Priti Prabhughate, PhD Research Director The Humsafar Trust

Ira* (formerly known as Ishwar) is 25 years old. She has always felt that she was a woman trapped inside a man’s body and desired to be a real woman. Her family taunted her, she faced ridicule and isolated in her village and decided to migrate to Mumbai to lead her life as a transgender. Ira lives with her guru and does begging and sex work for a living. Ira is contemplating emasculation, in the past her experiences with doctors makes her weary of seeking services from a hospital. These experiences were those of neglect, discrimination, refusal to examine her rectum, when she complained of painful warts, and the worst of things happened when she was ultimately admitted to the male ward, where she felt ridiculed and humiliated. Some of her friends too share similar experiences. *not based on any particular individual, but is an aggregate of issues observed among individuals in clinical interactions

 They are people with Klinefelters syndrome – people with chromosomal deformities like XXY  All transgenders are emasculated  Transgenders are antisocial.  They have special powers to curse or bless others

 They are a high risk group for sexually transmitted infections (STIs) and HIV/AIDS  STIs – particularly anal and oral STIs  Difficult to diagnose, few standard procedures and protocols (although more than before)

 Few such studies in India  HIV prevalence a : ▪ MSM: 17% ▪ TGs: 68% ▪ Akwas: 60% ▪ Nirvanas: 77%  Thus, the HIV prevalence is very high in this group India: an emerging risk group for STIs and HIV. Indian J Dermatol Venereoal Leprol. Nov-Dec 2006;72(6): a Setia MS, Lindan C, Jerajani HR, et al. Men who have sex with men and transgenders in Mumbai,

 Also found that certain other STIs (such as syphilis markers [TPHA] and Herpes markers [HSV 2 IgG] was very high – 68%; and was associated with being HIV positive  Another study b with 205 transgenders found:  High VDRL and HIV prevalence (25% and 40% respectively)  About 49% had more than 10 partners in the past one month  About 64% reported sex work as occupation

 Psychologists, psychiatrists and physicians use the diagnosis of ‘Gender Identity Disorder’ (GID) Diagnosis is made if the following 4 conditions are fulfilled 1. Long standing and strong identification with another gender 2. Long standing disquiet about the sex assigned or a sense of incongruity in the gender-assigned role of that sex 3. Absence of any physical intersex characteristics. 4. Significant impairment at work, social situations or other important areas of life

 Surgical procedures: vaginoplasty, breast augmentation  Pre-surgery check ups, pschological/psychiatric evaluation, general health check-up  Post surgery complications – stenosis, incontinence, bleeding, infection

 Providing information about and exploring gender and sexuality issues  Understanding and making sense of the individual within the family, workplace and social system.  Exploring the various available options of management, their implications possible effects and risk  Developing an individual centered plan which includes various elements of psychotherapeutic input, family or systemic therapy, supportive psychotherapy, cross gender hormone therapy, Sex reassignment Surgery  Helping the individual to review the plan from time to time along with the team.

 Hormonal treatment: feminisation hormones, breast augmentation, fat redistribution, voice training  Multiple departments involved: Plastic surgery, Dermatology and STIs,endocrinology, speech therapy department (ENT), gynaecology, psychiatry  Thus care is a multidisciplinary team effort and should be considered as such

 Post care: acceptance of the new gender identity by self and the society  Issues after surgery: All the previous documents are with the male gender, post surgical change in name, gender etc.  Will there be an official notification post surgery?

Ira (formerly known as Ishwar) is 25 years old. She has always felt that she was a woman trapped inside a man’s body and desired to be a real woman. Her family taunted her, she faced ridicule and isolated in her village and decided to migrate to Mumbai to lead her life as a transgender. Ira lives with her guru and does begging and sex work for a living. Ira is contemplating emasculation, in the past her experiences with doctors makes her weary of seeking services from a hospital. these experiences were those of neglect, discrimination, refusal to examine her rectum, when she complained of painful warts, and the worst of things happened when she was ultimately admitted to the male ward, where she felt ridiculed and humiliated. Some of her friends too share similar experiences.

Social Issues -stigma -discrimination in health care - Issues of family, pressure to confirm - Ridicule and harassment Structural issues - medical fraternity ambiguous on legal status of SRS, thus no clear universal guidelines available - poor training on issues of gender/sexuality in medical institutions -lack of forums to redress experiences of discrimination in health settings. Psychological - concerns with self esteem - concerns with emotional problems like depression etc linked to stigma discrimination - dealing with rejection, non acceptance

 Structural level factors: For example, if there are separate male and female wards where do we admit transgenders?  If the transgender is non-castrated/has the male organs do we consider admitting them in the male wards?  Entry other than male/female should reflect in the hospital statistics

 Health priorities: Cosmetic procedures, hormonal treatment, breast augmentation procedures, sex reassignment surgeries  Identification of the physical space – who will do the procedure? Is it done in government hospitals? If not what are the costs of the procedures?  Traditional ways of removal of genitals. Complications of such procedures – bleeding, infection, and post- procedure stenosis, urinary complications

 Reforms in medical education  Need for developing standards of care for providing SRS (including pre-post op counseling, cosmetic intervention) uniformly applicable to the entire country  Policies of nondiscrimination in health services delivery  Enabling legal environment to register cases with consumer courts for issues of medical neglect and discrimination from health providers  Remember to think of them as humans too at a personal interaction level!

 Laying down systematic processes beginning with assessment to completion of a SRS for physicians and mental health professionals involved.  Guidelines specify legal requirements in terms of a formal diagnosis, documentation of treatment and safeguarding the rights and health of the person seeking SRS  Guidelines lay down procedures for treatments (surgical and hormonal), mental health interventions, prescribed durations and minimum required qualifications of the healthcare providers.