Bangalore, India - Discrimination in India’s healthcare system against transgender people remains rife despite new laws earlier this year aimed at ensuring them equal treatment.
Stress caused by the fear of being treated unfairly, worries about abuse and administrative hurdles are preventing many of the country’s two million transgender people from seeking medical care.
Many of those responsible for "transphobia" are medical professionals themselves, who remain largely uninformed about gender identity issues.
"We have to make our healthcare better, affordable and discrimination-free for everyone whether it is women or sexual minorities," said Shuba Chacko, the director of Aneka, an NGO that works with sexual minorities.
In April this year, India’s Supreme Court recognised transgender people as the "third gender" in a judgement that also observed that this community faces "large and pronounced discrimination" in healthcare.
The Civilian Welfare Foundation (CWF), an NGO based in the east Indian city of Kolkata, is studying the medical problems faced by transgender people in urban areas and the healthcare they receive.
CWF’s founder Shuvojit Moulik shared the case of Saikat, a transgender individual who died following a train accident while doctors could not decide whether to admit her to a male or female ward.
Among other respondents of the study is a young transgender woman, Anushri Banerjee (name changed), who told Al Jazeera that as a 22-year old, she was gang-raped by three men.
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She said that after asking her many embarrassing questions, doctors at a public hospital in Kolkata refused to treat her - even failing to prescribe the anti-HIV medicine recommended to rape victims.
Accessing healthcare services, even for common ailments, is traumatic for transgender people because they do not fit traditional gender roles.
Umesh P, who visited a hospital for a kidney problem a few months ago, did not tell staff that she was a transgender individual.
"It’s less complicated that way," she said. "We end up feeling embarrassed about ourselves after visiting hospitals. Treatments are cursory. Sometimes doctors prescribe medicines without even examining us. They’re afraid to even feel our pulse."
Umesh said transgender people are asked personal questions about their genitals or sexual lives, and medical staff, particularly in smaller clinics and government hospitals, are judgmental about their "deviant" behaviour.
Ridicule from her father and brothers made Sonika, a 33-year-old transsexual woman, run away from her village to the south Indian city of Bangalore, where she has lived for 15 years.
She now accompanies other transgender people on hospital visits, and told Al Jazeera that while staring and unwanted curiosity are common from other patients, derogatory remarks are mostly made by hospital staff.
"Our treatment is usually delayed - we are made to wait or run around various departments pointlessly," Sonika told Al Jazeera. "When we do get treatment we are laughed at."
Ignorance and indifference
A key problem transgender people face is ignorance of gender identity issues among medical staff, who acknowledge only saree-clad "Hijras" - India’s traditional male-to-female transsexuals who live as a community - as transgender people.
Dr PK Devdas, the medical superintendent at Victoria Hospital in Bangalore, said few doctors knew the difference between intersex, transgender or transsexual people, and most would not recognise female-to-male transgender people.
Doctors also shy away from being associated with transgender people for fear of resulting stigma.
"In a hospital other doctors look down on you if you are sensitive to transgenders - there’s definitely a stigma attached," Dr Devdas said.
CWF’s study found that clinics in Kolkata asked transgender patients to visit early in the morning or late at night when they were less likely to come into contact with other patients.
Nor are healthcare professionals in India well informed about treatments that transgender people undertake to transition to another gender, such as hormone replacement therapy (HRT) and sex reassignment surgery (SRS), leaving them ill-equipped to deal with this group’s particular needs.
Sonika - who underwent sex-reassignment surgery in a private hospital - said that few have the opportunity or the money for such operations.
This means that most male-to-female transgender people undergo illegal castration by unqualified medics in smaller towns such as Dindigul in Tamil Nadu and Palamaner and Kadapa in Andhra Pradesh.
Hijras are sometimes initiated into the community through "nirvaan", a symbolic rebirth ceremony that involves castration without anesthesia.
Serious side effects such as urinary infections and other chronic urological problems as a result of these crude methods are common.
Akkai Padmashali, a well known transsexual activist, told Al Jazeera that transphobia in India’s healthcare system merely reflects broader hostility in society as a whole.
| Doctors also shy away from being associated with transgender people for fear of resulting stigma [Elizabeth Soumya/ Al Jazeera]
Trangender people are often ostracised by their families or run away from home and, having dropped out of school and with no family support, usually survive by begging or sex work.
"We face rejection from an early age," she said. "Our siblings, friends and families reject us. There is no acceptance anywhere. Medical professionals are also part of this very society."
Sex work makes this community a high-risk group for HIV according to India’s National Aids Control Organisation (NACO), compounding the stigma they face says Padmashali.
The Centre for Sexuality and Health Research and Policy (C-sharp) a Chennai-based research agency, has recommended improved access to HIV services for transgender people.
It wants explicit policies on transgender-friendly registration and non-discrimination, and says healthcare workers need to be trained to provide non-judgmental care.
Shuba Chacko of Aneka believes greater sensitivity towards gender issues also needs to be part of the medical curriculum.
"We have to include these issues in the syllabus," she said. "The health of sexual minorities is hardly a priority in our public health system."
However, she added that at root the main problems are that in India access to health is not yet seen as right, communities seldom assert themselves, and the practices of healthcare workers often go unchallenged.
Padmashali says recent steps such as recognition of transgenders as the third gender and an initiative in the state of Karnataka to provide special wards for transgender people in government hospitals are encouraging - but what the community really needs is full equality.
"We are not looking for special treatment. When we visit a hospital, treat us like everyone else, because we are just as human."
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