What Does it Mean to be Transgender?

Gender identity can be a complex and nuanced experience. For many people, their internal sense of self (man, woman, or other) aligns with the sex they were assigned at birth. But for transgender people, this isn't always the case. Before we look into the healthcare challenges faced by transgender individuals, it's essential to grasp the essence of what it means to be transgender.

Glamika Patel, a transwoman currently pursuing her MBA, shares her thoughts on gender identity and what it means to be transgender for her, “Self-perception should match your gender, which is a psychological definition. People who are not happy because of their biological sex are transgender. Gender identity should not match biological identity.”

The term "trans" has become increasingly common, but it can encompass a range of experiences. At its core, being trans is about gender identity. This is a person's internal sense of being male, female, or other. It's distinct from the sex assigned at birth, which is typically based on the physical anatomy observed at birth (genitals, hormones). 

For Nikita Bandre, a transwoman pursuing her law degree, the journey of self-identification and realising her gender identity was a process. “Through my childhood (my sex assigned at birth was male), and as I grew up, I became more girlish; when I reached college, I realised I was in the wrong body. I felt more like a girl, not like a boy. It made me realise my choices are different. So slowly, slowly, things were changing,” she says.

On the flip side, Glamika came to the realisation of her gender identity at a much younger age, “When I started going to school, I always wanted to wear girl dresses; however, due to pressure from the teachers, I always wore male dresses. At home, I had full freedom from my parents, and they never used to say anything about my dresses. Then I started getting a feeling of why, in school, they were stopping me from wearing female dresses. That’s when I began thinking, why am I male? I should’ve been a female.”

While the exact cause of transgender identity is still being researched, there's growing evidence suggesting a biological component. Studies using brain imaging have shown structural differences between the brains of transgender people and those who identify with their assigned sex. 

It's crucial to understand that being transgender is not a mental illness. The internal compass of the body might not align with the assigned sex. This mismatch can cause distress, known as gender dysphoria. It can manifest as discomfort with one's body, a desire to live as a different gender or a general feeling of unease.

Major medical associations like the American Psychiatric Association (APA) recognise this. The APA categorises the distress some trans people experience due to gender dysphoria as "gender dysphoria disorder" but emphasises that the identity itself is not a disorder.

Glamika shares some of her mental health struggles and how her spirituality helped her overcome, “Some days, I feel alone. But I feel like God supports me, and I pray to him. God has always sent someone to help me. I went to Vrindavan. I met a trans model, Dipanjali Chhetrii, and spent time with her. I felt happy with her company.”

Nikita also struggled with her mental health while coming to terms with her gender identity and before she underwent gender affirmation procedures, “Before the transformation, I was in a male body. I used to get tense due to society. During college time, I used to go into depression, but I am a fighter, so I have overcome it.”

Similarly, Avantika Gurung, a transwoman, faced her share of mental health struggles. Starting young, Avantika was first taken to a psychiatrist in 2008 or 2009. Her psychiatrist mentioned her feelings and thought processes were unnatural, “They were giving me certain tablets which was like, sleep deprivation tablets or food deprivation tablets. The psychiatrist explained to my parents that I was wrong and tablets would fix me.”

Eventually, at a later stage in life, Avantika went through a nervous breakdown, which helped her and her parents come to terms with her gender identity.

The meaning of transgender is an umbrella that encompasses a diverse range of identities beyond the male-female binary. Here are some key terms:

• Transgender Men: A trans man who was assigned female at birth.
• Transgender Women: A transgender female is someone who identifies as a female but is labelled as male at birth.
• Non-Binary: People who don't identify exclusively as male or female. They may identify with a gender that is male and female (bigender) or fluid between genders (genderfluid).
• Genderqueer: A term some use to describe a non-binary gender identity that challenges traditional gender norms.
• Transexual: An older term some still use, but transgender is generally preferred as it's a broader term that can also encompass people who are non-binary or genderqueer, whose gender identity doesn't fall neatly into the categories of "man" or "woman”.

This journey of aligning the external body with the internal identity is called medical transition. Medical transition encompasses a range of steps, which may include hormone therapy, gender-affirming surgeries, and other medical interventions tailored to the individual's needs and goals. 

However, it's essential to understand that the decision to undergo medical transition is profoundly personal and varies significantly from person to person. Each individual's journey is unique, influenced by personal preferences, cultural context, access to healthcare, and the support of their community and loved ones. 

Glamika Patel highlights the difference between intersex and transgender, “Intersex is organ-related; however, transgender is psychological. Intersex means they have both organs, including the vagina as well as the testicles. Transgender is someone who has a female organ but thinks like a male and vice versa.”

The transgender reproductive system is an important area of healthcare that is concerned with the specific needs of transgender and gender-diverse individuals. It encompasses a range of topics, from fertility concerns to accessing appropriate sexual and reproductive healthcare.

For transgender men, reproductive health might involve wanting to get pregnant, needing contraception, or seeking care for their existing reproductive organs. It's important to note that testosterone therapy, a common part of gender affirmation for trans men, can affect fertility. Sperm banking is an option for those who might want to father children in the future.

Trans women's needs are equally important. Hormone replacement therapy (HRT) can impact ovulation, so some transgender women may choose to preserve their fertility before starting HRT. They may also need contraception or care related to their reproductive anatomy. It's important to remember that not all transgender people may identify with a binary gender (man or woman). Non-binary individuals have diverse reproductive needs as well. Some may not identify with any particular gender and may or may not desire pregnancy.

A common concern for many transgender people is the impact of hormone therapy and transgender surgeries on fertility. Discussing these possibilities with a healthcare provider who is knowledgeable about transgender health is crucial before starting any treatment. Many transgender people also want to have children. There are various family planning options available, including adoption, surrogacy, or using sperm/eggs from donors or a partner.

Unfortunately, transgender people often face discrimination in healthcare settings, making it difficult to access the care they need. Finding a provider who is understanding and respectful of trans identities is essential for ensuring good health outcomes. There are resources available to help transgender people find qualified providers and learn more about their reproductive health options.

While access to healthcare for transgender people in India is improving, there's still a gap between policy and implementation. Here's a look at some resources available on ongoing challenges:

The National Health Mission (NHM) in Tamil Nadu is a pioneering effort. They've established "Gender Guidance Clinics" within public hospitals. These clinics act as a central location for transgender healthcare needs, potentially including gender-affirming procedures. However, as of March 2023, only three such clinics exist in Tamil Nadu. You can find more details about these clinics and the broader challenges faced by transgender healthcare in India in a report by the Public Health Foundation of India: Public Health Foundation of India - MEETING THE HEALTHCARE NEEDS OF THE TRANSGENDER COMMUNITY.

NGOs play a crucial role in supporting transgender healthcare. The India HIV/AIDS Alliance (IHAA) works with the Wajood program, which addresses the sexual and reproductive health rights (SRHR) of transgender people alongside preventing gender-based violence.

Another influential NGO is the Indian Professional Association for Transgender Health (IPATH). They collaborate with the World Professional Association for Transgender Health (WPATH) to improve the quality of transgender healthcare in India. IPATH has published valuable guidelines like the "Indian Standards of Care: ISOC-1". 

Other than doctors, Nikita accessed resources like the Humsafar Trust, “They spoke to us about transgender healthcare and HIV. They also talk about different tests specific to transgender people. I also used the Color Positive Foundation. These are NGOs for LGBTQIA+ people to help them and educate them about healthcare.” 

The Transgender Persons Protection of Rights Act 2019 mandates states to provide essential healthcare services like gender-affirming surgeries, hormone therapy, counselling, and insurance coverage in at least one government hospital. 

There's a beacon of hope for the future. The All India Institute of Medical Science (AIIMS) in New Delhi plans to open a Centre of Excellence for transgender healthcare in 2024. This initiative could significantly improve access to specialised care. 

It is important to understand the trans community is a part of the society and should be treated equally like other genders. Trans people can do much better if provided with proper facilities in healthcare.

While challenges remain in India, there are promising developments. Increased access to culturally competent providers and continued policy implementation are vital to ensuring equitable healthcare for all transgender individuals in India. By fostering open communication and understanding, healthcare professionals can play a key role in improving the health and wellbeing of the transgender community.

Medically reviewed by:

Dr B.S Mahesh, Clinical Psychologist