DOI: https://doi.org/10.21203/rs.3.rs-44619/v1
Protecting vulnerable populations from COVID-19 pandemic is a strategic imperative particularly considering they are at an increased risk for a wide range of issues. Based on the telephonic interview with twelve transgender women from Gujarat, India, this paper highlights the vulnerability factors for transgender individuals during a world-wide pandemic. Amongst others, transgender community members who struggle to cope financially, mentally, or physically with the crisis are also a vulnerable group that requires attention. Authors discuss key perspectives to meet the health needs of this group. Findings also offer broad insights into bolstering mental health, provisioning and encouraging availing psychological services in addition to essential healthcare services. It is critically important to address this population’s special needs during public health crisis such as COVID 19 and beyond. More studies are needed in this area to illuminate unique considerations for healthcare workers while providing care to this important group.
Transgender individuals remain marginalized and often they are deprived of their healthcare entitlements because of their gender identity outside the normative binary (Ming et al 2017). The fear of being stigmatized and ridiculed by healthcare professionals discourages them from using healthcare services (Chakrapani, 2016; Ganju & Saggurti, 2017) which is now leaving them at increased risk of not being tested or treated for COVID-19 (Deb, 2020). COVID-19 has posed physical as well as mental health risks of this marginalized population as well. Deb (2020) rightly drew attention to the distresses faced by the transgender community in India during the COVID-19 pandemic. The concern is not just about the lack of healthcare facilities, but also about the lack of dialogue and inclusion of transgender people regarding their healthcare.
The government of India has declared a lockdown from 23rd March 2020 which was extended till 3rd May 2020. As a result, public places are closed, movements are restricted by police and physical distance, hand and cough hygiene practices are recommended to prevent further spread. As of the 4th of May 2020, India had 42,836 confirmed cases of COVID-19 and 1,389 of them died resulting in more than 3% fatality rate While effective in responding to the disease, many people, particularly transwomen and hijra have been negatively impacted. However, their situation is not known. Various studies have been conducted to understand the impact of the pandemic on people who are infected, other affected and vulnerable people, healthcare workers, etc since the inception of COVID-19 pandemic (for example, Armitage & Nellums, 2020; Banerjee et al, 2020; Hall et al, 2020; Kang et al, 2020; Kluge et al, 2020; Lima et al, 2020; Roy et al, 2020; Spoorthy, 2020; Wenham et al, 2020) but studies are limited on the transgender/hijra population. The present study gauges knowledge about COVID19, food insecurity, access to healthcare services, and psychological reactions of transgender/hijra population in Gujarat during COVID-19.
Semi-structured telephone interviews were conducted with twelve TG women residing in Gujarat between 27nd March to 30th April 2020. The first author provides free telephone psychological support for transgender individuals in Gujarat, India. Respondents had called to seek psychological support and brief interviews were conducted with their consent. Off the total, two transgender individuals denied interview. Interviews were transcribed, qualitatively coded and analyzed using thematic content analysis. Locations are de-identified to maintain confidentiality.
Most respondents (8) identified them as transwomen while four (4) had self-identified as hijra.[1] All respondents were almost equally represented from urban areas (7) and semi-urban areas (5). Key themes emerged from the data are health literacy, health conditions, fear, stigma & discrimination, decreased access to healthcare, food insecurity and psychological reactions.
Health literacy
Many transgender people in India lack education. Out of the total, nine respondents had studied until 8th grade, two studied until 10th grade and only one had graduation. Most of them (10) were not aware of precautions for preventing COVID-19 infection, correct source of information for COVID-19 and treatment centres.
“…most of our community members [transgender women and Hijra] are not educated and hence awareness on precautions for preventing Coronavirus infection is limited.” Transgender woman
A belief that coronavirus cannot infect us influences adherence to preventive measures. One respondent describes,
“We live together…almost 6-7 in one room, maintaining physical distance is difficult. Many amongst us have a cough and cold but are not aware of correct practices...I know but being a Chela2 [disciple], no one listens to me…only listens to Guru but our Guru believes that nothing will happen to us.” Hijra person
Health conditions
Many (5) suffer from chronic conditions like diabetes, asthma, TB or HIV. It added that more than half of the respondents (8) consumed tobacco and alcohol (6) which make them more vulnerable to the COVID-19 infection (WHO, 2020).
Fear, Stigma and discrimination
Members of the transgender community have expressed their fears at not being able to physically isolate. In India, many in this community already have serious healthcare challenges related to HIV and now older transgender persons who are at greater risk of the coronavirus infections are feeling extremely vulnerable given the lack of transgender-friendly healthcare facilities (CDC, 2020).
“I am worried, what if I am infected with Coronavirus. I don’t want to die too
early.” Transgender woman
“If someone from our community gets infected, we will be quarantined in the hospital. Some hospitals put us in the male ward and some in the female ward. Recently, my community member was admitted in the male ward despite she was in women’s clothing and was ‘nirvan’ [castrated penis]. Such an incident traumatizes an already infected with corona trans person.” Hijra person
“not only the infected transgender person will have to deal with the physical and emotional trauma of being infected by the virus, but will also have to undergo negative attitude from the healthcare providers as well as fellow patients.” Transgender woman
As these quotes illustrate, a COVID-19 positive transgender person might encounter two-fold stigma, firstly because of their gender identity, then because of their COVID-19 positive status. These are potential to expose them to violence and hate crimes. Their past experiences with the healthcare system might drive transgender community members away from reporting COVID-19 symptoms which will further spread the virus (James, et al., 2016; Ortiz, 2016).
Decreased access to healthcare
India’s health system focuses largely on the sexual health of transwomen with little thought given to their other health needs. Nevertheless, in crises such as this, even sexual healthcare services take a backseat as efforts are diverted to responding to the immediate emergency (Sohini, 2020; CDC, 2020). As access to general healthcare is reduced, especially sexual health services including HIV prevention and treatment, the effect on transwomen will be manifold. The situation is likely to be worse in rural areas where health services are just limited to health centers and hospitals (Singh, 2020). Furthermore, many transgender women living with HIV are experiencing severe impacts on their livelihoods (Mantri, 2020).
Food insecurity
Largely most transgender individuals are forced to be dependent on undignified work such as dahnada (sex work), badhai (ceremonial collections by dancing and singing on auspicious occasions like marriages or childbirth) or begging (in the train or on the highway Toll Booth) due to lack of education. This has left many trans community members unable to earn any money. One respondent said,
“We used to earn about 300-400 every day by begging and during auspicious functions. But all these have stopped now. We are worried about meeting our ends” Hijra person
With little savings and social security benefits, many have a massive challenge to deal with — depleting food supplies. The Indian State Government has started providing food support (wheat, rice, pulses and sugar) through the public distribution system (Economic Times, 2020). Surprisingly, none of the interviewees received the benefit. One respondent said, “none of us have received food from the Government.” Many of them were not aware of such food provision, which is reflected in the respondent’s words, “we are not aware of such a scheme.”
Psychological reactions
Most respondents (9) expressed psychological symptoms such as fear of COVID-19 infection, anxiety, hopelessness, suicide ideation. Three respondents had fear of death due to not accessing ART. Many of them live in the COVID-19 hotspots, which have fuelled excessive fear of COVID-19 infection.
[1] Hijra individuals in India would be considered trasngender women in the United States. Many countries use equivalent terminology.
2 Hijra community has strict hierarchical structure which is different from general society. Hijra individuals live together in a household, usually called “gharana” (tradition), headed by “Nayak” (topmost leader and mentor) and few “Gurus” (next level leaders and mentors). Several Chela (disciples) live under one “Guru”.
Transgender friendly healthcare services in India is largely remains distant dream. Health workers in India continue to treat gender incongruence with sex assigned at birth as a psychological deviation or consider it a mental illness (Chakrapani, 2016). Therefore, the intersection of body politics, transphobia, normative social standards, and bio-medical focus essentially distorts the psycho-social realities of the transgender communities in India.
Vulnerability of transgender to COVID-19 infection
According to the National Centre for Transgender Equality (NCTE), a US-based non-profit,
Transgender individuals have compromised immune system and thus many from the community are at a greater risk of infection (NCTE, 2020). Many of transgender adults in India suffer from chronic conditions like diabetes, asthma, TB or HIV. Some studies have highlighted high substance use among the transgender community (Chakrapani et al, 2017; Goyal et al, 2014; Humsafar Trust, 2012; Muraleedharan et al, 2018). More than half the community consumed tobacco, which only made them more vulnerable to the disease since COVID-19 affects the respiratory system (CDC, 2020). Adding to the problem, many of them live in the congested areas, and which are COVID-19 hotspots. Considering the majority in the community do not have government identity cards, a bank account and health insurance, they are unlikely to receive state support as of now.
Strategies most recommended to control the spread of COVID-19 such as social distancing, cough hygiene, frequent handwashing and wearing masks (WHO, 2020; Ministry of Health & Family Welfare, 2020) are not easy for transgender individuals who live in highly dense communities with insecure housing and poor sanitation. Often many transgender members have chronic illnesses diabetes, asthma, HIV and tuberculosis (NACO, 2017; Ortiz, 2016; Stop TB Partnership, 2018). As a result, they are now at increased risk of contracting COVID-19 because they are spending time in public places, cannot practice physical distancing and isolation, or recommended handwashing practices. The need for refining vulnerability is highlighted in the Lancet Global Health editorial (Lancet Global Health, 2020)
Owing to the discrimination, violence and lack of availability in services and support from the government and society at large, mental well-being of transwomen is also at stake. For all the reasons mentioned above, transwomen are likely to be significantly impacted by the COVID-19 pandemic more than their cisgender peers. They should be considered a vulnerable population and interventions deemed urgent.
Good practices amidst crisis
Despite vulnerabilities and challenges faced by many transwomen, community-based organizations across various parts of the country are coming together to prepare dry food kits, and distribution to the needy (Hindustan Times, 2020). Some community-based organizations have started crowdfunding for the support of fellow-transgender community members (Caritas, 2020; Sebastian, 2020). Such initiatives have offered some respite to the trans-community, however, not enough to provide support to the community-at-large.
Issues related to access to healthcare, food security and mental health support
The study has highlighted barriers to access healthcare facilities, food insecurity and mental health problems. A transgender community advocate from West Bengal has urged for separate LGBT COVID-19 isolation wards (Praveen 2020). Deb (2020) argues, “this would resolve the long-standing problem of discrimination from healthcare professionals…and subordination within hospitals.” These factors, if unaddressed, will likely result in a high COVID-19 fatality rate in the transgender community. Responses to COVID-19, thus, should consider this vulnerability and make provisions to ensure the mental health and well-being of transwomen. COVID-19 pandemic response without human rights framework will have a major impact on the 2030 Sustainable Development Goals (Avafia, Konstantinov, Esom, Sanjuan, & Schleifer, 2020). The actions by the governments, the international community, the private sector, civil service organizations, and individuals will certainly shape the trajectory of the epidemic and its impact on vulnerable people especially transgender persons worldwide.
Lessons to learn
The government must make gender (including transgender/Hijra) disaggregated COVID-19 data available in the public domain. At the same time, policymakers must ensure that there is equitable and meaningful representation of transgender individuals in designing interventions and policymaking. It is important to keep in mind that grievance redressal mechanisms should be in place to address rights violations. Human and financial resources must not be diverted from essential healthcare services and ongoing health programmes. Knowledge and healthcare-related services can be promoted through mobilising additional resources to existing HIV prevention programmes. Community-based organizations working with Transgender Individuals can play a crucial role in educating the community, ensuring adherence to preventive measures and facilitating access to healthcare and other essential care services. Therefore, capacity building of key leaders from the transgender community must take precedence. Further, existing healthcare services should be sensitive to transgender issues. Provisioning gender-affirmative psychological services and encouraging them to avail the same is vital. The State Government can capitalize on this opportunity to address this population’s basic needs, mental and physical health issues during public health emergencies such as COVID 19.
Authors did not come across any primary studies on the impact of COVID-19 on the transgender community during study period. As Dr. Aditi Hegde rightly proposes, research on the impact of COVID-19 on transgender individuals must be addressed by academic and government institutions by investing in gender-conscious, gender-responsive research (Hegde 2020). More studies are needed to illuminate unique considerations for provisioning, encouraging access and delivering healthcare services thereby protecting health rights of transgender population.
Limitations of the study
The urgency of the situation incurs some limitations to the study. Using telephonic mental health support limits the participation of those transgender individuals who have better health-seeking behaviour. Since the number of study participants are limited, findings cannot be generalized. Thus, the findings of this study need to be interpreted in the study context only specifically within the Transgender women and Hijra community in Gujarat. Future supplementary research should be more tailored and targeted survey using a phone interview and online survey to reach out a maximum number of transgender individuals to mitigate this.
Despite the attempts made by the state, community-based organizations, and trans activists, the transgender community continues to experience discrimination in health care services, and which are more amplified during public health emergencies like COVID-19. Eventually their right to healthcare is neither respected, protected nor fulfilled. Access to adequate health care is a fundamental human right that is critically important. In times of public health crisis such as this, the consequences of the denial of health rights are extensive.
Incidentally definitions of vulnerable groups are changing amid the COVID-19 pandemic. Besides elderly people, those with ill health and comorbidities, or homeless or under-housed people, transgender population, who struggle to cope financially, mentally, or physically with the crisis, are also vulnerable group require attention. Essentially we are arguing that access to basic healthcare services, food security, mental health and psychosocial support to the transgender community is crucial in the fight against COVID19. More researches should be encouraged in this area.
Ethics approval:All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by research ethics committee of community based organization (Date 25/03/2020; No. REC/AMD/2020/3).
Consent to participate: Informed consent was obtained from all individual participants included in the study.
Consent to publish: The participants have consented to the publish results that does not identify any participants to the journal for wider dissemination of the study findings.
Funding: None
Conflicts of interest: The authors declare that they have no conflict of interest.
Availability of data and material: Data and material is available; however, due to confidentiality data will not be shared.
Code availability: Not applicable
Authors' contributions: AP has conceptualized and coordinated the study. AR aided in the manuscript writing. Both authors have reviewed the manuscript, and approved the final version.
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