Transcript Access to Health Services for Hijra Community Dhaka

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Content
• Hijra culture
• Aims and objectives of research
• Methodology
• Results
• Limitations
• Recommendations
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Hijra Culture
Hijra is:
“the name given to a fulltime 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)
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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
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– Commercial sex work (CSW)
Hijra Culture
Rejected from:
• Family
– Lack of social
support
– Mental health
• School
– Lack of education
• Society
– Health services
– Within hijra society
• Religion
• Constitution
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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.
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Methodology
• Heterogeneity sampling
– Age distribution
– Geographical distribution
– Level of income
– Castration status
– HIV status
– Which hijra community they associated
with
– Type of employment
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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
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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)
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Results
Provision 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
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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 *
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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”
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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)
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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”
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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
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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
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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)
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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
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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
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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
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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”
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Limitations
• Feud between hijra communities
– Time
– Skewed answers
• No financial assistance
– Translators
– Cutter/dai ma
– Dhaka district
• Location of FGDs
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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
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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
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Recommendations –
Implementation
• Financing system
– General health
– Transitioning services
• Discussion with hijra near RAH
• Audit by donors
– Community Politics
• Future projects
– Rolling Continuation Channel Program
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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
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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. Sharful Islam Khan (PhD, MD, BSc)
– Md. Nazmul Alam (BSc)
• Hijra Guide and Translators
– Kanok Bala
– Md. Rashid Mamun
– Md. Jishan Talukder
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