of income of many transgender women, including those in the hijra subculture who largely rely on money from providing blessings, begging, and sex work. Many have expended savings and taken high-interest loans, contributing to psychological distress. For hijras engaged in sex work, challenges to negotiating condom use and adhering to COVID-19 protective measures increase risks for contracting HIV and COVID-19 amid decreased access to HIV services. Many transgender women face challenges accessing COVID-19–related government welfare programs as they lack legal gender identity documents. Multisectoral and transgender-competent approaches are needed to mitigate the impact of the pandemic.

Introduction

India ranks second in the world in the number of people diagnosed with novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) infection, fourth in coronavirus disease 2019 (COVID-19) deaths. As of December 31, 2020, India reports 10,286,023 cases and 148,968 deaths due to COVID-19.¹ A national COVID-19–related legally enforced lockdown began on March 25, 2020, and was still in place in some form in January 2021 in several regions, continuing to severely disrupt many spheres of life. Transgender women, with disproportionate health burden related to HIV² and psychosocial syndemic conditions (such as depression, problematic alcohol use, and violence victimization)^3,4 before COVID-19, may be particularly vulnerable to its social, economic, and psychological impacts.

We discuss the impact of the COVID-19 pandemic and related control measures on economic well-being and mental and sexual health of transgender women. Perspectives are drawn from our team's two decades of experience conducting research and providing services to sexual and gender minority communities, and online news articles.

Impact on Economic Well-Being

Transgender women or trans feminine people in India are a diverse population. Transfeminine people have several indigenous gender-diverse identities, such as hijras or kinnars in North India, and thirunangai, shiv-shakthi, or mangalmukhi in South India. Hijras are a visible subculture of transfeminine people with a complex hierarchical social structure, including Gurus (masters), who are senior hijras, and Chelas (disciples). Hijras largely earn a living through doli-badhai (providing blessings or singing, dancing, and drumming in ceremonies), mangti (begging from shopkeepers/public), or sex work^3,5—all of which entail face-to-face interactions.

In January 2021, many Indian states continued to apply lockdowns of varying degrees.^6,7 Amid the pandemic, hijras receive meager donations from shopkeepers and the general public (pre-COVID ∼INR 500 to 1000 [$7 to 13] per day to <INR 150 [$2] per day); they are also seen as potential vectors of disease, with public posters in Hyderabad indicating, “If you talk to transgenders, you will get Corona.”^8,9 Public attitudes toward transgender people have worsened in some regions. Formal employment is rare among transgender women, most of whom are forced to leave their families at a young age without education; many have now lost their jobs that largely required physical contact (masseuses, hairstylists, dancers) and are at heightened risk for psychological distress due to financial stressors.

Most hijras in sex work meet clients in public spaces and cannot readily switch to virtual spaces due to low literacy and lack of access to smartphones. Trans community leaders report that some transgender women in sex work tried using “gay” dating apps, such as Grindr and Blued, with profiles indicating “she-male” or “bottom,” but they are unable to find clients who prefer transgender women. Many profiles of potential clients state “meet only after lockdown” with some warning “money seekers” to “stay away.” Furthermore, those transgender women who engage in sex work often do so without personal protection (face masks), and sometimes without condoms, increasing their vulnerability to both HIV and coronavirus infection.

Owing to loss of income coupled with price increases of essential items, many hijras are unable to afford food, rent, and utilities.¹⁰ Despite government orders that landlords not demand rent during lockdown, transgender women have been asked to pay rent in a timely manner and told to vacate,¹¹ adding to their distress. Some transgender people have resorted to exhausting meager savings (including those for gender-affirmative surgeries), sold their jewelry, or borrowed money at usurious interest rates, in addition to past unpaid loans.

Impact on Sexual and Mental Health

Transgender women faced barriers in accessing HIV/STI testing, gender-affirmative care, and HIV/STI treatment in public hospitals before COVID-19.^12–14 COVID-19 lockdown has exacerbated this situation. HIV preventive interventions supported by India's National AIDS Control Organization (NACO) largely implemented by nongovernmental organizations (NGOs) and community-based organizations (CBOs) are almost exclusively based on face-to-face outreach. Lockdown measures have also led to closures or disruptions of NGO/CBO clinics offering HIV testing, and clinical and counseling services for HIV and sexual health.

Although community agencies and independent transgender-friendly health care providers are increasingly offering mental health counseling online, these services reach only a limited number. Hijras and many other transfeminine subgroups are disproportionately illiterate, not tech-savvy, and have limited Internet access.

Media reports further indicate that voluntary or accidental disclosures of gender identity of young trans people during lockdown have resulted in violence and harassment from family members, with limited access to safer living spaces, legal intervention, or peer support.^15,16

NACO has previously implemented multimonth dispensation of medications in government antiretroviral treatment (ART) centers and created “link ART centers” in selected NGOs and CBOs, including networks of people living with HIV.¹⁷ Despite these measures to mitigate HIV treatment disruptions, transgender people, still face multiple challenges in access. In particular, those from rural areas and individuals stranded in other cities amid lockdowns encounter barriers, such as lack of transportation and locally valid ART identification cards, and involuntary disclosure of HIV status to law enforcement authorities during travel.¹⁸

Before the pandemic, transgender women, many of whom have not disclosed their gender identity to their families, received support in face-to-face interactions with peers and community agency staff. Lockdowns and mobility restrictions have constrained access to these support systems despite compounding of psychological distress due to loss of income and employment, and increases in gender identity stigma. Many transgender women now report anxiety and depression when thinking about their future.

Barriers in Accessing Relief Measures from the Central and State Governments

Both central and state governments have announced COVID-19 relief measures (financial aid, food, and health schemes) for economically vulnerable populations^19,20 as well as transgender-specific relief schemes (Table 1). Nevertheless, many transgender women are unable to access these programs as they lack legal identity documents, such as ration cards, national identity (Aadhaar) cards, and bank accounts in chosen names,²¹ along with sometime requirements for gender certificates from district magistrates.²² For example, the Humsafar Trust, a long-established CBO in Mumbai and Delhi providing outreach services to >1500 transgender women, could nominate only 85 (5.6%) who already had official documentation to register for the National Institute of Social Defense program.

Table 1.

A Selected List of Coronavirus Disease-19–Related Government Schemes and Relief Measures in India

COVID-19–related schemes and relief measures	Examples
Central government:
General schemes that can be accessed by transgender people	Pradhan Mantri Garib Kalyan Yojana (Prime Minister's welfare scheme for the poor)—free ration for 3 months and one-time direct cash transfer of INR 1000 ($14) for vulnerable communities
	Atmanirbhar Bharat Yojana—COVID-19 special economic package
Schemes and relief measures that are exclusively for transgender people	The National Institute of Social Defence, under the Union Ministry of Social Justice and Empowerment, provided a one-time cash grant of INR 1500 ($21)
State governments:
General schemes that can be accessed by transgender people	Odisha: Madhu Babu Pension Yojana, which offers financial support for destitute elderly, differently-abled persons, and widows, is now open to at least 5000 eligible transgender people
	Jammu & Kashmir: Integrated Social Security Scheme is now open to transgender people and it provides financial aid of INR 1000 ($14) every month
Schemes and relief measures that are exclusively for transgender people	Kerala: Food aid and temporary housing
	Karnataka and Andhra Pradesh: Advance payment of pensions
	Tamil Nadu: “Third Genders Welfare Board” has so far provided INR 1000 ($14) three times from April to August 2020

All of these schemes and relief measures require transgender people to have valid legal identity documents and sometimes other paperwork such as gender certificate from district magistrate.

COVID-19, coronavirus disease 2019.

Conclusion

COVID-19 has interrupted progress toward health-related goals for transgender women,²³ exacerbating social and economic vulnerability amid pre-existing structural inequalities and marginalization due to intersections of gender identity, sex work, and HIV status. Our intersectionality analysis highlights the disproportionate impact of COVID-19 on transgender communities in India and the fact “we are not all in this together”²⁴ in contending with the COVID-19 pandemic. COVID-19 has intensified the pervasive stigma and discrimination faced by transgender people as they are now seen as potential ‘vectors’ of infection, highlighting the need to take active steps toward stigma reduction.

Government relief measures need to be adequate and accessible, including to sexual and gender minority communities. Continued financial support, not only one-time small cash grants, is needed until COVID-19 is controlled. Importantly, required documentation (e.g., legal gender identity) for accessing relief schemes for transgender people should not be so restrictive as to exclude a vast majority of this population. However, long-term solutions for income insecurity (e.g., support for education, skill building, and self-employment) need to be devised for transgender people.

Intensified gender minority stress, along with pandemic-induced financial stress and pandemic-related stigma are likely to contribute to psychosocial syndemic conditions, such as anxiety and depression. As a result, psychosocial support should be made available to transgender people in the form of face-to-face, virtual, or phone counseling, including referrals to trans-friendly mental health and social services. Psychological support helplines run by governmental and nongovernmental agencies should be sensitive to gender minorities.

Interventions to ensure uninterrupted HIV prevention (testing, availability of condoms and oral HIV pre-exposure prophylaxis) and treatment services should be intensified, including online services through NACO. An uninterrupted supply of medicines, such as antiretrovirals, should be ensured through multi-month prescriptions, and collaboration with CBOs to distribute the medicines at individuals' residences (as implemented by a sex worker CBO).²⁵ NGOs and CBOs migrating to online psychological support and clinical services need to promote community connectedness and peer support amid COVID-19 restrictions.

Overall, proactive steps to eliminate underlying structural and social inequalities should be a long-term goal to improve the physical and mental well-being of transgender people, as well as to reduce the impact of COVID-19 and foster inclusion and resilience in preparedness for future pandemics.

Abbreviations Used

ART

antiretroviral treatment

CBO

community-based organization

COVID-19

coronavirus disease 2019

NACO

National AIDS Control Organization

NGO

nongovernmental organization

SARS-CoV-2

severe acute respiratory syndrome coronavirus 2

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Dr. V.C. was supported by the DBT/Wellcome Trust India Alliance Senior Fellowship (IA/CPHS/16/1/502667). Dr. Newman was supported, in part, by grants from the International Development Research Centre (IDRC; 109555), Ottawa, Canada, and a Social Sciences and Humanities Research Council Partnership Grant (SSHRC; MFARR-Asia, 895-0219-1020). The views expressed herein do not necessarily represent those of IDRC or its Board of Governors, or SSHRC.

Cite this article as: Chakrapani V, Newman PA, Sebastian A, Rawat S, Shunmugam M, Sellamuthu P (2022) The impact of COVID-19 on economic well-being and health outcomes among transgender women in India, Transgender Health 7:5, 381–384, DOI: 10.1089/trgh.2020.0131.