Despite the promise of inclusive healthcare under the Ayushman Bharat scheme, transgender and gender-diverse individuals in India continue to face systemic barriers due to flawed implementation and policy gaps.
In an earlier article, we highlighted the struggle of the transgender community to access gender affirmation procedures. Here, we explore the disconnect between international guidelines, legal mandate, and the reality on the ground, and how gender-affirming healthcare can be made safer and inclusive.
SOP that is not based on international guidelines
The policy framework and Standard Operating Procedures (SOP) for the Ayushman Bharat scheme for transgender persons are not backed by scientific research. Moreover, they do not comply with Transgender Persons Act, 2019. The act does not mandate a transgender certificate to get gender- affirming healthcare. However, having a transgender certificate is mandatory to be eligible for the Transgender Healthcare (TG Plus) card. This could gatekeep many transgender individuals from availing the benefits of the scheme, experts say.
The Act mandates the creation of a health manual following the World Professional Association for Transgender Health (WPATH) guidelines. However, the Standard Operating Procedures for Medical Treatment of Transgender Persons issued by the Directorate General of Health Services (DGHS) do not align with these guidelines. Experts and activists working for the welfare of transgender persons point out that the SOPs not only violate the provisions of the Act, but also restrict many from accessing gender-affirming healthcare.
What is gender incongruence?
Gender incongruence (GI) is a term that describes a person’s persistent experience of an incompatibility between that person’s gender identity and the gender expected of them based on their birth-assigned sex. While the WPATH guidelines recognise GI through informed consent, the DGHS SOP requires proof, such as certificates from a mental health professional.
Zainab Patel, trans activist and one of the petitioners in the landmark NALSA case and the marriage equality case, highlights this contradiction. “While the DGHS SOP mandate a psychiatric evaluation, the WPATH guidelines are against it. Also, it is not required to possess such a report to get a transgender certificate from the National Portal for Transgender Persons. Thus, the DGHS guidelines effectively gatekeep transgender persons from getting surgeries by mandating the psychiatric evaluation,” says Zainab.
Now, let’s break down some important points in the WPATH guidelines:
- Assessment for GI focuses on informed consent rather than treating it as a disorder. It explicitly cautions against requiring lengthy “proof” of gender identity.
- Contains separate chapters for children/adolescents (e.g. puberty blockers, parental consent) and for non-binary populations.
- Encourages mental health support, but does not require therapy or prolonged assessment for care.
- The readiness for surgery should be based on informed consent and should not enforce a stringent pathway.
- Advocates the recognition of the needs of a gender-diverse population without sticking to a set of procedures based on a linear, binary-focused pathway.
Read more: High cost of ‘free’ healthcare: Many hurdles to accessing Ayushman Bharat
DGHS SOP vs international guidelines
The DGHS SOP is in contrast with the above-mentioned WPATH guidelines:
- The DGHS SOP requires a certified diagnosis of GI by a mental health professional or one year of hormonal therapy followed by a certificate. This leads to certification for one’s gender identity and hence mandates certificates to get gender-affirming healthcare.
- According to WPATH guidelines, GI is not considered a medical disorder. Assessments should be based on informed consent, with patients fully understanding risks and options. The guidelines discourage demanding extensive “proof” of identity. While certification may be relevant in legal contexts, requiring it for healthcare violates the Transgender Persons Act.
- The DGHS SOP requires an individual to be above the age of 18 years to be eligible for gender- affirming surgery. But the WPATH guidelines have detailed recommendations for children and adolescents. They recommend involving guardians in the assessment and treatment process. Also, the Transgender Persons Act recognises the ability of a minor to apply for a transgender certificate through parents or guardians.
- While the international guidelines have separate chapters for gender non-binary and intersex populations, the DGHS guidelines do not have enough provisions to support the healthcare needs of a gender-diverse population.
Thus, the Ayushman Bharat scheme will deny benefits to people without certificates from mental health professionals, adolescents and gender-diverse people.
“The DGHS guidelines should be revised to align with the WPATH’s informed consent model, to make it more inclusive,” Zainab adds.
Excluding the gender-diverse population
Another concern is the lack of understanding of needs of the queer community. Sree Parvathi, a gender-fluid individual, underwent breast mammoplasty (reduction surgery) at Government Medical College, Trivandrum, five years ago. The procedure was botched, she says. Her experience underscores the urgent need to recognise the unique requirements of gender-diverse populations and establish clear medical guidelines to ensure safe, affirming care.
Healthcare policies must be inclusive and responsive to these specific needs, rather than excluding gender-diverse communities. This also requires schemes like Ayushman Bharat to expand and include such communities, experts suggest.
Cosmetic procedures as life–saving procedures
In 2022, the Central government announced provisions for cosmetic surgery under the Ayushman Bharat scheme. It also claimed that India will be the world’s first country to provide free-of-cost facilities like cosmetic surgery to the transgender community. But this underlines a lack of understanding that for transgender persons, all gender-affirming care should be considered as life-saving procedures.
“What is a cosmetic procedure for a cis-het person will be a life-saving procedure for a transgender person,” says Dr Sanjay Sharma, CEO and Managing Director of Association for Transgender Health in India (ATHI). Calling these procedures cosmetic denies transgender individuals GST exemption, so they are left with the financial burden of essential gender-affirming procedures.
Read more: Proper healthcare for trans persons still a distant dream in Chennai
Holistic approach for a quality healthcare
Several cases of medical negligence against transgender and gender diverse people have been reported in India in recent years. Healthcare procedures vary across hospitals, and there’s no uniform system to assess their quality.
Dr Sanjay notes that bringing all kinds of transgender healthcare, including mental health, endocrine care, gender affirming surgeries, plastic surgery, pharmacology, etc., under one roof is important. And many private institutions that provide transgender healthcare lack a holistic and interdisciplinary approach.
Accessing endocrine care and gender-affirming surgeries is complex and costly for transgender persons, as they have to look for the services themselves. This makes it more difficult to make benefit claims under Ayushman Bharat
Public healthcare institutions like AIIMS, JIPMER, etc., have world-class facilities and multi-speciality healthcare systems. Dr Sanjay adds that these institutions have a greater scope to provide holistic healthcare to transgender persons. They could also provide training to private healthcare practitioners. “Different departments also have trained social workers, which could be of great help.”
A national programme for transgender and gender diverse healthcare
Dr Sanjay calls for a national programme that could help identify and recognise transgender and gender diverse persons and provide them with healthcare without gatekeeping. Revising the SOP based on international guidelines and scientific procedures should be the first step.
India must move beyond symbolic inclusion. While it is important to speed up the implementation of Ayushman Bharat scheme for transgender persons, going forward, policy reforms must prioritise the following to make the scheme truly inclusive and ensure equitable healthcare for transgender and gender-diverse populations.
What needs to be done, moving forward
- Stricter implementation of Transgender Persons Act 2019 and Rules 2020.
- Inclusion of gender-diverse persons in policies
- Including transgender and gender-diverse healthcare in medical curricula.
- Revising the SOP for transgender healthcare by DGHS based on WPATH guidelines.
- Identifying potential public healthcare institutions to develop them into one-stop healthcare centres for all queer-affirmative healthcare.
- Training of doctors and healthcare workers to provide competent medical care to transgender persons.
- Developing need- and informed consent-based regulations for healthcare procedures for the community.
- Increasing the budget for transgender people’s welfare.
Addendum: Since the publication of this article, the Directorate General of Health Services has responded to our queries, saying that the SOP for medical treatment of transgender persons prepared by the directorate and available on its website align with WPATH Standards of Care. “The guidelines have been adapted to the country. The SOP is a dynamic, living document, which will be subject to revision reflecting ongoing research, societal changes, feedback from users and stakeholders, and changes in global guidelines. Any revision process will involve subject experts and stakeholders,” Amita Bali, Deputy Director General (Planning), DGHS, said in an email to Citizen Matters.