Much of the current work on COVID-19 demonstrates the impact this pandemic had on either cisgender men or women, neglecting the consequences gender minorities have to suffer because of the cis/hetero-normative patriarchal institutions present in Indian society. It is essential to move beyond a binarised notion of gender that places people into distinct categories. Addressing how gender minorities have been affected is necessary to identify and support those that urgently require assistance. This research paper emphasises the exclusionary practices that the transgender community in India faces from the state and society, aggravated by COVID-19.
For the sake of this paper, the term transgender is used to include all identities associated with the term. The findings of this research paper highlight the exacerbated financial insecurities the community has encountered due to COVID-19 and its ensuing lockdown, the existing health issues and co-morbidities that increase their susceptibility and vulnerability to the COVID-19 virus, their lack of access to healthcare facilities, and their inability to practice the prescribed preventive measures.
India is a society with distinct cultures, languages and religions, and the country has institutionalised particular norms. These norms have established the supremacy of heterosexual, upper-caste, upper-class Hindu cisgender heterosexual men. Through this formation of hegemonic masculinity, society has also normalised the notion of a gender binary which is considered natural. Data collection in the country is not gender-focused. According to a 2020 report by the International Development Research Centre (IDRC), "Gender-disaggregated data does not reflect the reality of all gender minorities and cannot be used to make development decisions, especially for the inclusion of transgender and intersex persons, who are often misrepresented or absent in this data." Due to this, the transgender community is compelled to experience several socio-economic problems.
The Indian educational system reflects deeply entrenched cis-heteronormative biases, making it a hostile and unsafe environment for trans students. Factors such as exclusion from society, poverty, and violence further contribute to the poor participation of the community in the school. According to a study conducted by the National Human Rights Commission (NHRC) in 2017 among 900 transgender individuals in four districts of Uttar Pradesh and the National Capital Region (NCR), "three in four transgender children in NCR and 82% in Uttar Pradesh either never went to school or dropped out before 10th grade." Deducing from the Circular Cumulative Causation theory developed by Swedish economist Gunnar Myrdal since education becomes a luxury for a major section of the transgender community, they have limited skills that further causes a lack of employment opportunities, making economic survival difficult.
The occupations the community then commonly engages in is singing and dancing in the form of a tradition termed badhai, wherein they earn money by blessing the newlywed couples and pregnant women at public functions. Some members of the community even engage in sex work due to their economic circumstances. On a national level, a study conducted by the Department of AIDS Control (DAC) under the National AIDS Control Programme-IV across 17 states revealed that around 62% of the transgender community indulge in sex work, with the highest number being in Uttar Pradesh. A survey conducted in the district of Jalandhar by Preeti and Shyamkiran Kaur in Punjab, India, revealed that when the hijras fail to get an adequate sum as badhai, eight out of 20 of them ranging between 17 to 40 years indulge in sex work to sustain their livelihood even though it is an illegal activity.
Social stigma, continuous discrimination, and low self-esteem also contribute to unsafe sexual practices. Due to their unsafe sex practices, lack of counselling on safe injecting practices in India and hormone therapy not being practised under medical care, this leads to an increase in the risk of HIV transmission among transgender individuals. This can also be seen from the latest national estimates in 2019 by the National AIDS Control Organisation (NACO), according to which, the prevalence of the Human Immunodeficiency Viruses (HIV) among Hijra/Transgender (H/TG) people is 6 to 13 times higher than the adult prevalence.
Transgender-friendly healthcare services in India are also not available, and healthcare workers disregard gender incongruence. Transgender women continue to be deprived of healthcare entitlements, and the fear of being ridiculed or ostracised by healthcare professionals discourages them from using available healthcare services. The Transgender Persons (Protection of Rights) Act, 2019, has made it more difficult for the concerned persons to get necessary documentation that reflects their gender identity to access the various government welfare schemes. Additionally, it has taken away the transgender community’s right to self-identify their gender due to the biased cis-normative procedures followed by the Indian government.
The Act also states that if the family of a transgender person is not able to take care of them, they must be placed in rehabilitation centres, denying their right to join other transgender communities. It fails to acknowledge alternative family structures that the transgender community has created after being abandoned by their biological families, denying them the right to join other transgender communities that can provide them with the support they require. Hijras systematically organise themselves in hierarchical communities, called gharanas, under which a guru adopts chelas. The chelas then become responsible for taking care of their gurus. This system depicts how social security works within their community. It is an institutionalised lifestyle that defies the cis-heteronormative notion of a family.
At the outset, this paper aims
1. To raise awareness regarding the economic consequences of the pandemic on the transgender community.
2. To acknowledge the impact of existing health issues.
3. To discuss the lack of access to healthcare facilities.
4. To inform about the community's inability to implement preventive measures.
This research is purely based on secondary data. The data has been collated from research journals, research papers, newspaper articles and government reports, which has then been summarised and analysed.
Heightened economic insecurities
The transgender community depends on the informal sector since traditional jobs revolve around badhai, begging, and sex work. The lockdown imposed in March 2020 to curb the COVID-19 pandemic adversely impacted their livelihood because of the shutting down of red-light areas and the imposed bans on weddings and other forms of celebration. The pandemic has specifically had an unwelcome impact on the occupation of badhai hijras. Owing to the decline in the number of social and religious gatherings, some badhai hijras have been forced to adopt begging at traffic signals and shops, an activity many of them consider to be insulting (Kaur & Kaur 2020).
Even transgender sex workers are also experiencing difficulties, loss of income, increased discrimination, and harassment because of the criminalisation of organised prostitution in the country. Although prostitution is legal in India, "soliciting services of prostitution at public places, carrying out prostitution activities in hotels, being the owner of a brothel, pimping, indulging in prostitution by arranging a sex worker, arrangement of a sex act with a customer" are considered illegal under the Indian Penal Code. Police in India abuse the Immoral Traffic (Prevention) Act (ITPA) to restrict any form of prostitution and arrest any offending woman. Sex trafficking interventions do not consider that the sex worker might be of age, not actually be a victim of trafficking or even wish to continue work in the commercial sex trade (Bhattacharya, 2019). Thus, many hijras are compelled to give a big part of the meagre salaries they earn as sex workers to police personnel as bribes.
Since both sex work and badhai are not given recognition as types of small businesses, the transgender community was unable to access economic support or labour support granted by the Indian government. Other than the Kerala government, no Indian state made an effort to secure transgender rights even after they promised assistance to deprived sections of the population. The Pradhan Mantri Garib Kalyan Yojana announced in March 2020 also did not refer to transgender individuals.
The National Institute of Social Defence (NISD) did provide Rs.1,500 to around 4,500 transgender individuals from different states in the country when they approached the government for assistance. However, this is only 1% of the transgender population as according to the 2011 Census, 4.88 lakh people belonging to the community (transgender activists state this is a conservative estimate). When state governments such as Gujarat started providing food support through their public distribution system to transgender, they did not receive it (Pandya & Redcay, 2021).
Firstly, a proper enumeration of the transgender community has never been conducted on a state level, and it is impossible to assume how many might benefit from such packages. Secondly, as noted earlier, many do not have identity cards that certify their gender and record their dead names (Chakrabarti, 2020). Lastly, many transgender individuals have a history of internal migration because of which they no longer have access to the former address linked with their government-approved ID cards. Even those with valid documentation believe that the food supplied to them is not adequate to feed the people they support. This problem occurs because the hijra community wishes to provide financial aid to their gurus and gharanas that are not recognised by Indian law and state bureaucracies (Goel, 2020). Hence, even if the Centre and State governments attempt to release relief packages for the transgender community, they will not be able to avail the benefits.
With the lack of social security benefits and little savings, their biggest challenge becomes the depleting food supplies. The circumstances have forced them to take massive loans from private money lenders and not banks because of no documentation. Due to their financial conditions, they find themselves in a cycle of loans and debts, and they are no longer receiving the money they earlier used to pay off the previous dues.
Existing health issues and their relations with COVID-19
Numerous prevailing health conditions cause the transgender community to have lower levels of health in comparison to the majority of the population because of the general negligence towards their mental and physical health. At present, no specific information is available about the risk of COVID-19 on People with HIV (PWH). However, there are possibilities of complications arising if PWH develops the virus because of their compromised immunity.
According to the National Alliance of Mental Health Illness (NAMI), a United States-based advocacy group, transgender individuals and the LGBTQ+ community are three times more likely than cisgender heterosexual people to develop mental health conditions that include Generalised Anxiety Disorder (GAD), eating disorders, psychotic disorders, and major depression. This mental health crisis originates from numerous factors such as gender dysphoria, prejudice, social stigma, harassment, social exclusion, family rejections, and denial of civil and human rights. Thus, there is a high incidence of suicidal acts, suicidal attempts, self-harm injuries, and what is termed as Deliberate Self Harm (DSF) (Ortiz, 2016).
This stress causes the transgender community to consume alcohol and use tobacco, elevating the risk factors for cardiovascular diseases (CVD). Even though mental health and HIV/AIDS disparities are documented, the risk of CVD among gender and sexual minorities remains understudied. Mental health is generally linked with CVD mortality, and stress contributes to low-grade nonspecific inflammation linked to chronic disease that also comprises CVD (Caceres et al., 2017). Early clinical data on COVID-19 suggests that both the outcomes and vulnerability are strongly associated with CVD. Pre-existing CVD can worsen the results and substantially increase the risk of death in patients with COVID-19 (Nishiga et al., 2020).
Alcohol, tobacco, smoking also heighten the transgender community's possibilities to contract Tuberculosis (TB) and COVID-19. According to the World Health Organisation (WHO) data, People with HIV (PWH) are at 21 times greater risk of developing TB than people without HIV. Undernutrition, poverty, and low literacy rates remain the most prevalent risk factor for TB in India and are accountable for the highest proportion of TB cases in the country (Central TB Division, MOHFW, National Framework for A Gender-Responsive Approach to TB in India, 2019). Since TB leaves damage in the lungs and COVID-19 affects the respiratory organs, TB survivors are at an increased risk of developing more severe COVID-19 symptoms. It can be anticipated and assumed that people infected with both COVID-19 and TB may have poorer treatment outcomes, particularly if TB treatment is delayed.
Lack of access to healthcare facilities
During the COVID-19 pandemic, routine healthcare services were compromised for the standard population. This affected the transgender community, who get an even lower priority in ordinary times. The community's members seek healthcare for two distinct causes. One involves regular healthcare, and the other involves medical assistance for gender affirmation or transition. However, they endure significant health disparities that existed before the pandemic because the healthcare facilities are centralised around cisgender people. Medical professionals view transgender bodies as deviants because of a binarised view of sex and gender which causes stigmatisation and misinformation. Only a minority of doctors have proficiency in transgender medicine which limits access for the community, and additionally, transgender treatment does not form a part of traditional medical curricula, due to it being transphobic and homophobic. Thus, only a few physicians have the comfort level and requisite knowledge to support them (Safer et al., 2017).
Hence, the community tends to approach hospitals based on the gravity of their issue. If they consider their health issues insignificant, they depend on home remedies. If medical care becomes necessary, they prefer to visit medical practitioners they know (Ortiz, 2016).
The pandemic and especially the various lockdowns have also affected the access to medicines of Antiretroviral Treatment (ART) for PWH. As a result of the lack of transport facilities, the treatment schedule of many individuals has been disrupted. Even during the unlock phases, transgender individuals hesitate to visit treatment centres and hospitals because they are at a higher risk of developing COVID-19, as noted earlier. They also feel more vulnerable because of being deprived of their health entitlements.
Moreover, the Transgender Act of 2019 has made it compulsory to give proof of the surgery administered by a physician to apply for a change in gender certification. It does not consider that gender-affirmation surgeries can be inaccessible or prohibitively expensive. Therefore, even if the community does choose to visit healthcare facilities, it is not in their preferred gender. Trans people who have the money to support such surgeries have been forced to delay the surgeries due to the suspension of non-emergency medical care because of prioritising COVID-19 (Woulfe & Wald, 2020). They also fall under cosmetic and not medically necessary surgeries, which renders it outside the purview of insurance policies that can subsidise costs.
As a part of the transition process, many members of the transgender community seek regularly monitored hormone therapies. These therapies are implemented under the surveillance and strict guidelines of health providers. Before the pandemic, individuals with no comorbidities bought hormone injections from local pharmacies and asked health attendants present there to inject them. However, no one is available during the pandemic to assist them with the injections. Missing the regular doses can have harmful consequences, for instance, sudden discontinuation of these hormones can cause menopause-like symptoms in transgender women with physiological and emotional symptoms of hot flashes, weight issues, and anxiety. Postponing the therapy can cause adverse psychological stress and trauma, adding to the hassles of the community (Desai, 2019).
Access to COVID-19 health care is also difficult for the community. Transgender individuals are forced to face emotional and mental trauma because of being infected by COVID-19. Interviews conducted with a few members of the transgender community in Gujarat during COVID-19 reveal that they would not choose public healthcare services because they anticipate discriminatory attitudes there. They also have to tolerate the pessimistic attitudes of patients and healthcare providers (Pandya & Redcay, 2021). Additionally, infected transgender patients stay in the male or female isolation wards of the hospitals. The denial of separate isolation wards for the community can be traumatising. Many then choose not to report their COVID-19 symptoms because of their unpleasant experiences, further escalating the spread of the virus. If this remains unaddressed, then the pandemic's fatality rate will keep surging among the community.
Inability to adopt preventive measures
Preventive courses of action as proposed by WHO to control the spread of COVID-19 are only possible for the privileged sections of society in an over-populated country such as India. It does not regard various intersectional factors and that many marginalised communities cannot practice any of these safety measures. Strategies that include proper hygiene concerning coughing, wearing masks, physical distancing, and frequent hand washing are not possible for many transgender individuals since they reside in highly dense communities (Pandya & Redcay, 2021). Additionally, access to sanitation facilities is limited, they cannot acquire nutritious food, and they are specifically vulnerable to being left homeless. These factors affect their ability to stay fit or recover from the virus.
Searching for transgender-friendly housing was challenging even before the pandemic and has been exacerbated during the pandemic because of the limitations on interaction. Trans people often have to pay a much higher price than cisgender people for the same accommodations. There is also a risk of facing violence from landlords. As a result of sudden lockdowns, a burdensome housing environment developed into a homelessness crisis, with various reports stating that the transgender community were denied entry to their regular places of residence (Sahai, Agrawal, & Sheikh, 2020). Transgender individuals residing in slums do not have proper rent agreements with landlords, and cramped rooms have limited ventilation.
Transgender individuals have also been excluded from India's vaccination drives. By 30th June 2021, 32 crore Indians had been vaccinated; out of which 55, 886 were transgender citizens. The number of vaccinated transgender citizens only constituted 0.01% of the national population and 11.45% of the total transgender population, according to the 2011 census (Rathore, 2021). Such low numbers can be associated with neglect towards the community, and each step towards getting immunised involves various challenges. The principal barrier is vaccine hesitancy which developed from the community's traumatic interactions with the Indian healthcare system.
Moreover, the CoWIN system established to register for the vaccine is inaccessible for transgender individuals. The app initially insisted on online registration, with many in the community not having access to the internet, and a high illiteracy rate worsens the digital divide. Even those with access to technology have realised that the vaccine registration form does not offer a specific category for transgender individuals in the gender section. Instead, anyone that is not cisgender is placed in the other category, despite the 2014 National Legal Services Authority (NALSA) Judgement. The judgement asserted that a person's self-affirmed gender has to be mentioned correctly, especially in the context of a government policy that is compulsory. The form also insists on providing photo identification proof when an individual gets vaccinated. However, as mentioned earlier, many do not possess valid government documents.
Furthermore, little to no research has been conducted on the transgender community as far as the COVID-19 vaccine is involved. There is scepticism regarding how the vaccine would interact with gender affirmative surgeries, hormone supplements, or HIV treatments. Even the Human Rights Commission has called for attention to this underrepresentation of transgender individuals in medical trials, including those for vaccines.
RECOMMENDATIONS AND CONCLUSION
From the above discoveries, it is apparent that the transgender community remains neglected, and Nongovernment Organisations and civil society cannot sustainably accomplish the protection of the transgender community without policies favouring the community. Transgender individuals urgently need the attention of policymakers and decision-makers, particularly during the pandemic. The transgender community needs a guaranteed subsistence income (estimated at minimum Rs. 3,000 per month by the transgender community) to each transgender individual until the pandemic restrictions end. Programmes to ensure food security among the community by distributing monthly ration kits through the public distribution system need to be implemented.
Secondly, the Government of India (GoI) must make gender-disaggregated data on COVID-19 available in the public domain that addresses transgender individuals. Transgender Welfare Boards need to be developed in all the states to know the exact number of the transgender population since the state governments are failing to distribute relief packages to all members because of the absence of actual data, documentation, and registration. In addition to this data, policymakers must ensure the community's purposeful and impartial representation in designing policymaking and COVID-specific interventions.
More data and studies are also required to elucidate the specific considerations needed for providing, promoting access, and delivering healthcare services to transgender individuals. A sustained supply of essential medication to transgender individuals must be ensured, including tuberculosis care and treatment, hormone therapy, and other gender-affirming procedures. There has to be a coordinated effort by state governments to set up camps for transgender communities to create awareness about COVID-19 and provide guidance through the registration process for vaccines. Campaigns can be held and separate booths can be set up for them to make the procedure trans-friendly.
GoI must amend the iteration introduced in the Transgender Act 2019 to develop inclusive legislation and improve the process of official gender reconfirmation. To ensure that the community is involved in proposing changes, queer mobilisation is a prerequisite. The government should collaborate with transgender activists and organisations to ensure the existence of supportive spaces. These spaces can assist in providing mental, emotional, economic, and medical support to transgender individuals.
Evidence generated from future studies can assist administrators and policymakers in executing appropriate action for remodelling social protection schemes. With the need for data emerges the requirement of gender sensitisation to address the internalised prejudices of heterosexual and cisgender people. This sensitisation will assist them in realising the social circumstances of transgender individuals and communicating with them sensitively and considerately.
In conclusion, this paper would like to emphasise that while the entire world is combatting COVID-19, transgender individuals are also struggling with social elimination, access to healthcare services, means of survival, and layers of discrimination because of existing cis-heteronormative institutions.
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