SHAKTHI :

SHAKTHI, Studying Healthcare Accessibility among Kothi, Transgender, and Hijra Individuals, is a multi-year collaborative project between University of Connecticut and NGOs in an urban setting in India.Social movements and legal reforms have started to address health and human rights of transgender and gender diverse (TGD) people; yet the struggles for substantively accessing quality healthcare, social and economic rights still exist globally. In India, the lack of access to rights and healthcare among TGD people is compounded by intersectional impacts of patriarchy, stigma, discrimination, and violence. In addition, healthcare institutions in India have been historically built along rigid heteronormative and homophobic behaviors and attitudes. India recently introduced ‘The Transgender Persons (Protection of Rights) Act,’ (also called trans bill) in 2019 for improving the lives of the TGD people. Existing health research for TGD people in India has focused on their sexual health with emphasis on HIV using psychological and clinical methods and tools; while issues of substantive and rights-based access to healthcare, mental health, and well-being post trans bill have been neglected.

My dissertation, SHAKTHI: Studying Healthcare Accessibility among Kothi, Transgender and Hijra Individuals bridges this gap by drawing from theories of geographies of health and well-being, queer and trans geographies, and human rights to understand issues of substantive access to healthcare and human rights among TGD people after the passing of the trans bill in India. TGD people have become rights-bearing citizens in India, my dissertation explores are they rights-accessing citizens too? It addresses this broad question by answering the following questions: 

• What is the mental and overall health status of the gender-diverse community?
• How do existing disparities impact mental and overall health?
• What are the effects of everyday lived experiences (fear, stigma, struggles) and substantive human rights access (the actual ability of groups to exercise rights) on their healthcare access?
• How has COVID-19 (statewide lockdown and social distancing) impacted the community's alcohol and substance use behavior?

Is accessing healthcare still an ordeal for transgenders? We map the stories of their health and well-being and whether recent laws towards reforming transgender rights improved their healthcare.

Our stories resonate with the United Nation's  Sustainable Development Goals  (SDGs), which are a blueprint to achieve a better and more sustainable future for all, “leaving no one behind”, by 2030. Evidenced-based findings from our studies can provide insights and recommendations for reducing inequality ( Goal-10 ) among individuals with diverse gender identities ( Goal-5)  and improving their health and well-being ( Goal-3 )

British colonization had significant impact on making both post-colonial and modern-day India an unique region for non-binary gender communities in that they were historically recognized as distinct identities but were also facing severe discrimination and abuse.

Due to cultural-linguistic differences, a variety of names are used to describe people on a continuum of gender identities such as Aravani, Janana, Kinnar, Hijra, Kothi, or Dhurani; leading to a regional pattern as well. Recently, influenced by Western LGTBQ movement, 'transgender' or even 'third' gender are used as umbrella terms, causing more identity crisis.

Hijra is an Urdu word for both gender and cultural identities who are biologically male but express their gender identity through living as women (sometimes by sex-reassignment surgeries) and performing rituals such as dancing at weddings and blessings during child birth. A hijra is transgender but all transgenders are not hijras. Kothi, on the other hand, is a category for socioeconomically marginalized gender variant or ‘feminine’ same sex desiring males that gained visibility within the emerging institutional movement for LGBTQ rights in the late 1990s. Gender identities also vary by geographic regions in India (and in South Asia, see the map on the left); Janana is commonly used in Hyderabad and other cities of South India, whereas Dhurani is a generic term used in Kolkata and cities of Eastern India for any LGTBQ individuals soliciting sex work. Influenced by Western LGBTQ movements and the growing role of NGOs in shaping naming conventions and the funding that is available through them, many gender-diverse individuals began to use transgender in addition to local-cultural identity terms to attract NGO funding, particularly during the HIV/AIDS pandemic. Although project SHAKTHI focuses on hijras, kothis, and transgenders; the findings also align with other gender-diverse communities.

Recently India witnessed two major legal reforms to improve access to rights and overall quality of life of transgender communities.

On 6th September 2018, the Supreme Court of India ruled unanimously that Section 377 was unconstitutional "in so far as it criminalizes consensual sexual conduct between adults of the same sex", ending a century long fight by researchers of gender equality, activists, and transgender community member.  Read more on Section 377 .

The trans-bill expanded the legal meaning of ‘sex’ to include non-binary gender identities or the ‘third gender’ within statutory nondiscrimination protections. The inclusion of the third gender institutionalized a series of political, civil, social, cultural, and economic rights for transgenders. The bill was initially introduced in Indian parliament in 2014 and was not passed until 2019.  Read more on Trans Bill .

SHAKTHI's evidenced-based studies rely on primary data. I planned to collect data for over seven months of fieldwork . After obtaining ethical approvals from University of Connecticut's Institutional Review Board and local NGOs in Kolkata, field surveys were conducted in two phases: Phase-1 (May-August in 2019) and Phase-2 (December – February 2020) .

We started our surveys by distributing recruitment flyers (See below), targeted advertising on various social media platforms, and by word of mouth via the community leaders. We recruited 98 individuals who identified themselves as Hijras, Kothis, Transgenders (HKT) or with more than one identities.

Left photo: In a home of a transgender sex-worker in North Kolkata, showing less amenities, in a low-income setting. Right Photo: In a home of an economically well-off Kothi in South Kolkata. This further shows the justification of choosing FGD locations from different neighborhoods of the city.

HKT individuals are deprived of their self-dignity, bodily autonomy, and basic institutional rights including education, employment, and healthcare leading to an enormous proportion of unmet healthcare needs and low quality of life. The disparity in access to healthcare, both perceived and actual incidents of discrimination by healthcare providers in hospitals, lack of trained physicians for treating HKT patients and limited data for understanding their unique health issues, are among the many reasons contributing to negative health outcomes among non-binary gendered communities in India.

• Measure the physical and the mental health status of HKT individuals using a validated health measure (SF-12)
• Understand the influence of social determinants of health on their physical and mental health
• Identify spatial patterns of their physical, mental and overall health

A participant said “In this 40 years of my life I have given several interviews being a transgender, all health interviews only asked me about my sexual health. I am glad you asked about my physical and mental health as well.” 

• Gender-diverse communities in Kolkata have poor health-related quality of life.
• Hijra, kothi and transgender individuals have low physical and mental health status; mental health is at a crisis level and needs targeted interventions.
• Crisis of mental health does not vary by nuanced gender identities, it is widespread.
• Low income, young and old hijra, kothi and transgender individuals are most vulnerable.
• Findings resonated with the concern and appeal of the trans communities of Kolkata to provide immediate support for their growing unmet healthcare needs.
• Findings also contribute to the visions of the  Sustainable Development Goal 3  and  Goal 5  whereby a society would be inclusive of all people, irrespective of their gender identity, and that everyone should have equal opportunities for improving their health and wellbeing. 

“Mainstreaming of the trans-community is problematic. We have our own culture, our own language—we are a kind of indigenous community, which makes us distinct from other citizens of Indian. We cannot sell our distinctness…. my point here is—why should we change our culture? Clapping, for example, is our medium and language of expression—of ourselves, our joy, our sorrow—and for protesting the norms of colonized and so-called civilized society.”

A transgender activist illustrates above the continued struggle to substantively claim and access human rights and references the use of culturally grounded tools such as ‘talis’ (or clapping) in human rights activism in India. Here we narrate the struggles of the HKT individuals in legally establishing and substantively claiming their human rights. (See section Legal Reforms and Rights for recent changes in India). Rights are important for reducing inequality in workspace, education and healthcare, which are in line with the objectives of  Sustainable Development Goal 5  of gender equality and  Goal 10  of reducing inequality.

Stories of lived experiences from the voices of Hijra, Kothi, and Transgender individuals pre and post legal changes at educational, work, and healthcare spaces.

The passage of the transgender rights bill in India (See Section on Legal Reforms and Rights), consistent with the substantive human rights framework shows that activist struggles can lead to institutionalization of human rights. However, the voices of transgender participants show the extent to which the journey remains unfinished well after the creation of legal rights.

Non-discrimination based on gender is a political right, yet that right is not substantively guaranteed for people with non-binary gender identities; they continue to encounter barriers to their economic, social, cultural, and health rights. We need to pay attention to all facets and challenges they encounter to gain substantive access to rights and reduce inequality and claim equal treatment across institutions and spaces.