Access to Health Services for the Hijra Community Dhaka, Bangladesh Ciara Dempsey B.A. Int., MSc

1. Access to Health Services for the Hijra CommunityDhaka, Bangladesh Ciara Dempsey B.A. Int., MSc

2. Content • Hijra culture • Aims and objectives of research • Methodology • Results • Limitations • Recommendations

3. Hijra Culture Hijra is: “the name given to a full-time female impersonator who is a member of a traditional social organisation…of hijras, who worship the goddess Bahuchara Mata. Hijras may be eunuchs with partial surgical sex reassignment; their sexuoerotic role is as women with men” (Nanda 1999, p. 169)

4. Hijra Culture • Subcontinent – Bangladesh, India, Pakistan, Nepal and Sri Lanka • Estimated hijra population – 5,000 in Dhaka • Hierarchy of hijra community • Gurus and Chelas • Source of Income • Badhai – Blessing of fertility for newborns and newlyweds • Cholla Manga – Collecting/Begging money from markets • Commercial sex work (CSW)

5. Hijra Culture Rejected from: • Family • Lack of social support • Mental health • School • Lack of education • Society • Health services • Within hijra society • Religion • Constitution

6. Aims and Objectives • To understand where the hijra access treatment or advice on health issues whether through a recognised medical practitioner, a non-medical practitioner or other routes of access. • To investigate reasons why the hijra choose one health provider as opposed to another. • To explore if health organisations provide services to the hijra population. • To explore any health needs in this community which are not being met at present.

7. Methodology • Heterogeneity sampling • Age distribution • Geographical distribution • Level of income • Castration status • HIV status • Which hijra community they associated with • Type of employment

8. Methodology • In-depth interviews (10) • Key informant interviews (5) • Service Providers • Focus group discussions (2) • Ghunguri community • 1 group of 5 gurus • Participants had undergone castration or urethral reconstruction • Shyambazari community • 1 group of 5 chelas • Participants had not undergone castration or urethral reconstruction

9. Methodology • Access • Hijra guide • ICDDR,B • Ethics • TCD and ICDDR,B • Consent forms and services information • Pilot test • Conventional Content Analysis • Hsieh and Shannon (2005) and Ezzy (2002)

10. ResultsProvision of Services • NGO Clinics (Badhan Hijra Sangha and Shustha Jibon) • Funded by FHI and USAID • Services provided • STI (sexually transmitted infection) checks and related medication • Counselling • Free condoms and lubricant • HIV Voluntary Counselling and Treatment • Free prescriptions for general health problems • Somewhere to rest • TB testing

11. Provision of Services • No hepatitis testing or treatment • Not comprehensive “The Badhan NGO provides free medicine only for STIs. Aside from these diseases, we suffer from…psychological problems, addiction etc. that are totally ignored…it is necessary to establish a modern mental health unit” • Community Politics *

12. Community Politics “They only invite us for the World AIDS Day rally. They charged 150-200 Taka donation for that rally” “We have to do something to stop the corruption in Badhan and Shustha Jibon”

13. Provision of Services • Drug Sellers (not pharmacists) • “free prescription but medicine has to be bought from here” • Traditional healers • Medical doctor • Difference in communities • Cutter / dai ma (midwife) • Rome American Hospital • Urethral reconstructive surgery (500) • Vaginoplasty (0) • Breast enhancement (0) • Hormone therapy (not recommended)

14. Barriers - Financial • Extra prescriptions for STIs • Different experience between communities • “Local private medical doctor usually give me a discount. I always pay 50% bill” • RAH • Local hijra tax • Financing options available • “50% today, 50% later”

15. Barriers - Accessibility • Distance • Convenience and cost • Availability • One day a week • 12-14 patients • Identify as male or men who have sex with men. • Urban V’s Rural • “If anyone exposes her hijra identity there, it would be hard for her to live and access medical services” • Travel to India

16. Barriers- Discrimination • Doctors at NGOS were “very much sensitised” • Private clinics and hospitals • “They neglect us, regarding us as sex workers. Sometimes the doctors behave as if we are creatures of a different planet…In Government hospitals we need to stand in a queue to see a doctor and there we have to face a dilemma; whether we should stand in the gent’s or ladies line, or both of them sometimes do not allow us enter their line” • Disclosure of being CSW • Lack of training

17. Transitioning – Hormone Usage • Contraceptive Pill • Mayabori and Shukhi • Guru • Hijra friend • Drug seller • NGO – not promoted now • Side effects • Kidney/liver damage (6) • Headaches (4) • Breasts development not guaranteed (1) • No knowledge (4) • No answer (2)

18. Transitioning – Hormone Usage • Steroids • Only two participants • Decartion • Fyrectin • Oradexon – Cow steroid, illegal • More beautiful = more sex clients • Side effects mentioned • Spots • Loss of physical fitness • Gained weight

19. Transitioning – Castration • Ritual • Non-medical, member of hijra community • Bahuchara Mata Goddess • 40 days of rest • Side Effects • Pain • Urethral problem • Bleeding • Infection • Death • Legality

20. Transitioning – Urethral Reconstruction at RAH • Early days: • Carried out at night • No STI/HIV tests pre procedure • No mental health check • Today: • Local hijra approve of procedure • STI/HIV tests are carried out • No mental health check • Some urethral problems • Advised to stay 3-4 days, most leave early • Legality

21. Transitioning – Vaginoplasty and Breast Enhancement at RAH • Neither performed to date • Expensive procedures • Some interested • Concerns • Expected ability to give birth • Hygiene • “Everybody would like to have sex with her. So it would be necessary to wash that everyday otherwise she would get some infection”

22. Limitations • Feud between hijra communities • Time • Skewed answers • No financial assistance • Translators • Cutter/dai ma • Dhaka district • Location of FGDs

23. Recommendations – Future Research • Why hijra do not avail of certain services • HIV VCT and counselling • Vaginoplasty • This research did not cover in depth • Dental health • Mental health • Addiction services • Difference between communities • Neutral venue for FGDs and IDIs

24. Recommendations – Implementation • One-stop shop • Trialled in New York (Melendez and Pinto 2009) • Improve distribution of information • mental health facilities, HIV VCT services and transitioning services • Provide Hepatitis service • Difference of opinions • Further health promotion with community • Medical Universities curriculum

25. Recommendations – Implementation • Financing system • General health • Transitioning services • Discussion with hijra near RAH • Audit by donors • Community Politics • Future projects • Rolling Continuation Channel Program

26. Conclusions • Increased knowledge • First of its kind in Bangladesh • Highlighted gaps and barriers in healthcare provision • Use of findings by other subcontinent countries • Global, human rights issue

27. Acknowledgements • Participants • Centre for Global Health, Trinity College Dublin, Ireland • Eilish McAuliffe (BSc, MSc, MBA) • Susan Bradley (BSc, PGCE, MSc) • International Centre for Diarrhoeal Disease Research, Bangladesh • Dr. SharfulIslam Khan (PhD, MD, BSc) • Md. NazmulAlam (BSc) • Hijra Guide and Translators • KanokBala • Md. Rashid Mamun • Md. JishanTalukder