Secret Lives of Hijra: A Mixed Methods Study of HIV-Positive Third Gender People in Hyderabad, India

Background

Hijra are considered neither men nor women, but rather occupy a third gender category in South Asian culture. Hijra are typically individuals who have been assigned male gender at birth and who identify with more effeminate gender roles and gender expression. In the postcolonial context, many hijra work as panhandlers and sex workers, often while keeping their dual gender identities hidden from their families, friends and neighbors. Minimal research has examined the impact of HIV stigma on health outcomes for third gender individuals. Utilizing mixed methods, the goal of this study was to examine the differential impact that HIV stigma has on: 1) depression and 2) the utilization of HIV services.

Methods

In the first phase of the study, 150 individuals (50 cisgender men, 50 cisgender women, and 50 third gender people) living with HIV were asked to complete a survey on their experiences with HIV stigma and depression. Multiple linear regression was utilized to examine the association between HIV stigma and depression. Multinomial logistic regression was utilized to predict utilization of medical care, operationalized by having made at least one medical care visit in the past year. In the second phase of the study, 32 individuals living with HIV in Hyderabad were recruited for in-depth, semi-structured interviews: 16 cisgender women and 16 hijra. Interviews were conducted in two languages: Hindi/Urdu and Telugu. All interviews were digitally audio-recorded, then subsequently translated and transcribed. The data analysis program, Dedoose, was utilized for thematic content coding and analysis.

Results

The mean age of hijra respondents was 36.04. The majority (72%) of respondents were from scheduled castes, scheduled tribes, or other backward classes. Mean monthly income was 9,558 Rupees. HIV stigma was found to be very highly correlated with depression (p=.006), as was the interaction between HIV stigma and gender (p=0.000). Similarly, HIV stigma was strongly associated with the utilization of medical care (p=0.027), as was gender (p-0.003). Qualitative data analysis revealed that many hijra reported living two distinct lives: one in the daylight, where they fulfilled a role of husband and father in their home with their family, and another at night, where they lived as hijra with circles of friends and other sex workers. Those who felt internally conflicted about these dual identities felt high levels of stigma, forcing them to lead their lives as hijra in secret. The experience of living with HIV intersectionally compounds these experiences of living in secrecy.

Discussion

The compounding impacts of stigma on physical and mental health outcomes for third gender people living with HIV in India have not been adequately appreciated by researchers or policymakers. To address physical and mental health disparities among people living with HIV in South Asia, greater attention must be paid to the unique challenges to the access of care faced by third gender people. State AIDS Control Societies in south India need to fund structural level interventions that will tailor programs to the specific needs of the hijra community in south India.