Three years ago, when Manohar, a transgender man, visited a tertiary government hospital in southern Tamil Nadu seeking gender-affirming care, he was met not with support but with judgement. “I had not come out to my family at that point, so I had to go to the hospital wearing a churidar. I had long hair too. The doctors refused to treat me. They told me, ‘If you are a trans man, why are you dressed like a woman’ and asked me to cut my hair, put on pants and a shirt, and come back,” he alleges.
Mr. Manohar, now 28, had to seek a certificate of “recognition” from the District Magistrate, in line with the Transgender Persons (Protection of Rights) Act, 2019, after which the doctors agreed to treat him.
Accessing healthcare is still a Herculean task for transgender and gender-diverse people, even in Tamil Nadu, a State celebrated for its progressive transgender welfare policies including the establishment of 12 transgender clinics across the State that offer free gender-affirming surgeries. From judgemental stares and misgendering (addressing by gender assigned at birth) to the outright denial of care based on their identity, the barriers are many.
Although trans women, too, face serious challenges, the experiences of trans men and gender-diverse people who were assigned female at birth (AFAB) – including non-binary people – reveal a different set of hurdles, say activists and transgender health experts. They say the healthcare system for such individuals remains constrained by limited research, poor understanding of their identities, and a one-size-fits-all model of care.
Gaps in medical understanding
Fred Rogers, transgender rights activist and director of the Urimai Kural Trust, a trans rights organisation based in Chennai, supporting trans and gender-diverse individuals, says that even accessing general healthcare – such as treatment for a fever or cold – often feels impossible for transmasculine people (individuals assigned female at birth who identify with or have a predominantly masculine gender identity or expression) “Many healthcare professionals are not even aware of these identities to begin with. People in the community are forced to rely on a small network of recommended doctors: doctors who will treat us with dignity, who will not judge us, misgender us, or use our deadname (name given at birth, which was changed as part of their transition).”
L. Ramakrishnan, a public health professional and vice president of SAATHII, a Chennai-based NGO, explains that the trans movement in India was led by trans women, and they have historically and culturally been more visible. “This, therefore, has shaped our view on gender incongruence, and there is a lack of understanding of who trans men and AFAB individuals are, even among healthcare professionals.”
Air Cmde Sanjay Sharma (retd.), who heads the Association for Transgender Health of India (ATHI), says that for transmasculine people, primary care is generally given by gynaecologists, but since specialists delivering these services are usually trained to see gender in a binary fashion, patients often experience ridicule or hostility.
Gender incongruence vs Gender dysphoria
Gender incongruence is a persistent mismatch between a person’s experienced gender and the sex they were assigned at birth. It is not a disorder, but a human condition. Gender dysphoria is the distress experienced when a person’s gender identity does not align with the sex they were assigned at birth. Not all transgender people experience dysphoria; it is a clinically diagnosable condition.
Gatekeeping, unethical practices
According to intersex activist Gopi Shankar Madurai, the fundamental issue is that medical professionals do not provide affirmative care; they treat gender incongruence as a disorder. “There is always this question of whether you are trans enough. Not everyone can come out to their families, and doing so might be harmful for them but this is not something that is widely understood.”
Dr. Sharma says that care providers also tend to gatekeep care. “For instance, the first point of contact is the psychiatrist. Only after a psychiatrist gives you a diagnosis of gender dysphoria can you receive other care. Care, however, should not depend upon whether you have dysphoria or not; it should depend upon whether you are gender incongruent or not.”
Dr. Ramakrishnan further points out that some medical professionals also view trans men through a patriarchal, heteronormative, and reproduction-oriented lens – because of their sex assigned at birth. “There have been instances of surgeons refusing hysterectomies for trans men who have not birthed children,” he notes. He also highlights that certain unethical and unscientific practices continue, such as vaginal examination or asking patients to expose their chests, even when they have clearly stated that they have not undergone top surgery.
Unsupervised hormonal therapy
For trans men, gender-affirming care may include hormone replacement therapy (HRT), in which testosterone is administered to induce masculinisation and suppress female secondary sex characteristics. There is however, a two-fold problem with hormones: inadequate information given by medical professionals many of whom are also not fully aware about the effects of the hormones, and self-medication by patients.
Hafiz, a 29-year-old trans man who has been on HRT for over two years, says he used to receive his testosterone injections from doctors at the government hospital. However, with the introduction of the Chief Minister’s Comprehensive Health Insurance Scheme in T.N., accessing free hormones now requires a two-day hospital admission. “As I come from a conservative family, I cannot get admitted to hospital without raising concerns. So I get the prescriptions and buy the hormones elsewhere,” he says. This is the case with many other trans men too.
While hormones are generally prescribed in doses of 100 mg, 250 mg, or 1,000 mg, there is no strict guideline linking dosage to body weight, according to trans persons. Mr. Hafiz says often, the available stock determines what is given. “Some trans men may seek higher doses to achieve desired masculinisation, such as increased beard growth, because proper guidance is not provided. Hormones are readily available in the market and online, and there is little oversight from medical professionals on dosage.”
Medical professionals also often do not provide adequate information about the risks of hormones, and many themselves lack awareness, Mr. Hafiz adds: “These are steroids, and without careful monitoring, they can lead to serious long-term side effects, including kidney problems, heart attack, stroke, and diabetes. For individuals with underlying health conditions, hormone therapy may also have immunosuppressive effects, yet this is rarely addressed by doctors.”
Dr. Ramakrishnan points out that in the private sector, the unavailability of affordable endocrinologists, who are also trans-affirming, causes many to self-medicate.
What needs to change
One of the key issues, says Gopi Shankar Madurai, is the lack of research on gender-affirming care. “Medical professionals often do not know whether trans men undergoing hormone therapy can safely receive vaccinations for instance. They simply do not have the information because it has not been studied or taught,” they explain. Madurai notes that the Indian Council of Medical Research (ICMR) and State medical mechanisms are yet to establish medically ethical and affirmative protocols for persons living with diverse gender identity/expression and sex characteristics (GIESC) care, leaving providers without clear guidelines to ensure safe, respectful treatment.
Dr. Sharma notes that while there has been tremendous progress in transgender healthcare research, it has nearly all happened in the West.
The training of care providers poses another massive barrier. “There is an effort by the government to make space for gender-affirming care. But care providers, even if they are well-meaning and sympathetic, are not completely trained,” Dr. Sharma notes. He calls for a structured training of medical professionals and the application of standardised protocols, which have been peer-reviewed and are evidence-based. Current standardised protocols that are applied globally are those developed by the World Professional Institution for Transgender Health (WPATH), an association of professionals. Dr. Sharma, who represents India in WPATH, and is part of the World Health Organisation’s experts group on transgender health also highlights the importance of a community-based cadre: people who have lived experiences to be brought into the government’s healthcare delivery system.
Slight, slow progress
Certain contentious practices, such as to do with clothes, have been discarded by the government at the gender clinics now, says M. Sugumar, who previously headed the gender clinic at Rajiv Gandhi Government General Hospital, Chennai. Moreover, “this is an evolving discipline, so medical practices will also evolve accordingly,” he notes. The T.N. government, he adds, conducts periodic gender sensitisation training, with the help of NGOs, not just for doctors specialising in gender care, but also for medical practitioners across hospitals.
Mr. Rogers and others, in 2024, filed a petition in the Madras High Court seeking better healthcare protocols for trans individuals. The Court, hearing the petition recently, has allowed the petitioner to file a rejoinder affidavit suggesting improvements to the government’s existing SOPs with respect to medical and surgical care for trans persons.
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