One In Two Trans Men Struggle To Access Basic Healthcare: Study

Most trans men and transmasculine individuals in India end up seeking private medical care because of multiple hurdles to government schemes, says a study

Despite multiple government measures, trans men and trans masculine persons face several barriers to health care, a recent study has concluded. The study, ‘Our Health Matters’, was released last Friday by a collective of four organisations.

Only 46% of the 377 trans men interviewed from 22 union territories and states had access to a doctor for their general health concerns, shows the study conducted between November 2022 to January 2023 by the Transgender Welfare Equity and Empowerment Trust (TWEET) Foundation in collaboration with the Transmen Collective, a Delhi-NCR based support group for transmen, the Drexel University and the Population Council.

Up to 33% of respondents avoided healthcare for fear of being mistreated, and 80% of those who had surgery paid for it themselves or took the help of friends and family. Only one participant could access free surgery at a government hospital. Transgender persons in India have been included in public welfare schemes such as the Support for Marginalized Individuals for Livelihood and Enterprise (SMILE) Scheme that provides them educational and skilling opportunities, health, housing services and the Ayushman Bharat scheme that offers health insurance benefits. But social attitudes and bureaucratic hurdles make it hard for them to access these benefits, as the study explains.

The study focuses on trans men and trans masculine persons’ social inclusion, mental health, and access to health care. Trans men refers to people who identify as men and were assigned a female gender at birth. Transmasculine is a broader term that refers to people who were assigned female at birth and may identify as men, trans, non-binary, or any other identity. To be brief and inclusive, the study as well as this report uses the term “transmasculine” to refer to the entire community. 

Barriers To Healthcare

Only 30% of transmasculine persons interviewed are aware of the Ministry of Social Justice and Empowerment’s SMILE scheme, of whom only 8% had applied and actually received the help they requested. However, this scheme can only benefit those transgender individuals who possess a transgender certificate issued by the National Portal for Transgender Persons. 

However, as Behanbox reported earlier, the issuance of these certificates is fraught with bureaucratic delays, gender biases and digital access issues. 

The new study further shows that of the 51% transmasculine persons who had applied for a transgender ID card, half encountered a delay in the process, and another half struggled to understand the process of applying. Nearly half (49%) did not even apply for the ID card. 

The Transgender Persons (Protection of Rights) Act, 2019 mandates a comprehensive insurance scheme to cover several health issues, as well as gender-affirmative surgeries for transgender persons. The central government in 2022 included transgender people in its Ayushman Bharat Scheme under which transgender persons are eligible for health insurance coverage of up to Rs 5 lakh. But it is not fully operational, allege several transmasculine sources. An official with an allied government institution too admitted this. This scheme is also hobbled by the need to present a transgender ID certificate, says the study.

In the absence of accessible public healthcare systems, many transgender people have no choice but to turn to expensive private hospitals, says the report. 

No Guidelines On Transition Healthcare

During the report launch, Ranveer, a trans man from Surat recounted his experience of gender affirmative healthcare. A botched phalloplasty, a surgery to repair or construct a penis, ended up costing him Rs 2.5 lakh though it was conducted at a renowned Delhi hospital. The surgery also left him with 52 stitches and chronic pain. “Our bodies are not for experimentation. For doctors, it’s just a surgery, but for us it’s our life’s dream,” he says.

We met Kiran Raj, the state coordinator of Telangana’s Transgender Welfare Board, who recounted being subjected to an intrusive examination when he went to procure his Gender Dysphoria (GD) certificate. This kind of exam is prohibited under the Transgender Persons (Protection of Rights) Rules 2020.

These experiences are not rare and some have even led to deaths, as Behanbox reported earlier. Annayah Kumari Alex, Kerala’s first transgender women radio jockey, had died by suicide after undergoing a traumatic gender affirming surgery. 

“There are no concrete guidelines for gender affirmative surgery, or standards of healthcare for transgender people in India. In their absence, transgender persons who are eager to get a top surgery or a bottom surgery done, do whatever doctors and medical practitioners tell them, even if these practices are not safe. Doctors too take advantage of their desperation, and also ask patients to undergo expensive tests which are not necessary. The whole business is that of a money making machine, in which it’s trans people’s health that suffers,” says Vihaan Vee, one of the researchers of the ‘Our Health Matters’ report.

One of the major recommendations of the study as well as the Transgender Persons (Protection of Rights) Act is to create gender-affirmative healthcare guidelines in alignment with the 8th edition of the World Professional Association for Transgender Health Standards of Care (WPATH). These standards provide clinical guidance to healthcare professionals on how to help transgender and non-binary persons access safe, preventive and transition related and gender-affirmative care. 

Invisibilisation Of Trans Men

India has 4,87,803 transgender persons, according to the 2011 Census. Activists consider this a gross underestimate. Nearly all other major official data sources provide sex-related data in a binary male-female format. This excludes transgender, intersex and other non-binary sexual identities, limiting their access to social security benefits. Even amongst transgender persons, very few research studies have focused on transmasculine persons. The new study’s scoping review (a process in which several research articles are reviewed on a large scale) of lesbian, gay, bisexual, and transgender health in India from 2010 to 2021 finds that of 177 articles, only 1% included transmasculine persons.

These are the first findings on the transmasculine community, its access to health, social inclusion and mental health.

Shaman Gupta, CEO of the TWEET Foundation, which runs two shelter homes for transgender persons in Haryana and Maharashtra, notes that while the discourse around transgender people has grown, transmasculine people still remain invisible in mainstream gender discussions. 

“The interplay of patriarchy manifests differently for transmasculine people. For instance, our shelter home in Mumbai houses both trans women and transmasculine people. However, not once has a trans woman’s parents come with the police, or beaten us up to get them back who has run away. But this happens all the time for transmasculine people,” says Gupta. “Also since transmasculine people are assigned female at birth, they have to deal with all the patriarchal restrictions on mobility, agency and independence. Escaping marriage, and the space of the home is so difficult for transmen and transmasculine people, that they continue to be invisible.”

Community Support And Mental Health

The study also revealed that about one-third of the transmasculine people interviewed had moderate or severe depression, while 45% had moderate or severe anxiety. Almost half (44%) had ever seriously considered suicide, while over a third had attempted it.

However, the study also found that transmasculine persons appeared less likely to consider suicide or to have other mental health challenges if they were employed, had support from family or in-person support groups, or had completed the gender-affirmative medical care they needed. As many as 78% of the people interviewed belonged to online groups, while 31% were part of in-person support groups.

In dealing with mental health challenges it is important to have a community network to lean on, said Gautam Ramchandra, co-chair of TWEET Foundation at a discussion following the release of the report. Access to mental health remains fraught for queer and trans people across India, especially from small-town India, as we have reported earlier.

A key recommendation of the report is the updating of medical, nursing and paramedical curricula to be responsive to transmasculine health, including but not limited to transition-related procedures.

There is a need to look at healthcare from the lens of the state and not doctors, says Aqsa Shaikh, associate professor of Community Medicine at Hamdard Institute of Medical Sciences and Research (HIMSR), Jamia Hamdard and the director of the Human Solidarity Foundation, a Delhi-based NGO. “We have to first hold our policies accountable and see that they translate into action. To open a transgender OPD at Delhi’s RML hospital is not enough. There is a need to commit to the realisation of rights of all transgender people in all sectors of life,” says Shaikh, at the event.

  • Ankita Dhar is a reporter with Behanbox. She is also a digital artist whose artwork has documented political prisoners in India.

Malini Nair (Editor)

Malini Nair is a consulting editor with Behanbox. She is a culture writer with a keen interest in gender.

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