Access to healthcare for transgender persons has long been framed as a question of welfare. But for trans men and gender-diverse people assigned female at birth (AFAB), it remains a deeper structural problem — one rooted in invisibility, poor medical understanding, and institutional gatekeeping. Recent accounts from Tamil Nadu, often cited as a progressive State on transgender welfare, reveal how far healthcare systems still have to go.
When healthcare begins with proving identity
The experience of Manohar, a trans man from southern Tamil Nadu, reflects a pattern seen across public healthcare institutions. When he approached a government hospital for gender-affirming care, doctors refused treatment because his appearance did not align with their idea of how a “trans man” should look. Only after securing a formal certificate of identity from the District Magistrate under the Transgender Persons (Protection of Rights) Act, 2019, did he receive care.
Such insistence on documentary recognition transforms healthcare into a conditional entitlement. For many trans persons who have not disclosed their identity to family or community, these requirements function less as protection and more as barriers to access.
Why trans men remain invisible in medical systems
The transgender rights movement in India has historically been led by trans women, who have had greater social and cultural visibility. While this has enabled important policy gains, it has also narrowed institutional understanding of gender diversity.
As a result, many healthcare professionals remain unfamiliar with transmasculine and non-binary identities. This lack of awareness affects even basic medical consultations. Misgendering, use of deadnames, judgmental behaviour, or outright refusal of treatment are commonly reported. Many trans men rely on informal networks to identify doctors who will treat them with dignity rather than suspicion.
The risks of unsupervised hormone therapy
Gender-affirming care for trans men often includes hormone replacement therapy (HRT), typically involving testosterone. However, access to safe and supervised hormone therapy remains limited in both public and private sectors.
Multiple constraints operate simultaneously:
- Doctors often provide inadequate counselling due to limited training in trans-specific endocrinology.
- Public insurance schemes may require hospital admission to access free hormones, which is not feasible for many.
- Affordable and trans-affirming endocrinologists are scarce in the private sector.
These gaps push many individuals towards self-medication. Testosterone is easily available through pharmacies and online platforms, often without prescription oversight. Without regular monitoring, this can lead to long-term complications such as cardiovascular disease, metabolic disorders, and heightened risks for those with existing health conditions.
Gatekeeping and a psychiatric lens on gender
A persistent concern is the continued framing of gender incongruence as a psychiatric disorder. In many healthcare settings, access to hormones or surgeries depends on a formal diagnosis of gender dysphoria by a psychiatrist.
Health experts argue that this approach is outdated and harmful. Care should be guided by informed consent and the individual’s understanding of their gender identity, rather than by rigid diagnostic thresholds. Gatekeeping reinforces the idea that patients must prove their authenticity, often compelling them to disclose their identity in unsafe environments.
Patriarchy and reproductive assumptions in care
For trans men and AFAB individuals, medical encounters are frequently shaped by patriarchal and heteronormative assumptions tied to their sex assigned at birth. This results in ethically troubling practices.
These include refusal of hysterectomies unless the patient has borne children, unnecessary and invasive examinations unrelated to the medical complaint, and demands to expose bodies despite expressed discomfort or dysphoria. Such practices deepen mistrust and discourage timely engagement with healthcare systems.
Why research and training lag behind
A central structural gap is the lack of India-specific research on transmasculine healthcare. Many doctors remain uncertain about how hormone therapy interacts with vaccinations, chronic illnesses, or long-term health outcomes — not due to unwillingness, but due to absence of evidence-based guidance.
Although transgender healthcare research has advanced internationally, especially in Western contexts, it has not been systematically adapted to Indian realities. Experts emphasise the need for standardised clinical protocols, mandatory gender-sensitisation in medical education, and inclusion of community members with lived experience within healthcare delivery systems.
Slow institutional change, cautious optimism
Tamil Nadu has initiated incremental reforms, including periodic gender-sensitisation training for doctors and gradual changes in practices at government gender clinics. Some earlier requirements related to clothing and appearance have reportedly been withdrawn.
In 2024, activists approached the Madras High Court seeking improved healthcare protocols for transgender persons. The court has permitted further submissions suggesting revisions to existing standard operating procedures, signalling a possible pathway for more inclusive and accountable healthcare governance.
What to note for Prelims?
- Key provisions of the Transgender Persons (Protection of Rights) Act, 2019.
- Meaning and components of gender-affirming healthcare.
- Role of State governments in delivering inclusive public health services.
What to note for Mains?
- Structural barriers faced by trans men and AFAB individuals in accessing healthcare.
- Limitations of psychiatric gatekeeping in gender-affirming care.
- Reforms needed in medical education, research, and public health policy to ensure inclusivity.
