Health Problems and Healthcare Seeking Behavior of Transgender People of Bangladesh

Faculty of Arts and Social Sciences
AMERICAN INTERNATIONAL UNIVERSITY- BANGLADESH (AIUB)
DISSERTATION ON
HEALTH PROBLEMS AND HEALTH CARE SEEKING
BEHAVIORS OF TRANSGENDER PEOPLE OF
BANGLADESH
An Internship Report Presented to the Faculty of Arts and Social
Sciences in Partial Fulfillment of the Requirements for the Degree of
Master’s in Public Health
Supervised by
Dr. Md. Nazrul Islam PhD
Submitted by
Taniya Islam
14-97828-2
Department of public Health
Date of Submission: January 8, 2016

DISSERTATION ON
HEALTH PROBLEMS AND HEALTH CARE SEEKING
BEHAVIORS OF TRANSGENDER PEOPLE OF
BANGLADESH

Letter of Endorsement
The Dissertation entitled “Health Problems and Health Care Seeking Behavior of Transgender
People of Bangladesh” has been submitted to the Office of Placement & Alumni, in partial
fulfillment of the requirements for the degree of Master’s in Public Health, Major in
Epidemiology, Faculty of Arts & Social Sciences on 08/01/2016, by Taniya Islam,
ID # 14-97828-2. The report has been accepted and may be presented to the Internship Defense
Committee for evaluation.
(Any opinions, suggestions made in this report are entirely that of the author of the repot. The
University does not condone nor reject any of these opinions or suggestions).
…………………………………..
Dr. Md. NAZRUL ISLAM PhD
Internship Supervisor

Approval Sheet
This Dissertation Report entitled “Health Problems and Health Seeking Behavior of
Transgender People of Bangladesh” in partial fulfillment of the requirements for the
degree of Masters in Public Health, Faculty of Arts and Social Sciences has been evaluated by a
panel of examiners with a mark of __________ (Latin Nomenclature).
_____________________
Research Supervisor
______________________ ______________________
Member (External) Member (Internal)
Research Defense Committee Research Defense Committee
______________________
Chairman
Research Defense Committee
The Dissertation Defense was conducted on _________________ at the
American International University-Bangladesh, Dhaka.
Attested By: Approved By:
_________________________ _________________________
Prof. Dr. Tazul Islam Dr. Carmen Z. Lamagna
Dean, Faculty of Arts and Social Sciences Vice Chancellor
American International University-Bangladesh American International University-Bangladesh

Declaration
I hereby declare that the research work reported in this Dissertation has been performed by me
and this work has not been submitted elsewhere for any other purpose.
I do hereby warrant that the work presented here does not breach any existing copyright.
Taniya Islam
ID- 14-97828-2
Session: 2014-2015
AIUB, Dhaka.

I
Acknowledgment
First of all, I am grateful to Almighty Allah for enabling me to complete this dissertation. I wish
to take the opportunity to express my gratitude to the respected Dean of Faculty of Arts and Social
Science, Department of Public Health of American International University –Bangladesh, Banani,
Dhaka and all faculty members of the dissertation committee of AIUB for their kind approval of
the topic of my dissertation entitled “Health Problems and Health Seeking Behavior
of Transgender People of Bangladesh”. With deepest pleasure and infinite pride, I
express my heartfelt gratitude and profound regards to my reverend guide Prof. Dr. Nazrul
Islam,Faculty of Department of Public Health of American International University -Bangladesh
for his scholastic guidance, persistent supervision and valuable suggestions throughout the whole
period of the study. In spite of his busy daily schedule he was kind enough to spare his valuable
time in helping me to prepare the dissertation.
I would also like to thank the transgenders who helped me with their valuable time and
information and support during the survey.
Taniya Islam

II
Table of Contents
Contents Page No
Acknowledgement I
List of Content II
List of Tables III
List of Figures VI
Abstract VII
Chapter 1 : Introduction
1.1 Introduction & Background 1
1.2 Research Question 5
1.3 Objectives of the study 5
1.4 Justification of the study 6
1.5 List of variables 6
1.6 operational definitions 7
1.7 Conceptual Framework 9
Chapter 2: Literature Review
Literature Review 10
Chapter 4: Methodology
3.1 Study Design 15
3.2 Study Period 15
3.3 Study locale 15
3.4 Study Population 15
3.5 Study Sample 16
3.6 Sampling Technique 16
3.7 Sample Size Calculation 16
3.8 Eligibility Criteria 17
3.9 Research Instrument 17
3.10 Questionnaire Design 17
3.11 Data Collection Technique 18
3.12 Data Entry 18
3.13 Data Verification 18
3.14 Data Analysis 18
3.15 Data Presentation & Interpretation 19
3.16 Data Quality Management 19
3.17 Study Limitation 19
3.18 Ethical Issues 20

III
Chapter 4: Result
Results 21
Chapter 5: Discussion Conclusion & Recommendations
5.1 Discussion
5.2 Conclusion 64
5.3 Recommendation 70
References 70
Annexure
Annexure A-1: Questionnaire in English
Annexure A-2: Questionnaire in Bengali
List of Tables
Contents Page No
Table-1: Distribution of the Transgenders According to their
Age
21
Marital Status
22
Level of Education
23
Occupation
23
Monthly Income
24
Number of Dependents
25
Housing Condition
26
Living Status of Transgender People
26
Source of Drinking Water
27
Latrine Type
27
Perceived Unsafety
28
Table-12: Distribution of the Transgenders According to the
Perceived Safety by Other People
28

IV
Experience of Violence
29
Violent
30
Forced to Sex
30
Inflicter
31
Health Problems
32
Skin problems
33
Eye Problems
33
Dental Problems
34
Sexually Transmitted Diseases
34
Seeking of Medical Help during Transition
35
Effectiveness of Medical Treatment during Transition
36
Chances of Getting HIV
36
Substance Abuse
37
Identify Health Seeking Behaviors
38
Knowledge of Health Care Delivery System of Bangladesh
38
Subject’s Medical Help Seeking
39
Provider Choice of the Respondent
39

V
Table-30: Distribution of the Transgenders According to having
Family Doctor
40
Gender of the Family Doctor
40
Satisfaction Regarding Service of Family Doctor
41
Treatment Believed as Most Effective
41
Experience of Receiving Treatment from an Unknown Doctor
42
Satisfaction Regarding Service of Unknown Doctor
42
Food Habit
43
Use Condom While Having Sex
44
Dental Check Ups
45
Satisfaction Regarding Service of Dentist
45
Awareness about Health Rights
46
Source of Refusal
47
Knowledge of When to Seek Help
47
Family Support
48
Community Support
48
Affordability of Prescription Medications
49
Table-46: Distribution of the Transgenders According to their 50

VI
Idea about the Government Allowance
Table-47: Relationship between Age of the Transgenders and
their Health Seeking Behavior
51
Table-48: Relationship Between Marital Status of the
Transgenders and their Health Seeking Behavior
52
Table-49: Relationship Between Education of the Transgenders
and their Health Seeking Behavior
53
Table-50: Relationship between Income of the Transgenders
and their Health Seeking Behavior
54
Table-51: Relationship between Living Status of the
55
Table-52: Relationship Between Experience of Violence of the
56
Table-53: Relationship between Being Unsafe in the Public
Places of the Transgenders and their Health Seeking Behavior
57
Table-54: Relationship between Experience of Forced Sex of
the Transgenders and their Health Seeking Behavior
58
Table-55: Relationship between Suicidal Tendency of the
59
Table-56: Relationship between Satisfaction of the
Transgenders with the Service of Unknown Doctors and their
Health Seeking Behavior
60
Table-57: Relationship between Substance Abuse of the
61
Table-58: Relationship between Experience of Refusal to Treat
of the Transgenders and their Health Seeking Behavior
62
Table-59: Linear Regression 63
List of Figures
Contents Page No
Figure-1: Distribution of the Transgenders According to their
Assigned Sex
22
Figure-2: Distribution of the Transgenders According to their 25

VII
Housing Status
Family Attitude towards them
29
Frequency of Experiencing Health Problems
31
Immunization Status
35
Frequency of Suicidal Ideation
37
Frequency of Regular Exercise
43
Adherence to Medications
44
Frequency of Being Refused to Treat
46
Figure- 10: Distribution of the Transgenders According to the
Availability of Doctors Near their Residence
49

VIII
Abstract
Title: Health Problems and Health Seeking Behavior of Transgender People of Bangladesh.
Introduction: Transgender is the state of one's gender identity or gender expression not matching
one's assigned sex. Marked out because of their sexual difference, they are a despised and
neglected minority. Studies show that LGBT people experience health issues and barriers related
to their sexual orientation and/or gender identity or expression. Transgender individuals are often
reluctant to seek medical care avoid or delay care or receive inappropriate or inferior care or are
denied access by providers due to transphobia/homophobia or a lack of knowledge or experience
with transgender health. In other words reason is negative personal experience, the assumption or
expectation of negative experience based on knowing of history of such experience in other
LGBT people, or both.
Objective: To find out the health problems and to determine the health seeking behavior of the
transgender people in Bangladesh.
Methods and Materials: This is a cross sectional study conducted between June 2015 to
November 2015 to find out the health seeking behavior of transgender people of Bangladesh. It
was conducted in Dhaka and Gazipur to determine the socio-demographic characteristics of
transgender people, to find out the health problems of the transgender people and to identify the
health seeking behavior of transgender people. Estimated sample size was 109. 105 questionnaires
were filled up by myself by face to face interview with the transgenders. Sample was collected by
snow-ball sampling technique and a pretested structured questionnaire was used to collect data.
Collected data was analyzed using SPSS version 20. Ethical consent was taken from Research
Committee of American International University- Bangladesh (AIUB) and written informed
consent was taken from the respondents.
Results: Most of the transgenders in this study were under the age group between 26-32 years. Sexual
orientation of 84 percent was from Male-to-Female. Significant association was found between age
of the transgenders and their health seeking behavior, between income of transgenders and their
health seeking behavior, between living status of the transgenders and their health seeking
behavior, between the transgenders’ being unsafe in public places and their health seeking
behavior, between substance abuse by the transgenders and their health seeking behavior, and
between the transgenders’ experience of being refused to treat and their health seeking behavior.
Though in cross table we did not find any relationship between education of the transgender
people and their health seeking behavior, and transgender people’s satisfaction with the treatment

IX
of an unknown doctor and their health seeking behavior; Linear regression revealed a significant
relation.
Study Implication: Transgenders people belong to a much marginalized population, who are
deprived of their human and health rights. Family rejection and social rejection along with
joblessness push them to delay healthcare seeking and to receive inappropriate treatment.
Recently Bangladesh Government has taken a number of steps to include the Transgender
population into the mainstream. To make these attempts successful, health has to be ensured for
that population first. The intent of this study was to find the barriers of access to health care as
faced by the transgender population.
Conclusion: This study shows the health problems and health seeking behavior of transgender
people of Bangladesh. It was found that none of the transgenders were employed by the
Government or any private organizations. Most of the transgenders stayed away from their homes
and their families, this, along with the families’ hostile and shameful attitude, prevented them
from getting support during their ailments. The society where they lived in did not include them
willingly, meaning they did not get community support, too. Past experiences of violence,
perceived public unsafety, and experience of being refused to be treated due to their gender
identity contributed to their poor health seeking behavior, though most of them identified modern
treatment as most effective.

1
Chapter 1
Background and Rationale
1.1 Introduction
Transgender is the state of one's gender identity or gender expression not matching one's
assigned sex.[1]
Transgender is independent of sexual orientation; transgender people may
identify as heterosexual, homosexual, bisexual, asexual, etc; some may consider
conventional sexual orientation labels inadequate or inapplicable to them. The definition
of transgender includes:
"Of, relating to, or designating a person whose identity does not conform
unambiguously to conventional notions of male or female gender roles, but
combines or moves between these."[2]
"People who were assigned a sex, usually at birth and based on their genitals, but
who feel that this is a false or incomplete description of themselves." [3]
"Non-identification with, or non-presentation as, the sex (and assumed gender)
one was assigned at birth." [4]
A transgender individual may have characteristics that are normally associated with a
particular gender and identify elsewhere on the traditional gender continuum, or exist
outside of it as other, agender, gender-neutral, genderqueer, non-binary, third gender, etc.
Transgender people may also identify as bigender, pangender, or along several places on
either the traditional transgender continuum or the more encompassing continuums that
have been developed in response to recent, significantly more detailed studies. [5]
The World Health Organization's Genomic resource center states: Intersex is defined as a
congenital anomaly of the reproductive and sexual system. [13]
The transgender in
Bangladesh, and in other parts of South Asia, are locally known as Hijras. In the West,
they are known as hermaphrodites or eunuchs. The transgender has been part of the South
Asian landscape for thousands of years. The transgenders are born male but grow up

2
feeling like and dressing as women. Marked out because of their sexual difference, they
are a despised and neglected minority. The official estimate of hijra people is just 10,000
souls. That is, at most, 2.5% of the total likely transgender population of Bangladesh. It is
not that easy to define a hijra. There are differences between the cultural definition and
the variety of individual lives and experiences. Hijras are culturally defined in terms of
their traditional occupation as performers on auspicious occasions, but not all hijras
perform.
Some hijras see them themselves as neither man nor woman, but there are also many who
very feel and behave like women. There is also the definition that relates to physical
sexuality. Many think that most hijras are hermaphrodites, but that is not true. Most hijras
are probably "made" rather than "born that way". Becoming a real hijra often means
going through the emasculation ritual by removal of the penis and testicles. Ideally, the
emasculation operation is performed by a hijra called a dai ma (midwife), a clear and
strong symbolic statement of the emasculation as rebirth.
Studies show that LGBT people experience health issues and barriers related to their
sexual orientation and/or gender identity or expression. Many avoid or delay care or
receive inappropriate or inferior care because of perceived or real homophobia or
transphobia, and discrimination by health care providers and institutions.,[17]
in other
words reason is negative personal experience, the assumption or expectation of negative
experience based on knowing of history of such experience in other LGBT people, or
both.[18]
Access to transgender health care is a global issue. In 2004 Venkatesan Chakrapani
reported that hijras 'face discrimination in various ways' in the Indian health-care system,
and sexual reassignment surgery is unavailable in government hospitals in India.[19]
In a
report on hijra social exclusion in Bangladesh by Sharful Islam Khan et al., it was said
that health facilities sensitive to hijra culture are virtually non-existent in Bangladesh.[20]
Transgender individuals are often reluctant to seek medical care or are denied access by
providers due to transphobia/homophobia or a lack of knowledge or experience with

3
transgender health. Additionally, in some jurisdictions health care related to transgender
issues, especially sex reassignment therapy, is not covered by medical insurance.[21]
Health seeking behaviors as accepted by the North American Nursing Diagnosis
Association, defined as a state in which a person in stable health is actively seeking ways
to alter his or her personal habits or environment in order to move toward a higher level
of health. “Stable health” is defined as the achieving of age-appropriate illness prevention
measures, with reporting of good or excellent health, and signs or symptoms of disease,
when present, being controlled [92]
.
The overarching goal of care for transgender persons, as articulated in the Standards of
Care for Gender Identity Disorders of the World Professional Association for
Transgender Health (formerly the Harry Benjamin Society), is “lasting personal comfort
with the gendered self to maximize overall psychological well-being and self-fulfillment.
[25]
According to Healthy People 2010, biases against gender identity differences must be
addressed to ensure access to quality health care and related services, eliminate health
disparities, and increase quality of life and years of healthy life for all Americans. [26]
Historically, particularly in Western culture, people who have not conformed to their
assigned gender role have been oppressed, and transgender people have been victims of
societal discrimination and marginalization [59]
.
Recently, transgender activists organized to challenge discrimination and violence as well
as negative stereotyping by the media [59, 60]
. Growth of the transgender movement
accelerated in the 1990s, advocating for civil rights for transgender people and seeking to
improve the health and welfare of the transgender community. Researchers also began to
document a variety of issues that are relevant to the transgender community, such as
discrimination, oppression, and the adverse social and health consequences of
discrimination and oppression. Although the volume of information about transgender
people is limited, key issues are emerging from the literature-- HIV/AIDS, suicide,
violence, and barriers to health care access. HIV/AIDS is a major health concern among
the transgender community. Studies have shown that transgender people are at risk of
HIV infection from unprotected sexual activity [57,61,63,64,65,66,67]
.

4
HIV prevalence rates among transgender people appear uniformly high. For example, in a
sample of 515 transgender people in San Francisco, 27 percent were HIV positive[63]
; in a
sample of 252 transgender people in Washington, DC, 25 percent were HIV –positive[57]
.
These rates are alarming when compared with the general population. In the year 2000 it
was estimated that between 850,000 and 950,000 people in the United States were HIV –
positive [68]
. Based on an estimated resident population of 283 million[69]
for the same
year, the percentage of U.S. residents infected with HIV is approximately .3 to .34
percent, much lower than the percentage of HIV -infected transgender people found in
studies to date. Suicide among transgender people has rarely been studied. Although
researchers have speculated that transsexuals are prone to suicide [70,71,72]
, only two
empirical studies were found that asked transgender people about suicide[57,62]
.
A study of 515 transgender people in San Francisco found that 32 percent of the sample
had attempted suicide [62]
. The percentage of transgender people who had attempted
suicide was lower (16 percent) among a Washington, DC, sample (N = 252), however, 35
percent had experienced suicidal ideation and among them, 64 percent had thought about
suicide because of gender issues [57]
. There has been much anecdotal evidence that
transgender people are victims of severe forms of violence. In recent years high profile
cases of violence against transgender people, such as Brandon Teena and Tyra Hunter,
have captured "mainstream" media headlines, but tragically the day-to-day violence
against transgender people remains virtually ignored. Studies, however, are beginning to
document violence as a major public health threat to the transgender community [54,55,57]
.
Bowen found that among 20 FTMs, 21 percent had been beaten as an adult and 71
percent had been beaten as children, defined as under age 21. More than one-third (36
percent) of the sample were sexually abused as adults, 50 percent were sexually abused
as children, 50 percent had been raped or sexually assaulted at some point during their
lives, and about two-thirds (64 percent) were afraid for their life or physical safety at
some point during their lives. Wilchins and colleagues (1997) surveyed 402
predominately white (70.9 percent) transgender people and found that 47 percent had
been assaulted during their lifetime. In the year before the survey, 16 percent of

5
respondents had been assaulted compared with data from the National Crime
Victimization Report, which found an 8.2 percent assault rate. The study also found that
14 percent of respondents had been either raped or the victim of an attempted rape[54]
.
Among 515 transgender people who took part in a needs assessment study in San
Francisco, 68 percent of MTFs and 55 percent of FTMs had been forced to have sex[55]
.A
needs assessment study of transgender people (N = 252) in Washington, DC found that
43 percent of respondents had been a victim of violence or crime[57]
. In Los Angeles, 47
percent (N = 244) of a baseline sample of MTFs reported that they had been physically
abused, and 80 percent had experienced verbal abuse [62]
. The literature also suggests that
transgender people experience barriers to health care access. Transgender people have
been denied health care services such as transgender -related care and HIV prevention
services [54,57]
. Lack of knowledgeable providers [73]
, insensitivity or hostility by providers
[57]
, and lack of health insurance were also found [57,62,73]
to be barriers to obtaining
general and transgender -related health care. Lack of access to a doctor may hinder the
general health of transgender people during the course of their lives.
1.2 Research Question
What are the health problems of transgender people of Bangladesh and what are their
health care seeking behaviors?
1.3 Research objectives
1.3.1General objective
-To find out the health problems and to determine the health seeking behavior of the
transgender people in Bangladesh.
1.3.2 Specific objectives
1. To determine the socio-demographic characteristics of transgender people.
2. To find out the health problems of the transgender people.
3. To identify the health care seeking behavior of transgender people.
4. To find out the barriers to health care seeking of transgender population.

6
1.4 Justification of the Study
Study supported that LGBT issues have been neglected by public health research and that
research unrelated to sexually transmitted diseases is lacking. LGBT issues were
addressed by 3777 articles, or 0.1% of all Medline articles; 61% of the articles were
disease-specific, and 85% omitted reference to race/ethnicity. Research unrelated to
sexually transmitted diseases addressed lesbians and gay men with similar frequency,
whereas bisexual persons were less frequently considered, and the least amount of
research focused on transgender individuals. [23]
A needs assessment study in
Philadelphia says: Twenty-six percent of respondents had been denied medical care
because they were transgender.[24]
Recently Bangladesh Government has taken a number of steps to include the Transgender
population into the mainstream. To make these attempts successful, health has to be
ensured for that population first. The intent of this study is to find the barriers of access to
health care as faced by the transgender population.

7
1.5 Listing of the variables
Independent variables
Socio-demographic factors :
Age
Sexual orientation
Education
Occupation
Monthly income
Housing status
Housing condition
Living status (with family/ homogenous
group)
Source of drinking water
Latrine type
Perceived public safety
Violence
Forced sex
Health problems
Acute and chronic illnesses
Immunization status
Medical help during transition
Perceived HIV risk
Substance abuse
Suicidal ideation
STD status
Number of lifetime disease: acute/chronic
Access to healthcare
Discrimination
Barriers
Dependent variables
Health care seeking behavior of
Transgender people

8
1.6 Operational Definitions:
Transgender people:
People who experience a mismatch between their gender identity or gender expression
and their assigned sex.[74][75][76]
Transgender is also an umbrella term because, in addition
to including trans men and trans women whose binary gender identity is the opposite of
their assigned sex (and who are sometimes specifically termed transsexual if they desire
medical assistance to transition), it may include genderqueer people (whose identities are
not exclusively masculine or feminine, but may, for example, be bigender,
pangender or agender).[75][77][78]
Other definitions include third-gender people as
transgender or conceptualize transgender people as a third gender,[79][80]
and infrequently
the term is defined very broadly to include cross-dressers.[81]
Hermaphrodite
An individual whose body contains tissue of both male and female gonads[82,83,84,85]
. The
ovaries and testes may be present as separate organs, or ovarian and testicular tissue may
be combined in the same organ (ovotestis). The ovarian and testicular tissues may be
present at the same time (synchronous hermaphrodite) or sequentially (when the sex
organs appear one after the other; protandrous when the testes come first, protogynous
when the ovaries appear first)[85]
. They may have many of the secondary sex
characteristics of both sexes [83]
.
Transvestite
A person with a compulsion to dress as a member of the other sex, which may be
essential to maintaining an erection and achieving orgasm [86]
. Or, a person and especially
a male who adopts the dress and often the behavior typical of the opposite sex especially
for purposes of emotional or sexual gratification [87]
Sanitary Toilet:
A closed pit toilet that has a platform with a hole in it and a lid to cover the hole when it
is not in use. The platform can be made of wood, concrete, or logs covered with
earth. Concrete platforms keep water out and reduce health problems because they are

9
easy to clean. A closed pit toilet should have a lining or concrete ring beam to prevent the
platform or the pit itself from collapsing. [88] A pit latrine or pit toilet is a type
of toilet that collects human feces in a hole in the ground. They use either no water or one
to three liters per flush with pour-flush pit latrines.[89]
When properly built and
maintained they can decrease the spread of disease by reducing the amount of human
feces in the environment from open defecation.[90][91]
This decreases the transfer
of pathogens between feces and food by flies.[90]
These pathogens are major causes
of infectious diarrhea and intestinal worm infections.[91]
Pit latrines are the lowest cost
method of separating feces from people.[3]

10
1.7 Conceptual Framework:
Independent Variables Dependent Variable
Socio-demographic
Characteristics
Age, education,
income, living status,
water and sanitation,
feeling unsafe,
experience of violence
Health Problems
Acute and chronic
illnesses, STD, Risk
of HIV, substance
abuse, suicidal
ideation
Health seeking
behavior of
Transgender
Population
Discrimination
Being refused to
treat, satisfaction
with treatment
Barriers to access
Lack of knowledge,
availability of
doctors, affordability
of medicine

11
Chapter 2
Literature Review
Transgender health issues are beginning to come to the attention of many health
practitioners and researchers. In fact, the desire to improve the treatment experienced by
transgender individuals led the American Public Health Association to pass a resolution
on transgender health issues during its 1999 annual meeting. [27]
Acknowledging health
care discrepancies is only a start, however. To provide much-needed services to this
population, researchers, educators, and health care professionals of all types need
concrete, comprehensible information about transgender individuals. Gender variations
have been documented for many years. Generally, female-to-male gender transgression
has been described as resulting from the inequality found between women and men and
women’s desire for status and resources, whereas male-to-female transgression has been
explained as resulting from the need to express an inner desire or has been eroticized.[28]
More recent explanations have been based on the medical model.
The term transvestite was used early in the 20th century to describe people (primarily
men) who dress in women’s clothing for their own interests (usually erotic).29
Later,
transsexualism (listed as gender identity disorder in the fourth edition of the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [30]
)
was used to describe a population of individuals whose feelings concerning their gender
involved more than a desire to dress in a particular set of clothes and a stronger
identification with gender values contrary to societal expectations.[31]
Transgender was originally used to differentiate those who seek medical intervention in
changing their gender from those who do not; however, this term later changed to
encompass a range of possible identities and behaviors, including transvestitism and
transsexualism (the way in which transgender evolved in usage has not been examined
fully). Currently, transgender, transvestite, and transsexual are at times used
interchangeably to describe individuals whose identities and social lives are very similar.
It is likely, however, that many people will not fit into traditional conceptions of
transvestite, transsexual, or transgender. The use of terminology has not been consistent

12
across time and among writers. The meaning of such terms varies among individuals as
well, and as a result there is little understanding of what people mean when they say they
are transgender or transsexual. For the sake of uniformity within this commentary,
however, the label transgender is used in a global sense, encompassing transvestites,
transsexuals, and self-identified transgender individuals.
Generally, people can be categorized across 4 characteristics: biological sex, legal–
institutional sex, social gender, and psychologic gender. Biological sex is usually
determined by people’s genitals but can encompass other factors such as chromosomes,
hormonal makeup, secondary sex characteristics, and other physiologic variations.
Furthermore, there are intersexed conditions that can create problems in regard to
categorizing infants as male or female (e.g., children born with ambiguous genitalia,
androgen sensitivity syndrome). These children may undergo surgical intervention so that
their genitals more clearly resemble those found on traditionally male or female children.
Legal–institutional sex refers to people’s designation on identification, forms, and even
questionnaires. There may be ways for people to change their legal–institutional sex;
frequently this requires some sort of professional intervention (i.e., needing to submit a
letter from one’s surgeon to change one’s birth certificate). However, different areas of
the country (and across the world) have different regulations allowing for such changes.
Social gender refers to how people present themselves in public: the clothing they wear,
their hairstyle, their physical characteristics, even how they act and talk.
Different cultures have different ways of explaining and dealing with gender variance;
some Native American cultures refer to two-spirit people (aspects of both genders), and
Hindu cultures include hidras (neither man nor woman). Social gender can also be
influenced by medical interventions used to change aspects of people’s appearance. Many
people go to great lengths to change aspects of their appearance (some of which is
necessary to change their legal sex). In addition, individuals may be consistent or
inconsistent in their gender presentation. People may have an inconsistent social gender
because one aspect of their gender is used for performances, fun, or even sexual behavior.
Psychologic gender refers to a person’s self-identification as a man or a woman.
However, these may not be the only options. Again, different cultures may allow for
other alternatives in the way people identify themselves. In addition, individuals may

13
create alternative identities. Some people who are part of a “queer” or “alternative”
subculture may use identities other than simply man or woman. The preceding is only a
short summary of the factors that can be used to describe sex and gender and to
understand the ways in which they can vary. There are many other factors that can
influence people, some of which have already been mentioned. Race, ethnicity, or culture
can influence how people identify themselves and the social roles that they desire or have
access to. Similarly, a person’s area of residence can involve variations in how sex is
institutionalized and how legal sex can be changed[32]
.
Finally, the resources available to people can influence their ability to pay for medical
interventions in addition to other strategies used to change their social gender or legal sex
(or both). It is not enough to know the definitions of labels (e.g., What is a crossdresser?
What is a transsexual?); it is more important to know that aspects of a person’s gender
and physical form can vary widely and be influenced by different factors. Health care
educators, researchers, policymakers, and clinicians need to know that transgender
individuals can vary widely but that, in general, all are still at risk for problems in
accessing and receiving health care. Transgender individuals are likely to experience
some form of discrimination or violence sometime in their lives. A study of transgender
individuals within the United States showed that approximately 60% had experienced
some form of harassment or violence and that 37% had experienced some form of
economic discrimination.[33]
In addition, focus group research conducted in San Francisco showed that among
transgender persons, a street lifestyle, lack of education and job opportunities, and low
self-esteem all contributed to drug and alcohol abuse.[34]
Increasing evidence
demonstrates that the rate of HIV infection among transgender women is high and that in
California the risk of infection may even surpass that for bisexual and homosexual
men.[35-38]
Reported seroprevalence rates exceed 20% and have been shown to be as high
as 60% among African Americans. Many transgender women (i.e., male to female) are at
risk primarily because of risky sexual behaviors, but sharing needles during the injection
of hormones or drugs is also a risk factor.[34-37]
These individuals may be difficult to
target through traditional prevention campaigns, and they may fear discrimination should
they seek services such as HIV/ AIDS education and testing.[39,40]
Insensitivity of health

14
care professionals has been cited as a reason that these and other services are not
accessed.[41]
Indeed, reports of insensitive behavior among health care providers (e.g.,
referring to transgender women as “he” and “him” and not acknowledging or respecting
their identity) suggest that services are severely lacking in terms of provision of culturally
sensitive interventions and, potentially, provision of HIV-related health care.[39,40]
Health
care service providers have found that helping transgender individuals obtain the services
they need (e.g., substance use treatment, housing, health care) is difficult because other
service providers may not want to work with transgender clients.[41]
Furthermore, lack of
sensitivity on the part of health care providers who do not respect the expressed gender
identity of transgender persons can adversely influence whether these individuals will
access and stay in treatment.[40,42,43]
Transgender persons may be resistant to seeking help because other transgender
individuals have reported past discriminatory treatment on the part of service providers.
Focus group research conducted in San Francisco and Minneapolis has shown evidence
of discrimination against transgender men and women within HIV/AIDS programs.[40,41]
Many programs are not sensitive to the needs of transgender individuals.[39,40]
Furthermore, studies have shown that doctors have somewhat negative opinions of
transsexual women.[44,45]
Overall, individuals who do not conform to traditional
conceptions of sex and gender are likely to be at risk for many health-related problems,
including, unfortunately, discrimination within the treatment setting.
Often, transgender people have 2 different sets of health care providers: one involved
with gender transition and one involved with regular health care visits. In addition to the
problems experienced by transgender men and women within health care settings,
traditional health care plans (public and private) do not cover the costs related to
changing one’s gender, leaving people to find other ways to fund their transition from
one gender to another.[46]
Individuals both within and allied to the transgender community
believe that the standards of care imposed by the Harry Benjamin International Gender
Dysphoria Association are regarded as authoritative by providers but as restrictive by
many clients.[47,48]
In addition, these guidelines have given rise to small groups of
“experts” within specific areas whose services are sought by all transgender persons
wishing to medically change their gender; those living in isolated areas may not have

15
ready access to such “experts” and may have to find other ways to go about their
transition. Current constraints on access to medical care related to gender changes may
place people at risk by forcing them to seek unsafe methods of making these changes
(e.g., using hormones bought off the street, sharing needles while injecting hormones).
The constraints for transgender youths are even greater; often, such youths are denied the
ability to change their social gender in any way within institutional settings, which may
force them back into situations that can place them at great risk. There is some support
for allowing transgender youths to begin the process of changing their gender; many do
so without trouble.[47,49]
The term intersexed refers to people born with physical differences that will result in their
being difficult to classify as either biologically male or biologically female. This
condition can assume various forms and involve the structure of one’s genitals, the
existence or nonexistence of specific reproductive organs, and chromosomes other than
XX and XY. Sometimes these physical differences are life threatening (e.g., affecting the
ability to pass urine from the body) and require surgical intervention. Other times,
however, the differences are aesthetic, and surgery is done so that the child can be more
readily identified as either male or female.[50]
Today, such aesthetically motivated surgeries are the focus of criticism from many
intersexed individuals. The Intersexed Society of North America (http://www.isna.org)
was formed in response to the individual cases of trauma caused by many of these
surgeries. The goals of this organization are to reform the treatment of intersexed
individuals, to limit the practice of surgical interventions to those that are medically
necessary, and to limit surgeries performed on children purely for the sake of
aesthetics.[50]

16
Chapter 3
Methods and Materials
3.1 Study design:
A cross sectional type of study was conducted among transgender people of Dhaka and
Gazipur.
This design was selected because it is simple, time saving, less expensive, and useful for
descriptive and evaluative purposes and to have some insights into the possible
association among variables.
3.2 Study period:
Study period was from June 2015 to December 2015.
3.3 Study locale:
Study locale was Dhaka and Gazipur district. These Districts were selected purposively
for convenience.
Dhaka is the capital of Bangladesh. Gazipur is a district located in the central part of
Dhaka division. The district has six upazilas namely: Gazipur Sadar Upazila, Tongi
Upazila, Sreepur Upazila, Kaliakoir Upazila, Kapasia Upazila, Kaligonj Upazila. As the
sampling technique would be non-probability in nature, these two districts have been
selected for easy access.
3.4 Study population:
Study population was the transgender population living in Bangladesh. Transgender
people are commonly known as “Hijras” in Bangladesh. They usually live with their own
community and collect money from local bazars, shops and passengers of public
transports to earn their livings.

17
Though the Government of Bangladesh is constitutionally obliged to ensure health for its
citizens [51]
and “Hijras” have been legally recognized as third gender in Bangladesh [52]
,
they still face a number of difficulties accessing healthcare. That is why this population
has been selected to be studied.
3.5 Study sample:
Study sample was transgender population living in the two selected districts, Gazipur and
Dhaka who meet up the eligibility criteria.
3.6 Sampling technique:
During data collection I used snow-ball sampling technique. Snow-ball technique is a
non- probability sampling technique where existing study subjects recruit future subjects
from among their acquaintances. This sampling technique is often used in hidden
populations which are difficult for researchers to access; example populations would be
transgender, drug users or sex workers. As my sample populations are the transgender, it
is difficult for me to have an easy access to them that is why I choose snow-ball method
for sampling.
3.7 Sample size calculation:
As I conducted a study within a very short period of time and with very limited amount
of resources, my study sample size was smaller. Sample size is calculated by the formula:
Where,
n= the desired sample size
z = the standard normal deviate, usually set at 1.96, corresponds to the 95% confidence
level.
p= the proportion in the target population estimated to have a particular characteristics
and desire accuracy at 50%
q= 1-p

18
= 1-0.5 = 0.5
d= degree of accuracy desired, usually set at 0.05
So the sample size is:
n = (1.96)2
(0.5) (0.5)
(0.05)2
Thus, the calculated number is 384.
Taking into consideration the constrain of time, I took 109 of them.
3.8 Eligibility criteria:
3.8.1Inclusion criteria: -Transgender people over twelve years of age
-Persons available at the time of data collection
-Persons willing to participate in the interview
3.8.2Exclusion criteria: -Persons who are not transgenders, e.g., transvetites,
hermaphrodites.
-Persons non co-operative.
- Persons who could not understand the purpose and nature
of the study.
3.9 Development of Research Instrument:
Instrument for data collection was a pretested semi-structured interview questionnaire.
Introduction about the research was given at the beginning of the interview to explain the
basic nature of the study to the respondent and consent from the participant was taken. I
assessed the health seeking behavior of the transgender people in Bangladesh by asking
questions.
3.10 Questionnaire Design:
In order to obtain relevant information, the interview schedule will be carefully designed
keeping in mind the objective of the study. The formal survey of each sample was carried

19
out by using the structured questionnaire. The questions was formed in English and then
translated into Bengali. So two types of questionnaires were formed for the transgender
population.
3.11 Data Collection Technique:
Procedure of data collection:
By using pre-tested semi- structured questionnaires, data was collected by direct
interview of the respondent. The researcher herself conducted face to face interviews. At
the very beginning of the interview I introduced myself with the participants and
explained the aim and objectives of the study to them.
3.12 Data Entry:
Data were entered into computer along with data collection. After conducting interview
data were be interpreted into computer.
3.13 Data Verification:
After data compilation, plots from the compilation data sheets were sorted carefully to
ensure all data sheets are correct. Once the data were captured into the SPSS then it was
checked again.
3.14 Data Analysis:
The surveyed data were converted into frequencies and percentage forms. After
collecting information from primary source, data were processed and analyzed by
following steps:
1. Review of collected data and information
2. Sorting of revised data and information
3. Analyzing data for easy explanation
Then Data entry into computer was continued along with data collection. Data checking
was done meticulous and corrections for any error. Data was analyzed using SPSS

20
(statistical package for social sciences) for windows version 20.0. Necessary tabulations
and cross-tabulations, charts and diagrams were drawn for summarizing and easy visual
presentation of data. The Data were analyzed by the following steps:
1. Frequency
2. Percentage
3. Chi-square (to determine the relation between variables)
4. Logistic Regression
3.15 Data Presentation and Interpretation:
After analysis, data were presented by tables, figures, diagrams and charts. Appropriate
graphs were also be used.
3.16 Data Quality Management:
Research instrument (questionnaire) was pretested with 10 units. Intensive care
was taken to maintain the quality of data by direct inspection during the data collection
and make sure about the validity of overall information collected from field. After
collecting data I looked for inconsistencies and other anomalies. Any incomplete or
inconsistent data was discarded. Data cleansing activities were performed. Missing and
unknown data were handled carefully.
3.17 Study Limitations:
Although this research was carefully prepared, I am still aware of its limitations and
shortcomings. First, because of the time limit, the study was conducted only on a small
size of population. To generalize the results for larger groups, the study should have
involved more participants. Secondly, as the study targets the transgender population of
the country which is a very marginalized and invisible population, the sampling
technique I used was snow-ball technique which is a non-probability technique that
compromises the external validity of the findings. In addition, the assessment of the
pretest and other events of the research were conducted by the author herself.

21
3.17 Ethical Issues:
The nature and purpose of the study was explained earlier to the respondents.
Approval of the research committee of American International University –
Bangladesh (AIUB) was obtained to conduct the study.
Consent was obtained from Participants and the aims and nature of the study was
explained to them before filling the questionnaire.
Privacy, confidentiality, anonymity of the participants has been maintained
strictly.
The participants have had freedom to participate in the study or refraining from
answering any question.

22
Chapter 4
Results & Findings
A cross sectional study was conducted among the transgender people of Gazipur and
Dhaka. A total of 109 transgenders were interviewed face to face with an interviewer
administered structured questionnaire with a view to find out the health problems and to
determine the health seeking behavior of the transgender people in Bangladesh. The
findings are presented below:
Table-1: Distribution of the Transgenders According to their Age
**
Mean: 31.75years, SD: ( ±8.703)
Table -1 reveals that 40.37 percent of the transgenders were under the age group between
26-32 years. Other age groups 12-18 years, 19-25 years, 33-39 years, 40-45 years, 46-52
years had frequencies 5.50 percent, 11.01 percent, 23.85 percent, 14.68 percent, and 4.9
percent respectively.
Age group Frequency Percentage
12-18years 6 5.50
19-25years 12 11.01
26-32years 44 40.37
33-39years 26 23.85
40-45years 16 14.68
46-52years 5 4.59
Total 109 100

23
Figure-1: Distribution of the Transgenders According to their Assigned Sex
Figure -1 reveals the sex of the transgenders at birth. This shows that the sexual
orientation of 84 percent transgenders was Male-to Female, and 16 percent transformed
them from Female-to-male.
Table-2: Distribution of the Transgenders According to their Marital Status
Marital Status Frequency Percentage
Single 48 44
Married 6 5.5
Widowed 6 5.5
Divorced 0 0
Living together 49 45
Other 0 0
Total 109 100
From Table-2 we can see that 45percent of the transgenders reported themselves as living
together with partners. 44percent transgenders were single. 5.5 percent of the study
sample was married and another 5.5 percent was widowed.
male
16%
female
84%
Sexual Orientation

24
Table-3: Distribution of the Transgenders According to their Level of Education
Level of Education Frequency Percentage
Illiterate 22 20.2
Primary 58 53.2
Secondary 18 10.5
Higher Secondary 6 5.5
Graduate 0 0
Others 5 4.6
Total 109 100
Table-3 shows the education level of the transgenders. The greatest proportion, i.e. 53.2
percent, reported that they had completed their primary education. 20.2 percent of the
transgenders were illiterate, whilst 16.5 percent completed secondary education and
5.5percent had continued their study up to higher secondary level. 4.6 percent of the
transgenders received madrasa education.
Table-4: Distribution of the Transgenders According to their Occupation
Occupation Frequency Percentage
Government Job 0 0
Private Job 0 0
Collection 5 4.6
Entertainment 0 0
Collection &
Entertainment
104 95.4
Total 109 100
Table-4 shows that 4.6 percent of the transgenders stated collection as their source of
income, and 95.4 percent also involved themselves in entertaining activities as well as
collection.

25
Table-5: Distribution of the Transgenders According to their Monthly Income
Income (BDT)
Frequency Percentage
1000 – 10000 77 70.6
11000 -20000 11 10.1
21000 – 30000 5 4.6
31000 – 40000 6 5.5
41000 – 50000 0 0
51000- 60000 5 4.6
61000 – 70000 0 0
71000 -80000 5 4.6
Total 109 100
Table-5 shows that 70.6 percent of the transgenders’ monthly income ranged between
1000-10000 BDT. 10.1 percent earn between 11000-20000BDT, 4.6 percent between
31000-40000BDT and 4.6 percent between 51000-60000BDT. 4.6 percent transgenders
reported that they earn between 71000-80000BDT. From this table we can see that there
is a great distance between the highest level and the lowest level of the transgenders’
monthly income.

26
Table-6: Distribution of the Transgenders According to their Number of
Dependents
No. of Dependents Frequency Percentage
0 5 4.6
2 5 4.6
3 16 14.7
4 22 20.2
5 24 22.0
6 5 4.6
7 11 10.1
8 16 14.7
9 5 4.6
Total 109 100
Table-6 demonstrates the number of persons depending on the transgenders’ income. 22
percent of the transgenders had to pay for the living of 5 people, and 20.2 percent of the
transgenders had 4 dependents. The highest number of dependents was 9, and 4.6 percent
of the transgenders had to pay for them. Only 4.6 percent of the responding transgenders
had no dependents.
Figure -2: Distribution of the Transgenders According to their Housing Status
Only 9.20 percent of the transgenders owned a house, as shown in Figure-2. The other
90.80 percent transgenders lived in rented houses.
own house
rented house
9.20%
90.80%
Housing Status of the Respondents

27
Table-7: Distribution of the Transgenders According to their Housing Condition
Housing Condition Frequency Percentage
Kacha 5 4.6
Semi pakka/ Tin shed 72 66.1
Pakka 32 29.4
Others 0 0
Total 109 100
Table-7 is about the condition of the house where the transgenders live in. 66 percent of
the transgenders’ houses were semi-pakka or tin-shed. 29 percent responded lived in
pakka buildings and 5 percent of their houses were kacha.
Table-8: Distribution of the Transgenders According to their Living Status of
Living Status Frequency Percentage
Alone 38 34.9
With family 16 14.7
With homogenous group 49 45.0
With family &
homogenous group
6 5.5
Total 109 100
Table-8 reveals that 45 percent of the transgenders, which is the greatest proportion, lived
with homogenous groups. 34.90 percent of them lived alone. Only 14.70 percent of the
transgenders lived with their family. 5.50 percent lived with their family and also with the
members of their homogenous group.

28
Table-9: Distribution of the Transgenders According to their Source of Drinking
Water
Source of Drinking Water Frequency Percentage
Boiled water 44 40.0
Tube well water 41 37.6
Supply water 24 22
River 0 0
Pond 0 0
Others 0 0
Total 109 100
As Table-9 shows, 40.3 percent of the transgenders drink water after boiling. 37.61
percent drink tube well water. 20.02 percent of the transgenders told that they drank the
supply water directly.
Table-10: Distribution of the Transgenders According to their Latrine Type
Latrine Type Frequency Percentage
Sanitary 87 79.8
Unhygienic 22 20.2
Total 109 100
Table-10 shows that 79.82 percent of the transgenders use sanitary latrine, and the other
20.18 percent do not have a sanitary latrine.

29
Table-11: Distribution of the Transgenders According to their Perceived Unsafety
Percieved Unsafety Frequency Percent
Yes 73 67.0
No 36 33.0
Total 109 100.0
Table-11 shows the frequency of transgenders feeling unsafe in public places. 67 percent
of the transgenders reported that they felt unsafe in public places. The other 33 percent
did not feel unsafe.
Table-12: Distribution of the Transgenders According to Perceived Safety by Other
People
Perceived Safety by Others Frequency Percent
Yes 32 29.4
Not always 61 56.0
No 10 9.2
Nothing understood 6 5.5
Total 109 100.0
Table-12 depicts the frequency of transphobia perceived by the transgenders among other
people. 29.36 percent of the transgenders confirmed the perception of transphobia among
other people. 55.96 percent of them told that transphobia was not always present in other
people. 9.174 percent told people were not afraid of them at all and 5.505 percent had no
idea about this.

30
Figure -3: Distribution of the Transgenders According to their Family Attitude
Figure-3 shows the attitude towards the responds of their families. 35.78 percent of the
transgenders’ families felt shameful towards them, and 30.28 percent were hostile. 33.94
percent of the transgenders’ families were friendly towards them.
Table-13: Distribution of the Transgenders According to their Experience of
Violence
Experience of Violence Frequency Percent
Yes 71 65.1
No 38 34.9
Total 109 100.0
As shown in Table-13, 65.14 percent of the transgenders have experienced domestic
violence in their lifetime, and 34.86 percent have not.
friendly
hostile
shameful
33.94%
30.28%
35.78%
Family Attitude Towards the Respondent

31
Table-14: Distribution of the Transgenders According to their Violent
Violent Frequency Percentage
Family members 45 63.4
Community people 10 14.1
Family member & Community people 16 22.5
Total 71 100.0
63 percent of the transgenders were violated by their family members, 14 percent by
community people and 23 percent by both family members and community people; as
shown in Table-14.
Table-15: Distribution of the Transgenders According to their Experience of Forced
to Sex
Forced to Sex Frequency Percent
Yes 66 60.6
No 37 33.9
No idea 6 5.5
Total 109 100.0
Table-15 shows the frequency of transgenders experiencing forced sex. 60.55 percent of
them had been forced to sex in their lifetime, while 33.94 percent had not and 5.51
percent refrained from answering.

32
Table-16: Distribution of the Transgenders According to their Sex Inflicter
Inflicter Frequency Percent
Family member 12 18.2
Community people 49 74.2
Unknown 5 7.6
Total 66 100.0
66 transgenders (60.6 percent) answered to this question. Among them, 74.20 percent
reported the imposer to be from their own community, and 18.20 percent from their
family members and 7.6 percent reported them to be unknown.
Figure -4: Distribution of the Transgenders According to their Experience of Health
Problems
All of the transgenders (100 percent) reported being affected by illness in their lifetime.
yes
100%
no
0% not sure
0%
Experience of health problems

33
Table-17: Distribution of the Transgenders According to their Health Problems
Diseases Frequency Percentage
Typhoid 12 11
Jaundice 28 25.6
Diabetes
Malaria
Tuberculosis
Dengue
5
0
0
0
4.6
0
0
0
Hypertension 11 10.1
Typhoid & Jaundice 11 10.1
Typhoid & Hypertension 5 4.6
Typhoid, Jaundice & Diabetes 5 4.6
Typhoid, Jaundice, Diabetes
& Hypertension
5 4.6
Typhoid, Jaundice & Others 5 4.6
Typhoid, Jaundice,
Hypertension & Others
5 4.6
Others 17 15.6
Total 109 100
Table-17 shows that 25.6 percent had suffered from jaundice, 11 percent from typhoid,
10.1 percent from hypertension, 9.2 percent from diabetes. 15.7 percent of the
transgenders had other diseases like kidney disease, fever, common cold etc.

34
Table-18: Distribution of the Transgenders According to their Skin Problems
Skin problems Frequency Percentage
Eczema 54 49.5
Fungal Infection 11 10.1
Eczema & Scabies 5 4.6
Eczema & Fungal infection 6 5.5
Eczema & Warts 6 5.5
No idea 27 24.8
Total 109 100
Table-18 shows that 49.5 percent of the transgenders reported of being suffered from
eczema, 10.1 percent from fungal infections, 4.6percent from scabies, 5.5 percent from
warts.
Table-19: Distribution of the Transgenders According to their Eye Problems
Eye problems Frequency Percentage
Eyesight problem 21 19.3
Conjunctivitis 17 15.6
No idea 5 4.6
Eyesight problem &
Conjunctivitis
15 13.8
Eyesight problem & Night
blindness
6 5.5
None 40 36.7
Others 5 4.6
Total 109 100
Table-19 shows that 19.3 percent of the transgenders had some problem with their
eyesight. 5.5 percent had night blindness and 15.6 percent suffered from conjunctivitis.

35
Table-20: Distribution of the Transgenders According to their Dental Problems
Dental Problems Frequency Percentage
Sensitivity 40 36.7
Dental carries 5 4.6
Sensitivity & Gum problem 11 10.1
Sensitivity & Dental carries 5 4.6
None 48 44.0
Total 109 100
Table-20 shows the frequency of dental problems suffered by the responding
transgenders. 36.7 percent had sensitivity, 10.1 percent had gum problems and 4.6
percent had dental carries. 44 percent of the transgenders had no dental problems.
Table-21: Distribution of the Transgenders According to their Sexually Transmitted
Diseases
Sexually Transmitted
Diseases
HIV/AIDS 0 0
Gonorrhea 0 0
Syphilis 0 0
Chlamydia infection 0 0
No idea 39 35.8
None 70 64.2
Others 0 0
Total 109 100
Table-21 shows that 35.8 percent of the transgenders had no idea about what sexually
transmitted disease they had, and 64.2 percent reported that they had no sexually
transmitted disease.

36
Figure-5: Distribution of the Transgenders According to their Immunization Status
Figure-6 shows that 45.90 percent of the transgenders claimed that they had completed
their immunization schedule. 10.10percent remembered that their immunization was
incomplete and 44 percent were not sure about their immunization status.
Table-22: Distribution of the Transgenders According to their Seeking of Medical
Help during Transition
Medical Help During
Transition
Yes 76 69.7
No 33 30.3
Total 109 100
70 percent of the transgenders went for medical help during their transition and 30
percent did not, which has been shown in Table-22.
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
complete incomplete not sure
45.90%
10.10%
44%
Immunization Status of the Respondents

37
Table-23: Distribution of the Transgenders According to the Effectiveness of
Medical Treatment during Transition
Effectiveness of Medical
Treatment During Transition
yes 28 36.8
no 21 27.6
no idea 27 35.5
Total 76 100.0
Table-23 shows the effectiveness of medical treatment during their transition as
perceived by the transgenders.66 transgenders answered to this question, among them
36.84 percent stated that it helped them, 27.63 percent said it did not and 35.53 percent
said that they had no idea about it.
Table-24: Distribution of the Transgenders According to their Chances of Getting
HIV
Chances of Getting HIV Frequency Percentage
High 0 0
Medium 32 29.4
Low 33 30.3
None 44 40.4
Total 109 100
Table-24 shows that, as the transgenders marked themselves, 30 percent of them had
moderate chances of getting infected by HIV, 30 percent had low chances and 40 percent
marked themselves as risk free.

38
Table-25: Distribution of the Transgenders According to Substance Abuse
Substance Abuse Frequency Percentage
Yes 82 75.2
No 27 24.8
Total 109 100
75 percent of the transgenders reported some form of substance abuse and 25 percent
reported themselves to be negative as shown in the pie chart of Table-25.
Figure-6: Distribution of the Transgenders According to their Suicidal Ideation
Figure-7 reveals that 40.4 percent of the transgenders had suicidal ideation, 55.0 percent
did not have suicidal ideation and 4.60 percent had no idea about suicidal ideation.
Yes No No idea
40.40%
55%
4.60%
Frequency of Suicidal Ideation

39
Table-26: Distribution of the Transgenders According to their Ability to Identify
Health Seeking Behaviors
Identify Health Seeking
Behavior
Preventive care 18 16.5
Curative care 53 48.6
Both 38 34.9
Total 109 100
Of the 109 transgenders, 34.90 percent identified health seeking behavior as both
preventive and curative care. 48.60 percent identified it as only curative care and 16.50
percent identified it as only preventive care; which is shown in Table-26.
Table-27: Distribution of the Transgenders According to their Knowledge of Health
Care Delivery System of Bangladesh
Knowledge of Health Care
Delivery System of Bangladesh
Frequency Percent
Yes 43 39.4
No 48 44.0
No idea 18 16.5
Total 109 100.0
Table-27 shows the frequency of the transgenders having knowledge of Healthcare
delivery system of Bangladesh. 44 percent stated that they had no knowledge about it,
while 39.40 percent knew about it. The other 16.5 percent had no idea.

40
Table-28: Distribution of the Transgenders According to their Medical Help
Seeking
Subject’s Medical Help Seeking Frequency Percent
Regular health checkups 16 14.7
When few symptoms are present 32 29.4
When symptoms get severe 61 56.0
Total 109 100.0
Table-28 shows when the transgenders usually seek for medical help. 56 percent of them
seek for medical help when the symptoms get severe. 29percent go for medical help
when they had a few symptoms and only 15 percent reported to go for regular health
checkups.
Table-29: Distribution of the Transgenders According to their Provider Choice
Provider Choice of the
Respondent
Frequency Percent
Private practitioner 61 56.0
Homeopath 11 10.1
Kobiraj 5 4.6
Dispensary owner
From health worker
Community clinic
Upazila health complex
Spiritual healer
32
0
0
0
0
29.4
0
0
0
0
Total 109 100
56 percent of the transgenders went to see a private practitioner when they were
ill. 29.40 percent went to Dispensary owners, 10.10 percent went to homeopath
and 4.6 percent went to kobiraj; as shown in Table-29.

41
Table-30: Distribution of the Transgenders by having Family Doctor
Family Doctor Frequency Percent
yes 37 33.9
no 72 66.1
Total 109 100.0
As in Table-30, 66 percent of the transgenders had a family doctor, 34 percent did not.
Table-31: Distribution of the Transgenders According to the Gender of the Family
Doctor
Gender of the Family
Doctor
Male 37 100
Female 0 0
Total 37 100
Table-31 shows the gender of the transgenders’ family doctors. 100 percent of the
responding 37 transgender persons’ family doctor was male.

42
Table-32: Distribution of the Transgenders According to their Satisfaction
Regarding Service of Family Doctor
Satisfaction Regarding Service of
Family Doctor
Highly satisfied 10 27.0
Satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Dissatisfied
Highly dissatisfied
27
0
0
0
0
0
73.0
0
0
0
0
0
Total 37 100.0
As shown in Table-32, 73 percent of the 37 transgenders were satisfied with their family
doctor’s treatment, and 27 percent were highly satisfied.
Table-33: Distribution of the Transgenders According to the Treatment Believed as
Most Effective
Treatment Believed as Most
Effective
Frequency Percent
Prescription treatment 97 89.0
Dispensary medication 6 5.5
Homeopathy
Traditional healing
Spiritual healing
6
0
0
5.5
0
0
Total 109 100.0
89 percent of the 109 transgenders identified prescription treatment to be the most
effective treatment method. 5.5 percent stated that homeopathy was most effective and
another 5.5 percent said dispensary medication was effective; which has been shown in
Table-33.

43
Table-34: Distribution of the Transgenders According to their Experience of Taking
Treatment from an Unknown Doctor
If Taken Treatment From
an Unknown Doctor
Frequency Percent
Yes 46 42.2
No
Don’t remember
63
0
57.8
0
Total 109 100.0
In Table-34, it shows that, 42.20 percent of the transgenders had taken treatment from an
unknown doctor and 57.80 percent had not.
Regarding Service of Family Doctor
Satisfaction Regarding Service of Family
Doctor
Frequency Percent
Highly satisfied 0 0
Satisfied
Somewhat satisfied
12
0
26.1
0
Neither satisfied nor dissatisfied 6 13.0
Somewhat dissatisfied 11 23.9
Dissatisfied
Highly dissatisfied
17
0
37.0
0
Total 46 100.0
As shown in Table-35, 37 percent of the 47 transgenders were dissatisfied from the
treatment of unknown doctors. 23.90 percent were somewhat dissatisfied, 13 percent
were neither satisfied nor dissatisfied, and 26.10 percent were satisfied.

44
Table-36: Distribution of the Transgenders According to their Food Habit
If The Subject Takes Food
Elements Proportionately
Frequency Percent
Yes 71 65.1
No 22 20.2
Not sure 16 14.7
Total 109 100.0
As Table-36 shows, only 29 percent of the transgenders confirmed of having a balanced
diet. 9 percent did not take a balanced diet and 62 percent were not sure about it.
Figure-7: Distribution of the Transgenders According to their Frequency of Regular
Exercise
As shown in figure-7, only 10.1 percent transgenders reported to take regular physical
exercise, when the other 89.90 percent did not.
yes
no
10.10%
89.90%
Regular Exercise by the Respondents

45
Table-37: Distribution of the Transgenders According to their Usage of Condom
While Having Sex
Use Condom While
Having Sex
Frequency Percent
Yes 44 40.4
No 34 31.2
Not always 31 28.4
Total 109 100.0
Table-37 shows the frequency of using condoms by the transgenders. 41 percent stated
that they use condoms, 31 percent said they do not use condoms and 28 percent stated
they use condoms, but not always.
Figure-8: Distribution of the Transgenders According to their Adherence to
Prescription Medication
As figure- 8 shows, 64.20 percent of the transgenders took medications timely and
accordingly to the prescription, 30.30 percent missed the medicines sometimes and 5.50
percent did not take medicines rightly.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Always Sometimes No
64.20%
30.30%
5.50%
Respondent's Adherence to Medication

46
Table-38: Distribution of the Transgenders According to their Frequency of Dental
Check Ups
Dental Check Ups Frequency Percent
Yes 21 19.3
No 88 80.7
Total 109 100.0
Table-38 shows, 81 percent of the transgenders did not get any dental checkup. The other
19 percent had.
Regarding Service of Dentist
Satisfaction Regarding Service of Dentist Frequency Percent
Highly satisfied 11 52.4
Satisfied
Somewhat satisfied
10
0
47.6
0
Neither satisfied nor dissatisfied 0 0
Somewhat dissatisfied 0 0
Dissatisfied
Highly dissatisfied
0
0
0
0
Total 21 100.0
As shown in Table-39, of 21 transgenders, 52.40 percent were highly satisfied and 47.60
percent were satisfied with their dental treatment.

47
Table-40: Distribution of the Transgenders According to their Awareness about
Health Rights
Awareness About Health
Rights
Frequency Percent
Yes 47 43.1
No 51 46.8
Not sure 11 10.1
Total 109 100.0
46.80 percent transgenders did not know about their health rights. 43.10 percent knew,
and 10.10 percent were not sure as shown in Table-40.
Figure-9: Distribution of the Transgenders According to their Experience of Being
Refused to Treat
As figure-9 shows, 52.30 percent of the transgenders had been refused to treat while the
other 47.70 percent did not.
52.30%
47.70%
Being Refused to Treat
yes
no

48
Table-41: Distribution of the Transgenders According to their Source of Refusal
Source of Refusal Frequency Percent
Health worker 6 10.5
Doctor
Nurse
6
0
10.5
0
Other stuff
Homeopath
Kobiraj
Ojha
Dispensary owner
45
0
0
0
0
78.9
0
0
0
0
Total 57 100.0
As shown in Table-41, of the 52 transgenders, 78.9 percent reported that the source of
refusal to treat were the non-medical staff of the facility. Only 10.50 percent were refused
by health workers and 10.10 percent were refused by doctors.
Table-42: Distribution of the Transgenders According to their Knowledge about
When to Seek Help
When to Seek Help Frequency Percent
Yes 27 24.8
No 62 56.9
Not sure 20 18.3
Total 109 100.0
As shown in Table-42, 56.9 percent transgenders did not know when to seek medical
help. 24 percent of them knew when to seek help, and 18.3 percent were not sure.

49
Table-43: Distribution of the Transgenders According to their Family Support
Family support Frequency Percent
Yes 34 31.2
Sometimes 22 20.2
No 53 48.6
Total 109 100.0
Table-43 shows that 48.6percent transgenders did not get any help from their family
when they were ill. 31.2 percent got family support, and 20.2 percent got support from
their families occasionally.
Table-44: Distribution of the Transgenders According to their Community Support
Community Support Frequency Percent
Yes 27 24.8
Sometimes 38 34.9
No 44 40.4
Total 109 100.0
Table-44 shows that 40.4 percent transgenders did not get any help from their
neighbors/community when they were ill. 31.2 got community support, and 20.2 percent
got support from their community occasionally.

50
Figure-10: Distribution of the Transgenders According to the Availability of
Doctors near their Residence
As we can see in figure- 10, 68.80 percent of the responding transgenders stated that
doctors were available near their residence. 31.20 percent had no doctor serving near
their residence.
Table-45: Distribution of the Transgenders According to their Affordability of
Treatment
Affordability Frequency Percent
Yes 67 61.5
Sometimes 37 33.9
No 5 4.6
Total 109 100.0
Table-45 reveals that 61.5 percent of the transgenders could afford the medicines
prescribed by the doctors. 33.9 percent had sometimes found difficulty to do so, and 4.6
percent could not buy the prescription medications.
0.00%
20.00%
40.00%
60.00%
80.00%
yes no
68.80%
31.20%
Availability of Doctors Near Residence

51
Table-46: Distribution of the Transgenders According to their Idea about the
Government Allowance
Allowance enough or not Frequency Percent
Yes 5 4.6
No 80 73.4
No idea 24 22.0
Total 109 100.0
Table-46 shows that 73.4 percent of the transgenders did not find the allowance that the
government provides as sufficient to maintain a healthy lifestyle. 22 percent had no idea
about the government allowance, and only 4.6 percent thought that the allowances were
sufficient.

52
Table-47: Relationship between Age and Health Care Seeking Behavior of the
Transgenders
Age
Health Care Seeking
Behavior
Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Below 18
years
0
0 %
6
100.0%
6
100.0 %
8.069a
.006Above
18 years
61
59.2 %
42
40.8%
103
100.0 %
Total
61
56.0 %
48
44.0 %
109
100.0 %
Fisher’s exact test
Table- 47 reveals that none of the transgenders below 18 years received modern
healthcare and 59.2 percent of the transgenders aged above 18 years received modern
treatment. There is association between age of the transgenders and their choice of
healthcare provider (p< 0.05).

53
Table-48: Relationship between Marital Status and Health Care Seeking Behavior
of the Transgenders
Marital Status
Health Care Seeking
Behavior
Total Chi-
square
P- value
Modern
Treatment
Traditional
Treatment
Single 27
50.0 %
27
50.0 %
54
100.0 %
1.544a
.250Have
partner
34
61.8 %
21
38.2 %
55
100.0 %
Total
61
56.0%
48
44.0%
109
100.0%
Table- 48 reveals that 50.0 percent of the transgenders who are single took modernized
healthcare and 61.8 percent of the transgenders having partners took modern treatment.
There is relationship between marital status of the transgenders and their choice of
healthcare provider.

54
Table-49: Relationship between Education and Health Care Seeking Behavior of the
Transgenders
Education
Health Seeking Behavior
Total Chi-
square
P-value
Modern
Treatment
Traditional
Treatment
Illiterate
9
47.4%
10
52.6 %
19
100.0%
.690a
.453
Literate
52
57.8%
38
42.2%
90
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table-49 shows that 47.4 percent of the transgenders who are illiterate received
modernized healthcare and 57.8 percent of the literate transgenders received modern
treatment. There is relationship between literacy of the transgenders and their choice of
healthcare provider.

55
Table-50: Relationship between Income and Health Care Seeking Behavior of the
Transgenders
Income
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Below 10
thousand
29
46.8%
33
53.2%
62
100.0%
4.927a
.033Above 10
thousand
32
68.1%
15
31.9%
47
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table- 50 states that 46.8 percent of the transgenders whose income is below 10 thousand
BDT per month received modernized healthcare and 68.1 percent of the transgenders
whose income is below 10 thousand BDT per month received modern treatment. There is
association between literacy of the transgenders and their choice of healthcare provider
(p< 0.05).

56
Table-51: Relationship between Living Status and Health Care Seeking Behavior of
the Transgenders
Living status
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
With family
44
50.6%
43
49.4%
87
100.0%
5.079a
.031Without
family
17
77.3%
5
22.7%
22
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table-51 reveals that 50.6 percent of the transgenders who live with their family received
modernized healthcare and 77.3 percent of the transgenders living without family
received modern treatment. There is association between living status of the transgenders
and their choice of healthcare provider (p< 0.05).

57
Table-52: Relationship between Experience of Violence and Health Care Seeking
Behavior of the Transgenders
Experience of violence
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Yes
44
62.0%
27
38.0%
71
100.0%
2.983a
.106
No
17
44.7%
21
55.3%
38
100.0%
Total 61
56.0%
48
44.0%
109
100.0%
Table- 52 states that 62.0 percent of the transgenders who took modernized healthcare
had experience of violence and 44.7 percent of the transgenders who took modern
treatment had no experience of violence. There is relation between past experience of
violence of the transgenders and their choice of healthcare provider.

58
Table-53: Relationship between Being Unsafe in the Public Places and Health Care
Seeking Behavior of the Transgenders
Being Unsafe in
Public Places
Health Care Seeking Behavior
Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Yes
51
69.9%
22
30.1%
73
100.0%
17.328a
.000
No
10
27.8%
26
72.2%
36
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table- 53 reveals that 69.9 percent of the transgenders who received modernized
healthcare had been unsafe in public places and 27.8 percent of the transgenders who
received modern treatment had not been unsafe in public places. There is association
between past experience of being unsafe in public places of the transgenders and their
choice of healthcare provider (p< 0.001).

59
Table-54: Relationship between Experience of Forced Sex and Health Care Seeking
Experience of forced
sex
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Yes
34
51.5%
32
48.5%
66
100.0%
1.343a
.324
No
27
62.8%
16
37.2%
43
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table-54 shows that 51.5 percent of the transgenders who received modernized
healthcare had experienced forced sex and 62.8 percent of the transgenders who received
modern treatment had no experience of forced sex. There is relation between experience
of forced sex of the transgenders and their choice of healthcare provider.

60
Table-55: Relationship between Suicidal Tendency and Health Care Seeking
Suicidal tendency
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Yes
23
52.3%
21
47.7%
44
100.0%
.408a
.560No
38
58.5%
27
41.5%
65
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table-55 reveals that 52.3 percent of the transgenders who had suicidal tendency
received modernized healthcare and 58.5 percent of the transgenders who had no suicidal
tendency received modern treatment. There is relation between suicidal tendency of the
transgenders and their choice of healthcare provider.

61
Table-56: Relationship between Satisfaction with the Service of Unknown Doctors
and Health Care Seeking Behavior of the Transgenders
Satisfaction with the
service of unknown doctor
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Dissatisfied
28
82.4%
6
17.6%
34
100.0%
2.435a
.317Satisfied
12
100.0%
0
0.0%
12
100.0%
Total 40
87.0%
6
13.0%
46
100.0%
Table- 56 reveals that 82.4 percent of the transgenders who were dissatisfied with the
service of unknown doctor received modernized healthcare and 100 percent of the
transgenders who were satisfied with the service of unknown doctors took modern
treatment. There is relation between satisfaction level of the transgenders with the service
of unknown doctors and their choice of healthcare provider.

62
Table-57: Relationship between Substance Abuse and Health Care Seeking
Substance abuse
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Yes
51
62.2%
31
37.8%
82
100.0%
5.217a
.027No
10
37.0%
17
63.0%
27
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table-57 shows that 62.2 percent of the transgenders who had abused substances
received modern healthcare and 37.0 percent of the transgenders who did not abuse
substances received modern treatment. There is association between substance abuse of
the transgenders and their choice of healthcare provider (p< 0.05).

63
Table-58: Relationship between Experience of Refusal to Treat and Health Care
Seeking Behavior of the Transgenders
Experience of
Refusal to Treat
Health Care Seeking
Behavior Total Chi-
square
P-
value
Modern
Treatment
Traditional
Treatment
Yes
40
70.2%
17
29.8%
57
100.0%
9.793a
.002No
21
40.4%
31
59.6%
52
100.0%
Total
61
56.0%
48
44.0%
109
100.0%
Table-58 represents that 70.2 percent of the transgenders who had experience of refusal
to be treated received modern healthcare and 40.4 percent of the transgenders who had no
experience of refusal to be treated received modern treatment. There is association
between substance abuse of the transgenders and their choice of healthcare provider (p<
0.05).

64
Table-59: Linear Regression
We can test for the statistical significance of each of the independent variables. This tests
whether the unstandardized (or standardized) coefficients are equal to 0 (zero) in the
population. If p<.05, we can conclude that the coefficients are statistically significantly
different from 0 (zero). The t-value and corresponding p-value are located in the “t” and
“r” columns.
Model Unstandardized
Coefficients
Standardiz
ed
Coefficient
s
t p
B Std. Error Beta
(Constant) 1.340 .177 7.563 .000
Age -1.094 .188 -.503 -5.828 .000
Monthly income .450 .103 .449 4.376 .000
Living status -.035 .144 -.028 -.242 .810
Being unsafe in
public place
-.203 .129 -.192 -1.572 .119
Substance abuse .193 .133 .168 1.454 .149
Experience of
refusal to treat
-.018 .127 -.018 -.144 .886
Marital status -.404 .094 -.407 -4.310 .000
Education .280 .106 .214 2.632 .010
Experience of
violence
-.135 .099 -.129 -1.356 .178
Forced to sex .604 .067 .594 8.990 .000
Suicidal ideation .133 .091 .132 1.472 .144
Satisfaction
regarding the
treatment of
unknown doctor
-.516 .090 -.712 -5.751 .000
From this table we can see that there is a significant relationship of the transgenders’
health seeking behavior with their age, monthly income, marital status, education,
experience of forced sex, and satisfaction regarding treatment of an unknown doctor.

65
Chapter 5
Discussion, Conclusion & Recommendations
5.1 Discussion
A total of 109 transgenders were studied. In this study most of the transgenders were
from 26-32 years age group. Their percentage was 40.37 and only 4.59 percent of the
transgenders were from 46-52 years age group. Other age groups were 12-18 years, 19-
25 years, 33-39 years, 40-45 years, 46-52 years with percentages 5.50 percent, 11.10
percent, 23.85 percent, 14.68 percent, 4.59 percent respectively. The mean age of the
transgenders was 31.75 years with a Standard Deviation of (±8.703). 84 percent of the
respondents transformed from Male-to-Female, and 16 percent were from Female-to-
male.
45 percent of the transgenders were living together with their partners. 44 percent were
single, 5.5 percent were married and 5.5 were widowed. 53.2 percent of the transgenders
had completed primary education. 20.2 percent transgenders were illiterate, 10.5 percent
were secondary passed, and 5.5 percent went up to higher secondary education. 4.6
percent were from other educational background like Madrasah.
95.4 percent transgenders said that they collected money and involved themselves in
entertaining activities for their daily living. 4.6 percent said that they only collected
money for their living. There was a great variation in their monthly income range. The
lowest income reported by them was BDT 3000, while the highest monthly income was
BDT 80000. The highest percentage was in the 1000-10000BDT group, 70.6 percent
transgenders reported that their income was in this range. 10.1 percent earn between
11000-20000BDT, 4.6 percent between 31000-40000BDT, and only 4.6 percent between
71000-80000BDT. The number of dependents varied from none to up to 9 persons. 22
percent of the transgenders had 5 people who depend on their income. 4.6 percent
transgenders had 2 dependents, 14.7 percent had 3 dependents, 20.2 percent of the
respondents had 4 dependents, 4.6 percent had 6 dependents, 10,1 percent had 7

66
dependents,14.7 percent had 8 dependents and 4.6 percent had 9 dependents. Only 4.6
percent of the transgender did not have to pay for anyone other than themselves.
Of the 109 transgenders, only 9.20 percent had own house. The rest 90.80 percent lived
in rented houses. 66 percent of the transgenders’ houses were semi-pakka or tin-shed. 29
percent lived in pakka buildings and 5percent of their houses were kacha. 45 percent of
the transgenders, which is the greatest proportion, lived with homogenous groups. 34.90
percent of them lived alone. Only 14.70 percent of the transgenders lived with their
family. 5.50 percent lived with their family and also with the members of their
homogenous group.
40.3 percent of the transgenders drink water after boiling. 37.61 percent drink tube well
water. 20.02 percent of the transgenders told that they drank the supply water directly.
This may be due to their lack of knowledge about the disaster that unsafe water can bring
about, or lack of ability to afford the fuel required for the boiling of water. Their long
money collecting period may also be a reason. 79.82 percent of the transgenders use
sanitary latrine, and the other 20.18percent do not have a sanitary latrine, which indicates
their low quality living status.
67 percent of the transgenders reported that they felt unsafe in public places. The other 33
percent did not feel so. 29.36 percent of the transgenders confirmed the perception of
transphobia among other people. 55.96 percent of them told that transphobia was not
always present in other people. 9.174 percent told people were not afraid of them at all
and 5.505 percent had no idea about this. Kenagy and Bostwick [53]
found that 56 percent
transgenders felt unsafe in public, and 43 percent felt uncomfortable in public. 35.78
percent of the transgenders’ families felt shameful towards them, and 30.28 percent were
hostile. 33.94 percent of the transgenders’ families were friendly towards them.
65.14 percent of the transgenders have experienced some form of violence in their
lifetime, and 34.86 percent have not. 63 percent of the transgenders were violated by their
family members, 14 percent by community people and 2 percent by both family members
and community people. 60.55 percent of them had been forced to sex in their lifetime,
while 33.94 percent had not and 5.51 percent refrained from answering. 74.20 percent

67
reported the imposer to be from their own community, and 18.20 percent from their
family members and 7.6 percent reported them to be unknown. Bowen[54]
found that
among 20 FTMs, 21 percent had been beaten as an adult and 71 percent had been beaten
as children, defined as under age 21. More than one-third (36 percent) of the sample were
sexually abused as adults, 50 percent were sexually abused as children, 50 percent had
been raped or sexually assaulted at some point during their lives, and about two-thirds
(64 percent) were afraid for their life or physical safety at some point during their lives.
Wilchins[54]
and colleagues (1997) surveyed 402 predominately white (70.9 percent)
transgender people and found that 47 percent had been assaulted during their lifetime.
All of the transgenders (100percent) reported being affected by illness in their lifetime.
25.6 percent had suffered from jaundice, 11 percent from typhoid, 10.1 percent from
hypertension, 9.2 percent from diabetes. 15.7 percent of the transgenders had other
diseases like kidney disease, fever, common cold etc. 49.5 percent of the transgenders
reported of being suffered from eczema, 10.1 percent from fungal infections, 4.6 percent
from scabies, 5.5 percent from warts. 19.3 percent of the transgenders had some problem
with their eyesight. 5.5 percent had night blindness and 15.6 percent suffered from
conjunctivitis. 36.7 percent had sensitivity of teeth, 10.1 percent had gum problems and
4.6 percent had dental carries. 44 percent of the transgenders had no dental problems.
35.8 percent of the transgenders had no idea about what sexually transmitted disease they
had, and 64.2 percent reported that they had no sexually transmitted disease.
45.90 percent of the transgenders claimed that they had completed their immunization
schedule. 10.10 percent remembered that their immunization was incomplete and
44percent were not sure about their immunization status. 70 percent of the transgenders
went for medical help during their transition and 30 percent did not. Among those who
seek help, 36.84 percent stated that it helped them, 27.63 percent said it did not and 35.53
percent said that they had no idea about it.
As the transgenders marked themselves, 30 percent of them had moderate chances of
getting infected by HIV, 30 percent had low chances and 40 percent marked themselves
as risk free. Kenagy and Bostwick[53]
found that most of them perceived that that had
either a low chance (51 percent) or no chance (37 percent) of having AIDS. 75 percent of

68
the transgenders reported some form of substance abuse and 25 percent reported
themselves to be negative. 40.40 percent of the transgenders had suicidal ideations, 55
percent did not have that and 4.60 percent had no idea about the question. A study of 515
transgender people in San Francisco found that 32 percent of the sample had attempted
suicide[56]
. The percentage of transgender people who had attempted suicide was lower
(16 percent) among a Washington, DC, sample (N = 252), however, 35 percent had
experienced suicidal ideation and among them, 64 percent had thought about suicide
because of gender issues[57]
.
Of the 109 transgenders, 34.90 percent identified health seeking behavior as both
preventive and curative care. 48.60 percent identified it as only curative care and 16.50
percent identified it as only preventive care. 44 percent transgenders stated that they had
no knowledge about it, while 39.40 percent knew about it. The remaining 16.5 percent
had no idea. 56 percent of them seek for medical help when the symptoms get severe. 29
percent go for medical help when they had a few symptoms and only 15 percent reported
to go for regular health checkups. This little use of healthcare may be due to their
inability to identify health seeking behavior.
56 percent of the transgenders went to see a private practitioner when they were ill. 29.40
went to Dispensary owners, 10.10 percent went to homeopath and 4.6 percent went to
kobiraj. 66 percent of the transgenders had a family doctor, 34 percent did not. 100
percent of the transgender persons’ family doctor was male. In most cases, these family
doctors were their relatives or family friends. Of the 173 people who answered the
question "Do you have a doctor or primary care physician?" in a needs assessment study
by Gretchen P. Kenagy, about two-thirds (67.1 percent) had a doctor or primary care
physician[58]
. 73 percent of the transgenders who had a family doctor were satisfied with
their family doctor’s treatment, and 27 percent were highly satisfied. 89 percent of the
109 transgenders identified prescription treatment to be the most effective treatment
method. 5.5 percent stated that homeopathy was most effective and another 5.5 percent
said dispensary medication was effective. Over the counter medication was preferred by
the transgenders as it saved them from the cost of the doctor’s visit. Also, they mostly
suffered from normal seasonal flue or common cold which over the counter drugs could

69
treat. The transgenders who told homeopathy was effective did not go for modern
treatment at all.
42.20 percent of the transgenders had taken treatment from an unknown doctor and 57.80
percent had not. This may be the result of their perceived transphobia or inability to pay
for the doctor’s visit.37 percent of the 47 transgenders who received treatment from an
unknown doctor were dissatisfied from the treatment of unknown doctors. 23.90 percent
were somewhat dissatisfied, 13 percent were neither satisfied nor dissatisfied, and 26.10
percent were satisfied. This satisfaction level may contribute to their and their peers’
healthcare choice.
Only 29 percent of the transgenders confirmed of having a balanced diet. 9 percent did
not take a balanced diet and 62 percent were not sure about it. This may be due to lack of
knowledge, living alone or poverty. Only 10.1 percent transgenders reported to take
regular physical exercise, when the other 89.90 percent did not. When asked about his,
they told that they had to walk all day for collecting money, so they did not bother to take
time for exercise. 41 percent transgenders stated that they use condoms, 31 percent said
they do not use condoms and 28 percent stated they use condoms, but not always. This
careless behavior may result from their low self-esteem, lack of knowledge about
Sexually Transmitted Infections, unavailability of condoms. This may also related to their
marking themselves as with medium or low chances of getting the HIV virus. 64.20
percent of the transgenders took medications timely and accordingly to the prescription,
30.30 percent missed the medicines sometimes and 550 percent did not take medicines
rightly.
Though 56 percent transgenders reported of having dental problems, 81 percent of the
transgenders did not get any dental checkup. The other 19 percent had. Of this 19 percent
transgenders, 52.40 percent were highly satisfied and 47.60 percent were satisfied with
their dental treatment. 46.80 percent transgenders did not know about their health rights.
43.10 percent knew, and 10.10 percent were not. This lack of information may be the
cause of their poor health seeking behavior.

70
52.30 percent of the transgenders had been refused to treat while the other 47.70 percent
did not. This refusal may be attributing to their health care seeking behavior, too. Of the
transgenders who were refused to treat, 78.9 percent reported that the source of refusal to
treat were the non-medical staff of the facility. Only 10.50 percent were refused by health
workers and 10.10 percent were refused by doctors. In Kenagy and Bostwick’s
population, 12 percent of the transgenders were refused routine medical care because of
their identity. Another 23 percent said they had been refused transgender related medical
care. 14 percent faced difficulty getting emergency medical care for being transgender[53]
.
56.9 percent transgenders did not know when to seek medical help. 24 percent of them
knew when to seek help, and 18.3 percent were not sure. This, may be, was related to
their poor identification of health seeking behavior. 48.6 percent transgenders did not get
any help from their family when they were ill. 31.2 got family support, and 20.2 percent
got support from their families occasionally. 40.4 percent transgenders did not get any
help from their neighbors/community when they were ill. 31.2 got community support,
and 20.2 percent got support from their community occasionally. The transgenders who
were living with homogenous group told that their fellows looked after them when they
were ill. This lack of family and community support may be the cause of their poor health
care choices and poor health outcomes. 68.80 percent of the responding transgenders
stated that doctors were available near their residence. 31.20 percent had no doctor
serving near their residence. 61.5 percent of the transgenders could afford the medicines
prescribed by the doctors. 33.9 percent had sometimes found difficulty to do so, and 4.6
percent could not buy the prescription medications. 73.4 percent of the transgenders did
not find the allowance that the government provides as sufficient to maintain a healthy
lifestyle. 22 percent had no idea about the government allowance, and only 4.6 percent
thought that the allowances were sufficient.
Cross tabulations of the transgenders’ Health Seeking Behavior (provider choice) were
done with other variables. From the 2×2 tables several findings were revealed.
Significant association was found between age of the transgenders and their health
seeking behavior (P-value .006), between income of transgenders and their health seeking
behavior (P-value .033), between living status of the transgenders and their health

Health Problems and Healthcare Seeking Behavior of Transgender People of Bangladesh

Health Problems and Healthcare Seeking Behavior of Transgender People of Bangladesh

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