Many transgender people who are using hormones are mostly attracted by its short-term benefit of amplification in their feminine look and seem to be ignorant about its dark side
Nepal is a very liberal country in terms of recognizing and providing rights to sexual and gender minorities. While many countries around the world are on denial on the existence of these populations in their countries, constitution of Nepal has impressively recognized the rights of Sexual and Gender Minority (SGM) as fundamental rights. Nepal currently acknowledges its transgender community by allowing a third category of ‘others’ (meaning gender other than male or female) on passports, citizenship certificates, electoral rolls and immigration forms. Despite being liberal in recognizing and providing rights to this population, there are many issues that are being overlooked. In many countries around the world the transgender individuals, sex workers and men having sex with men have high prevalence of HIV in comparison to other population. So the response globally has always focused on providing education on HIV, other sexually transmitted infections and safe sex behavior. Different dimensions related to male to female transgender individuals are mostly neglected with the focus being on HIV and Sexually Transmitted Infections (STI) prevention.
The obsession for beauty pushes many transgender individuals to adopt different practices such as hormone therapy, injecting silicone, gender-affirmation surgery, breast augmentation, mechanical therapy for body or facial hair, and voice therapy. However, due to the high costs especially for gender-affirming surgery and the experience of healthcare-related stigma, hormone use among transgender individuals is gaining popularity. In our study with Nepali transgender people, we found that one of the most common practices among all transgender people is the haphazard and rampant use of hormones. Access to information about hormones and their use through healthcare providers is alarmingly poor. Decision to take hormones is largely influenced by their peers and their self-medication is unsupervised, suggesting they are unaware about the types of the hormones they use, their side effects or required doses.
Hormones are either brought from local pharmacies or from abroad mostly from Thailand with the friends who visit there. The notion that one can buy better ‘quality hormones’ abroad influences their decision to use these particular ones. There is no any counseling on the use of hormones. Many transgender people who are using hormones are mostly attracted by its short-term benefit of amplification in their feminine look and seem to be ignorant about the dark side of it. They may have different health problems in the long run which they are currently undermining. For example, studies in other countries have reported numerous health risks of hormone use such as venous thromboembolism, elevated liver enzymes, gallstones, decrease in hemoglobin, low sexual desire, reduction in facial/body hair, increased rate of myocardial infarction or depression. However, some studies have also reported positive effect of hormone therapy on quality of life of transgender population. Therefore, more information and counseling needs to be provided to this population regarding hormone use so that they can have more informed choices.
The obsession for beauty sometimes compels transgender people to go to the next level where they take different surgical measures which may range from a minor surgical procedure to major one like sex reassignment surgery. Someone may claim that just like any other girl it is normal for a transgender women to choose hormone use or opt for any type of surgery. It is her right. Of course, it is a right of transgender women to go for any kind of surgery or beauty amplification process. However, due to the existing stigma and discrimination, many transgender individuals in Nepal may seek these services from unqualified health providers or perform it clandestinely in non-medical environment. Furthermore, before receiving any of these services neither they receive proper counseling nor they know where to seek health services in case of complications. For example, some of our study participants took extra doses of hormones to see immediate physical changes. Thus, all these practices need to be made safe by providing proper education and information.
Although millions of dollars are currently being invested for prevention of HIV and STI in this population and trained peer educators are providing basic HIV and STI education, they do not provide any education and information on hormone use, complications of hormone use and other surgical procedures. There has been no any effort from either development partners or government to integrate hormone counseling in the existing models of providing HIV and STI services. Although transgender population in Nepal constitute a small proportion, to achieve universal health coverage as envisioned in the Sustainable Development Goals (SDG), it is imperative to understand the need of health care and their risk behaviors. Existing interventions targeting transgender individuals in Nepal may act as a platform when providing information, education and communication around hormone therapy. The latter needs to be embedded into the existing services to support Nepali transgender people and to offer them informed choice in gender-affirming care.
Regmi is Bournemouth University, UK-based public heath researcher and Neupane is MEL officer at Australian Federation of Aids (AFAO), Bangkok