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 Table of Contents  
DEBATE/PERSPECTIVE/VIEWPOINT
Year : 2020  |  Volume : 36  |  Issue : 4  |  Page : 284-288

Care of transgender individuals in India: A clinical perspective


1 Schizophrenia Research Foundation (I), Chennai, Tamil Nadu, India
2 Sree Vikas Center for Hormones and Mental Health, Chennai, Tamil Nadu, India

Date of Submission27-Apr-2020
Date of Decision09-Jul-2020
Date of Acceptance18-Jun-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Shiva Prakash Srinivasan
Schizophrenia Research Foundation (India), R/7A, North Main Road, Anna Nagar (West), Chennai - 600 091, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_88_20

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  Abstract 


India is making rapid strides in recent times in recognizing and providing legal supports to the transgender community. An increasing number of individuals are seeking medical assistance for gender-affirming medical interventions. Many medical and surgical practitioners working with transgender clients in the Indian subcontinent face clinical and social challenges. In this article, we highlight some of the common challenges experienced by healthcare professionals and the solutions adopted in providing care for transgender clients.

Keywords: Challenges, clinical services, solutions, transgender


How to cite this article:
Srinivasan SP, Chandrasekaran S. Care of transgender individuals in India: A clinical perspective. Indian J Soc Psychiatry 2020;36:284-8

How to cite this URL:
Srinivasan SP, Chandrasekaran S. Care of transgender individuals in India: A clinical perspective. Indian J Soc Psychiatry [serial online] 2020 [cited 2021 Jan 18];36:284-8. Available from: https://www.indjsp.org/text.asp?2020/36/4/284/305957




  Introduction Top


The recognition that there are individuals whose gender did not match their biological sex has been present from antiquity. In a country with a rich heritage such as India, transgendered individuals have been described in mythology both as deities and as heroes. The care of individuals with gender dysphoria is a relatively new phenomenon within the medical community. The first documented center for the care of persons who had gender dysphoria was based out of Berlin in 1918 by Magnus Hirschfeld.[1] He was a German physician who had offered care based on his “Adaptation therapy” at his Institute for Sexual Science, while his contemporaneous colleagues were trying to find a “cure” for the condition. He supported people living “according to their nature” rather than their assigned sex. This is coming to the forefront in low- and middle-income countries such as India where people are being given a voice through various legal and constitutional changes.[2] The medical community at this time is at a crossroad where they have to address the needs of this minority group with needs that may differ from other groups. This article attempts to highlight to both care providers and policymakers the challenges that have been faced in the care of transgender individuals in a country where care systems are still being developed. We also discuss a few of the solutions that we have implemented in the course of our work.


  Aspects of Clinical Care Top


Diagnostic challenges

”A 28-year-old female came to the clinic from out of town at the recommendation of friends that she made online to get an evaluation for gender reassignment. A detailed history revealed that she had been bullied in school and had witnessed domestic violence between her parents. She dropped out of school and started working as a salesperson. She realized that she was attracted to females and one female, in particular. She reported that she wanted a gender reassignment surgery because she did not ever want to be ill-treated as a female and that society (and the girl's parents) would not accept matrimony between them.”

Gender dysphoria is the distress that a person feels due to a mismatch between their gender identity and their sex assigned at birth. This term has undergone many iterations through the mental health classificatory systems. Both the ICD-10 and DSM-5 highlight the distress about the experience of natal sex as one of the most important components of diagnosing this condition. Unlike sex which is biologically determined and in a way, immutable, gender is a social construct. There are components of masculinity and femininity that have “norms” in the society that we live in. Furthermore, in India, there is low knowledge about sexuality and sexual practices[3] even among college-going youth. This issue is further complicated by a lack of knowledge about gender health even among medical professionals,[4] which may lead the provider to ask questions related to the transgender identity, which may be unrelated to their current care. Further, most of the providers (about 73%) in a study seeking knowledge about gender affirmative care do so as to fill a community need, and about 64% do so because of the previous contact with a trans-individual.[5] A question regarding sexual preferences is rarely if ever asked in a clinical encounter.

Put together, it is possible in a country like India to have negative attitudes and behaviors toward any particular sex – sexism. This could motivate individuals to seek gender reassignment, whereas, in reality, they might be seeking equality and participation and a sense of safety. In the person mentioned above, the only reason for seeking a change currently was to be able to “legally marry” the female who she liked with the acceptance of society. This particular situation throws light on the challenges of making a diagnosis of gender dysphoria, when the masculine gender is coveted rather than a feminine one. Thus, while considering a diagnosis of gender dysphoria, the astute clinician would need to consider not only the diagnostic criteria but also attempt to take into account the sociocultural norms of the individual presenting for help.


  Assessment Challenges Top


”A 32-year-old male presented to the clinic with symptoms of low mood, suicidal ideas, social anxiety, problem with sleep, and appetite that have been present for nearly 2 years. He reported that he had been aware of his gender dysphoria from teenage, but belonging to a family with strong religious convictions, he was always unable to express his need to change. He reported having tried talking to his parents about it, but his mother would coerce him emotionally back into being a male. He reported that the emotional symptoms had been a problem from the time his parents had demanded him to get married. He refused to bring his family to treatment/evaluation as he did not want to involve them.”

Mental health problems are common in the community with nearly 50% of the common mental health issues emerging in adolescence and nearly three-fourths before the mid-twenties.[6] This is also the time that the youth experience changes in their gender roles and expectations, and thus, most individuals with gender dysphoria present. There is considerable evidence supporting the magnitude of victimization and social ostracism that transgendered individuals face.[7],[8] This extends not only into the community but also into the person's own home where they do not get the support of their families. Furthermore, there is a detailed review of the increased risk of depression and anxiety among transgendered individuals as compared to cis-gendered individuals.[9] An interesting finding from this review was that persons undergoing gender-confirming medical or surgical interventions over a period were found to have rates of mental health problems no more than the general public.

The mental health profession is moving away from categorizing transgendered individuals as persons with a disorder. This has reflected in moving the diagnosis from gender identity disorder in DSM-IV TR to gender dysphoria in the DSM-5 and moving trans-sexualism and gender identity disorder of childhood from the mental health section of the ICD-10 to the conditions related to sexual health in the ICD-11. The role of mental health professional is not unimportant. The review summarizes the role of the mental health professional in (1) facilitating the diagnosis of gender dysphoria, (2) assessing psychiatric comorbidity, (3) exploring the readiness for gender-confirming medical interventions, and (4) supporting the trans-person through the health pathway.[9]

In clinical practice, we face the issues of dropouts from the consultation. Many individuals seek the assistance of a mental health professional purely for getting a “gender identity certificate,” rather than considering the long-term mental health issues that may need to be addressed. Thus, in clinical practice, we have to compress an evaluation of the gender dysphoria and capacity to make decisions with education about the potential mental health problems that may be associated with hormonal treatment. This is in addition to addressing any medical or mental health issues that the person may be dealing with immediately. To achieve the goal of providing considerate and appropriate care, a trans-affirming model of care provision is provided, and some of the components of which are mentioned in [Table 1].[10] An attempt to dedicate a specific time of the week failed in our clinic as persons visiting from afar do not usually get appointments. This too affects the quality of the interactions during a busy clinic.
Table 1: Trans-affirming care model framework

Click here to view



  Referral/Networking Challenges Top


”A 26-year-old trans-man came to the center for a mental health evaluation before initiating hormonal therapy from out of town. Some peers who had already undergone the process referred him to the center. He expressed intense displeasure that the consultant involved did not have a clinic on the said day.”

Social media has been a great source of support for transgender individuals.[11] There are several social groups online that provide information and support including financial assistance and employment opportunities, in India. Referral to clinical spaces and providers comes through word of mouth and peer referral. While having first-hand information regarding safe spaces is helpful for an individual who is seeking assistance for the first time, sometimes, incomplete information leads to difficulties as mentioned in the above case scenario. There are lists of providers online; however, in a country like India, it is seriously underpopulated and seldom used.[12],[13]

Similar challenges are faced in the care of trans-women and trans-men as it involves a multidisciplinary team.[14] As per the World Professional Association for Transgender Health (WPATH), this involves primary care physicians, psychiatrists, psychotherapists, endocrinologists, fertility specialists, gynecologists, dermatologists, and otolaryngologists. Private practice in India does not lend itself to having all these specialists under one roof. Similarly, having physicians who are “trans-friendly” if not colocalized needs to be in constant touch with each other to provide coordinated care. In general, transgender individuals who have undergone gender confirming interventions do not receive quality primary medical care.

At this time, in our city in India, the transgender groups are quite active in collecting information about the providers who would provide affirmative care. Supporting and enhancing the transgender groups' information collection and dissemination would be an important task going forward.


  Management Protocol Challenges Top


”A 28-year-old self-identified male but born as a female came to the clinic from about 200 km away to get a gender identity certificate before initiating gender-confirming surgical interventions. When explained that there was a center that provided care for transgendered individuals in his town, he reported that they had told him to get a certificate from another mental health professional before initiating surgery.”

As per the previous census in India, the transgender population was evaluated to be around 4.8 lakh individuals.[15] Despite the growing numbers, these individuals have not received the necessary medical and mental health attention that they deserve.[16] Even now, there are no protocols that directly address either the management of a transgender individual or the process and procedure to help them transition. Clinical practice is guided by the Endocrine Society and WPATH guidelines.[14],[17] Some of the components of which may not have a direct bearing on the cultural context of India. This leads to confusion and significant hardships for the individuals who already are ostracized by society and have financial difficulties. In recent times, efforts have been made to streamline the protocols of providing care for transgender individuals, especially in the realm of surgical interventions.[18]

From the medical angle, the hormonal treatment for trans-individuals should be considered after a detailed history, physical examination, and laboratory investigations. The common laboratory investigations are mentioned in [Table 2]. It is important to understand that not all transgenders would prefer to undergo a hormonal or surgical transition.[19] Since hormonal treatment for female to male transgender individuals is to be continued life long, a discussion about the risks and benefits of the treatment much include a discussion about the costs. The management should also focus on substance use behaviors and safe sex practices.[20],[21]
Table 2: Laboratory investigations commonly prescribed

Click here to view


Cost is a major restriction in the implementation of a guideline-based treatment protocol. The financial limitation is one of the most commonly cited constraints as the hormonal assays, the recurring costs of hormones, and the surgical interventions are expensive. Usually, the hormones have a monthly recurring cost that runs into hundreds of Indian Rupees, while when done in a private facility, the costs of surgery run close to one lakh Indian Rupees. This too varies according to the place where the surgery is done. Furthermore, choices of medications are also driven by the costs of the medications. For example, while Gonadotrophin Releasing Hormone (GnRH) agonists are available in India, they are prohibitively expensive. Similarly, even though fertility preservation options are discussed before the initiation of cross-sex hormonal treatments, very few individuals take up the option. With the emergence of pharmacies available online, sometimes, well-meaning transgendered individuals take unsupervised treatment which may lead to further medical complications that may drive up the costs. In our clinical practice, the majority of patients prefer hormonal transition without surgical procedure.

In India, free healthcare is provided through government hospitals. The inclusion of medical and surgical management for transgender individuals as a part of the public health system will allow for equitable distribution of resources, as well as assist in the creation of the multidisciplinary teams. This is a model that has been tried in Tamil Nadu and has been very progressive in the care of transgender individuals.


  Social Challenges Top


While working in a center with an electronic medical record system, getting the third gender or transgender included in the records can be a challenge. Further, educating the staff to ask for the gender of the individual and not to assume based on the appearance of the individual visiting the clinic is an important task. Many gender dysphoric individuals being alienated in a community are unable to sustain employment and are thus unable to financially support their medical needs.

Stigma is a complex social phenomenon characterized by negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against others. It connotes a sense of disrespect and functions as a barrier for the person to function in society. There are a lot of stigmas associated with persons who are “unclear” about their gender. This is true in even developed countries such as the US.[7] This review discusses how transgendered individuals experience stigma at all the structural (societal norms and policies that restrict access to resources), interpersonal (verbal harassment, physical violence, and sexual assault), and individual levels (of creation of an environment of anticipation of discrimination). This discrimination, prejudice, and stereotypy lead to significantly negative physical, social, and mental health outcomes that the transgender individuals face. In a study from a major city in India,[22] nearly 40% of the transgendered individuals had some mental health problems and help-seeking was very low. Furthermore, the job opportunities described by them included begging, prostitution, and dancing at ceremonies. Another review[23] explicates, in detail, the various social ails that the transgender faces in India.

At the structural level, to create a safe environment in the center that we work, we have been educating all the staff about gender. Common changes include training to approach transgender individuals with respect, to make them comfortable, to understand and learn about preferred names and pronouns, and to set up a common restroom without differentiating as “He” or “She.”[24] There have been recommendations to improve the knowledge of healthcare providers about gender sensitivity and transgender-related issues to reduce the barriers to help-seeking[25] among transgender individuals. At the systemic level, the inclusion of the third gender in the legal lexicology has helped the transgender individuals to better advocate for their rights.[2] This cause has been furthered by The Transgender Persons (Protection of Rights) Act, 2019 passed in India[26] that guides to be inclusive in the care and working with transgendered individuals.

The data suggest that in terms of gender equality, India ranks 27 of the 27 countries studied in the youth wellness index in 2017.[27] There are no data regarding the inequity, which transgender individuals face. As of now, Tamil Nadu is one of the states which has made the greatest strides in providing social protection programs for the male to female transgender individuals (Araivani).[28] While they have provided several supports, the eventual goal of any social intervention would be to move away from a charity-based intervention to one of the rights-based interventions. It is only now that transgender individuals are engaging in positions of responsibility based on their abilities rather than discriminated against because of their expressed gender.[16] This would require greater dissemination of knowledge about transgender clients, providing equal opportunities at least in government settings to function to the best of their abilities.


  Conclusions and Recommendations Top


The pathway to care for transgendered individuals is fraught with multiple difficulties, including social, legal, financial, and medical. As mentioned above, there are many difficulties that the practicing clinician faces in the care of a trans-man or woman. We have attempted to present the difficulties and some of the solutions to the challenges mentioned above. These are summarized in [Table 3. India is at a point of developing services to support the care of transgender individuals, and it has an opportunity to learn from the available data to support this marginalized community.
Table 3: Summary of issues and recommendations

Click here to view


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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