This article has been written by Meenakshi Mishra pursuing a Diploma in Content Marketing and Strategy from Skill Arbitrage.

This article has been edited and published by Shashwat Kaushik.

Introduction

Transgenders are that part of society that is most neglected, underserved, and underrepresented. Not so much is written about their problems. In this study, we will focus on epidemiology and the challenges transgender people face in gaining essential healthcare.

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An individual’s assignment as male or female is based on the phenotypic appearance of the external genitalia at birth. Gender identity is an individual’s perceived or experienced gender, which may differ from the sex assigned at birth. The Transgender Persons (Protection of Rights) Bill, 2016 defines transgender people and their rights.

Cisgender is the term for those whose gender identity or expression is similar to the sex assigned at birth. Transsexual is a term used to categorise those who identify as transgender and use medical and surgical means for physical transition. Transgender is a term that includes all individuals whose gender identity or expression is different from the birth sex. They may be classified under three categories:

  • Transmen;
  • Transwomen;
  • Nonbinary;

Transmen are those with female gender at birth and affirm a male identity. Transwomen are those with male gender at birth and a feminine identity. Nonbinary is a broad term that is used for genderqueer, agender, bigender, and genderfluid, which cannot be categorised under the two sexes. Mostly, they prefer to be called with pronouns according to their gender identity/expression. They may have legal documents like a driving license, insurance, or passports with the sex assigned to them at birth.

There are a few other terms which are used nowadays, like

Sexual orientation means physical and emotional attraction to persons of a particular gender. Gender identity means the experienced gender by an individual. This will cover cisgender and transgender.

Gender expression means an expression of the gender using clothing style, mannerisms, behaviour, hairstyle, attitude, gait, etc.

Gender non-conformity means a different behaviour in gender expression from what is expected by society. However, as we are aware, pathological processes do not work based on gender incongruity. The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnosis of gender dysphoria describes the mental distress or impairment arising due to conflict between one’s experienced/expressed gender and one’s assigned gender. It should create problems in social, occupational, and other areas of functioning lasting for 6 months.

Medicine offers treatments for gender dysphoria. A person suffering from gender dysphoria may undergo many interventions like cross-sex hormones and/or gender-affirming surgeries. However, financial barriers may hinder the adoption of these practices. The World Professional Association for Transgender Health, Standards of Care, version 7, recommended a psychological assessment by a qualified medical practitioner for the treatment of gender dysphoria to confirm an individual’s capacity to consent.  

Transgender: a stigma for cultured society

Despite the social awareness, unemployment, depression, anxiety, interpersonal violence, family rejection, discrimination, mental and physical abuse, suicidal tendencies, substance abuse, and HIV cases are highest among the transgender.

The Transgender Persons (Protection of Rights) Bill, 2016 has the following main features:

  • Recognition of the ‘third gender’: In accordance with the NALSA judgement, the bill provides legal recognition to the ‘third gender’.
  • Definition of a transgender person: The bill defines a transgender person as someone who is neither entirely female nor entirely male, or a combination of both, or neither. This includes transmen, transwomen, genderqueers, and individuals with intersex variations.
  • Prohibition of discrimination: The bill prohibits all forms of discrimination against transgenders, in line with the Indian Constitution. Any discrimination, whether in public or private, will attract a strict penalty.
  • Establishment of a National Council: The bill proposes the establishment of a National Council to safeguard the interests of transgenders. The government will be responsible for providing basic support such as self-employment, rehabilitation, and healthcare to the transgender community.
  • Issuance of identity cards: Individuals belonging to the third gender must obtain identity proof provided by the District Magistrate as per the recommendations of a screening committee.

Obstacles in the life of transgender

Social discrimination, intolerance, and stigmatisation are major causes in the way of achieving optimal healthcare for transgender people. Despite the efforts of NGOs and the government, the real life of transgender people is still filled with hardships. They feel fear of the insensitivity of the healthcare professionals towards their gender, name, and pronouns. Layman is normally habitual of filling out forms with only two sexes, male and female. There are challenges faced in the case of outpatient restrooms and sharing of common rooms in inpatient units.

Additional challenges faced by people who change their sex

Hormonal and surgical options adopted by transmen and transwomen are neither so easy nor so cheap. They have to be under observation and be followed every three months in the first year of starting their cross-section hormonal therapy and then once or twice every year afterwards. Regular monitoring of physical changes, cardiovascular risks, hormonal levels, and adverse effects is necessary. Insurance companies also do not cover these types of surgeries.

The pathology and laboratory medicine perspective

In hospitals and clinics, the transgender community is regularly excluded and they are kept separate from gaining proper health facilities. They are also human beings like you and me. They may also need medicines and surgical procedures. Their healthcare is most frequently delayed due to fear of discrimination and non-inclusive healthcare. As we are moving towards acceptance of transgender people as members of society and providing them with proper healthcare facilities, we need to focus on certain issues like training staff, doctors, and nurses for treatment. 

Only a few transgenders can get medical aid, as they may have difficulty approaching compassionate health providers with transgender patient experience. Other barriers to getting proper treatment include financial limitations, comorbidities, and stigmatisation. Due to these factors, they may take hormonal therapy from street vendors, internet sources, friends, pharmacists, and other non-traditional sources. This unsupervised hormonal treatment can pose threats of different types. HIV seroconversion is also one of them occurring from needle sharing or unconscious administration of hormones.  Hypercoagulability, deep vein thrombosis, pulmonary embolus, and thromboembolism are some other threats caused by unsafe hormonal therapy. Some other effects are depression, mood swings, hyperprolactinemia, elevated liver enzymes, migraines, and decreased insulin sensitivity. They are not taking hormones on doctors’ prescriptions, so they may take high- doses and utilise multiple hormones concurrently to achieve faster effects. However, there is a population that is avoiding hormonal therapy due to side effects, lack of medical care, cost of hormones, and physician refusal to prescribe. A study in New York suggested that only 58% completed a medical evaluation before the hormone treatment. 

The main transgender challenges in pathology are

  • Inflexibility of electronic medical records: Electronic medical records have no documentation for the third gender person. 
  • Lack of trained healthcare providers: Unfamiliarity among medical professionals with the requirements of this population. Staff and doctors are not trained in the treatment of transgender people. They are not aware of their problems and for treating them properly. 
  • Lack of research material: Very few research materials are available for their healthcare so it is a difficult task to find the normal values in their cases.
  • No reference range of laboratory tests for this population: A major problem in the diagnostic treatment of transgender people is the absence of normal reference values for laboratory tests. Interpretation is more complicated in the case of tests that have sex-specific reference ranges like liver enzyme, creatinine, and haematocrit levels.
  • No clear guidance regarding gender classification for blood donation.
  • Lack of pathological sampling: Handling and interpreting surgical and cytological specimens from transgender individuals is rare.

If a transgender person wants to visit a hospital, there are a lot of challenges in front of him or her. Gender dysphoria, epidemiology, and terminology are the key factors in understanding the diseases. The transgender community faces a variety of challenges in the laboratory and pathology fields, as no proper documentation of the case studies is done. Challenges include EMR limitations, lack of reference ranges, and handling surgical specimens. Many people are still unaware of hormonal and surgical options available for gender transition.

Challenges specific to transwomen are:

  • Limited reference range data: Very few research materials are available for their treatment.
  • Laboratory test results may vary by sex: As seen commonly in normal male and female laboratory values for certain tests vary with sex, age, and other factors. Transwomen and transmen also can have different laboratory test values. 
  • Long-term anti-androgenic therapy may affect results in prostate cancer treatment.
    • Sample cannot be diagnosed easily due to identity discrepancy.
    • Long-term anti-androgenic therapy may affect interpretation.
    • Biopsy cannot be done accurately due to less familiarity and hormonal effects.

Challenges specific to transmen are:

  • Limited reference range data: Very few research materials are available for their treatment. 
  • Laboratory test results may vary by sex: As seen commonly in normal male and female laboratory values for certain tests vary with sex, age, and other factors. Transwomen and transmen also can have different laboratory test values. 
  • Long-term testosterone therapy may affect the results of pap smear tests done for identifying cervical cancer
    • Sample cannot be diagnosed easily due to identity discrepancy.
    • Long-term testosterone therapy may affect interpretation.
    • Inadequate smear’s presence.

Transmen and transwomen both face difficulties in achieving health care. They should get knowledgeable and friendly healthcare support to get treatment. Healthcare providers should be competent to provide hormone therapy and other treatments according to currently accepted standards.

Differences between transgender and intersex

Being transgender refers to a person whose gender identity differs from the sex assigned to them at birth. Transgender individuals may identify as male, female, non-binary, or another gender identity that does not conform to the binary of male and female. They may or may not choose to undergo medical or social transition to align their physical appearance and social identity with their gender identity.

Being intersex refers to a person who is born with sex characteristics that do not fit the typical definitions of male or female. Intersex individuals may have variations in chromosomes, hormones, or reproductive organs. These variations can be visible at birth or may not become apparent until later in life. Intersex individuals may identify as male, female, intersex, or another gender identity that reflects their unique experiences and sense of self.

Key differences between being transgender and being intersex:

Gender identity:

  • Transgender individuals have a gender identity that differs from the sex assigned to them at birth.
  • Intersex individuals do not necessarily have a gender identity that differs from the sex assigned to them at birth.

Medical interventions:

  • Transgender individuals may choose to undergo medical interventions such as hormone therapy, surgeries, or both to align their physical appearance and social identity with their gender identity.
  • Intersex individuals may or may not choose to undergo medical interventions to normalise their sex characteristics or to address any health concerns related to their intersex traits.

Social recognition:

  • Transgender individuals often face social stigma and discrimination due to their gender identity. They may experience challenges in accessing healthcare, employment, housing, and other essential services.
  • Intersex individuals may also face social stigma and discrimination due to their unique sex characteristics. They may experience pressure to conform to binary gender norms or may be subjected to medical interventions without their consent.

Legal and policy implications:

  • Legal and policy frameworks often fail to recognise the rights and needs of transgender and intersex individuals. This can result in discrimination, lack of access to appropriate healthcare, and barriers to legal recognition of gender identity.

It is important to respect the self-identification and experiences of transgender and intersex individuals. Creating inclusive and supportive environments for both communities is crucial in promoting human rights and equality.

Gender dysphoria

Gender dysphoria, also known as gender identity disorder, is a condition in which a person experiences a deep and persistent feeling of discomfort or distress because of a mismatch between their gender identity and their sex assigned at birth. This can cause significant psychological and emotional distress and can lead to a variety of problems, including depression, anxiety, and social isolation.

The causes of gender dysphoria are not fully understood, but it is thought to be caused by a combination of biological, psychological, and social factors. Some people who experience gender dysphoria may have a brain structure that is more similar to the brain structure of the gender they identify with, rather than the gender they were assigned at birth. Others may have a hormonal imbalance that affects their gender development. Psychological factors, such as childhood trauma or abuse, may also play a role in the development of gender dysphoria.

People who experience gender dysphoria may feel like they are trapped in the wrong body and may desire to live as the gender they identify with. They may choose to transition to their desired gender through a variety of means, such as hormone therapy, surgery, and social transition.

Gender dysphoria can be a challenging condition to live with, but there are a number of resources available to help people who are struggling. There are support groups, therapists, and doctors who specialise in gender dysphoria. There are also a number of organisations that advocate for the rights of transgender people.

With the right support, people who experience gender dysphoria can live happy and fulfilling lives.

Conclusion

Healthcare institutions should arrange formal training of the staff members for transgender health issues. They should be aware of the complexities of the transgender treatment. Proper facilities should be available in the hospitals. Research and studies should be conducted and motivated in the field of transgender health concerns. These additional features in our medical sector will improve the lives of transgender people.

The problems faced by the transgender community were put forward by many social activists from time to time. In that process, only a meeting was organised by the Ministry of Social Justice and Empowerment on 2nd August 2013 to discuss issues like social stigma, discrimination, education, public health care, employment opportunities, etc. The meeting was held in the presence of government representatives, transgender community representatives, and university professors. In the meeting, a committee was formed to study the problems of the transgender community and search for solutions.

In India, the Transgender Persons (Protection of Rights) Act, 2019 (Legislative Aspects), having nine chapters in total, is in effect. This Act prohibits discrimination against the transgender community and gender identity acceptance through a certificate issued by the District Magistrate. This law also has the provision for allowing a person to change gender, either as a male or female, through surgery, if the District Magistrate is satisfied after receiving an application. The government took this step to protect and give them equal opportunities to achieve education and health facilities. There are also penalties and punishments mentioned in the law for sexually abusing or exploiting them.

But are laws helpful in making them a part of society? Can any of you mix with one of the transgender in your classroom or your workplace? Still, only a part of the population is aware of this law. Also in the process of certification, the physical examination of a transgender person can make them uncomfortable.

Only making laws is not satisfactory. We need to broaden our thought process to accept them as a part of society. Include them in our schools, colleges, and workplaces so that they are not forced to beg in the streets. Their families should support them in living a normal life. The government should also support them by providing proper facilities like separate urinals for transgender people in public places to prevent them from engaging in abusive behaviour.  The Transgender Persons (Protection of Rights) Act, 2019, has several serious flaws and argumentative clauses that need to be addressed. The transgender community has owned a special place in our society since ancient times. Now it’s time to give them their proper place with due respect and dignity.

References

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