Barriers to Healthcare for Transgender: Analysis on Affirmative Environment in Social-Legal Aspects

I. Introduction

The term "transgender" is multi-faceted and complex, especially where consensual and precise definitions have not yet been reached. While often the best way to find out how people identify themselves is to ask them, not all persons who might be thought of as falling under the transgender 'umbrella' identify as such. Transgender can also be distinguished from intersex, a term for people born with physical sex characteristics "that do not fit typical binary notions of male or female bodies".³

In India, it can be known by different terminologies based on different regions and communities such as:

• Kinnar–a regional variation used in Delhi/ the North and other parts of India such as Maharashtra.
• Aravani –a regional variation used in Tamil Nadu. Some Aravani activists want the public and media to use 'Thirunangi' to refer to Aravanis.
• Kothi -a biological male who shows varying degrees of 'femininity.' Some may also identify themselves as 'Kothis,' but not all Kothis identify themselves as transgender.
• Jogtas/Jogappas: Jogtas or Jogappas are those persons who are dedicated to and serve as a servant of Goddess Renukha Devi (Yellamma), whose temples are present in Maharashtra and Karnataka.⁴

The Transgender Persons (Protection of Rights) Act, 2019 is an act of the Parliament of India enacted with the main purpose of safeguarding the rights of transgender people, their welfare, and other matters related to them. As per Section 2(k) of the Act, "transgender person" means a person whose gender does not match with the gender assigned to that person at birth and includes trans-man or trans-woman (whether or not such person has undergone Sex Reassignment Surgery or hormone therapy or laser therapy or such other therapy), person with intersex variations, gender queer and person having such socio-cultural identities as kinner, hijra, aravani and jogta.⁵

Broadly speaking, the concept of transgender is extensive in its address, denoting the identity crisis and diversity of practices embodied between or beyond the categories of male and female. The roots of Transgender in India dates back to thirteen and fourteen centuries. During the Mughals period, they enjoyed an influential position and were considered one of the crucial figures in the society, but after the British stepped into India, their position got altered and was considered "a breach of public decency." This led to exclusion from the society or a group and then became a subject of everyday abuse and discrimination even after the collapse of British rule in India.

Many research has been carried out around the globe stressing the issue of Identity, Health, and Social stigmata, and efforts have been made to get their rights and freedom by trying to provide legal protection in the eyes of the law. The roles and the behaviours of transgender to perceive themselves as distinctly male and female may vary depending upon the individual's preferences; however, the identification of transgender remained doubtful until 2011, because the Indian census and Indian election commission classified them as 'others' But after a long struggle, in 2014 the Indian supreme Court under the Justice K.S. Radhakrishnan and A.K.Sikri bench has passed a resolution to recognize the third gender category (NALSA V/S U.O.I. Case, 2014).⁶

As a transgender, it is pretty obvious to face many medical issues in the body. The first problem faced as a transgender is Gender Dysphonia. This is a type of disorder that can occur at any time and any place of education, work etc., in a transgender. It creates a lot of headaches that occur because of the problems these people have been facing socially and economically in society. This happens because of the change of hormones in the body from man to woman or vice versa. Many surgeons have tried to invent recovery for the problem, but the body structure and change in the hormones or from chest to breast or penal to vaginal transformation has become a tough job in the history of medical science.

Another main problem that occurs is a transgender is 'M.S.M.' men having sex with men. This tends to create health issues like S.T.I. and H.I.V. viruses which altogether have a high percentage of occurring in transgender as a whole. This happens because of the lack of medical awareness and literacy problems. H.I.V. prevention education is a must to be given to all transgender communities. No difference was found in transgender men or women in the use of the condom, drug usage or alcohol consumption though the risk of H.I.V. occurred high with 17% in transgender people. With a theory of less indulgence with different parties at one time in spite of that too transgender were at high risk of H.I.V. This risk was specifically low in 'M.S.M.' but was considerably high in 'W.S.W.,' i.e. in women having sex with women because of their loose parts.⁷

Transgender persons suffer significant health disparities in multiple arenas. Real or perceived stigma and discrimination within biomedicine and the health care provision, in general, may impact transgender people's desire and ability to access appropriate care. Transgender health care includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies, for transgender individuals. But transgender may be at greater risk for health problems because they don't always see a healthcare provider when they need to. It may be that they feel embarrassed, have had a bad experience, fear judgment, or have a healthcare provider who is uninformed.

II. Healthcare challenges faced by Transgender Community

A. Physical Health Concerns in Transgender Individuals

People of any sexual orientation can face health problems. But people who are transgender may be at greater risk for health problems because they don't always see a healthcare provider when they need to. It may be that they feel embarrassed, have had a bad experience, fear judgment, or have a healthcare provider who is uninformed. Transgender individuals have specific health care needs. They may have behavioural health concerns, and they're also at higher risk of developing health problems.

Historically, transgender persons have faced discrimination and harassment based on their gender identity, both in their personal lives and within the context of the healthcare system. Transgender patients face a number of unique challenges and inequities within the healthcare system.

1) Access to Health Care: Transgender persons may avoid medical care for fear of being rejected. Many have been turned away by health care providers or had other negative experiences. Not all providers know how to deal with specialized transgender issues. Often, transgender health services are not covered by insurance. For these reasons, transgender persons may not access the care they need.⁸

It's not easy to find a health care provider who knows how to treat transgender people. Some providers may not agree to treat them. Others might not understand them or feel that there's something wrong with them.

2) Sex reassignment therapy: Various options are available for transgender people to pursue physical transition. Sex reassignment therapy helps people change their physical appearance and/or sex characteristics to accord with their gender identity; it includes hormone replacement therapy and sex reassignment surgery. Preventive health care is a crucial part of transitioning, and a primary care physician is recommended for transgender people who are transitioning.⁹

The goal of sex reassignment surgery, also known as gender reassignment surgery, is to align the secondary sexual characteristics of transgender people with their gender identity. As hormone replacement therapy, sex reassignment surgery was also employed to diagnose gender dysphoria.

3) Hormonal Issues: Hormone replacement therapy is primarily concerned with alleviating gender dysphoria in transgender people. Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of individuals as they transition. Access to hormone replacement therapy has been shown to improve quality of life. Despite the improvement in quality of life, there are still dangers with hormone replacement therapy, particularly self-medication. An examination of the use of self-medication found that people who self-medicated were more likely to experience adverse health effects from preexisting conditions such as high blood pressure as well as slower development of desired secondary sex characteristics.

Hormone therapy for transgender individuals has been shown in medical literature to be safe when supervised by a qualified medical professional.

Monitoring of risk factors associated with hormone replacement therapy is crucial for the preventive health care of transgender people taking these treatments. But the use of hormones has risks such as

• Testosterone can damage the liver, especially if taken in high doses or by mouth.
• Estrogen can increase blood pressure, blood glucose (sugar), and blood clotting.
• Anti-androgens, such as spironolactone, can lower blood pressure, disturb electrolytes, and dehydrate the body.¹⁰

4) Heart health: Transgender persons may be at greater risk for heart attack and stroke. This is due to hormone use, along with cigarette smoking, high blood pressure, and diabetes.

Transgender persons smoke and use tobacco products at much higher rates than others. Also, studies have shown that transgender persons have higher rates of alcohol abuse and dependence. This can lead to several severe health problems, including heart disease, high blood pressure, lung disease, and cancer.

5) Cancer: Transgender who still has a uterus, ovaries, or breasts are at risk for cancer in these organs. Transgender are at risk for prostate cancer, though this risk is low. Transgender people are at a slightly higher risk of developing cancer tied to hormone use. Depending on the transition stage, the breasts, uterus, ovaries, prostate, or liver can be affected. Appropriate screenings, including prostate, breast, and pelvic exams, should be a part of routine health care. After gender-affirming surgery, groups such as transgender women tend to have adverse outcomes of surgery, such as visceral injury, fistulas, vaginal prolapse, and pelvic floor disorders, which occur because of the complex nature of the gender reassignment and require long-term care after surgery.

6) Injectable Silicone: Many transgender persons use silicone injections to enhance their appearance. The injection of silicon by non-medical persons is a dangerous practice that can lead to serious health problems. Silicone, when administered by someone who is not a doctor, can move through the body and disfigure it. Also, silicone injected outside of a health care setting is typically not medical grade, may be contaminated, and is often injected using shared needles, which can transmit hepatitis.

7) Substance Use: Transgender persons use substances at higher rates compared to others. Substances used include amphetamines, including crystal meth, marijuana, ecstasy, and cocaine. The use of these drugs has been linked to higher rates of H.I.V. transmission through impaired decision making during sex. Although the long-term effects of these substances are unknown, evidence suggests that their prolonged use is likely to have serious negative health consequences.

8) Sexually Transmitted Diseases (S.T.D.s): Transgender persons are at risk for sexually transmitted diseases. These include infections for which there are effective cures (gonorrhoea, chlamydia, syphilis, pubic lice or crabs) and those for which treatments are more limited (H.I.V., hepatitis A, B, or C, human papillomavirus). Safe sex, including barriers, is key to preventing S.T.D.s.

9) Obesity: Many transgender people are overweight and don't exercise. Unhealthy body weight can contribute to several health problems ranging from heart disease to depression.

10) Transgender Violence: Transgender and gender-expansive people face a disproportionately high risk of physical and sexual violence in our society, much of which is motivated by hate or fear and stems from a lack of understanding and acceptance. This violence can be perpetrated by loved ones, family and friends, or strangers and can occur in home, school, workplace, or street.¹¹

11) Intimate partner violence (sometimes domestic violence) involves physical or emotional harm by a significant other — usually a partner, spouse or date. Typically, intimate partner violence begins with verbal threats and escalates to physical abuse, which is why it's important to recognize it early and get help as soon as possible. Intimate partner violence often involves manipulation and control. Some of the barriers faced by gender-expansive survivors of intimate partner violence include:

• Access to support services.
• Lack of training on the part of service providers.
• Discrimination in shelters.

III. Mental Health Concerns in Transgender Individuals

Members of the transgender community are also at increased risk of mental health issues.¹² They are at increased risk of experiencing depressed moods, seriously considering suicide, and attempting suicide. Understanding the physical health monitoring of such patients is important in reducing the risk of physical complications and signaling to patients that as mental health professionals, they are aware of their health care needs, which would certainly foster engagement. There are several Mental Health challenges faced by the Transgender community in their day to day life.

Gender dysphoria: Transgender individuals may experience distress and sadness as a result of their gender identity being inconsistent with their biological sex. This distress is referred to as gender dysphoria. A concept designated in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), the American Psychiatric Association's (A.P.A.'s) official listing of psychiatric disorders, as clinically significant distress or impairment related to a strong desire to be of another gender which may include the desire to change primary and/or secondary sex characteristics. Not all transgender or gender diverse people experience dysphoria.

Due to many factors like Homelessness, homophobic bullying and others, transgender individual suffers mental harassment, which affects their psychological health. Some of which are as follows-

1) Depression-In today's world, depression has become a common disease. Many people are suffering from depression, especially youth. The transgender child got bullied in school and many public places, leading to depression. Depression is a mental disorder and can be described as loneliness, anger etc. It is a severe kind of disease in which the lifestyle of a person gets completely changed. People suffering from this get angry and sad without any reason, they live alone, they don't talk to other people, they don't get social, they harm themselves, sometimes even try to commit suicide.

2) Anxiety-Anxiety is also a serious kind of mental disorder that affects the lifestyle of people. Due to the anxiety, many major diseases like panic attacks, stress disorder, post-traumatic disorder and other mental diseases can happen. Homophobic bullying gives rise to anxiety. When a transgender child gets bullied, he/she experience a feeling of fear and worry, which results in causing anxiety.

3) Suicidal tendencies-It is very difficult for any person to commit suicide. But when any person suffers hatred, discrimination, rejection and bullying from society and sees no reason for living, he tends to commit suicide. Suicide is a burning issue of the country, and there are so many reasons like unemployment, poverty, physical or mental cruelty, failures, bullying etc., for the commission of suicide. The impact of homophobic bullying on a transgender child gives rise to suicide attempts.

4) Lower Self Confidence- self-confidence is a must to develop an individual's personality. Self Confidence helps every person build their career, win competitions, sports, and every aspect of life. Because of homophobic bullying, self-confidence among transgender children has been reduced. They don't participate in cultural activities, sports activities or in any other competitions, which highly affects their mental health.

5) Autism-Autism is a mental disorder in which a person impairs the ability to communicate and interact with other people. A transgender child usually doesn't interact much with others, and if they get bullied by someone, they feel afraid to talk and lack social relations giving rise to the problem of Autism.

6) Bipolar Disorder-It is a disorder in which a person suffers mood swings, feels demotivated and depressive low. After getting homophobic bullied, a transgender child suffers mood swings that affect his/her daily activities. The transgender child does not sleep properly sometimes have nightmares which results in causing these diseases.

7) Schizophrenia-In this disease, a person's ability to think and act is affected. It is a severe disease that affects the life of any person. The ability to think and act is an important part of everyone's life. By homophobic bullying, a transgender child loses the ability to think and act in a particular situation. Their mental capacity is highly affected, which results in causing schizophrenia.¹³

Identifying as transgender is not a mental health disorder, and transgender patients should be treated medically rather than psychiatrically. However, transgender patients often benefit from speaking with a mental health professional about the impact of discrimination, stigma, and lack of social support on their mental health.

IV. Barriers to Health Care for Transgender Individuals

What is Gender Identity Discrimination?

Gender identity discrimination in health care settings occurs when you are denied equal access to health care and services and/or subjected to a hostile or insensitive environment because you are, or are perceived to be, transgender or gender non-conforming. Such discrimination may be compounded with discrimination based on other characteristics (i.e. race, sex, sexual orientation, disability, etc.). Some examples of gender identity-related health care discrimination are:

• Being denied complete or partial health insurance coverage; and
• Inappropriate treatment from health care providers, facilities, or community-based organizations.

Gender identity discrimination in ignorance, insensitivity, and outright bigotry is alienating and keeps people from accessing medically necessary care, such as hormone therapy, surgery, and mental health services. Health care injustice has life-long effects on people's ability to learn, work, and care for themselves mentally and physically. ¹⁴

There are numerous barriers to health care for transgender individuals, with the largest barrier reported by transgender individuals being the paucity of knowledgeable providers.

Lack of Knowledge: The biggest barrier to safe hormonal therapy and appropriate general medical care for transgender patients is the lack of access to care. Despite both guidelines and data supporting the current transgender medicine treatment paradigm, transgender patients report that a lack of providers with expertise in transgender medicine represents the single largest component inhibiting access. Transgender treatment is not taught in conventional medical curricula, and too few physicians have the requisite knowledge and comfort level.

Impact of COVID-19 pandemic: As a medical and socially vulnerable group, transgender individuals face numerous health disparities and mental health problems. The coronavirus disease 2019 (COVID-19) pandemic brings international health concerns and devastating psychological distress on a global scale to many populations. Transgender individuals are now facing unprecedented difficulties with mental, physical, and social wellbeing, as well as difficulties accessing health care.¹⁵

Before the pandemic, there existed many barriers to transgender individuals accessing health care, such as a shortage of specialized healthcare professionals; as a result, very few transgender individuals receive gender-affirming surgeries and hormone interventions, especially in low-income and middle-income countries. As a marginalized group, inequalities faced by transgender individuals in policies and social aspects, such as legislated policies based on binary gender norms, could increase the risk of illness and mortality during the COVID-19 pandemic. In addition, to prevent the potential overload of healthcare systems by COVID-19 cases, most hospitals have cancelled or postponed elective procedures to save resources. Thus, it is even more difficult for transgender individuals to access hormone interventions and gender-affirming surgeries.

Besides access to health care, it is also important to highlight the mental health issues of transgender individuals. Previous studies showed that gender-affirming surgery was associated with reduced mental health problems. Because of the difficulties caused by COVID-19 discussed above, likely, transgender individuals are also facing challenging situations with regards to their mental health. Difficulty in accessing hormone interventions was associated with high levels of anxiety and depression due to uncertainty about the availability of future treatments and struggles with maintaining unwanted gender identities during the COVID-19 pandemic.

The pandemic has exposed the deep vulnerabilities of India's healthcare system. Much of this is blamed on India's low expenditure on public health –1.29% of the G.D.P. (in 2019-20), lower than most other countries. Another critical reason for the weak public health in India is the absence of a statutory framework that guarantees a fundamental right to health. There is a need to make the right to health a fundamental right – and implement it within the framework of legal devices and human rights principles of solidarity, proportionality, and transparency which will help India address the challenges posed by COVID19. Implementing the right to health within India's framework of cooperative federalism will build capacities where they are most needed – at the grassroots.¹⁶

1) Other reported barriers include:

a) Financial barriers (lack of insurance, lack of income),

b) Discrimination

c) Lack of cultural competence by health care providers

d) Health systems barriers (inappropriate electronic records, forms, lab references, clinic facilities)

e) Socioeconomic barriers (transportation, housing, mental health)¹⁷

V. Role of Legislation in Transgender Healthcare

According to World Health Organization, Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease.¹⁸

From the definition itself, it is indicated that the condition of life of the individual should incorporate physical, mental & social wellbeing & must be devoid of disease & infirmity. Thus, WHO has played the best supportive role in guiding health policy development and action at the global and national levels, with an overall objective of ensuring & attaining the highest standards of health care to all the people worldwide. WHO has not only given a wider definition to HEALTH but also brought the vision of HEALTH CARE.

The Constitution of India does not expressly guarantee a fundamental right to health. However, there are multiple references in the Constitution to public health and on the role of the State in the provision of healthcare to citizens.

The Directive Principles of State Policy in Part IV of the Indian Constitution provide a basis for the right to health. Article 39 (E) directs the State to secure the health of workers. Article 42 directs the State to be just and humane conditions of work and maternity relief. Article 47 casts a duty on the State to raise people's nutrition levels and standard of living and improve public health. Moreover, the Constitution does not only oblige the State to enhance public health, but it also endows the Panchayats and Municipalities to strengthen public health under Article 243G (read with 11th Schedule, Entry 23).

Given no explicit recognition of the right to health or healthcare under the Constitution, the Supreme Court of India in Bandhua Mukti Morcha v Union of India & Ors interpreted the right to health under Article 21, which guarantees the right to life. In State of Punjab & Ors v Mohinder Singh Chawla the apex court reaffirmed that the right to health is fundamental to the right to life and should be put on record that the government had a constitutional obligation to provide health services. In State of Punjab & Ors v Ram Lubhaya Bagga, the Court went on to endorse the State's responsibility to maintain health services.

VI. Statutory Recognition and Transgender Health

The Transgender Persons (Protection of Rights) Act, 2019¹⁹ ('Transgender Persons Act') seeks to recognize the identity of transgender persons and prohibit discrimination in, inter alia, the fields of education, employment, healthcare, holding or disposing of property, holding public or private office and access to and use of public services and benefits.

In 2014, the Supreme Court of India, in the case of National Legal Services Authority v. Union of India,²⁰ established the foundation for the rights of transgender persons in India by recognizing 'transgender' as the 'third gender' and lying down several measures for the prohibition of discrimination against transgender persons and protection of their rights. The judgment recommended reservations for transgender persons in jobs and educational institutions and the right of transgender persons to declare their self-perceived gender identity without undergoing a sex reassignment surgery.

The law relating to transgender persons includes²¹:

1) Non-discrimination: It prohibits the discrimination of transgender persons at educational establishments, in employment or occupational opportunities, healthcare services and access to public facilities and benefits. It further reinforces transgender persons' right of movement, right to property and holding of a public or private office.²²

2) Certificate of identity: It provides for a right to self-perceived gender identity and casts an obligation on the district magistrate (a designated government official) to issue a 'certificate of identity as a transgender person, without the requirement of any medical or physical examination. It further provides that a person undergoing surgery for change of gender to either male or female may make an application for issuance of a revised certificate indicating a change in gender.²³

3) Healthcare facilities: The appropriate Government shall take the following measures in relation to transgender persons, namely:—

a) To set up separate human immunodeficiency virus Sero-surveillance Centres to conduct sero-surveillance for such persons in accordance with the guidelines issued by the National AIDS Control Organisation in this behalf;

b) To provide for medical care facility including sex reassignment surgery and hormonal therapy;

c) Before and after sex reassignment surgery and hormonal therapy counselling;

d) Bring out a Health Manual related to sex reassignment surgery in accordance with the World Profession Association for Transgender Health guidelines;

e) Review of medical curriculum and research for doctors to address their specific health issues;

f) To facilitate access to transgender persons in hospitals and other healthcare institutions and centres;

g) Provision for coverage of medical expenses by a comprehensive insurance scheme for Sex Reassignment Surgery, hormonal therapy, laser therapy or any other health issues of transgender persons.²⁴

Through the enactment of this law, India has brought itself at par with the international standards on human rights protection, as envisaged by the United Nations Office of the High Commissioner for Human Rights in 2015, where it recommended States to begin 'issuing legal identity documents, upon request, that reflect preferred gender, eliminating abusive preconditions, such as sterilization, forced treatment and divorce'²⁵. Similarly, the 2015 World Health Organization Report recommended that governments 'take all necessary legislative, administrative, and other measures to fully recognize each person's self-defined gender identity, with no medical requirements or discrimination on any grounds.'²⁶

VII. Suggestions to ameliorate the Healthcare condition of the Transgender community

1) Assessment and early screening of the health of Transgender individuals: It is important for healthcare systems to establish assessment screening and provide a monitoring service to ensure the psychological wellbeing of this vulnerable population. Inclusive assessment of the mental and physical health of transgender individuals that includes quality of life, physical functions, surgical complications, and hormone-related health problems. These assessments could identify transgender individuals at a high risk of developing severe psychological or physical health problems. Early screening could help to provide timely interventions for symptoms that could occur.

2) Special Laws to abolish Discrimination: The right to Health is part and parcel of the right to life, and therefore right to health is a fundamental right guaranteed to every citizen of India under Article 21 of the Constitution of India²⁷.

Special laws should be made and applied to prohibit discrimination on the basis of sexual orientation or gender identity status in the provision of all goods and services, including medical care. Additionally, equal healthcare access should be guaranteed for transgender patients under the Constitution.

3) N.G.O.s and Association to cater the issue: More associations and N.G.O.s should come up with a vision to fight for the rights of the Transgender community. To give recommendations for the issue and monitor its proper execution. These issues include access to health care, health history, hormones, cardiovascular health, cancer, S.T.I.s and safer sex, alcohol and tobacco use, depression, injectable silicone, and fitness.

4) Education: For the community to enjoy equality and reach its full potential in society, transgender people must be included in all aspects. When provided with a nurturing atmosphere, this strong workforce can contribute to the country's G.D.P. through their increased skill sets.

a) Education in school and college: Investment in public education on gender incongruence by government and private partners, with a focus on being sensitive to transgender people's rights and attentive to their unique needs.

b) Give members of the transgender community an equal chance to attend higher education institutions. Accountability must be established to identify the causes for such students' dropout.

c) Social and legal policies affecting the lives of transgender persons should be gender positive, with the goal of facilitating chances for transgender individuals to live congruent with their gender identification.

d) A few chapters dedicated to describing the anatomical differences between male and female bodies. The same chapters in the school curriculum must incorporate information on transgender people.

e) Specific counselling for transgender children (including transwomen and transmen)

f) Comprehensive counselling for transgender children's family members about specific challenges and strategies to handle.

g) Medical Education: Equal opportunity for all healthcare professionals to enter, prosper, and develop within healthcare institutions.

h) Transgender cadaver available for anatomy classes

i) The National Medical Commission may choose to incorporate a transgender-specific course.

j) Medicine as one of the post-graduate choices.

5) Priorities for Future Research: Although it is clear that transgender patients suffer from a shortage of competent providers for their health care, the specific explanations for that gap remain to be studied. There must be an early research priority to establish a rigorous determination of the ability of the health care system to provide adequate care for transgender individuals along with a careful assessment of causes for deficits.

6) Assess bias and other barriers to Healthcare: Assess the knowledge and sophistication of the provider workforce to provide transgender medical care – along with barriers to that education. Lack of knowledge may manifest as assumed complexity of knowledge needed along with a report of anxiety regarding uncertainty. Identify solutions to overcome the knowledge gap.

a) Assess bias and other barriers to provider care independent of knowledge. The other barriers may include fear of the stigma associated with providing transgender medical care. Other barriers may also include bias in the structure of clinics, forms, and electronic medical record systems, in addition to gaps in knowledge and bias among support staff. Identify solutions to the gaps which are not solely a lack of knowledge.

b) Determine the degree to which 3rd-party payer policy impedes access. Determine change needed to overcome the financial barrier to care.

c) Evaluate other barriers, including societal stigma, mental health issues among patients, and socioeconomic issues that represent barriers to transgender individuals receiving high-quality care. Evaluate strategies to overcome these barriers.

7) Cancer screening: An important aspect of physical health monitoring in transgender patients is cancer screening. Transgender individuals are often overlooked when it comes to national cancer screening programs. Unless they have undergone chest reconstruction surgery, Transgender patients should undergo breast screening, as would be the case for natal females. Transgender patients should undergo cervical screening if cervical tissue remains (i.e. they have not undergone a hysterectomy). Transgender patients will remain at risk of prostate cancer as with natal males, so clinicians should remain vigilant if these patients present with lower urinary tract symptoms.

The Guwahati High Court has asked the Assam Government if it has proposed any scheme to look after the health issues of the members of the Transgender community. A Division Bench comprising Chief Justice Sudhanshu Dhulia and Justice Manash Ranjan Pathak further directed the Central Health Ministry to come up with the list of beneficiaries under the Ayushman Bharat Yojana, who are members of the transgender community from Assam.²⁸

The direction was passed today while hearing a P.I.L. filed by transgender activist Swati Bidhan Baruah²⁹, raising several issues faced by said community members in accessing health and medical facilities. The P.I.L. was filed in 2018, demanding inclusion of the transgender community as beneficiaries under Centre's Ayushmaan Bharat Scheme, which allows low-income families to subsidise avail health insurance.

After hearing the petition, the Bench directed the ASGI to furnish the list of beneficiaries within two weeks. The Bench further directed the State counsel to apprise the Court how soon a separate wing for the treatment of the transgender community can be opened in Guwahati Medical College and Hospital.

VIII. Conclusion

The main transgender healthcare challenges in pathology/laboratory medicine practice include the inflexibility of electronic medical records in documenting affirmed gender, unfamiliarity among medical and laboratory professionals with the needs of and terminology related to the transgender population, lack of reference ranges for laboratory tests, unclear guidelines regarding gender classification for blood donation eligibility criteria, and paucity of experience in handling and interpreting surgical and cytological specimens from gender-transitioning individuals. Directed efforts to overcome these shortcomings, coupled with a more welcoming posture, are essential to achieving the highest standards of care for the transgender population.

To conclude, despite increasing awareness and decreasing stigmatization of the transgender population, many barriers must be overcome before we can fulfil our long-term goal of achieving the highest standards of care for members of this diverse societal subgroup. This change will especially aid pathology staff members, such as those in phlebotomy and transfusion medicine, who interface directly with patients. Healthcare facilities should incorporate formal training in transgender health issues and provide inclusive structural facilities, such as unisex restrooms. In anatomic pathology, personnel should be aware of the complexities in handling and interpreting specimens and biopsies from transgender patients. Ultimately, fulfillment of these goals will allow transgender patients to maximize their overall health, psychological wellbeing, and self-actualization.

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IX. Reference

1) https://www.vumc.org/lgbtq/key-transgender-health-concerns

2) https://en.wikipedia.org/wiki/Transgender_health_care

3) https://www.hopkinsmedicine.org/health/wellness-and-prevention/transgender-health-what-you-need-to-know

4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239622

5) Rajpurohit, Govind S.; Singh, Abhimanyu (2021, May 5). "Transgender Rights in India".

6) Gorton N, Grubb HM (2014). General, Sexual, and Reproductive health. In L. Erickson-Schroth. Trans Bodies, Trans Selves: A Resource for the transgender community (pp. 215-240). New York: Oxford University Press.

7) Rood, Brian A.; Reisner, Sari L.; Surace, Francisco I.; Puckett, Jae A.; Maroney, Meredith R.; Pantalone, David W. (2016). "Expecting Rejection: Understanding the Minority Stress Experiences of Transgender and Gender-Nonconforming Individuals". Transgender Health.

8) "What Does Transgender Mean? | Gender Identification Facts". www.plannedp arenthood.org. Retrieved 2019-10-23.

9) Connolly, Maureen D.; Zervos, Marcus J.; Barone, Charles J.; Johnson, Christine C.; Joseph, Christine L. M. (2016-11-01). "The Mental Health of Transgender Youth: Advances in Understanding". Journal of Adolescent Health. 59 (5): 489–495.

10) Zucker, Kenneth J.; Lawrence, Anne A.; Kreukels, Baudewijntje P.C. (2016). "Gender Dysphoria in Adults". Annual Review of Clinical Psychology.

11) Bränström R, Pachankis JE. Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. Am J Psychiatry. 2019 doi: 10.1176/appi.ajp.2019. 19010080. published online Oct 4.

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Footnotes

1. Author is an Associate Professor at Department of Law, University of Rajasthan, Jaipur, India.

2. Author is a Research Scholar at Department of Law, University of Rajasthan, Jaipur, India.

3. Outline of transgender topics, available at: https://en.wikipedia.org/wiki/Outline_of_transgender_topics ↩

4. Dr.Rathna Kumari K R, Socio–cultural elimination and insertion of trans-genders in India, 6 IJRAR 494- 501 (2019) ↩

5. THE TRANSGENDER PERSONS (PROTECTION OF RIGHTS) ACT, 2019, No. 40, Acts of Parliament, 2019 (India). ↩

6. National Legal Ser.Auth vs Union Of India & Ors on 15 April, 2014 ↩

7. Diganth Raj Sehgal, Transgender and Rights of Transgender, available at: https://blog.ipleaders.in/transgender-rights-transgender/ ↩

8. Joshua D. Safer,a Eli Coleman,b Jamie Feldman,b Robert Garofalo,c Wylie Hembree,d Asa Radix,e and Jae Seveliusf, Barriers to Health Care for Transgender Individuals, available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802845 ↩

9. Transgender health care, available at: https://en.wikipedia.org/wiki/Transgender_health_care#Sex_reassignment_therapy ↩

10. Vanderbilt University Medical Center, Program for LGBTQ Health, available at: https://www.vumc.org/lgbtq/key-transgender-health-concerns ↩

11. Johns Hopkins Medicine, available at: https://www. hopkinsmedicine.org/health/wellness-and-prevent ion/transgender-health-what-you-need-to-know ↩

12. Trans Mental Health Study 2012. McNeil et al. 2012, available at: http://www.gires.org.uk/assets/M edpro-Assets/trans_mh_study.pdf ↩

13. Rajpurohit, Govind S.; Singh, Abhimanyu (2021, May 5). “Transgender Rights in India”. ↩

14. Transgender Law Center, Transgender Health and the Law; Identifying and Fighting Health Care Discrimination, available at: http://transgenderlaw center.org/wp-content/uploads/2012/07/99737410-Health-Law-Fact.pdf ↩

15. Yuanyuan Wang, Bailin Pan, Ye Liu, Amanda Wilson, Jianjun Ou and Runsen Chen, Health care and mental health challenges for transgender individuals during the COVID-19 pandemic, 8 The Lancet, P564-565 (2020) ↩

16. NISHANT SIROHI, Declaring the right to health a fundamental right, https://www.orfonline.org/expert-speak/declaring-the-right-to-health-a-fundamental-right/ ↩

17. The International Center for Transgender Care, Health Issues of Transgender Patients, available at: https://thetranscenter.com/holistic-therapy/health-issues-of-transgender-patients/ ↩

18. Preamble to the Constitution of the WHO as adopted by the International Health Conference (Official records of the WHO, no 2, P. 100 ↩

19. The Transgender Persons Act was passed by the lower house of the Indian Parliament on August 05, 2019, by the upper house of the Parliament on November 26, 2019 and finally received the Presidential assent on December 05, 2019. It has been brought into effect by the Indian Government on January 10, 2020. The Transgender Persons (Protection of Rights) Rules, 2020 were notified on September 29, 2020. ↩

20. National Legal Services Authority v. Union of India A.I.R. 2014 S.C. 1863. ↩

21. Supra note 5 ↩

22. Section 3 of the Act - Prohibition against discrimination ↩

23. Section 5 of the Act- Application for certificate of identity ↩

24. Section 15 of the Act- Healthcare facilities ↩

25. Human Rights Council, United Nations General Assembly (2015), “Discrimination and Violence against Individuals based on their Sexual Orientation and Gender Identity”, Report of the Office of the United Nations High Commissioner for Human Rights (A/HRC/29/23), dated May 04, 2015. Available at: https://undocs.org/A/HRC/29/23 ↩

26. Ajay Singh Solanki and Nishith Desai Associates, India’s new law on the protection of rights of transgender persons, available at: https://www.ibanet.org/article/0f3ae21b-0170-4bf7-95dd-45b07ef1caf6 ↩

27. Article 21 - Protection of life and personal liberty: No person shall be deprived of his life or personal liberty except according to procedure established by law ↩

28. Live Law, Do You Have Any Scheme To Look After Health Issues Of Transgender Community?: Gauhati High Court Asks Assam Govt, available at: https://www.livelaw.in/news-updates/scheme-to-look-after-health-issues-of-transgender-communitygauhati-high-court-asks-assam-govt-171608?infinitescroll=1 ↩

29. Swati Bidhan Baruah vs The State Of Assam And 2 Ors ↩