India's trans and queer people should demand better health care

After almost three decades of fighting, queer people in India won a long overdue battle when the Supreme Court of India decriminalized same-sex sexual acts among consenting adults in 2018. Since then, I have often been asked where I see India’s queer movements going. Is it going to be marriage equality? Something else?  With recent celebrations of Pride Month in mind, I argue for the need of queer people to demand a better, more inclusive and more affordable public health care system.

Honestly, this shouldn’t come as a surprise. We know that queer people have been disproportionately affected by the current Covid-19 pandemic and the lack of a robust public health care system. During the pandemic, working-class transgender people in India have lost major sources of income (sex work and ceremonial begging) and are at a risk of being evicted from their rented houses. Many queer people have had to stay at their homes with abusive family members for an extended period of time during the lockdowns, and this has had a severe effect on their mental health. Many working-class queer and transgender people live in communes with a large number of other people, which makes maintaining physical distancing quite a task, increasing the chance of Covid transmission. Also, queer and transgender people who are living with HIV are at a higher risk of severe illness from the coronavirus.

Moreover, many queer and transgender people are refused health care at public hospitals, and many cannot afford expensive private hospitals. Even when health care is available at an affordable price, queer people are met with infrastructural issues. For example, most public hospitals are not equipped with specific wards for transgender people, or do not allow transgender people to be accommodated in wards of the gender that they identify with. The medical and nonmedical staffs in these hospitals are rarely sensitized and trained to handle issues specific to queer and transgender people.

While stigma and discrimination make it very difficult for most queer and transgender people in India to access health care, even during the pandemic, the situation is compounded by the government’s apathy, non-implementation of policies, and a systemic and systematic breakdown of the public health system. Both the 2013 NALSA vs. Union of India judgment from the Supreme Court and the Transgender Person’s (Protection of Rights Act) 2019 mention that the government should work towards providing affordable and accessible health care to transgender individuals, while also training health care staff to be sensitive towards issues faced by transgender persons. Similar provisions are also suggested by the 2018 judgment of the Court. However, these provisions have not been implemented.

Moreover, the public health infrastructure in India is terribly understaffed. To compound the issues of access further, the public health system in India is being increasingly privatized. This privatization limits the access of health care for those who cannot afford private health care. Decision-making about health care has become increasingly centralized, with the Prime Minister’s Office and the Ministry of Health and Family Welfare making most of the decisions, while voices from the margins and the grassroots are increasingly being ignored.

The irony in not asking for an affordable and accessible health care system is the fact that there is a huge intersection between various Indian public health movements and queer-rights movements. An example of this is the queer and trans mobilizations that happened around the HIV/AIDS pandemic in the late 1980s, 1990s and 2000s. As HIV/AIDS was recognized as an epidemic in the country and the various phases of the National AIDS Control Program were being implemented, certain queer and transgender communities ( “men who have sex with men” and “transgender”) were identified as high-risk groups.

Various public health and civil rights groups, nongovernmental organizations (NGOs) and community-based organizations (CBOs) not only received international and government funding for targeted intervention in these “MSM” and “TG” groups, but also used these funds to build solidarity and awareness, as well as employing queer-trans people as outreach workers. During a time when it was the state’s and the society’s firm belief that both homosexuality and HIV/AIDS are foreign imports because the moralistic Indian society has no space for them, the queer movement could articulate itself publicly through the HIV/AIDS narrative. In fact, the first few petitions asking for the decriminalization of same-sex sexual acts between consenting adults were filed by NGOs and civil-rights groups whose focus was HIV/AIDS intervention.

Of course, this almost solitary focus on HIV/AIDS is not without critique. The intervention approach was biologically essentialist and reduced queer and transgender people to the kinds of sex they were having rather than engaging with larger questions of identity and politics. Public articulations of queerness became primarily focused on gay men and some transfeminine identities, while leaving out lesbian and bisexual women, and many transmasculine and nonbinary identities. The focus on HIV/AIDS has also limited what demands queer and transgender people can make from the public health system; the demands have gotten restricted to accessible antiretroviral therapy (ART), hormone replacement therapy (HRT) and sex-reassignment surgeries (SRS). 

There are various problems with NGOization of the queer movement in India as well. Some of these NGOs have been called out for corruption. Moreover, most of the NGOs that gained prominence through the HIV/AIDS intervention movement were led by elite, metropolitan queer- (and sometimes) trans people, which alienated NGOs and CBOs from rural and suburban places. These NGOs also did not engage with caste-class dynamics, therefore leading to the queer-trans mobilizations losing out on intersectional nuances. These NGOs often also functioned in an exploitative manner. Outreach workers, who primarily consisted of working-class queer and transgender people, were paid meager salaries while putting in most of the effort at the ground. Moreover, there was hardly any push for a better public health care system from these NGOs barring calls for an increased number of HIV-testing centers and ART centers.

In moves that further affect queer people negatively, the Indian government has also canceled the registration of many NGOs that were working for the rights of queer and transgender people. Along with this, according to the current regulations of the Indian government, any NGO participating in “political activities” cannot accept foreign or transnational funding. Moreover, despite India having the third-highest number of people living with HIV/AIDS in the world (2018 data), the broadcasting of condom ads has been prohibited from 6 A.M. to 10 P.M..

In these moments, it is crucial that queer people mobilize and call for a robust, affordable and accessible public health system—a public health system that does not just intend to intervene, but that involves queer and transgender people in the decision-making process. We need a public health system where queer and transgender people are not discriminated against, and a public health system that not only promises free ART, HRT and SRS, but also engages with sexual and mental-health care needs, has sensitized staff in public hospitals and does not harm the dignity of queer and transgender people. Not all of us will benefit from rainbow-dyed hair, free offers from corporate businesses, and marriage equality, but all of us will benefit from a kind, supportive and accessible public health care system.