HIV/AIDS and Global Health: Hijras and HIV

Our third year HIV/AIDS and Global Health module, which explores broader anthropological questions around HIV/AIDS, illness and healing, sexual and reproductive relationships, and global health. As part of the module students are required to design a HIV awareness poster or research proposal. This week, we are featuring a poster assignment by Jana-Sharmila Sen on HIV among the Hijra community in India.
Jana-Sharmila Sen
Jana’s bio: I’m an Anthropology student at Roehampton, graduating in summer 2019. In the course of the third year ‘HIV/AIDS and Global Health’ module, I created an HIV awareness poster focussing on the HIV pandemic in India. Given my half Indian background, I knew about the Hijras’ (transgender people) marginalized position in Indian society, presenting one of the groups most vulnerable to HIV. As my passion lies in Social Anthropology, I intended to examine the social dynamics ofHijra communities, promoting a culturally sensitive approach for the poster.

Hijras – Indian Transgender Communities

On HIV Vulnerability and the Fear of Talking About It

This poster has been designed to generate further conversation on HIV among transgender or ‘Hijra’ communities in India. Compared to how transgenderism is perceived in Western societies, Hijras do not claim to have been born with the wrong sex, but to be of a “third gender” (Kalra, 2012). Thus, they claim to be neither female nor male. Hijras used to earn money by dancing and giving blessings on weddings or other occasions (Nag, 2001; Chakrapani et al., 20181). Changes in Indian society have led to the Hijras losing their cultural importance, forcing a great proportion of them into sex work (Kalra, 2012). Sex work has exposed many Hijra to a concerningly high risk of HIV transmission (Nag, 2001).

The poster shall tie in with the issue of HIV vulnerability among Hijra sex workers. As a marginal group in India, Hijras have been subject to extreme discrimination and structural violence (Dutta et al., 2019). Targeting a HIV poster towards a deeply biased Indian society, which has deeply entrenched perceptions of Hijras, could be somewhat unsuccessful. Thus, this poster has been designed to approach Hijra within their communities, promoting a self-help aspect. Even though Hijras know about HIV testing, the social stigma attached to HIV often makes them hesitate to reveal a positive HIV status (Chakrapani et al., 20181). The poster mainly addresses the gurus of the Hijra communities, which will be looked at more closely in the following. The poster could lead to gurus creating more measures to protect Hijras involved in sex work, and should promote unity among Hijras to tackle the HIV problem together.

Hijra & HIV poster

Hijras in Indian Society and the Risk of HIV

The word ‘Hijra’ originates from Urdu, and means hermaphrodite – describing a person that combines female and male genitals (Nag, 2001). Even though most Hijras in India are men dressing as women, they claim to be of neither female nor male sex, but a ‘third gender’ (Nanda, 1986). There are many categories of Hijra, several with specific names (Cohen, 1995). For the purpose of my poster, however, I decided to focus on two main types that Hijras themselves claim to be the ‘real’ Hijra: those who are born hermaphrodite and those who are made hermaphrodite through castration (Reddy, 2005).

Both of these Hijra types dress like women, which could be because of their identification with the Hindu goddess Bahuchura Mata (Lal, 1999). We may suggest Hijras are asexual beings, yet, they are believed to bring fertility to newlywed couples and newborn babies through Bahuchara Mata, rendering them an important spiritual body of Indian culture (Cohen, 1995). Dancing and giving blessings on weddings and other events used to be their main mode of subsistence (Mal, 2018); however, through globalisation, Indian society has lost touch with the Hijra’s spiritual significance, forcing many into sex work (Kalra, 2012).

The dynamics of globalisation, sex work and poverty can be seen as reasons why Hijra communities have been pushed into extreme marginalisation (Goel, 2016). The high vulnerability to HIV transmission through sex work aggravates their situation (Nag, 2001). The main customers of Hijra sex workers are men, including truckers and rickshaw pullers (Chakrapani et al., 20181). Hijra usually work in specific areas, e.g., in public parks or by highways (Chakrapani et al., 20181). The high risk of HIV lies in the fact that customers often require sex without condoms – as the Hijras are dependent on the money, they may often accede to customers’ requests, and condom use remains infrequent (Chakrapani et al., 20181+2).

In the history of HIV, India has continuously represented an epicentre of the virus (Thomas et al., 2005). However, the latest reports by the Indian NACO (National Aids Control Organization) show a decrease in newly infected people and generally better control over the epidemic (2017). Average HIV rates among Hijras are at 7.5%, which is 28 times more than rates among the rest of the population (Chakrapani et al., 20182; NACO, 2017). Transgender people also experience the highest prevalence of HIV among all fringe groups in India (Ganju & Saggurti, 2016). Concerning is also that only 34% of HIV prevention projects address Hijra sex workers, whereas 77% cover female sex workers (Chakrapani et al., 20181). These numbers reveal that throughout Indian organisations, the government and other institutions, Hijras are a less included community.

Gurus, Chelas and Structural Violence: Ethnographic Insights

As a marginalised group, Hijras live in close communities generally away from the rest of society (Mal, 2018). The communities consist of ‘gharanas’, similar to clans, which are strictly hierarchical (Nanda, 1986). The ‘Nayak’ presents the head of the ‘gharana’, with several ‘gurus’ (teachers) beneath them (Kalra, 2012). Each guru teaches a group of Hijras, who then become ‘chelas’ (students) in Hijra conduct, traditions and behaviour (Kalra, 2012). The chelas also give part of their income to the gurus in exchange for accommodation, food and security (Chakrapani et al., 20181).

“What is it that we have except our gurus? Our gurus are our saviors. They have rescued us from the harsh and brutal world. We have no one that we can trust, even our families, the one to which we were biologically born, have disowned us. […]”(Goel, 2016: 539)

In her ethnography of Hijras in Delhi, Goel here cites a Hijra talking about the gurus, representing the gratitude of the whole community. Further, this quote indicates that many Hijras have been turned down by their families and society, who often do not accept their sexual orientation. In desperate times, the Hijra communities take them in and protect them.

Hijras are generally aware of HIV, its modes of transmission and also about how to get tested (Chakrapani et al., 20181). However, one of the main problems surrounding HIV and Hijras is that once they know they have a HIV-positive status, many are hesitant to reveal it to society, but also to their own community and thus to their gurus (Chakrapani et al., 20181). The underlying stigma around HIV in India and the heavy discrimination Hijras face in Indian society could be contributing factors in this matter (Solomon et al., 2016; Mal, 2018).

For long time, Hijras did not have any rights to vote, to own property or have official documents (Kalra, 2012). They are often denied basic social services, such as those of the health, educational or employment sector (UNDP India, 2010). One of the main issues associated with such structural violence is the government’s problem of seeking to assign them to either male or female gender, which does not accord with how Hijras identify themselves (Mal, 2018). The Transgender Persons Bill of 2016 was a way to help transgender people gain legal status (ICJ, 2018). Instead, the law complicated bureaucratic processes, as well as maintaining and facilitating even more social stigma and discrimination (ICJ, 2018; Dutta et al., 2019). Hijras also face discrimination in the health sector, because health care staff are generally not trained in transgender health needs; moreover, when they are HIV positive the stigma in Indian health care settings may be even higher (Diehl et al., 2017; Ekstrand et al., 2013).

Dutta et al. (2019) in their ethnographic account of the ‘jogappas’, a group of transgender women in South India, stress also the physical and verbal abuse transgender people are exposed to on a daily basis by police officers. Gurus often help their chelas out of such situations, as we can read in Ganju & Saggurti: “The guru supports us. If there is a fight, or police raid, the guru gets us released. Our guru also gives us money” (2016: 912). This emphasises the aspect of security the gurus give the chelas. The gurus are in many ways close to their chelas, protect them and can generally be said to care for them.

Justification for the Poster

The Hijras of India face several difficulties in their lives: confusion and ignorance towards their sexual identities, exclusion by society, extreme discrimination and structural violence, as well as high vulnerability to HIV through sex work. Although the Indian court has approved laws in favour of the transgender community, social and cultural discrimination still jeopardise their lives. In the context of HIV, this poster is needed because Hijra sex workers are among the highest risk groups in India. Even though they know about HIV, they are often afraid to talk about it among their own community but also with doctors or others in society, given the discrimination and stigma. An unrevealed positive HIV status can lead to a further spread of the virus.

My analysis supported the view negative perceptions of Hijras are firmly fixed in Indian society. Hence, I decided to address this poster directly to the Hijra community. We could see that gurus have close relationships with their chelas and to certain extents are powerful to intervene in dangerous situations, which is why the poster is directed at the gurus. My approach here was to encourage the gurus to raise the HIV topic with their students, and, by this, de-stigmatising the virus and controlling the epidemic within their communities. Further, the poster can open possibilities for the whole Hijra community to unite and facilitate conversation on how to collectively fight their HIV crisis. Even though there have been many HIV awareness and some ART programmes for the transgender communities, there is still inconsistent condom use and a lack of adherence to ART among them (Chakrapani et al, 20182, Piña et al., 2018). Much important research on Hijras’ social dynamics is lacking, which would help to better target HIV programmes (Chakrapani et al., 20182). Thus, this poster can be an approach to help Hijras find their own measures against HIV.

Creative Decisions

The Hijra transgender identity is founded in Hindu mythology and tales (Goel, 2016). According to Holm (1984), Hinduism lives on images and picturesque stories. Thus, I decided to draw a colourful picture of three Hijras, since they may understand issues better when emphasized with pictures. HIV often does not show any symptoms or bodily changes for several years (HIV.GOV, 2017). The slogan “You cannot tell, unless you ask”is directly connected to the picture of the Hijras, emphasizing that one may not see HIV on the drawn Hijras, but it could affect anyone in the community. The Hijras are intentionally drawn in a line, suggesting unity and a self-help aspect. “Ask your Chelas and talk about their HIV status”should address specifically the gurus and encourage them to talk to their chelas about HIV, because the chelas may be afraid to discuss their status. The last sentence “Care for each other, for HIV does not care”shall be a reminder of the main principle of Hinduism, which is to care for one another and especially for those in need (Shukla, 2004).

We may note that if the poster were to be put up in India, the language used should preferably be the local Indian language. It is more authentic and perhaps not all Hijras know English.

Use of the Poster

The poster is expected to be used in Hijra communities everywhere in India. The first challenge for the use of the poster now represents the question of who distributes it. While the Indian population perceives Hijras partly with awe, they also feel disgusted by and afraid of them (Patel, 2010), suggesting that most Indians may not even go close to a Hijra community. One way of bringing the poster to the communities are national organisations such as the Avahan AIDS Initiative, which aims to provide coverage of health care for all risk groups in India (Dandona & Benotsch, 2011). The initiative could send out their community health workers who are trained to work in marginalised communities and understand their social dynamics (Lorway, 2017). If the communities are still impenetrable, the poster could also be placed in areas where Hijras frequently engage in sex work.

The poster is a small approach to solving a much larger problem, which can only be solved by changing Indian society. The poster could encourage Hijras to go to the doctor together, united against discrimination, however, the stigma around Hijras and HIV may not change. Thus, the poster could have a much broader impact if it were part of a de-stigmatisation campaign aimed at Indian society, which could also be run by organisations like Avahan. Antiretroviral treatment in India is generally free (Chakrapani et al., 2009) but Hijras may be afraid to go to the doctor because of discrimination. As part of a nationwide campaign, the health care sector would have to be trained on how to treat transgender people. As an emergency measure, it could also help to bring antiretroviral treatment directly into the Hijra communities, for example through community health workers.

References

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Chakrapani, V., Newman, P.A., Shunmugam, M., Kurian, A.K. & Dubrow, R. (2009) Barriers to Free Antiretroviral Treatment Access for Female Sex Workers in Chennai, India. AIDS PATIENT CARE and STDs. 23(11) pp.973-980.

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Piña, C., Dange, A., Rawat, S., Jadhav, U., Arnsten, J.H., Chhabra, R. & Patel, V.V. (2018) Antiretroviral Treatment Uptake and Adherence Among Men Who Have Sex With Men and Transgender Women With HIV in Mumbai, India: A Cross-Sectional Study. Journal of the Association of Nurses in AIDS Care.29(2) pp.310–316.

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