Prior to the Act coming into effect, Tamil Nadu was the first state in India to open a free clinic, named “Gender Guidance Clinic” (earlier called Transgender Clinic), exclusively for transgender individuals to facilitate their access to gender affirmative care. While the official 2011 Census indicates a total number of 22,364 transgender people living in the state; this is likely to be an underestimation and unofficial estimates point to around 44,000. The state is known for its progressive social movements and is also the first to establish a Transgender Welfare Board under the Department of Social Welfare and Women Empowerment.
I carried out this research initially at the Ramalingaswami Centre on Equity and Social Determinants of Health supported by UNU-IIGH for a project on promising practices of gender integration in government health programs. Along with a non-binary researcher, I interviewed trans women and trans men who volunteered to share their experiences of visiting these clinics. We also interviewed healthcare providers and members of Non-Governmental and community-based organisations working with LGBTQIA+ on their health and welfare.
What emerged from this research was the fact that despite the existence and good intentions of these clinics, major access barriers remain. Some of these barriers emanate from patriarchal notions of masculinity and femininity being closely tied to ‘male’ and ‘female’ bodies deeply ingrained within medical institutions. In the Indian context, patriarchy in the medical profession has resulted in the reduction of female bodies into sites for reproduction as demonstrated by a long history of coercive female sterilisations, irrational hysterectomies, and restrictive abortion services. The lack of training on gender, sexuality, issues of consent, autonomy, and human rights in the medical curriculum is creating unique challenges for transgender individuals negotiating their healthcare access.
Despite the removal of ‘transsexualism’ as a disorder and the acknowledgement that people with trans and gender-non-conforming identities are not mentally ill within the International Classification of Diseases 11, the narratives strongly suggest the lack of shift in healthcare professionals’ attitudes and protocols. A young doctor in the study said, “This is a kind of rare disease, that needs counselling”. Some providers also conflated sexual orientation and gender identity, wrongly attributing the client’s motivation for gender transition arising from same-sex attraction.
While negotiating the convoluted pathways to access services, firstly, all clients coming to the clinic must obtain a Transgender Card by approaching the District Magistrate. Despite acknowledging the self-perceived nature of gender identity, the Transgender Act contradicts itself in specific sections by conferring excessive powers to the Magistrate and Medical Officers. For instance, a change of gender identity from male to female or vice versa is contingent upon a ‘surgery’ certified by the Chief Medical Officer of the medical institution. Furthermore, despite evidence of violence within the family against people of minority genders, the Act states that applications for a Transgender identity card can be made only by parents/guardians for those below 18 years of age (Sec 5). The legal institutions in India have also long perpetuated gender stereotypes undermining the right to bodily autonomy and agency of persons marginalised due to their sex, religion, caste/race, age, disability, sexual orientation, gender identity and expression and sex characteristics.
Secondly, in the process of accessing affirmative treatments, transgender clients interviewed, who mostly hail from low-income backgrounds and lack negotiating power, reported excessive gate-keeping by healthcare professionals resulting in delays, frustrations, and dropouts. Clients are forced to undergo physical and repetitive psychiatric evaluations. This reveals the medical professionals’ reluctance to acknowledge that diagnosis of gender dysphoria is intended to facilitate access to gender-affirmative treatments. For instance, a condition of having to prove lived experiences with the identified gender is freshly imposed on clients even though many trans people have already lived in secrecy in their self-identified gender for many years.
Respondents reported being frustrated and traumatised by the repeated questions about their past. The attitudes towards trans men and transmasculine individuals were found to be much harsher than towards trans women. While one clinic required a single psychiatrist’s opinion of gender dysphoria, another insisted on two opinions. There were many unwritten rules to abide by, such as having to appear in the clinic dressed only in the gender one wants to transition. Doctors also decided the sequence and duration of hormonal and surgical treatments. For example, breast implantation was offered only after penectomy (the removal of the penis). We also found posts of counsellors and social workers, who could play a crucial role in accompanying and emotionally supporting the transgender clients, remaining vacant for a long time.
Our research reveals that the clinics do not follow the World Professional Association of Transgender Health (WPATH) guidelines for standards of care even though the Act specifically mentions the need to adopt them. A representative of, the Association for Transgender Health in India, the Indian chapter of WPATH, told us that there has been no formal sensitisation or training for the healthcare professionals posted at these Gender Guidance Clinics. A large poster on the walls of the clinic titled “Gender Inclusive Policy” lists out the “dos and don’ts” for the provider, such as using appropriate pronouns, updating themselves with the latest guidelines, and demonstrating respect towards transgender clients.
However, apart from making the policy clearly visible to all, the authorities had not put in any systematic training requirements for providers or grievance redressal mechanisms for penalising disrespectful behaviours. Disturbingly, some of our interviewees described outright violations of bodily integrity and sexual harassment. A young trans man was subjected to unnecessary vaginal examination by a public health provider under the pretext of ‘protocol’. An NGO member reported that another trans man was asked to expose his genitals without being provided with valid reasons. Another trans woman felt her body was used as an exhibit and for teaching purposes without her consent. The death by suicide of Ananya Alex in the neighbouring state of Kerala in 2021, owing to a botched gender reassignment surgery in a private hospital, has sparked apprehension among transgender clients on the surgical skills of providers. It was thus left to chance if a transgender client who stepped into the Gender Guidance Clinic would be treated with respect and dignity, be involved in shared decision making or provided with established standards of care.
While welcoming the opening of such free clinics for transgender individuals to prevent exploitation by fraudulent private providers, the LGBTQIA+ solidarity networks in Tamil Nadu have also been concerned with such flaws and gaps in services. They have been raising their concerns directly with heads of medical institutions, or the Transgender Welfare board. They have also approached legal recourses and as a result, many progressive judgements have been issued in favour of LGBTQIA+ people.
Even before conversion therapies were banned at the national level, the High Court of Madras put an end to such therapies in a landmark ruling involving a lesbian couple who sought protection against police harassment. Earlier the High Court of Madras had also instructed the government to ban sex reassignment surgeries on intersex infants. A recent Public Interest Litigation filed in the High Court of Madras resulted in the Health Department reopening the Gender Guidance Clinics long after the COVID-19 lockdown was lifted. The petitioner also challenged the practice of healthcare professionals at the clinic insisting that clients bring their parents even when they are adults.
However, LGBTQIA+ networks are apprehensive of always relying on the Court to come to their rescue. Their demand is for the Government and its wings, medical, legal, educational institutions and society at large to start treating them as more than just bodies that need to fit into one of two boxes.