https://doi.org/10.33698/NRF0230-Raju Ram Runwal ,Manjula Thakur, Sushma Kumara Saini, Sandeep Mittal, Sandhya Ghai
Abstract : Introduction : Transgender people live in selected place in Deras and away from their families. They have restricted outside activity and no support by family member and society. It has a strong impact on their health and life style. As this population is hard to approach, there is need to explore their physical health and life style. Objective : To assess the Physical health status, life style and issues of hijra/transgender women in India. Methodology: Sixty participants willing to participant registered with non government organization were enrolled by purposive sampling in Chandigarh. Data was collected by Interview schedule and Bio Physiological assessment. The data was analyzed by using descriptive and inferential statistics like frequency distribution, mean, and Pearson’s correlation coefficient.Results:The mean age was 33±10.6 years. More than one-fourth of participants were illiterate and only 26.75% were educated up to matriculation. Majority (90%) of them were engaged in taking badhai and getting money to manage their finance. Majority (92%) of the participants had central obesity (WHR > 0.85cm) and 36.6% were obese as per BMI. Only few reported diabetes mellitus (6.7%), hypertension (6.7%) and HIV infection (6.7%). Only 15% of the subjects had only one regular partner where as 48.3% of the subjects had multiple partners for sexual relation. Sixty eight percent were having smoking habit, eighty percents of the participants’ preferred personal doctor and the private hospital for the seeking treatment. Conclusion: Poor health, less education, unemployment, multiple sexual partner, obesity and substance abuse are some health issues needed to be stressed to improve the overall life style of transgender women.
Keywords
Transgender, Physical health, life style
Correspondence at
Mrs Manjula Thakur
Tutor
National Institute of Nursing Education (NINE) PGIMER, Chandigarh.
Introduction
For male ‘he’ is used, for female ‘she’ is used, but for hijra neither ‘he’ nor ‘she’ is used Transgender is an umbrella term for persons whose gender identity, gender expression, including male to female and female to male sex reassignment . Gender expression refers to the way a person communicates gender identity to others through behavior, clothing, hairstyles, voice and body characteristics.1
In India Transgenders are called as Kinnar, Hijra & Chakka. But different words are used in different regions. i.e. Aravan, Chakka, Hijra, Jogappa, Khusra, Kinnar, Kojja, Napunsak etc. They are identified as biological male sex but defined as not men/ not woman but as a third gender. These people have their own language in which many words are taken from Farsi. 2 These people were living in Deras. These Deras are called as ‘Gharanas’ in society e.g. Bapu Dham Gharana. These people are known by their Gharanas and each Gharana is lead by Guru. They follow the orders given by Guru.3 These people some studies are conducted on health issues of transgender but still the problems related to their health, life style and other issues are still unexplored. Keeping this in mind the need was felt to conduct a study in this regard.
Present study was conducted to identify the Physical health status, Issue and life style among transgender. Finding of this study will work as evidence so that in future some managerial actions can be planned to combat the identified issues of transgender. Society and health professionals can be sensitized related to the health problems and health issues of transgender and manage them effectively by making efforts to bring them in general pool and not excluded from society were facing several problems such as sexual abuse, violence and deprivation of human rights by Traffic Police and Railway Police and illegal penalty4. Some studies shows an associations between parental rejecting behaviors during transgender adolescence that lead to the use of illegal drugs, depression, attempted to suicide, and sexual health risk by young adults. They live in closed environment in relation with guru and chelas. Their activities are restricted to their living places. The restrictions on their activities may effect their physical health and life style.
Methodology
An exploratory study was conducted on transgender living in different parts of Chandigarh and registered with Non Government Organizations for implementing HIV intervention. Ethical approval was obtained from the Institute’s Ethics Committee, Postgraduate Institute of Medical Education and Research, Chandigarh. Total 100 transgender women were registered with the NGO but only 60 of them were available and willing. Written informed consent was sought before interviewing. Data was collected from the each subject in Dera. They were interviewed using interview schedule to collect information regarding Socio-demographic and life style. Physical assessment was done as per protocols prepared for different procedures such as height, weight, hip circumference and waist circumference, blood pressure, hemoglobin, Random blood glucose. Body mass index (BMI) and waist hip ratio (WHR) were calculated and CVD risk was assessed by WHO/ISH risk prediction chart. It took 30 minutes for each subject for data collection. In the end Participants were informed about their health status. They were given health education related to problems and referred to appropriate centre. The raw data was entered into the coding sheet. The data was analyzed by using both descriptive and inferential statistics like frequency distribution, mean, and Pearson’s correlation coefficient. The finding were interpreted and presented with the help of tables.
Results
The Socio demographic data of participants revealed that nearly half of (48.3%) study participants were in young age of 25- 34 years and only few (1.6%) participants were also above 65 year. Age ranged from 19-65 year with mean age 33.3±10.67 year. One fourth (26.7%) of the participants were illiterate and only a few 5% participants were matriculate. Majority (90%) of them were begging (asking for ‘Badai’) and a few (5.3%) of them were in private jobs. Most (81.7%) of the participants were residing as Guru and chelas.
As per the bio Physiological measurement of the participant 63% of the participants had normal blood pressure, where as one fourth of the participants were found to have Pre hypertension. Majority (78%) of the participants were having normal blood sugar level (70- 110gm/dl), 66.7% of the study participants had normal hemoglobin (12gm/dl) as per WHO Telequist scale method, 36.6% of the study participants were overweight, and majority (91.6%) of them had central obesity (WHR was >0 .85). CVD risk assessment was done for only 16 subjects who were above 40 years of age. Among them 87% of the study subject had <10% risk of cardio vascular disease in next ten years as per WHO/ISH risk prediction chart. As per health history a few (6.7%) of the study, participants were suffering from diabetes mellitus, hypertension and human immune deficiency virus. Only one participant was handicapped suffering from disability of lower limb since birth. Sixteen percent of the subjects’ had family history of diabetes mellitus. (Table: 1)
Table 1: Bio -Physiological measurement of the study participants
N=60
| Participants characteristic | n(%) |
| Blood Pressure (mmHg) | |
| Normal ( 120/80) | 38(63.3) |
| Pre hypertension (121/81-139/89) | 15(25.0) |
| Hypertension (above 139 /89) | 07(11.6) |
| Random Blood sugar (mg/dl) | |
| Normal (70-110) | 49(81.66) |
| Hyperglycemia (> 110) | 11(18.33) |
| Hemoglobin (gm/dl) | |
| 10 (moderate anemia) | 16(26.7) |
| 12 – 14 (normal) | 44(73.4) |
| Cardiac vascular disease risk assessment(> 40 year of year)* N=16 | |
| <10% risk in next 10 year | 14(87.5) |
| 10-20% risk in next 10 year | 02(12.5) |
| Health history | |
| Diabetes mellitus | 04(06.7) |
| Hyper tension | 04(06.7) |
| HIV Positive | 04(06.7) |
| Others ( gastritis, thyroid ) | 01(01.7) |
| Handicapped | 01(01.6) |
| Family history of any disease | |
| Hypertension | 02(03.3) |
| Diabetes mellitus | 10(16.7) |
| Heart disease | 01(01.7) |
| Body Mass Index | |
| Underweight (17-18.5) | 02(03.3) |
| Normal (18.5-25) | 36(60.0) |
| Over weight (25-30) | 22(36.6) |
| Wrist circumference (cm) | |
| Normal ( < 80 ) | 16(26.6) |
| Central obesity | |
| 81-90 cm | 14(23.3) |
| 91-100 cm | 22(36.6) |
| >100 cm | 08(13.3) |
| Waist hip ratio (cm) | |
| < 0.85 normal | 05(08.3) |
| >0.85 (central obesity) | 55(91.6) |
*WHO/ISH risk predication chart
As per life style point of view. Very few participants (6.7%) were performing physical activity like walking, cycling & yoga. 68.3% of the study participants had smoking habits like Biddi, Cigarette and Huka, 40% of the participants were smoking less than 25 cigarettes per weeks and 23.3% of participants were smoking 26 -50 cigarette per week. More than half of the study participants were alcoholics. Alcohol consumption of 23.3% participants was more than 300 ml per weeks and few (5%) of the study participants were taking smack. (Table no 2.)
Table 2: Life style of the study
As per Sexual history thirty seven percent of the participants were not in sexual relationship. Whereas 48.3% of the participants had multiple partners for sexual relation, 36.8% percent of the participants were having 1-2 times Sexual Contact per weeks, and 24% of the participants were having sexual contacts more than two times per week. Only a few (5%) of the study participants were not using condom during sexual relation. Most of (81.7%) of the participants were aware about STD and 95% participants were aware of the HIV also. Most (80%) of the participants were tested for HIV in last six months and 83.3 % of the study participants were tested for STD in last
participants
N=60
3 months. (Table no 3)
|
Table 3: Sexual history and awareness about sexually transmitted disease
N=60
| Variable | n(%) | |
| Sexual history | ||
| No partner | 22(36.7) | |
| One regular partner | 09(15.0) | |
| Multiple partner | 29(48.3) | |
| Sexual contact per week | N- 38 | |
| One time | 15(39.4) | |
| Two times | 14(36.8) | |
| More than two time | 09(23.6) | |
| Use condom | N- 38 | |
| Yes | 35(92.3) | |
| Not using | 03(07.8) | |
| Awareness about STD | 49(81.7) | |
| Awareness about HIV | 57(95.0) | |
| Tested HIV | ||
| < 6 months | 48(80.0) | |
| > 6 months | 12(20.0) | |
| Tested STD | ||
| < 3 months | 50(83.3) | |
| > Month | 10(16.6) | |
As per treatment seeking behavior of the study participants’ eighty percents (80%) of the subjects preferred the private hospital for the seeking medical treatment. Twenty three percents of the study subjects were facing problem during seeking medical treatment from hospital. Nearly half (45%) of the subjects expected govt. to implement Equal Right Commission 2016. Few (10%) of subjects felt that there should be Separate doctor and wash room, ward, Pharmacy.(Table No. 4)
Table 4 : Treatment seeking behavior of the study subjects
N=60
| Variable | N (%) |
| Source of seeking medical treatment | |
| · Government hospital | 12(20.0) |
| · Private hospital | 48(80.0) |
| Facing problem during seeking treatment | |
| · Ignore and Rejection, | 13(21.6) |
| · Comments (Chheka, Hijra,) | 10(16.6) |
| Expect from Govt. health area | |
| · Equal Right Commission implementation 2016 | 27(45.0) |
| · Separate doctor, wash room, ward, and pharmacy. | 06(10.0) |
Significant correlation was found in age and income with Body Mass Index. Significant correlation (p< 0.05) was found in income with BMI. BMI and general well being score. (Table No. 5)
Table 5: Correlation between the variable
N=60
| Age | Income | BMI | Hemoglobin | W.H. Ratio | |
| Age | ——– | r = 0.383
p = 0 .003 |
r = 0 .256
p =0 .049 |
r= -0.241
p = 0.064 |
r =0.127
P = 0.334 |
| Income | ——– | r =0 .419
P =0 .001 |
r =0 .129
P= 0 .327 |
r= 0.090
P = 0 .493 |
|
| BMI | ——– | r = .095
P = .471 |
r = 0 .183
P = 0 .161 |
||
| Hemoglobin | ——– | r=0 .158
P .228 |
|||
| W.H. Ratio | ——– |
Discussion
Transgender are the people who have a gender identify or gender expression different from their assigned sex. Actually hijra means the person with congenital ambiguous genital organ that could not be identified as either male or female. This is a community which is discriminated not only by the society but by the family members too. The health status, life style and are unexplored. Hence the present study was undertaken. Since this population is difficult to access, so to approach them the help of a Non Government Organization (NGO) Chandigarh was sought. NGO has registered all the transgender of Chandigarh to implement HIV prevention intervention.
Health status is an important component to assess the overall health of a person, which includes physical health, life style and related health issues. It was found in the present study that most of transgender were having normal hemoglobin, blood pressure and blood sugar level. This may be because majority of them were in the age group of 19-34 year. Though two third of them had normal Body Mass Index, but majority of them had central obesity because they were living in closed environment and majority were physical inactive.
Healthy life style is a key to good health and poor life style leads to many health problems and non communicable diseases. Finding of the present study revealed that life style of transgender was Unhealthy. Only four subjects were performing physical activity like walking, cycling and yoga. The Low physical activity was indicated as majority of the subjects had central obesity. But the present study also revealed that 68% of the subjects were Smoking cigarette, Beddi or Hukka and alcohol. Behavior is increasing the risk of liver, cardiac and renal problem in future. A study was conducted in 2007 revealed that higher risk for cancer, CVDs, liver disease, mental illnesses are more likely to smoking, alcoholism, use of drugs, and engaging in other high risk behaviors.5 In present study they also had family history of diabetes mellitus and heart disease which is further making them vulnerable to NCDs along with other risk factors.
Sexual desire is the physiological need of human being. Some transgender community cannot have natural sexual relation, so they are engaged in oral sex, anal sex, bisexual relationship that makes them more vulnerable to sexual transmitted diseases / blood borne diseases like STDs, HIV/ AIDS, Hepatitis B & C. The present study revealed that approximately half of the subjects had multiple sexual partners and 6.7% of them were HIV positive, which to much higher than the general population. A study conducted in 2009 in Mumbai STI Clinic. Reported very high HIV prevalence (68%) and syphilis prevalence (57%) among hijra/ transgender.6 Again in 2015, the study conducted in Chennai reported that transgender had higher prevalence of HIV and STD than in general population.7 this may be because they do not observe safe sex practices. But findings of the present study were different than this study as 93% of transgender were using condom during sexual relation. This may be because they were enrolled with NGO for implementation HIV prevention intervention.
Most of Transgender preferred private clinic/ hospital for seeking treatment. It was found in the present study that 23% of the subjects reported that they faced several problems for seeking treatment in hospital i.e. rejection by health persons and even people commented them as Chhaka, Hijra. So they preferred private doctor for minor problems that too near their Deras. In 2005 some state government policies were made for Sex Reassignment Surgery (SRS) in Govt. Hospital in Tamil Nadu. A study was conducted in 2014 revealed that there was absence of gender transition services in Govt. Hospital, so transgender go to private clinic/ hospital for Sex reassignment surgery (SRS).8 Since private hospital charge too much so they also go to unqualified medical practitioners for surgery and some of them also go for hormone therapy. Traditional methods are risky i.e. removing male genitalia is being practiced. So they are approaching unqualified medical practitioners to prescribe hormone therapy, which is very dangerous to use. Some transgender even practice self administration of hormonal injection leading to increased risk for infection and diseases.
In order to improve the quality of life of transgenders and to bring them in general pool in April 2014 the Supreme Court recognized transgender as third gender and given right to have family by marrying each other, adopt children, right to inherit property without obstruction, right to free, compulsory education and medical education, right to claim a formal identity through Passport, Ration card and Driving license, Aadhar Card, Voter ID.9,10 But all the rights are not practically applicable in the system. Implementation needs to be stringent.
Though some efforts have been taken on the part of Government for the welfare of transgender and rules and regulation have been prepared. But for implementation of these regulations, the mindset of general population needs to be changed. This may take longer duration but it is a hope that things will change. Let us consider it, as a good start.
References
- Census of India 2011. [Cited on Feb.9 2016] A v a i l a b l e f o r http://www.census2011.co.in/transgender.php.
- History of transgender (online) [ cited on 2017 Jan 2 3 ] a v a i l a b l e f r o m:https://en.wikipedia.org/wiki/Transgender
- Sexsena life of eunuch. 1st ed. Mumbai: Santa publishing; 2011. P. 22 -60
- Anitha Problems faced by Hijras (male to female transgender) in Mumbai with reference to their health and harassment by the police. International Journal of Social Science and Humanity. 2015; 15:50-65.
- Snyder Trend analysis of medical publications about LGBT persons. Journal of Homosexuality (online) 1950-2007[Cited on 15 feb 2016];58(2):164-188.A vailablefrom: http://www.treadanalysisof medical.org.//pdf.file.
- Shinde S, Setia MS, Row –Kavi Male sex workers are we ignoring a risk group in Mumbai, India. Indian J dermatology venereal .2009; 75(1): 41-6.
- Dasarathan S, Kalaivani S. Study of prevalence of sexually transmitted infections/human immunodeficiency virus and condom use among male-to-female transgender. Indian journal of STD and AIDS2015; 7(15):17-20.
- Singh Y, Aher A, Shaikh S, Mehta S, Robertson J, Chakrapani Gender Transition Services for Hijras and Other Maleto-Female Transgender People in India Availability and Barriers to Access and Use. International Journal of Transgenderism.2014; 15(1): 1-15.
- Anand Supreme Court grants recognition to transgender as third category of sex. The Indian Express 2014 April 15; Sect. A: 4. [Cited on 19 Feb2 0 1 7 ] A v a i l a b l e f r o m : http://indianexpress.com/article/india/india- others/supreme-court-grants-recognition-to- transgenders-as-third-category-of-sex/
- Sharma Transgender comes into their own with Aadhaar. The Indian Express 2013 Sept 7; Sect. A:
- [Cited on 19 Feb. 2017]. Available from: http://indianexpress.com/about/unique- identification-authority-of-india/page/2/