CHALLENGES FACED BY TRANS MEN

COMMUNITY SEEKING GENDER-AFFIRMATIVE

HEALTHCARE

WORK PLAN FOR INLAKS SHIVDASANI FELLOWSHIP FOR

SOCIAL ENGAGEMENT 2023.

SUBMITTED BY
ADAM HARRY
pilotadamharry@gmail.com
 CHALLENGES FACED BY TRANS MEN
TOPIC:
COMMUNITY SEEKING GENDER-AFFIRMATIVE
HEALTHCARE

INTRODUCTION
Transgender, describes an incongruence between an individual’s sex
assigned at birth and their current gender identity, Individuals with an
alignment between their assigned sex and gender identity are
considered cisgender. The transgender population represents a
spectrum of gender identities and expressions. Transgender women,
or male-to-female (MTF) individuals, were assigned male at birth and
currently identify as women or female; transgender men, or female-
to-male (FTM) individuals, were assigned female at birth and now
identify as men or male. Some, but not all, transgender people
undergo gender-affirming medical interventions such as hormone
therapies, gender-affirming surgeries, and other procedures. The
number of adults who identify as transgender in Kerala according to
the survey conducted by the Government of Kerala in 2014 is
approximately 20000 however, the absence of a consistent definition
for the term transgender and the social stigma associated with
transgender identities likely contribute to under-reporting. The term
transgender is part of the (LGBTQIA+) acronym that represents both
sexual orientation and gender identity groups. Lesbian, gay, bisexual,
and sometimes queer are used to express sexual orientation, which
includes sexual and/or romantic attraction to people of a different
gender. Transgender people have a range of sexual orientations,
including but not limited to gay, bisexual, asexual, queer, and
heterosexual and can be attracted to cisgender men/women and/or
other transgender people.
Gender-affirming medical care is the provision of transition-related
medical services that supports a transgender person’s own gender
identity. Some transgender individuals choose to social transition
(e.g., change their name, pronoun, gender expression) and/or
medically transition (e.g., cross-sex hormones, surgery) to align their
gender expression with their gender identity, while others choose to
have a gender expression or identity outside of the traditional gender
binary (e.g. gender non-conforming people). Everyone will not
choose to transition or to follow every possible step. Those who carry
out the transition process according to their own, have a safer self-
image and have lower depression rates and better communication in
their relationships. Gender transitioning is a process that requires not
only social support but also psychological and medical support.

REVIEW OF LITERATURE
Stigma has the ability to affect transgender health at multiple levels.
Using an applied ecological model, a study was undertaken to analyze
stigma at the structural, interpersonal, and individual levels. (1)It is
shown that changing attitudes have allowed transgender people to
become more visible in society. However, the increased visibility of
transgender people also highlights the high prevalence of adverse
health outcomes that exist in some transgender communities – health
inequities linked to the societal stigma attached to gender-
nonconforming identities and expressions.
Health and related issues have been the major focus of many studies.
Health inequities for transgender people are hypothesized to be
multifactorial with risks including systematic, social and economic
marginalization, pathologizing, stigma, discrimination, and violence,
including healthcare systems and settings.(2)
Social and economic exclusion are therefore conceptualized as causal
pathways to adverse health. There is a unique and significant
association between discrimination in healthcare as well as other
settings of public accommodations. It was also found that many
transgender individuals resorted to postponing needed medical care
when sick or injured and they also postponed routine preventive care.
This postponement many times led to medical emergencies that
required special emergency or urgent care. The treatment seeking
behaviour indicated a mistrust in doctors, leading to treatment by
them only in case of aggravated conditions, which inflates the cost of
treatment seeking and increases the burden of disease. (3)
Transgender individuals have a variety of health needs that require
accessible, affordable, and quality healthcare. For those seeking
medical transition, this can include gender-affirming medical care
such as hormone therapy, surgery, and support services like
counselling. Insurance-based denials are common barriers for
transgender and non-binary individuals in accessing medically
necessary gender-affirming care. (4)
The transition process can have a significant impact on young
transgender and non-binary individuals (TNBI), especially regarding
their mental health. Among 225 young adults in Spain, between 14
and 25 years of age, who identify themselves as TNBI, four different
aspects were analyzed: difficulties related to the transition process;
main current difficulties; if the current difficulties are due to the
participants’ sexual orientation or gender identity; and if participants
feel the need of changing something in their lives.(5)

Social Gender Affirmation

Social gender affirmation is a key component in healthcare access,
utilization, and therapeutic relationships with healthcare professionals
and systems, but in its absence, transgender adults experience stigma,
prejudice, and discrimination. Non-affirming public spaces create life-
threatening conditions and barriers to healthcare for visibly gender-
nonconforming transgender women. Three qualitative studies
provided transgender women prioritized safety over risking their lives
travelling to healthcare appointments. The social context within
healthcare settings also influences healthcare utilization. (6)
Check-in and registration in healthcare settings were challenging
processes where transgender adults encountered insensitive staff and
structural obstacles, such as electronic health records and patient
intake forms.(6)
Transgender adults have a variety of reactions when patient intake
forms use the terms sex and gender interchangeably, as well as when
forms feature binary distinctions for sex/gender. Trans participants in
multiple studies reported having to interpret whether the facility
sought information about their gender identity or their sex. In these
studies, trans participants described feeling invisible when forms
contained binary distinctions for sex/gender; however, other
participants noted feeling affirmed by the dichotomous option
because they did not identify as a transgender man/woman, but as a
man/woman.(7) Further complications arise when trans individuals
provide their legal name, current name, and pronouns on intake forms.
Staff and clinical providers may exhibit uncertainty about which name
or pronoun to use, particularly when the physical presentation and
gender identity of the trans patient align with traditional
conceptualizations of gender. Despite the abundance of non-affirming
experiences in healthcare settings, more than half of the sample
interviewed by Hagen, Galupo reported feeling seen and respected as
a complete person by the affirming language and communication
approaches used by Planned Parenthood.(8)
One study-specific limitation is related to social gender affirmation.
Jaffer and colleagues38 sought to improve the quality of healthcare
for incarcerated transgender adults in the New York jail system.
Eligible participants were identified by cross-sex hormone use
documented within pharmacy records. This sampling approach
excluded those who did not want or desire cross-sex hormones, thus
their health needs and healthcare experiences were not evaluated. This
limitation also impacts findings reported in medical
gender affirmation.(9)
THE RATIONALE OF THE STUDY
Transgender people in Kerala experience social disadvantages such as
living below the poverty level, a higher rate of homelessness, sexual
and physical assaults, bullying, and unequal treatment or service in
public accommodations, and they are three times as likely to be
unemployed than the general public. They endure discrimination and
systematic oppression by healthcare professionals and within
healthcare settings. Discriminatory experiences include inappropriate
care, care refusal, and mistreatment by health providers. From the
literature review, it is evident that the studies pertaining to challenges
associated with the transmen community seeking gender-affirmative
health care are nominal. Most studies have transwomen as the focus
whereas the lives of transmen still remain unexplored. There is a need
to understand the challenges associated with the gender-affirmative
health care of the transmen community. The findings from the study
may help in suggesting suitable policy formulations relevant to the
community.
RESEARCH QUESTIONS
1. What are the barriers faced by the Transgender community
during medical intervention while undergoing gender-
affirmative treatment?
2. How do healthcare facilities work focusing on transgender
individuals?
3. How does the support system work among the transgender
community who is undergoing gender-affirmative treatment?

RESEARCH OBJECTIVES
 To study the barriers faced by the Transgender community
during medical intervention while undergoing gender-
affirmative treatments.
 To understand the healthcare facilities and accessibility focusing
on transgender individuals.
 To identify the existing support system.

PROPOSED METHODOLOGY

STUDY POPULATION
The universe of the present study is the transmen population in
Kerala.

STUDY DESIGN
To better understand the health care experience of transmen
community, a qualitative study design will be appropriate for the
study.

SAMPLE SELECTION PROCEDURE

The participants will be assigned through the purposive
sampling method. The participants for the present study include
transmen individuals who had undergone gender-affirmative
treatment (hormone therapy or surgical intervention or both).
The sample size will be finalized on the basis of data saturation
but we expect to cover 25 members of the group.

SELECTION CRITERIA
Inclusion criteria: Transgender men above 18 years of age who
had undergone gender-affirmative treatments (Hormone therapy,
surgical interventions or both) and have transgender ID cards
issued by the Government of Kerala.

DATA COLLECTION
Qualitative methods will be used in collecting data. The format
includes conducting an in-depth interview of the respondents
using an interview guide.
 PROCESS OF DATA COLLECTION
During the first phase, an exploratory study was conducted
among three or four participants (Collected details from
Transmen who faced difficulties while seeking medical help,
especially during their Gender affirmative treatments) and in the
second phase, the final data collection will be completed.

REFERENCE

1. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma

and health: A critical review of stigma determinants, mechanisms,
and interventions. Social science & medicine (1982) 2015; 147:
222–31. - Google Search [Internet]. [cited 2023 Jan 29]. Available
from:
https://www.google.com/search?q=White+Hughto+JM%2C+Reisne
r+SL%2C+Pachankis+JE.+Transgender+stigma+and+health%3A+
A+critical+review+of+stigma+determinants%2C+mechanisms%2C
+and+interventions.+Social+science+%26+medicine+(1982)+2015
%3B+147%3A+222%E2%80%9331.&rlz=1C1UEAD_enIN1002I
N1002&oq=White+Hughto+JM%2C+Reisner+SL%2C+Pachankis
+JE.+Transgender+stigma+and+health%3A+A+critical+review+of
+stigma+determinants%2C+mechanisms%2C+and+interventions.+
Social+science+%26+medicine+(1982)+2015%3B+147%3A+222
%E2%80%9331.&aqs=chrome..69i57.1013j0j7&sourceid=chrome
&ie=UTF-8
2. Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham
E, et al. Global health burden and needs of transgender populations:
a review. Lancet Lond Engl. 2016 Jul 23;388(10042):412–36.
3. Health and Healthcare Seeking Behaviour among Transgender in
Mumbai: Beyond the Paradigm of HIV/AIDS | Gupta | Social
Science Spectrum [Internet]. [cited 2023 Jan 29]. Available from:
http://www.socialspectrum.in/index.php/sp/article/view/54
4. Bakko M, Kattari SK. Transgender-Related Insurance Denials as
Barriers to Transgender Healthcare: Differences in Experience by
Insurance Type. J Gen Intern Med. 2020 Jun;35(6):1693–700.
5. Magalhães M, Aparicio-García ME, García-Nieto I. Transition
Trajectories: Contexts, Difficulties and Consequences Reported by
Young Transgender and Non-Binary Spaniards. Int J Environ Res
Public Health. 2020 Sep;17(18):6859.
6. CICERO EC, REISNER SL, SILVA SG, MERWIN EI,
HUMPHREYS JC. Healthcare Experiences of Transgender Adults:
An Integrated Mixed Research Literature Review. ANS Adv Nurs
Sci. 2019;42(2):123–38.
7. Sandelowski M, Voils CI, Barroso J. Defining and Designing
Mixed Research Synthesis Studies. Res Sch Natl Refereed J Spons -
South Educ Res Assoc Univ Ala. 2006;13(1):29.
8. Garofalo: The health of lesbian, gay, bisexual, and... - Google
Scholar [Internet]. [cited 2023 Jan 29]. Available from:
https://scholar.google.com/scholar_lookup?title=The+health+of+les
bian,+gay,+bisexual,+and+transgender+people:+Building+a+found
ation+for+better+understanding&publication_year=2011&
9. Reisner SL, Radix A, Deutsch MB. Integrated and Gender-
Affirming Transgender Clinical Care and Research. J Acquir
Immune Defic Syndr 1999. 2016 Aug 15;72(Suppl 3):S235–42.