Correspondence Address:
Abhik Sinha
281 Dumdum Park, Flat No C 13^rd Floor, Kolkata - 700 055
India

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Transgender (TG) people experience a gender identity that is different from their anatomical sex. They usually live or prefer to live in a gender role different to the one they are assigned at birth. TG is an umbrella term that can include transsexuals, cross-dressers, intersexed persons, gender variant persons, and many more.[1] Members of this population subgroup confront multiple health risks including HIV/AIDS and constitute a particularly overwhelming social and medical issue.[2] Estimates of HIV prevalence in the male-to-female TG population range from 11% to 78%.[3] Epidemiological data on other sexually transmitted infection (STIs) indicate high rates of syphilis, rectal gonorrhea, rectal chlamydia, and other STIs among Asian TGs.[1] India is no exception. As per data obtained from National AIDS Control Programme-III (NACP-III), TGs have the highest prevalence of HIV/AIDS among all the high-risk groups: thus, they are being given special importance in NACP-IV.[4] Ethnicity, socioeconomic status (i.e., having less than a high school degree), changing sexual partners frequently, and lifetime history of injection drug use, etc., are established correlates of HIV-positive status of this section of people.[5]

With this backdrop, the present study on such an important public health problem was planned in the city of Kolkata with the objectives of to find the pattern of sexual behavior among the TGs and to assess few aspects of their vulnerability to HIV/AIDS.

This was a community-based, cross-sectional survey done in the field practice area of “Kosish,” a nongovernmental organization (NGO) run by the TGs in Alipur area of South Kolkata metropolitan city of Eastern India. The targeted intervention (TI) program under the NACP-III for TGs was being implemented by this NGO. The study duration was 3 months from June to August 2012. Kosish had 21 hotspots (cruising areas of TGs for customers) in total. Out of them, 11, i.e., approximately 50% were selected by simple random sampling technique for the purpose of the present study. The hotspots were in the areas such as Budge Budge, Nungi, Akra, Kidderpore, and Santoshpur. All the TGs in the selected hotspots who gave informed consent were included in the study, and thus ninety such TGs could be involved. Information pertaining to sociodemographic characteristics and sexuality was gathered through focused group discussions and interviews of the individual study participants using a predesigned questionnaire in the local language developed by the National AIDS Control Organization. Interview of study participants was conducted after obtaining their written informed consent in the presence of a peer member and Out Reach Worker (ORW) after assuring confidentiality and anonymity. Blood samples were also collected from each study participants as per recommended standard procedure and sent to a private laboratory for venereal disease research laboratory (VDRL) testing along with proper disposal of biomedical wastes produced thereby. For the present study, ethical clearance was taken by West Bengal State AIDS Prevention and Control Society. Data were analyzed by SPSS software version 18.0.

Among the study participants, 55.6% were Kothis, 14.4% Hijra, and 15.6% Dupli. Analysis revealed that average age (mean ± standard deviation [SD]) of the study participants was 24.5 ± 7.5 years. Nearly 32.2% of the participants had read up to XII standard and 4.5% were illiterate. However, 80.0% of them had a job although about one-third reported to have a poor monthly income in the range of Rs. 3001–Rs. 5000. Nearly 21.1% of them solicited client in more than one location in the past 1 month. While analyzing the sex behavior practiced by the study participants, it was found that all of them had practiced anal receptive sex, whereas 73.3% had practiced oral receptive sex in the past 3 months [Table 1]. The age (mean ± SD) of first penetrative sex as revealed from the analysis was 13.38 ± 2.04 years. When asked about bisexual sex behavior, 25.5% of the participants reported to have vaginal/anal sex with a female during the past 3 months. Only 14.4% of the participants had a regular sex partner in the last 1 year. Among the study participants who exhibited bisexual behavior only in 15.6% cases, there was consistent condom use [Figure 1]. The bisexual study participants had sex with his girlfriend in 45.4% cases and in 24.4% cases with female sex workers. In case of TGs who did not have bisexual behavior, the consistent condom use was only 14.4%. Almost 22.2% of the study participants had a history of drug abuse in the past 1 year.{Table 1}{Figure 1}

It was revealed that 16.7% of the study participants had experienced sexual violence in the past 3 months. Almost 15.6% of them not at all informed the incidence of sexual violence while 6.7% informed health/TI workers regarding the fact. In 5.6% of the cases, the source of sexual violence was the partner, whereas in 3% cases, it was local antisocials and police in 4% cases. Among those who went for redressal, only 4.4% stated that there was redressal when informed about the sexual violence.

In the events of violence, the partner was always under the influence of drug/alcohol in 20% cases, and in 30% cases, they were sometimes under such influence.

Seventy Percent of the participants stated that they accept money for doing sex. Condom use among the commercial male partners was 15.4% and that among noncommercial male partners was 13.4%.

Analysis revealed that 41.1% respondents had the experience of breakage of condom in the past 1 year. It was found that 80% of the participants used lubricants during condom use.

When enquired about the source of condoms, it was found that supply of free condoms from TI program was not always persistent, but majority (70.0%) of the TGs got free condoms from TI workers. During lack of free supply, they had to buy condoms when needed. Here, also maximum (42%) of them bought condoms from TI workers. The other sources of buying condoms were chemist shops, private clinics, etc. It was explored that the NGO used to disburse major share of purchased condoms free of cost to the TG beneficiaries under the TI project. Moreover, the NGO allowed the ORWs to sell a certain portion of condom to the TGs at nominal cost. This was an innovative effort to make the ORWs financially self-reliant, as stated by the portfolio holders of the NGO. This was why sometimes TGs had to buy condoms from the ORWs. Nearly 71.1% of the participants stated that TI project workers met them >2 times in a month and 7.8% reported that they met twice in a month.

Out of the condom nonusers, majority (14.4%) could not use condom due to reported partner's preference and lack of idea about the beneficial role of condoms (10%).

It was revealed that 14.4% of the study participants had symptoms of STIs in the past 1 year. When enquired about the treatment, 7.8% had sought treatment from General Physician, 53.3% from sexually transmitted disease clinics including the one run by the NGO, and 10% from primary health care.

Blood sample for VDRL testing could be collected from 81 out of the 90 TGs under study. Nine TGs participated in the study but refused giving blood sample for VDRL. Out of 81 blood samples collected, 9 (11.1%) were VDRL reactive.

In the Pehchan project study in West Bengal by Biswas et al., the mean age of the study participants was 27 years.[6] In their study, Setia et al. observed the mean (±SD) age of the study participants as 25.3 (±4.6) years.[7] It was revealed that 33.3% TGs were in low monthly income group of INR 3001–5000. Wilson et al. in their study observed that 70% of the TG female youth had low monthly income, 43% had a history of homelessness, and 49% reported experiencing problems finding employment due to their gender identity.[8] In the present study, only 14.4% had a regular sex partner in the past 1 year. A study done by Sarkar et al. reported that 27% had regular sex partner.[6] In the present study, 21.1% used condom during last anal sex. Khan et al. observed that most of the Hijras understood the importance of condoms, but none used condoms consistently.[9] This study revealed that 16.7% of study participants had experienced sexual violence in the past 3 months. Clatts et al. in Vietnam reported that 11.4% of the TGs under study were subjected to violence.[10] The present study revealed that 11.1% prevalence of STI in TGs, whereas in the study by Setia et al. in Mumbai, it was 57% with very high HIV seroprevalence of 68% among Hijras.[7]

Thus, in these people, high-risk behavior as well as suboptimal program function increases their vulnerability to HIV/AIDS. More organized efforts should be directed to make these people self-reliant in terms of economic stability and empowerment in sex behavior to protect themselves and the community as well.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References