INTRODUCTION:

The acknowledgment of gender difference is not contemporary but possesses profound historical and cultural foundations throughout diverse nations. The phrase "third gender" broadly includes those who do not adhere to conventional binary gender classifications of male and female.

Historically, the Hijra community, frequently acknowledged as a separate gender, has been an essential component of South Asian cultural and religious traditions. Despite their historical importance, Hijras encounter extensive marginalization in modern society (Al-Mamun et al., 2022). Indigenous cultures in North America acknowledge Two-Spirit individuals whose identities surpass binary gender frameworks and are frequently linked to spiritual and ceremonial functions within their communities (Chisholm, 2018). Third-gender people have been regularly refused access to basic services, such as healthcare, despite this cultural recognition. Their exclusion arises from stigma, insufficient legal protections, and systemic deficiencies within healthcare institutions (Clark et al., 2023). The healthcare requirements of third-gender populations worldwide are inadequately met. These demographic experiences disproportionately elevated rates of physical and mental health challenges, including HIV/AIDS, depression, and substance addiction, exacerbated by societal ostracism.

Healthcare systems, conventionally structured around binary gender standards, frequently inadequately deliver gender-affirming care, hence exacerbating the marginalization of these individuals (Safer, 2016). The idea of gender has changed from the binary paradigm to acknowledge the third gender, which includes transgender, hijra, and non-binary people, as a vital component of cultural variety. In India, third-gender communities have been historically revered and marginalized (Dutta & Roy, 2014). The hijra community has played important cultural and spiritual roles; however, systemic discrimination has marginalized them within health, education, and economic systems (Kalra, 2012). The intersection of gender identity and healthcare highlights significant disparities: Individuals identifying as third gender encounter widespread inequities, including inadequate access to primary care and insufficient gender-affirming services (Subramaniapillai et al., 2024). The policies for transgender, especially health care access in India, have been a major drawback for them. With the significant NALSA v. Union of India ruling in 2014 and the establishment of the Transgender Persons (Protection of Rights) Act in 2019, deficiencies in healthcare for the third gender continue to exist. The Government of India provides specific amenities for the third gender community, which includes: (i) UMBRELLA SCHEME ‘SMILE’ LAUNCHED IN 2022 Rs 365 Cr allocated for 5 YEARS for " SMILE (Support for Marginalised Individuals for Livelihood and Enterprise) ", Moving towards a Gender-inclusive society under the (Ministry of Social Justice and Empowerment), (ii) The Transgender Persons (Protection of Rights) Act 2019, (iii) Transgender Persons (Protection of Rights) Rules, 2020, (iv) National Council for Transgender Persons established on 21st August 2020, and (v) National Portal for Transgender Persons represent initiatives undertaken by the Government of India to promote the inclusion of the third gender community in mainstream society ((Ministry of Social Justice and Empowerment, 2022).

Transgender individuals often face stigma in medical environments, insufficient knowledge among healthcare professionals, and exclusion from insurance systems (Bhattacharya et al., 2022). Furthermore, inequalities in access to gender-affirming surgeries, sexual and reproductive healthcare, and mental health support illustrate systemic neglect. These barriers are exacerbated by socio-economic challenges such as unemployment and housing insecurity, which further limit access to quality care (Jarrett et al., 2021).

In accordance with the gender norms of society, the fundamental needs include mental and psychological characteristics that are relevant to sexual health. HIV, sexually transmitted infections, and other diseases that are prevalent in the population of people who identify as third gender continue to receive insufficient attention, which represents a significant health risk that has to be addressed. In order to guarantee that people who identify as third gender have equal access to opportunities, it is necessary to formulate policies that will combat the social stigma that is experienced by members of the community and encourage acceptance within society. This review analyses the interaction of policy, cultural attitudes, and healthcare systems in influencing health outcomes for third-gender individuals. This paper analyses existing literature, successful interventions, and ongoing challenges to elucidate the healthcare needs of the third gender, advocating for inclusive, equitable, and culturally sensitive healthcare reforms in India and beyond.

LITERATURE REVIEW:

The systematic prejudice that third-gender people experience in healthcare settings is a major theme in the literature. Studies indicate that healthcare professionals frequently lack adequate training to meet the specific needs of third-gender individuals, leading to instances of misgendering and disrespectful conduct by staff (Skuban et al., 2023). Refusal of treatment resulting from provider biases. Individuals exhibit reluctance to pursue healthcare services as a result of anxiety associated with stigma (Zeeman et al., 2018). The National Transgender Discrimination Survey conducted in the United States indicated that 28% of participants experienced harassment in medical environments, while 19% reported being explicitly denied care due to their gender identity (Kearns et al., 2021). Gender-affirming treatment, which includes hormone therapy and surgical procedures, is essential for numerous individuals identifying as third-gender. Financial constraints sometimes restrict access, as numerous health insurance plans fail to cover gender-affirming procedures (Snow et al., 2019). The limited availability of specialized clinicians and clinics constrains access, particularly in rural and underserved regions (Zeeman et al., 2019.). Legal obstacles in numerous countries, including the mandate for psychological evaluations prior to obtaining gender-affirming care, exacerbate delays and emotional distress (Kearns et al., 2021). Mental health disparities are notably significant among third-gender populations due to societal stigma and marginalization. Research findings indicate increased levels of despair, anxiety, and suicidal ideation in this population (Kota et al., 2020). Minority stress theory explains the detrimental effects of ongoing stigma, discrimination, and internalized prejudice on mental health (Kearns et al., 2021). Programs that integrate mental health care with various medical therapies have shown improved outcomes for gender-diverse individuals (Snow et al., 2019). Cultural differences profoundly influence the healthcare experiences of individuals identifying as third gender. The Hijra community is legally recognized in certain South Asian nations, such as India, Pakistan, and Bangladesh. Despite this recognition, healthcare policies and services designed to meet their needs remain insufficient and inadequate (Hossain, 2017). Research indicates that inclusive policies and programs can markedly diminish disparities in healthcare access for third-gender individuals. Implementation of anti-discrimination legislation and policies in healthcare settings. Educating healthcare professionals on gender sensitivity and diversity and extending health insurance coverage to encompass gender-affirming treatments Conclusive Evaluation (LEAD 2016). The study underscores the necessity for institutional reforms to rectify the disparities encountered by third-gender individuals in healthcare. Implementing inclusive practices and policies enables healthcare systems to deliver equitable care and enhance health outcomes for marginalized populations (Stroumsa, 2014). Making decisions presents ethical issues for healthcare professionals (HCPs) who provide gender-affirming medical care (GAMC). This involves reconciling shared decision-making frameworks with professional expertise while managing uncertainties in gender identity treatment. Multidisciplinary approaches involving mental health professionals, endocrinologists, and surgeons are essential for enhancing ethical practices in Gender-Affirming Medical Care (Gerritse, 2022).

The COVID-19 pandemic intensified existing healthcare issues for transgender and nonbinary populations. Barriers comprised postponed gender-affirming surgeries and heightened mental health vulnerabilities resulting from compelled de-transitioning in specific socio-cultural contexts. Structural inequalities, including economic instability and healthcare inaccessibility, exacerbate these issues, highlighting the necessity for comprehensive healthcare policies to assist marginalized groups during crises (Jarrett et al., 2021). An expanded view of gender health disparities highlights the significance of intersectionality. Nonbinary and transgender individuals frequently encounter intersecting discrimination related to race, socioeconomic status, or disability. Layered inequities necessitate intersectional approaches in policy and practice to achieve inclusive healthcare systems (Tan, 2019). Transgender individuals in India face considerable obstacles in obtaining routine healthcare services, primarily attributable to societal stigma and the gender-binary framework of the healthcare system. Research indicates that these barriers are exacerbated by adverse socioeconomic conditions, such as low educational attainment, unemployment, and inadequate housing (Pandya and Redcay 2020). These factors result in diminished health-seeking behaviors and heightened susceptibility to non-communicable diseases such as diabetes and cardiovascular conditions. The psychological impact of these barriers, particularly increased minority stress, intensifies mental health issues (O’Neil et.,al 2015). In Kerala, the development of gender-affirming care initiatives are progressing, yet systemic deficiencies remain. Gender-affirming services, including hormone therapy and surgical procedures, frequently face accessibility issues stemming from elevated costs and restricted availability within public healthcare facilities. Kerala's "queer-friendly hospital initiatives" announcement has faced slow implementation, underscoring the necessity for improved policy execution and capacity enhancement within public healthcare systems (Nayar & Vinu, 2023). The "Our Health Matters" study highlights the specific challenges encountered by transmasculine individuals in India. The 2019 Act advocates for improved access to transition-related care, encompassing hormone therapy and surgeries; however, transmasculine individuals frequently encounter discrimination and a scarcity of facilities for these procedures. Government initiatives such as the 'Ayushman Bharat TG Plus' card present potential solutions by encompassing gender-affirmative surgeries; however, their accessibility and efficacy differ among states. The research supports the implementation of more inclusive and evidence-based policies to mitigate these gaps (Chakrapani et., al 2024). The Trans care COVID-19 study employed an intersectional framework to investigate the healthcare experiences of various gender identities, including hijras, kinnars, and non-binary individuals. The findings indicate that intersecting factors, including caste, class, and regional identities, contribute to further layers of marginalisation. This approach highlights the necessity for comprehensive and inclusive healthcare policies that take into account the diverse identities within the transgender community (Raghuram et., al 2023). A study conducted in western Rajasthan identified the socio-demographic challenges encountered by transgender individuals in obtaining healthcare services. The study identified obstacles including insufficient awareness of healthcare rights and entitlements, social stigma, and economic difficulties.

A significant number of participants indicated the necessity for public healthcare facilities to offer gender transition-related services, including hormone therapy and surgical procedures. Furthermore, they indicated challenges related to discrimination by healthcare providers, insufficient mental health support, and restricted access to gender-inclusive insurance options (Kaur Ahuja et.,al 2024). Tamil Nadu has implemented Gender Guidance Clinics in public hospitals to cater to the distinct healthcare requirements of transgender individuals. These clinics offer complimentary gender-affirmative surgeries, enhancing access to vital healthcare services. The initiative emphasised mental health support, respectful treatment, and the resolution of systemic issues such as insurance coverage for transgender-specific needs. The GGC model demonstrates the influence of robust government ownership and intersectoral collaboration in mitigating healthcare disparities (Seshadri, et., al 2023). A study in PLOS Global Public Health examines the obstacles encountered by transgender individuals in obtaining routine healthcare in India. Economic exclusion, inadequate gender-sensitive medical education, and systemic stigma present considerable obstacles. The Transgender Persons (Protection of Rights) Act of 2019 seeks to address these concerns by providing provisions such as gender-affirmative care and insurance coverage. Nonetheless, its implementation is characterised by inconsistency (Raghuram et., al 2023). Transgender individuals experience increased risks for HIV, mental health disorders, and other chronic conditions, exacerbated by limited healthcare access and discriminatory practices within medical environments (Kota et., al 2023). Despite the decriminalisation of homosexuality in India in 2018, systemic discrimination continues to exist within the healthcare system. A 2021 article in BMJ outlines the experiences of transgender individuals facing inappropriate treatments and biassed medical opinions, which hinder their willingness to seek care. The report identifies issues such as outdated medical curricula that perpetuate stereotypes, thereby further marginalising LGBTQ+ patients. Addressing systemic gaps necessitates the revision of educational materials and the implementation of gender-sensitive policies within healthcare institutions (Arora et.,al 2022). The Wire's research critiques the exclusionary practices within India's healthcare systems, notwithstanding legal advancements. Transgender individuals frequently encounter barriers to care, verbal harassment, and insufficient acknowledgement of non-binary identities. Recommendations involve the establishment of dedicated clinics, the integration of inclusive practices, and the training of healthcare professionals to implement patient-centered approaches that acknowledge diverse gender identities (Raghuram et al., 2024). A qualitative study examined the intersectional challenges faced by hijra and non-binary communities in India. These groups encounter multiple obstacles, from caste, class, and regional disparities. Intersectional frameworks are crucial for addressing specific healthcare needs, including access to hormone therapy and mental health support. The research highlighted the importance of engaging community members in designing policies to create culturally appropriate healthcare solutions (Kaur & Singh 2024).

The idea of gender has changed from the binary paradigm to acknowledge the third gender, which includes transgender, hijra, and non-binary people, as a vital component of cultural variety. In India, third-gender communities have been historically revered and marginalized. The hijra community has played important cultural and spiritual roles; however, systemic discrimination has marginalized them within health, education, and economic systems. The intersection of gender identity and healthcare highlights significant disparities: individuals identifying as third gender encounter widespread inequities, including inadequate access to primary care and insufficient gender-affirming services (Singh et al., 2024). Despite the significant NALSA v. Union of India ruling in 2014 and the establishment of the Transgender Persons (Protection of Rights) Act in 2019, deficiencies in healthcare for the third gender continue to exist. Transgender individuals often face stigma in medical environments, insufficient knowledge among healthcare professionals, and exclusion from insurance systems. Furthermore, inequalities in access to gender-affirming surgeries, sexual and reproductive healthcare, and mental health support illustrate systemic neglect. These barriers are exacerbated by socio-economic challenges such as unemployment and housing insecurity, which further limit access to quality care (Bhattacharya et al., 2022).

The Transgender Persons (Protection of Rights) Act 2019 aims to integrate the third gender community into mainstream society by providing specific provisions, including non-discrimination, the right to live and earn a livelihood, welfare scheme benefits, the establishment of a national council for transgender persons, and the right to residence. The Transgender Persons (Protection of Rights) Rules, 2020, aims to ensure equal opportunities for transgender individuals in healthcare, education, employment, access to public property, and benefits related to private property ownership (Press Information Bureau, 2022).

The SMILE umbrella scheme emphasises the welfare and rehabilitation of transgender individuals and those involved in begging. The provisions encompass medical care, counselling, education, skill development, and economic support. Implementation will require collaboration with state governments, local entities, and diverse organisations to guarantee comprehensive support and social inclusion. Garima Grehs: Shelter Homes for Transgender persons provide shelter home facilities for the third gender community under the SMILE schemes. Additionally, various skill enhancement programs and comprehensive medical care facilities are operated under the ministry's program for employment generation among third gender individuals. National Portal for Transgender Individuals A transgender individual may apply for the transgender card (TG card) without the necessity of physical presence at the office. (Press Information Bureau, 2022)

RESEARCH METHODOLOGY:

This review article employs a structured and systematic methodology to collect, evaluate, and synthesize existing literature and research, as well as to comprehensively analyze the healthcare challenges and opportunities faced by the third-gender community. The research design utilizes a literature review framework, concentrating on peer-reviewed articles, policy documents, case studies, and grey literature to discern patterns, gaps, and advancements in third-gender healthcare. This method combines narrative review techniques for comprehensive understanding with systematic approaches to maintain rigor. Data sources comprise peer-reviewed journals from databases including JSTOR and Google Scholar and reports from international health organizations such as the World Health Organization (WHO), UNAIDS, and the Indian Ministry of Health. Furthermore, the inclusion of government policies, exemplified by the Transgender Persons (Protection of Rights) Act, 2019, alongside reports from non-governmental organizations, community studies, and publications from advocacy groups, is noted. Media articles addressing healthcare challenges encountered by the third gender in particular regions offer additional insights. The selection of literature is based on inclusion criteria that prioritize research from the last ten years, studies addressing healthcare challenges, barriers, and interventions for third-gender individuals, and research that examines India's socio-cultural and policy context. Exclusion criteria remove non-peer-reviewed studies and articles focusing primarily on LGBTQ+ healthcare without a specific emphasis on third-gender experiences. The data collection process involves multiple steps, starting with keyword searches including “third gender healthcare,” “transgender health in India,” and “health barriers for hijras,” employing Boolean operators to enhance precision. Titles and abstracts that are pertinent are screened, and the studies that meet the criteria are reviewed in their entirety for eligibility. A data extraction sheet documents essential study details, including objectives, methods, findings, and limitations. Thematic analysis identifies recurring patterns, including stigma, inadequate provider training, and systemic exclusions, while emphasizing effective interventions such as Tamil Nadu's Gender Guidance Clinics. Policy analysis assesses the effects of legislative actions, including the NALSA judgment, on healthcare accessibility. Comparative analyses examine healthcare access and outcomes across different states and socio-economic contexts, identifying effective adaptation practices pertinent to the Indian context. This methodology provides a detailed understanding of the complex healthcare experiences of the third-gender community.

RESULTS OF THE REVIEW:

The analysis of third gender and healthcare uncovers important insights into barriers, advancements, and essential future directions for attaining equitable healthcare systems. The findings can be summarized as follows:

1. Ongoing Obstacles to Healthcare Systemic Discrimination: Individuals identifying as third-gender encounter stigma and prejudice in healthcare systems, evident in insensitive interactions with providers and, in certain instances, outright denial of care. Exclusion in economic and social contexts. High poverty rates, unemployment, and social exclusion exacerbate the difficulties in accessing quality healthcare services. Healthcare providers exhibit a significant gap in understanding the specific needs of third-gender individuals, particularly concerning gender-affirming care and mental health support. Regulatory and Policy Structures. Recent legislative developments, such as the Transgender Persons (Protection of Rights) Act, 2019, and the NALSA judgment (2014), have created a framework to improve healthcare accessibility.

The limited access to healthcare for transgender individuals due to discrimination within the health system. The primary focus was on identifying the subjectively effective reasons that transgender individuals attribute to their experiences of discrimination in healthcare. This indicates that minimising discrimination in healthcare requires more than merely imparting knowledge about transsexuality. The focus is on altering the personal attitudes of health professionals, potentially through reflection on their own gender identity(ies). Integrating transgender individuals may be a viable approach to implementing measures aimed at reducing their discrimination (Skuban et al., 2023).

A significant shift in attitudes regarding transgender medicine can be accomplished through a simple and readily implementable intervention. Transgender patients face significant obstacles to medical care, with insufficient physician knowledge identified as a primary barrier to access. Transgender medicine is rarely included in conventional medical curricula. A simple content change in the medical school curriculum significantly increased students’ self-reported willingness to care for transgender patients 9 Safer et al., 2013).

2. Challenges in Implementation: The implementation of policies is inconsistent and impeded by inadequate training, resource limitations, and socio-cultural resistance across different regions. Case Studies and Programs Tamil Nadu has positioned itself as a leader by implementing initiatives like Gender Guidance Clinics and offering free gender-affirming surgeries, serving as a model for other states. Interventions led by NGOs have been essential in providing support, increasing awareness, and educating healthcare providers and third-gender individuals.

The discussion compares and contrasts the authors' conceptual model with Ryvicker's behavioral-ecological model of healthcare navigation in light of the findings. This paper highlights the essential requirement for increased research focused on non-binary youth, as well as studies that incorporate this population in the research design. The focus of young individuals on hormones is significant, as they perceive challenges mainly as hindrances to hormone access rather than as barriers to holistic care. Specialist gender services can offer support including speech and language therapy, assistance with legal document changes and paperwork, peer support groups, family counselling, and family planning services, all of which may be gender-affirming (Kearns et al., 2021).

Health-seeking behaviours are frequently inadequate as a result of stigmatisation within healthcare environments. Intervention programs must be culturally sensitive and should focus on enhancing knowledge and awareness regarding HIV (Human Immunodeficiency Virus) and STIs (Sexually Transmitted Infections) among MSM (men who have sex with men) and TGs (transgender individuals). The MSM population in India is at an elevated risk for acquiring STIs, including HIV. Herpes and syphilis are prevalent sexually transmitted infections (STIs) that exhibit a significant association with HIV. Sexual health programs can significantly enhance awareness among transgender individuals and men who have sex with men, particularly regarding anal sex, which has been associated with a higher incidence of anal cancer in reported cases. This leads to a number of sexually transmitted diseases that can be prevented by promoting sexual health education, implementing government awareness campaigns that can encourage the use of condoms, and implementing other safety precautions during sexual activity to promote the health of the third gender community (Setia et al., 2006).

3. Unique Healthcare Needs: The limited availability of affordable and accessible gender-affirming surgeries and hormone therapies has created a significant unmet need. Mental health support services are insufficient, considering the high prevalence of depression, anxiety, and stress resulting from societal rejection and stigma related to healthcare. Preventive and primary healthcare for the third gender often overlooks essential medical needs, including reproductive health and chronic disease management.

Research should assess the knowledge and biases of the medical workforce throughout various stages of medical training concerning transgender medical care. It should evaluate the adequate availability of practitioners for the necessary care, identify more inclusive social structural barriers, and examine the status of a framework for financing appropriate care. Lack of access to healthcare due to a shortage of clinicians with adequate knowledge of the issue is the largest obstacle that transgender people report (Safer et al., 2016).

Enhancing the health of transgender and nonbinary communities necessitates prioritising increased access to gender-affirming resources with the help of initiatives such as digital prescriptions, flexible interventions like telehealth, and support for current transgender health initiatives. Reduced access to gender-affirming resources and transgender and nonbinary people's capacity to live their gender identity globally are linked to the COVID-19 dilemma (Jarrett et al., 2021).

Community participation involves the active engagement of transgender and third-gender populations in healthcare planning and policymaking to ensure their specific needs are effectively met. Encourage further investigation into third-gender healthcare to improve evidence-based interventions and identify service deficiencies. The review emphasizes that achieving equitable healthcare for the third gender requires a comprehensive approach that includes legal, institutional, and societal reforms. While progress has been made, substantial systemic reforms are essential to address healthcare disparities and foster an inclusive, respectful, and affirming environment for all individuals.

CONCLUSION:

The third gender community, despite receiving increasing global and societal recognition, continues to face oppression in various aspects of their lives. Achieving gender equality is a significant milestone. The acknowledgement of health rights for transgender individuals, as well as the obstacles they face in accessing healthcare services, has been established by both the Supreme Court and legislative entities, as evidenced by the NALSA judgement and the Transgender Persons (Protection of Rights) Act 2019. The issue of mistreatment in mental health settings represents a critical area for investigation concerning GM individuals, who face significant disparities in mental health outcomes. Individuals from marginalised communities frequently encounter rejection and diminished quality of care in both medical and mental health environments. Research findings suggest that negative experiences, commonly observed at the interpersonal level, are frequently linked to the heteronormative health system. Addressing these challenges necessitates comprehensive systemic and structural efforts that recognise community diversity and acknowledge the intersectionality of experiences. Clinical practice interventions aimed at addressing gender prejudice must be comprehensive, sustained, experimental, assessed through standardised procedures, and formulated with a gender perspective. Moreover, it is essential to examine not only the binary classification of women and men but also the continuum of gender equality.

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Received on 27.11.2024 Revised on 10.01.2025

Accepted on 11.02.2025 Published on 19.03.2025

Available online from March 28, 2025

Res. J. of Humanities and Social Sciences. 2025;16(1):33-40.

DOI: 10.52711/2321-5828.2025.00007

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