European Journal of Cardiovascular Medicine

Universal healthcare emphasizes that all individuals should have access to quality healthcare services without having financial hardships. ¹

Gender Identity refers to an individual’s internal knowledge of being male, female or another gender.  Globally about 0.3 to 0.5% of the population are transgenders2.Transgender community is a community whose gender expression differs from their assigned sex at birth. They can be identified as Transwoman or Transman3. Transgender persons experience specific healthcare needs in relation to psychiatric support, hormonal therapies ,sex reassignment surgeries, increased incidence of noncommunicable diseases, substance abuse disorders mental health issues like depression, anxiety etc. ⁴

A good healthcare system addressing the needs of transgenders is essential in the private and public healthcare facility.

The health disparities and barriers to accessing healthcare of transgenders should be addressed to promote health equity and justice.2 The barriers were categorised at healthcare system, individual level and community level according to Ahuja et al ²

LGBTIQ Community face significant challenges accessing healthcare in both rural and urban settings ⁵

The LGBTIQ+ community, including transgender persons, continues to experience significantly reduced access to healthcare in both rural and urban settings due to stigma, discrimination, and lack of trans inclusive policies5. This study explores these challenges in the context of Ernakulam District, Kerala.

LITERATURE REVIEW

A Transgender person is defined as someone whose gender identity does not align with biological sex. This diverse group includes transmen, transwomen, individuals with intersex variations, genderqueerpersons and sociocultural identities such as kinnars and hijras. Gender dysphoria refers to the clinically significant distress resulting from incongruence between experienced gender and assigned sex persisting for at least six months 6

Gender affirming interventions such as hormone therapy, surgery or psychotherapy are seeked by many Transgenders; although not all can access these treatments due to financial, medical or social constraints. Lack of accessible, affordable and competent healthcare remains a major barrier in India and globally.

Aden et al points out several challenges faced by transgender individuals in accessing healthcare. These include individual level factors such as lack of health insurance ,interpersonal discrimination from healthcare providers and system level issues such as lack of provider training and absence of trans inclusive policies .Among those who had accessed healthcare in the previous year 33% reported negative experiences such as harassment ,assault or refusal of treatment and 23% avoided healthcare due to fear of mistreatment 6Strategies suggested to improve care include creating affirming healthcare environments ,developing strong non-discrimination protections ,training healthcare providers and enhancing career pathways  for transgender persons .

In low and middle income countries stigma  and discrimination in healthcare setting is common .Inappropriate questioning ,invasive examinations  and refusal of care are often encountered by transgenders .These result in delayed healthcare seeking and poor health outcomes .Barriers to gender -affirming treatments include lack of trained healthcare providers, high costs unwillingness of physician to prescribe hormones and lack of health insurance . Consequently, many transmen resort to unprescribed hormone use obtained through informal networks or black markets, posing significant risks7 .

Poteat et al. describe multiple challenges faced by Black transgender women in HIV care, including interruptions in antiretroviral therapy, poor adherence, and difficulty achieving viral suppression. Contributing factors included homelessness, substance use, violence, prioritizing gender-affirming care over HIV management, and structural barriers to participating in research8.

The National AIDS Control Organization (NACO) White Paper highlights significant health disparities among transgender individuals in India, including disproportionate burdens of sexual, reproductive, and mental health concerns. Stigma, discrimination, lack of legal recognition, and exclusion from mainstream health systems limit access to adequate care. The Integrated Biological and Behavioural Surveillance (IBBS) reports low coverage of essential services for transgender persons due to programmatic focus mainly on HIV/STI services. The report reviews Indian models such as the Trans Sunshine Clinic (Imphal) and TransMitr Clinics (Hyderabad, Pune, Thane), which provide community-led gender-affirming care, STI/HIV prevention, and general healthcare services.

The White Paper further recommends establishing Centres of Excellence for transgender health, implementing gender-sensitive and rights-based social protection measures. It also recommends reducing stigma, and strengthening healthcare provider training. It emphasizes the importance of collaboration among State AIDS Control Societies, social welfare departments, transgender welfare boards, and community-based organizations.9

Rupesh et al. highlight ongoing challenges faced by transgender individuals in India despite recent legal advancements. These include stigma, discrimination, victimization, and exclusion from education, employment, and housing, all of which impede healthcare-seeking behaviour. The authors argue for revision of undergraduate and postgraduate medical curricula to include transgender health, including AETCOM modules. They also recommend establishing specialized transgender clinics staffed by multidisciplinary teams including endocrinology, urology, psychiatry, and gynaecology.10

Overall, the literature consistently demonstrates that transgender individuals experience substantial barriers in accessing healthcare. These barriers arise from systemic discrimination, inadequate provider training, limited access to gender-affirming services, and poor integration of transgender health into mainstream public health systems. Improving provider competence, strengthening inclusive policies, integrating mental and reproductive healthcare, and establishing dedicated services are vital for addressing these inequalities.

RESEARCH QUESTION

What are the challenges faced by Transgenders in accessing health care  

Objectives:

1. To identify the challenges faced by transgender individuals in accessing Health care
2. Assess issues related to informed consent, privacy, and discrimination in medical care.

A cross-sectional study was conducted among transgender individuals residing in Ernakulam District, Kerala. Ernakulam was selected as it has one of the highest transgender populations in the state, primarily due to migration for improved economic opportunities and relatively better access to healthcare services. The study population included adults aged 18 years and above who self-identified as transgender. Sample Size The sample size was calculated using the formula: N = Zα²pq / d² Assuming a prevalence of 50% for accessing any form of healthcare services, with a 95% confidence interval and a 10% absolute precision, the required sample size was calculated to be 96. This was rounded to 100. A 10% precision level was chosen as this was a preliminary, exploratory study. The final number of participants included was 106. Questionnaire Development A structured questionnaire was developed after reviewing relevant literature and obtaining expert input. The questionnaire was prepared in English and Malayalam and reviewed for content validity, clarity, and relevance by subject experts. It comprised six sections: Demographic and socioeconomic characteristics (5 items) Access to healthcare (8 items) Informed consent practices (4 items) Stigma and discrimination (3 items) Confidentiality and privacy (3 items) Ethical concerns in healthcare (3 items) Additionally, two open-ended questions were included to capture personal experiences and suggestions for improving transgender-inclusive healthcare. Ethical Considerations & Approvals Data collection began only after receiving approval from: Institutional Review Board, Government Medical College Ernakulam (Ref: F4/2024-25/007, dated 08/04/2025) Institutional Ethics Committee, Government Medical College Ernakulam (Ref: 11/25, dated 13/06/2025) Participants were provided with an information sheet and written informed consent was obtained after explaining the purpose and voluntary nature of the study in Malayalam. No personal identifiers were collected to ensure anonymity and confidentiality. Sampling Method Convenience and snowball sampling methods were used through transgender community networks and outreach activities. Data were collected using self-administered questionnaires distributed during an outreach screening camp conducted by the Sexually Transmitted Diseases Clinic (Pulari Clinic), a tertiary teaching hospital in Ernakulam. DATA ANALYSIS Data from 106 completed questionnaires were entered into Microsoft Excel. Descriptive statistics including frequencies, percentages, and graphical representations were used to summarize the findings across key domains such as access to healthcare, informed consent, discrimination, privacy concerns, and ethical issues.

SECTION 1: DEMOGRAPHIC PROFILE

Graph 1:Age Distribution:

 Most respondents (n = 60) were between 25–34 years of age. The median age was 29 years, indicating a predominantly young study population.

Graph 2: Gender Identity:

 The majority identified as Transwomen (81.1%), followed by Transmen (10.4%), Non-binary individuals (7.5%), and Others (0.9%).

Graph 3: Education Level:

More than half (53.8%) had secondary-level education.

Distribution:

No formal/vocational education: 13.2%

Primary education: 53.8%

Higher secondary: 17.0%

Bachelor's/PG degree: 16.0%

Graph 4: Employment Status:

52.8% were employed, 28.3% were self-employed, and 18.9% were unemployed.

Graph 5: Monthly Salary Distribution:

47% earned between Rs.10,000–20,000 per month. Most fell within lower-income brackets.

Graph 6: Have you undergone gender-affirming treatments (hormones/surgery)?

SECTION 2: ACCESS TO HEALTHCARE

Graph 6 Access to Gender-Competent Doctors

Only 36.8% reported having access to doctors knowledgeable about transgender health.

A substantial 63.2% lacked access, reflecting significant provider training gaps.   
 

Graph: 7

Q8: Do you avoid seeking health care because you fear being discriminated against?

 A significant percentage of the participants  (38.7%) actively avoids healthcare due to fear of discrimination.
Nearly equal numbers (37.7%) do not experience this fear, suggesting highly variable experiences across different providers and regions.

Graph:8: Have you ever been denied treatment because of your gender identity?

          One-third (33%) have experienced direct denial of treatment due to gender identity. 

Graph 9: Are doctors knowledgeable about transgender health?

41.5% perceived providers as always knowledgeable; however, 58.5% disagreed, indicating inconsistent competence. .

Graph 10: Do you discuss menstrual and sexual health issues with your doctor?

 Only 34% discuss menstrual and reproductive health problems  with their doctor. Over 65% avoid these conversations. This suggests either provider discomfort, patient hesitation, or both.

Graph11: Are you hesitant to seek gender health care?

 Over one-third (34.9%) of the participants hesitate to seek gender-specific care. This combined with those who "sometimes" hesitate (20.8%) indicates that slightly more than half have reservations about seeking specialized care.

Graph12: Do doctors treat you with appropriate respect?

 More than half (58.5%) of the participants  report being treated with respect. However, 40.5% still report insufficient or inconsistent respect, suggesting room for improvement in provider attitudes.

SECTION 3: INFORMED CONSENT -

Graph13: Were you properly informed about the risks and benefits before starting hormone therapy?

 Exactly half (50%) of the study population report having proper informed consent regarding hormone therapy. While the other half (50%) were not adequately informed.

Graph14: Have you been explained the various treatment options related to gender identity?

     Exactly half (50%) were explained treatment options. The other half did not receive adequate information about alternative treatments. This limits patient autonomy in decision-making.

Graph15: Do doctors pressure you to follow a mandatory treatment course?

Nearly half (49.1%) report not being pressured, suggesting that at least some providers respect patient autonomy.

Graph16: Are your treatment decisions fully respected by doctors?

 42.5% of the participants  feel their decisions are fully respected. 57.5% experience insufficient respect for their treatment choices. This indicates a significant paternalistic approach by some providers.

SECTION 4: SATISFACTION & INFORMED CONSENT

Graph 17: Satisfaction with Doctor's Approach:

 Despite facing discrimination and privacy violations, over 70% of participants who have access to healthcare report, satisfaction with their doctor's approach, suggesting that when transgender patients find supportive providers, outcomes are positive.

Graph 18

Question 24:Mental Health support before treatment

"Have you received mentalhealth support before undergoing treatmentment related to gender identity?"

Mental Health Support:

Most respondents indicated receiving mental health support before treatment, which is an important aspect of comprehensive transgender healthcare.

The high satisfaction rate among those with access to care is encouraging, but must be considered alongside the significant access barriers.

Graph 19

Have you been explained the long-term consequences of hormone therapy and surgery?

Interest in Sharing Experiences:

Are you interested in sharing your experiences?"

The majority (81.1%) of the participants are not interested in sharing their experiences publicly, possibly due to privacy concerns or fear of discrimination.

SECTION 5: RECOMMENDATIONS FOR IMPROVEMENT

Based on the open-ended responses about improving trans-inclusive healthcare:

Top Suggestions Include:

1. Change in staff behavior and attitudes (multiple responses)
2. More services specifically for transgender individuals
3. Awareness and sensitivity training classes
4. Dedicated transgender hospitals or health centers
5. More inclusive healthcare policies
6. Staff education on transgender issues
7. Equality in treatment

This study examined the barriers and experiences of transgender individuals in accessing healthcare in Ernakulam District. The results reveal substantial challenges across all domains, including access to gender-competent providers, informed consent practices, respect and autonomy, privacy, and discrimination. These findings align with national and global literature indicating that transgender individuals face multi-level barriers—individual, interpersonal, and systemic.

The demographic profile shows a predominantly young population, with most participants identifying as transwomen and having secondary-level education. Despite this, many remain in low-income brackets and face unstable employment, consistent with studies reporting socioeconomic marginalization among transgender communities. These socioeconomic constraints may further restrict access to healthcare and gender-affirming services.

Access to knowledgeable healthcare providers remains a major barrier. Only 36.8% had access to doctors trained in transgender health, consistent with global evidence indicating inadequate provider competence in transgender-specific care. More than one-third of participants avoided seeking healthcare due to fear of discrimination, and one-third reported actual denial of care. These findings reflect persistent violations of medical ethics, human rights, and India’s constitutional protections against discrimination.

Communication gaps were evident, with only 34% discussing reproductive or menstrual health concerns with providers. This likely reflects a combination of provider discomfort, inadequate clinical training, and patient apprehension. Stigma around reproductive health concerns among transgender people is well-documented and often leads to underdiagnosis and unmet healthcare needs.

Informed consent practices were insufficient. Only half of the participants received adequate counselling before hormone therapy or were informed about available treatment options. Informed consent is a fundamental ethical and legal requirement, especially for gender-affirming interventions that have long-term physical and psychological implications. The fact that 57.5% felt their decisions were not fully respected indicates a paternalistic approach by some healthcare providers, undermining patient autonomy.

Despite these challenges, satisfaction levels among those who did access healthcare were encouraging, with 70.8% reporting satisfaction with their doctor’s approach. This suggests that when providers are supportive and well-trained, transgender individuals experience significantly better outcomes. Mental health support was also commonly received prior to gender-affirming procedures, reflecting partial adherence to best practice guidelines.

Privacy breaches were reported by 45.3% of participants, including disclosure of gender identity without consent. Privacy is a critical ethical concern for transgender individuals, as breaches may expose them to stigma, violence, and discrimination. Such violations represent serious lapses in medical ethics and confidentiality standards.

Overall, the findings highlight systemic gaps in provider education, healthcare policies, and service delivery. Improving transgender healthcare requires structural reforms, targeted training, inclusive policies, and culturally sensitive practices across health systems. This study highlights significant inequities in healthcare access and ethical practices affecting transgender individuals in Ernakulam District. Barriers include discrimination, inadequate provider knowledge, insufficient counselling, lack of respect for autonomy, and breaches of confidentiality. Only a minority of participants had access to transgender-competent doctors, and many avoided care due to fear of discrimination. Informed consent practices were inconsistent, and more than half of the respondents experienced inadequate respect for their treatment decisions. These findings underscore the urgent need for health system reforms focused on transgender health. Priorities should include mandatory provider training, enforcement of anti-discrimination policies, improved informed consent procedures, establishment of transgender-friendly services, and integration of sexual and reproductive health into routine transgender care. Ensuring equitable, respectful, and informed healthcare is essential not only for improving health outcomes but also for upholding human rights. A coordinated, multisectoral approach involving healthcare institutions, policymakers, social welfare departments, and transgender community organizations is essential to eliminate structural barriers and promote health equity. Strengthening transgender-inclusive healthcare systems will contribute to safer environments, earlier care-seeking, and better overall health outcomes for transgender individuals in Kerala and beyond.

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