COVID-19: Who cares about trans bodies?

Life for the transgender community has never been easy and they always live on the margins of social existence. The COVID-19 related lockdowns in India have further distressed the social, health and economic outcomes of trans bodies. The transgender community has been uniquely and grimly impacted by the pandemic, and in the absence of gender affirming healthcare, welfare or social support measures, the community is pushed to the brink. 

Dr. Rima Ghosh, a researcher, activist and ally of the community, speaks with Shalini Yog Shah about the pandemic and the repercussions for transgender persons. She lays bare the hardships and crises the transgender people are facing in the pandemic. She has been researching and reporting on transgender rights and entitlements. Her decade long scholarly work on gender, sexuality and LGBTQI (lesbian, gay, bisexual, transgender, queer, intersex) issues has focused on discrimination faced by transgender and other gender and sexuality minorities in workplace, in the policy space, and loopholes and gaps in the system, which continue to overlook the needs of these communities.

Shalini Yog Shah: Why has the ongoing pandemic exacerbated the challenges and stigma faced by the marginalised transgender communities? Which facets of their life have borne the most brunt?

Dr. Rima Ghosh: The last census of India, in 2011, estimated the transgender population to be about 4.9 lakhs in the country. For the first time, the census had collected data on a category ‘Others’, apart from male and female gender categories. This figure, though, is an underestimate at best, as many are not ‘out’ to the world about their gender and many may not have revealed their self-perceived gender.

Historically, trans people have been visible in Indian literature and art. Despite their presence in the country’s cultural space traditionally, transgender people have been marginalised and discriminated against over the years and certain colonial laws criminalising them have further sidelined them and denied them their basic rights. Until recently they were invisible in discussions and movements for civil rights and human rights. They are the most marginalised among the queer/ LGBTQI identities. Shunned and abused by their families, they are forced to leave their homes, discontinue education due to harassment and bullying, which adversely impact their employability skills. They are also forced to migrate to new locations and big cities in the hope of living discreetly and without interference and, therefore, of escaping from abuse and violence of their birth families. Due to lack of education and low level of skills obtained, livelihood and employment opportunities are minimal and most trans women eke out a living through begging in traffic signals, dancing in wedding ceremonies and social functions or selling sex. Trans masculine people are mostly engaged in informal and contractual jobs. In bigger cities transgender people live in poor socio-economic neighbourhoods, often sharing rooms with others like them on rent.

A study, conducted by the Kerala Development Society on behalf of the National Human Rights Commission found that 99 per cent of transgender people experienced social rejection on multiple occasions, 52 per cent experienced harassment by school classmates and 15 per cent experienced it from their teachers, leading them to drop out of their studies. As many as 96 per cent of transgender people were forced to take low-paying or undignified work. The study further found that transgender people face an identity crisis in “gender-specific India”, where everything – from public utilities such as toilets, security checks at airports, ration cards, PAN cards and driving licenses – has gender identification. Though there has been recognition of their identity as citizens recently through the Supreme Court’s ruling of 2014 recognising them as ‘third gender’, they continue to face abuse and discrimination, and live precariously on the edge of the mainstream society. In the current times, when they were becoming a visible force in their movement to get their constitutional rights and gain recognition in the society, the pandemic has hit, slowing their cause and pushing them to further despair.

Perhaps, you have come across the news that posters had been stuck in a Hyderabad Metro Rail station in March 2020 warning people to stay away from transgender persons to avoid getting infected with COVID-19!

Early on, last year it was said that “the virus is a great equaliser”. The reality could not have been more on the contrary. It quickly became evident the deep inequities in living conditions, livelihoods and access to health has affected the marginalised and the poor overwhelmingly in this pandemic. The transgender and non-binary people have been one of the most adversely affected people in this pandemic. The challenges and stigma that they faced have increased manifold.

Firstly, they are more vulnerable to the infection. The immuno-compromised state of human immunodeficiency virus (HIV) positive transgender persons can be even more vulnerable to COVID-19. Added to this, the living conditions of trans people, in poor rented lodgings mostly, have a higher risk of exposure to the virus and its adverse outcomes; delays in getting healthcare and low access to support have made them vulnerable to stigma and discrimination. Perhaps, you have come across the news that posters had been stuck in a Hyderabad Metro Rail station in March 2020 warning people to stay away from transgender persons to avoid getting infected with COVID-19![i]

India had one of the world’s strictest lockdowns in 2020. Post the first wave and long lockdown in the country, when life was stumbling back to some normalcy from December, the more severe second wave began from end of February in 2021. Cases saw an upsurge from 8,365 cases per day to 1,03,558 cases per day in just 62 days, compared to similar spike of numbers in 110 days in the first wave, according the Union health ministry’s data.[ii] India reported more than 3 lakh cases in the peak of second wave, whereas in the first wave, the highest daily count of infections was less than 1 lakh in peak stage. The central and the state governments initially hoped that the second wave would not require lockdowns. However, though there were no lockdowns at the national level, authorities were forced to clamp lockdowns and impose strict restrictions at local and regional levels, when the surge in COVID-19 infections and deaths became too high from April 2021. Relaxations in phases began only in stages since the third week of June.

The rate of increase of cases and high positivity rate overwhelmed the health infrastructure, leading to acute shortage of availability of hospital beds and beds in COVID-19 care safe homes, desperate shortfall in supply of medical oxygen and curative drugs. In 2020, if cases were confined to big urban centres and district capitals of the states, the rural areas, small towns and other districts remote to the capital centres could not escape the virus in 2021. As the horror of the surge unfolded, localised strict lockdowns were imposed in most districts, small towns and rural areas in severely affected states like Haryana, Uttar Pradesh, Punjab in the north, Maharashtra, Kerala and Karnataka in the west and south of the country. This has meant loss of income for contractual workers and the marginalised, including transgender people, even in many smaller towns and villages in this lockdown. Almost all commercial and industrial units, private and government offices, except a few essential services and transport services, have come under restrictions and lockdowns. The extended lockdowns in this wave has hit the marginalised more severely.

Decisions to impose unplanned lockdowns and curfews on the streets had no understanding of ground realities. Those who live in unfriendly and unsafe environments and with families who don’t support them are prone to exacerbated emotional and physical violence and stigma, and mental trauma. Lockdowns have meant many queer people have been confined to ‘homes’, which are sites of violence. Trans people, many of them, are also facing issues around hormone therapies and sex-reassignment surgeries too, as these are not enlisted as emergency medical services under the COVID-19 norms. The transgender people have also not been able to take benefits from COVID-19 relief schemes, as majority of them do not have the required official documents and bank accounts.

They are facing subsistence issues, have bare minimum resources to sustain basic needs like rations, medicines or paying rents and other bills.

Shalini Yog Shah: What are the livelihood challenges the transgender people are facing?

Dr. Rima Ghosh: In India, unemployment rates shot up during the lockdown periods. According to the Centre for Monitoring Indian Economy (CMIE), the unemployment rate stumbled into double-digits between March and May 2020 when the complete nationwide lockdown was imposed due to the pandemic last year and it reached an all-time high of 27.11 per cent. The unemployment rate in India touched double-digit once again in May 2021 and was 14.7 per cent in the last week ended May 23, after almost a two-month lockdown in many states.[iii] A phone survey by Azim Premji University across 12 states in collaboration with civil society organisations shows the impact of the lockdown on employment and earnings of self-employed, casual, and regular wage/ salaried workers during the first lockdown in 2020. The survey results showed that 80 per cent of workers in urban areas and 57 per cent workers in rural areas reported employment loss among the said group, which roughly forms the informal sector employment in India.[iv]

Transgender people are employed primarily in the informal sector, mostly in occupations/ jobs with no regular income. Even in the formal sectors, most have contractual nature of work. Therefore, many have lost their livelihoods.[v] They are facing subsistence issues, have bare minimum resources to sustain basic needs like rations, medicines or paying rents and other bills. Many have been rendered homeless in this pandemic. Having low levels of education and skills due to discontinuation, and being dropouts from educational institutes as a result of bullying and abuse means transgender people do not gain employable skills for decent jobs and livelihood opportunities.

Trans women in India, as I said earlier, mainly earned their living through begging, singing and seeking alms in marriage and naming ceremonies, and also through paid sex. But extended lockdowns have meant they have no source of living. The lockdown periods have been most severe as those engaged in begging, dancing in weddings and naming ceremonies or sex work or have small road side business have no earnings.

Even when they waited eagerly, to get back to the streets post lockdowns, they were greeted with rude shock. Vehicular traffic and people are sparse on the streets. Social distancing and fear have also meant that people are apprehensive to roll down their windows or to come close and hand out cash to those begging. Long distance trains, local trains and railways stations are the places where trans women seek alms, but these services have been closed in lockdown periods and number of trains have been reduced due to the pandemic. Moreover, false beliefs and misconceptions that poor people live in unhygienic conditions and therefore are more likely to spread infectious fuel ignorant behaviours among people who avoid giving alms to transgender people. Sex workers are not getting customers and have been surviving through aids from organisations and charities.

Shalini Yog Shah: The pandemic has affected many in the community. How have they coped? What are the challenges they have faced in terms of isolation, home treatment and seeking medical and hospital treatment?

Dr. Rima Ghosh: Majority of transgender people live on rent, in inadequate accommodations, mostly shared with others, and depend on daily wages. The ‘stay at home’ orders during the pandemic and especially during lockdowns, therefore, have proved to be grandiloquence, impossible and a mockery of the marginalised. In shared accommodation, in one room, there is no space for isolation, if infected. Therefore, the transgender people had to look for safe homes and hospital wards. This has come with its own stress of staying in general wards of hospitals, with no dedicated separate wards. Even upon release from hospital, the recovering patient has to find a place for isolation. The community networks have helped in such situations with friends or acquaintances shifting out of spaces, by letting recuperating individuals stay for the said period. During the affected periods, the community people have been supporting the persons. Activists have raised money through crowd funding platforms like ‘Milap’ and sought personal contributions through network of allies and friends to be able to support their own community as well as other marginalised and homeless people in different states. In the second wave, with spiralling cases due to an infectious variant of the virus, many volunteers, allies and activists who have been actively working on the ground, were infected. Therefore, assistance and support have been challenging for all marginalised including the transgender people.

Transgender communities in most states have been demanding free treatment for COVID-19 infected transgender persons. Maharashtra, which was the worst affected during the first and second wave, had made the treatment free for all, including at government facilities, and brought all citizens in the state under the Mahatma Jyotibha Phule Health Insurance Scheme in May 2020. Similar steps to make treatment free were made by states like West Bengal in the first wave. Telengana and Uttar Pradesh too started giving free treatment for all affected by COVID-19 in government and a few private hospitals in the second wave. West Bengal and Telengana reserved beds for the transgender people in few government hospitals. Most states have also attempted capping treatment costs in private facilities. However, in spite of these measures due to severity of the second wave in 2021, just like the general people, transgender people affected by COVID-19 have found it difficult to get beds and timely treatment and medicines. The COVID-19 war room in Karnataka has estimated that 3,134 transgender persons have tested positive since the pandemic began, though activists feel it is an underestimate and many have succumbed to the virus.[vi]

Shalini Yog Shah: When you say that their hormone treatment and sex reassignment surgeries treatment schedules have got disrupted, how has this affected them and what are other ramifications?

Dr. Rima Ghosh: Trans men and trans women who are on hormone therapies and hormone blockers, to alter their appearance to their preference, are missing their scheduled injections and doses. As part of transition process, many transgender men and women seek and are under regular monitored hormone therapy. Transgender men use testosterone therapy to induce masculisation and suppress feminine characteristics. Trans women use estrogen therapy to help them develop feminine features, and anti-androgens are used to suppress masculinising features. These therapies are given by health providers under strict guidelines and monitoring surveillance.

Not only during the lockdown periods but even otherwise in this pandemic, trans people have complained of not getting appointments in hospitals for this purpose. Before the pandemic, those who do not have other comorbidity issues would buy hormone injections from local pharmacies and ask health attendants there to inject them. However, now no one is available to help them with the injections, as a trans man activist informed.

Vaccination acceptance is low among the transgender community also due to hesitancy as well as lack of proper information from competent authorities.

Missing the regular doses implies that the trans women’s transition to feminine physical characteristic will be halted. For instance, they will start re-growing facial hairs. Trans men take hormone therapy to stop their menstrual cycles and therefore will start menstruating again. Sudden discontinuation is also known to cause menopause-like physiological and emotional symptoms of hot flushes, night sweats, chills, weight issues and associated depression and anxiety. Hormone therapy has been shown to have positive physical and psychological effects on the transitioning individual and is considered a mainstay treatment for many patients. Stopping the therapy shows adverse psychological stress and trauma, which adds to the added suffering due to the pandemic.

Sex reassignment surgeries/ gender confirmation surgeries have come down drastically in numbers after the pandemic started. The Ramaiah Medical College of Bangalore, a preferred and well known centre for female to male sex reassignment surgeries, which usually saw 20 to 25 surgeries in a year, reports that surgeries have come to a standstill in the pandemic.[vii] As these are a costly process, individuals have to save up for a considerable period of time, and now with the pandemic, those who were waiting have faced delays. Hospitals do not see it as priority.

The pandemic and especially the lockdowns have also impacted medicines for antiretroviral treatment (ART) for persons living with HIV/ acquired immuno deficiency syndrome (AIDS). According to the United Nations Programme on HIV and AIDS (UNAIDS), HIV prevalence among transgender people in India is 3.1 per cent, higher than the national HIV prevalence among all adults of just 0.2 per cent. Trans women are more susceptible to HIV. Due to lack of transport facilities, many have disrupted treatment schedule, and even during unlock phase, they are scared to visit treatment centres and hospitals due to fear of contracting the virus.

Shalini Yog Shah: A very crucial prevention of the spread of the virus and epidemic fatalities is vaccination. What is the extent of vaccination among transgender community, in terms of accessibility and acceptance?

Dr. Rima Ghosh: The transgender community makes up only 0.013 per cent of the total vaccinated population of India so far (as of 9 am, 15 May 2020)[viii] ^[ix]. According to recent estimates, only 20,269 people under the ‘other’ category have received the vaccine. The ‘other’ category is the people who have not identified as male or female. Kerala takes the lead with 20.73 percent of its transgender population vaccinated. Assam became the first state to announce separate vaccination centres for trans gender population on 14 May 2021; following this, West Bengal also announced it will vaccinate trans genders on priority. All states need to take this up urgently and do special vaccination drives for trans gender individuals.

Vaccination acceptance is low among the transgender community also due to hesitancy as well as lack of proper information from competent authorities. Even many in the general mainstream population have been reluctant in the country, as you know, to get vaccinated. This is more common among those who are less educated and poor. There was a need for better public messaging about the vaccines, side effects and targeted messaging for this community.

Another significant reason for this low level of vaccination is lack of government identity cards and the challenge of technology. Initially when the drive started, and again now, individuals were/are required to register through smart apps on phone and schedule appointments. Not many among the community have smartphones or know the use of applications and have internet connections. There is also a general mistrust for hospitals and their facilities among this community. Activists also point to the very low representation of trans community in the vaccine trials, which may not be sufficient enough to measure side effects. Standing in queue with the mainstream people is discomforting too. Therefore, separate arrangements would be most welcome for them.

Transgender people have so far been reluctant due to fear of side effects they are hearing from those who have taken the shot. Moreover, many are undergoing hormone therapies with associated underlying medical conditions or suffering from HIV. Therefore, they are on immuno-depressants and their immunity is already compromised, and guided medical advice is required for them.

Shalini Yog Shah: How can the government, at local, regional and national level, ensure that the basic rights and facilities for transgender people are available during the lockdown and the pandemic? How are the civil society, NGOs and peoples’ collectives contributing?

Dr. Rima Ghosh: India’s strategy of COVID-19 pandemic response of strict and abrupt lockdowns has been biased against the poor working class and marginalised people and experts say the stimulus and relief packages offered show urban and technology leanings, making it difficult for target populations to obtain the benefits. Lockdowns were imposed assuming that most citizens had savings to survive for extended periods in the absence of livelihoods and income opportunities. Relief measures and cash transfers have been limited to rule out ‘inclusion errors’ according to experts, and have left out so many from their scope. The main relief of free rations was given through the National Food Security Act (NFSA)[x] ration cards or state rations cards and cash transfers were linked to Aadhar card and bank accounts. Many, especially members of the transgender community, lack those. Only migrant labourers, as a category, were identified to be able receive ration for two months last year through the state governments where they were working. However, the linking of free ration schemes through the ration cards has meant most transgender people who do not have ration cards have been excluded from such benefits. The community has been hit by homelessness, insecurities of food, poverty and trauma caused by the pandemic, which the government has duly failed to comprehend and address. Even during the second lockdown period, free rations have been linked to only those beneficiaries who have ration cards.

Targeted interventions exclusively for transgender people are required to help them with rations and other expenses like rent, electricity, water bills and medicines.

Since many transgender people do not have these government ID cards like Aadhar card[xi] or ration cards, they fall outside the ambit of such schemes. Trans activists wrote to the Union ministry of social justice and welfare asking to come to the aid of transgender people in the pandemic. The ministry, through the Backward Class Finance and Development Corporation, had transferred one-time cash assistance to 6,940 transgender people only, while India has an estimated transgender population of 4.9 lakhs; ration supplies were given to 1,229 trans persons only in Delhi, Uttar Pradesh, Assam, Chhattisgarh and Manipur.[xii] According the advocacy manager of Humsafar Trust, Mumbai, when they asked transgender people to be registered for the scheme, about 80 percent of those contacted informed they did not have bank accounts.[xiii]

Targeted interventions exclusively for transgender people are required to help them with rations and other expenses like rent, electricity, water bills and medicines. The governments at local and regional level should work through identified community-based organisations (CBOs) and NGOs to reach out to transgender beneficiaries. The governments at the centre and most states have failed to proactively take measures for transgender citizens. They only acted after public interest litigations (PILs) were filed in high courts or being urged to act regarding cash relief and vaccination availability on priority. Few states like Kerala, for instance, had provided ration kits in the last lockdown. West Bengal started giving free rations of grains to transgender people through token slips in the absence of ration cards from August 2020. Activists, however, point to the necessity and need of ration kits instead of distribution of free grains only; the kits should include cooking oil, pulses too. Moreover, due to loss of income and livelihoods, cash transfers are important to be able to cover basic expenses of rent and medicines. Tamil Nadu has announced a cash relief of Rs.4,000 for each transgender person without ration cards being a prerequisite. Such moves are the need of the hour but cash aids should be extended for each month to help them tide over adversity in the pandemic. The centre has announced one-time benefit of Rs.1,500 on 23 May 2021 to all transgender people provided they have valid identity cards. The mandatory requirement of official ID documents needs to be circumvented for this community and they can be reached through CBO networks.

For COVID-19 management and treatment, the state governments are opening COVID-19 safe homes, some of which should be opened dedicatedly for transgender people only. In general wards, for COVID-19 treatment, separate segregation within the ward is essential, as they face discomfort and stigma. This is to be done on priority basis, as some health experts predict another wave in few months. Low level of vaccination among the transgender persons needs to be addressed through focussed awareness programmes.

On the regular transgender health front, hormone therapy, sex reassignment surgeries, treatment of HIV infected transgender persons should not be sidelined. Rather, they should be kept as essential medical services as disruptions not only mean physical adversities, but psychological and mental distress for transgender individuals.

Vaccination drives need to be focussed towards transgender people and special camps and clinics should be opened only for them. The hesitancy towards vaccination can be broken through awareness drives to dispel any myth, especially since most are in hormone therapies. All transgender people need to be vaccinated. The community network and activists have started organising awareness sessions themselves. A recent one was by a medical doctor of Hamdard Institute of Medical Science and Research, who is a nodal officer of a COVID-19 vaccinations centre. She has spoken on issues about vaccinating those who are in hormone therapy or antiretroviral therapy for individuals living with HIV. Sustained awareness programmes like these by medical experts are needed to reassure the members of the community and dispel misinformation.

Many CBOs, NGOs and activists in their individual capacity have been giving out money and rations in this pandemic and especially during the lockdown periods. Keshav Suri Foundation (KSF) is reaching out to support the extremely marginalised transgender people through different NGOs in Mumbai, Bangalore and Chandigarh. The KSF has also started ‘Queering Quarantine’– an online series of talks, interactions and workshops – to help people cope with the lockdowns and pandemic. In Mumbai’s Dharavi, the Essar Foundation is providing monthly groceries to families, including transgender persons. ‘The Rainbow Initiative’ is a transgender sensitisation initiative spearheaded by the Essar Foundation. Recently, the Azim Premji Foundation has announced a COVID-19 relief fund for the transgender community in Bangalore urban district to provide dry rations and hygiene kits. Many activists and organisations have been helping by raising funds and distributing basic items of rations and medicines.

The networks of friends and acquaintances have been supporting their friends in need, through rations, monetary helps. Also infected people have been looked after through these networks and friend circles. This has proved to be a strong pillar in these trying times.

The need of the hour is: Funding agencies, CSR initiatives, and government initiatives must partner with local CBOS and NGOs in a more decentralised way, and not only with big organisations, to reach out to more transgender people.

Endnotes