ACCESS TO AND USE OF HEALTH CARE SERVICES FOR ALI/HIJRA/ARAVANI (MALE-TO-FEMALE TRANSGENDER/TRANSSEXUAL) COMMUNITY IN

1. ACCESS TO AND USE OF HEALTH CARE SERVICES FOR ALI/HIJRA/ARAVANI (MALE-TO-FEMALE TRANSGENDER/TRANSSEXUAL) COMMUNITY IN CHENNAI, SOUTH INDIA Venkatesan Chakrapani, Timothy Ebenezer, Anjali Fernandes, M Dhanam Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

2. BACKGROUND & OBJECTIVES • Ali community has been in India for centuries. Still there is lack of understanding about and acceptance of Alis among the public and health care providers. This study’s objective was to identify the health care service needs and access issues of Ali community. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

3. METHODS • In mid-2001, two Focus Group Discussions (FGDs) with 19 Alis & two in-depth interviews were conducted by a trained facilitator in Chennai. Nirvan Kothis (emasculated/"post-operative" Alis) & Aquwa Kothis (non-emasculated Alis in female/male attire) participated in the FGDs. Sessions were audiotaped, transcribed & analyzed qualitatively. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

4. DEMOGRAPHICS Focus Group Discussions Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

5. DEMOGRAPHICS In-Depth Interviews Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

6. RESULTS • Most Alis did not reveal that they were ‘Alis’ unless explicitly asked by the health care providers. This was irrespective of whether they were in male or female attire and whether emasculated or not. Fear of rejection, discrimination, shame and the attitude that it was unrelated to the presenting complaint were the common reasons given for this non-disclosure. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

7. RESULTS (Contd.) • Participants narrated many incidents which showed that in general most health care providers were ignorant of and insensitive to the issue of Alis. Co-patients in the hospital/clinic also discriminated against Alis. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

8. RESULTS (Contd.) • In some government hospitals even emasculated Alis in female attire were enrolled only as males and admitted only in male wards which had led to violence and sexual abuse by male patients. • Many incidents were narrated in which HIV-positive health care providers did not give Alis proper medical care. When some parents found out that their son was a ‘pottai’ or ‘Ombodhu’ (derogatory terms to mean Ali), they have taken their son to psychiatrists who have prescribed medications and given ‘counseling’ to convert in to a “man”. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

9. RESULTS (Contd.) • Sex Reassignment Surgery (SRS) is not done in government hospitals. Private qualified practitioners (general/plastic surgeons) also don’t do SRS. Some do SRS but charge heavily. Consequently, many Alis go to unqualified medical practitioners (‘quacks’) who do emasculation. Ritual emasculation by “Thai Amma” (a senior Ali) is now decreasing because it is done in a crude manner, even without anesthesia. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

10. RESULTS (Contd.) • Many Alis wanted SRS to be done freely in government hospitals. Also, many wanted mammoplasty, vaginoplasty as well as procedures for facial hair removal, scalp hair growth and changing their voice. Many Alis were taking hormonal tablets /injections from the information they get from other Alis since hormonal therapy is not offered by government or private doctors. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

11. RESULTS (Contd.) • Many Alis take up sex work because of lack of other job opportunities as well as to earn money for SRS. They had hard time in convincing their clients that “HIV is not manufactured from us [Alis]” because Alis are automatically associated only with HIV/AIDS. • Many incidents in which HIV-positive Alis were discriminated by the health care providers were narrated. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

12. RESULTS (Contd.) • Many had thought about or attempted suicide and many were consuming alcohol due to non-acceptance by their family/society and lack of self -worthiness and meaning in life. Many Alis mentioned “urine problem following the operation” (urinary stenosis/stricture following emasculation by Thai Amma or quacks) as the main health problem faced by their community. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

13. CONCLUSIONS • Health care providers should be trained in sexuality issues, especially transgender/ transsexual issues, to bring an end to the ignorance and insensitive associated with the issues of Ali community. • Guidelines for quality health care to the sexuality minorities should be developed and implemented. • Legal status of Sex Reassignment Surgery (SRS) needs to be clarified. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

14. CONCLUSIONS (Contd.) • Availability of free service for SRS in government hospitals can lead to decrease in the urinary problems that occur secondary to emasculation by Thai Amma or quacks (unqualified practitioners). • General public should be educated about sexuality issues so that Alis are accepted in the society. Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

15. TERMINOLOGY USED • Alis/Hijras are born as biological/anatomical males who reject their 'masculine' identity in due course of time to identify either as women, or not-men, or in-between man and woman, or neither man nor woman. • The term ‘Hijra’ is used in North India, while the term ‘Ali’ is used in Tamil Nadu. Many NGOs/CBOs as well as health care providers commonly use the term ‘Eunuch’ to denote Hijras/Alis. Almost all Hijras/Alis call themselves only as Kothis (Though feminine homo/bisexual males also call themselves only as Kothis) Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

16. TERMINOLOGY USED (Contd.) • 1. Nirvan Ali (Nirvan Kothi): Those who had undergone "Nirvana" ('Salvation' - as castration is known) i.e., removal of both testes and penis (voluntarily/willingly) and who are in woman’s attire. Traditionally, emasculation is done by a senior Hijra/Ali called ‘Daima’ (Hindi) or ‘Thai Amma’ (Tamil) which literally means ‘mid-wife’. These days, many Hijras/Alis undergo emasculation operation by quack doctors (fake medical personnel). Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

17. TERMINOLOGY USED (Contd.) • 2. Aquwa (Aquwa/Ackwa Kothi): Those who wear women’s or men's attire, but who have not yet undergone castration but may or may not want to undergo castration in the future. Many live as women under a Guru, while training in singing, dancing and other rites of the community, as they wait to attain Nirvana. Some of them are under "Gurus” who teach them about female mannerisms such as how to speak, sit and make gestures like woman. [This is equivalent to the 'real-life' experience/test in the western countries, during which the person who wish to have sex reassignment surgery has to live as a woman for about one or two years] Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002

18. TERMINOLOGY USED (Contd.) • 3. Zenana: Here even though they think of themselves as woman, these persons don't want to undergo 'castration' because they don't want to meddle with nature (i.e., mutilate themselves). These persons may be in men's or women’s attire. (Currently this term is not in common use with in the Hijra/Ali community. These days, these persons also come under Aquwa Kothis) Venkatesan C, et al XIV International AIDS Conference, Barcelona, July 2002