- Email: [email protected]
Transgender health in India and Pakistan
Correspondence
Addressing transgender health in a Lancet Series and in The Lancet Psychiatry1 constitutes a milestone for health professionals and social scientists. I draw conclusions from some of these papers on how we consider health, disease, and gender, and on the purpose of the nomenclatures we have developed and use. Given that transgender people have very common experiences of social rejection and violence, these factors are strong predictors of distress and mental illness.1 The proposal to shift descriptive elements of transgender identity from mental health and behavioural disorders (International Classification of Diseases [ICD]-10) to sexual health categories (ICD-11) represents an opportunity to combine public health with clinical objectives and promote health care as a human right.2,3 In many ways, this achievement results from the process that has also helped to combat violence against women. The long-lasting efforts of social (feminist) movements and the way epidemiology has addressed interpersonal violence as a public health issue4 have progressively converged, making violence a target for public health and human rights policies. The relation between feminism, human rights, and public health, although not fully understood, illustrates a broader endeavour in public health and epidemiology that the new proposals on the health of transgender people also show: reformulation of various social issues that involve health in social terms to provide pragmatic public health implementations. These approaches propose renewed definitions: debiologisation of sex by giving gender a social meaning and a reflection on what disease is. However, our social use of nomenclatures related to transgender people needs further discussion. The Lancet Series on transgender health helps us to www.thelancet.com Vol 388 November 26, 2016
understand that a binary dividing line between men and women might not be sufficient to provide transgender people with appropriate access to health care and their rights. The contentious debate about hyperandrogenism in female athletes reminds us that pursuing health care and human rights goals at the same time is difficult. Moreover, the possible new status for transgender identity in the ICD-11 could be ambiguous. On one hand, the new classification could provide better health care and give transgender people a diagnosis, which could be helpful from a social perspective. On the other hand, it might also lead to repathologisation of gender status as a dysfunction that is exceptionally tolerated by society.5 As continuums, gender and health still require our research and political efforts. I declare no competing interests.
Catherine Cavalin [email protected] Centre for European Studies, Sciences Po, Paris, France 1
2
3
4
5
Robles R, Fresán A, Vega-Ramírez H, et al. Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. Lancet Psychiatry 2016; 3: 850–59. Lo S, Horton R. Transgender health: an opportunity for global health equity. Lancet 2016; 388: 316–18. Winter S, Settle E, Wylie K, et al. Synergies in health and human rights: a call to action to improve transgender health. Lancet 2016; 388: 318–21. Rosenberg ML, Mercy JA. Assaultive violence. In: Rosenberg ML, Fenley MA, eds. Violence in America: a public health approach. New York, NY: Oxford University Press, 1991: 14–50. Parsons T. Social structure and dynamic process: the case of modern medical practice. In: Parson T, ed. The social system. London: Routledge & Kegan Paul Ltd, 1951: 428–79.
Transgender health in India and Pakistan Sam Winter and colleagues (July 23, p 318 and p 390)1,2 reported a much neglected health issue of transgender people, who have been officially recognised as a third gender citizen registration category in Nepal, Pakistan,
India, and Bangladesh, since 2010. Locally known as hijras (hijra), this civil recognition is profound for their social rights because it translates into confirmed allocation into government and education quotas. Despite the legal recognition, access to quality health care is alarmingly scarce compared with their cisgender counterparts. More concerning is their reduced engagement in health promotion and disease prevention activities especially related to sexual health, putting them at a higher risk of sexually transmitted infections, including HIV. The prevalence of HIV among transgender people in India is estimated to be 14·5%.3 In Pakistan, the HIV incidence among transgender people contributes up to 17·5% of the entire HIV population.4 Moreover, in Pakistan, approximately 71% of transgender sex workers who use injectable drugs have sexual relationships with other drug users and up to 33·7% of them did not use a condom in the last coitus with their clients.5 Similarly in India, the use of condoms during anal sex remains low and almost two-thirds of transgender people have no access to treatment of sexually transmitted infections. Of the interviewed respondents,6 only 59·2% (of 277 transgender people) had been referred for HIV testing and up to 67·1% had not been given proper counselling on antiretroviral therapy adherence even though the medication had been given. Additionally, because of social discrimination and stigma, most transgender people in India and Pakistan have no opportunity for schooling or access to higher education, eventually leading to poor health literacy. Even though transgender people in Pakistan and India have been given their civic identity, they are still vulnerable to verbal and psychological abuse by medical personnel. Unsurprisingly, HIV prevalence among transgender sex workers is eight times higher compared with their cisgender counterparts in Pakistan. Also, there are hardly any anti-discrimination laws in place to safeguard equality in health-care access
For more on The Lancet Series on transgender health see http://www.thelancet.com/ series/transgender-health
Getty Images
Gender and health: between nomenclatures and continuums
2601
Correspondence
for transgender people in Pakistan and India. Albeit with a prominent visibility of hijras in the community such as in contesting for local, provisional, and national legislative assemblies, there is still a long way to go before they can elicit political support and destigmatise their former identity to receive proper medical care and prevention measures against sexually transmitted infections and HIV. We declare no competing interests.
Long C Ming, Muhammad A Hadi, *Tahir M Khan [email protected] Unit for Medication Outcomes Research and Education (UMORE), School of Medicine, University of Tasmania, Hobart, TAS, Australia (LCM); School of Healthcare, University of Leeds, Leeds, UK (MAH); and School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia (TMK) 1
2
3
4
5
6
Winter S, Settle E, Wylie K, et al. Synergies in health and human rights: a call to action to improve transgender health. Lancet 2016; 388: 318–21. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016; 388: 390–400. Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence. Glob Public Health 2016; 11: 849–65. Singh S, Ambrosio M, Semini I, et al. Revitalizing the HIV response in Pakistan: a systematic review and policy implications. Int J Drug Policy 2014; 25: 26–33. Melesse DY, Shafer LA, Shaw SY, et al. Heterogeneity among sex workers in overlapping HIV risk interactions with people who inject drugs: a cross-sectional study from 8 major cities in Pakistan. Medicine (Baltimore) 2016; 95: e3085. Shaikh S, Mburu G, Arumugam V, et al. Empowering communities and strengthening systems to improve transgender health: outcomes from the Pehchan programme in India. J Int AIDS Soc 2016; 19 (suppl 2): 20809.
Uncontrollable medicine prices in Pakistan Published Online November 7, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)32120-1 For the Lancet Commission on essential medicine policies see Online/Commission http://dx.doi.org/10.1016/ S0140-6736(16)31599-9
2602
The Sustainable Development Goal 3 presented by the UN1 emphasises that there is an urgent need to ensure that everyone has access to quality treatment at affordable costs. Therefore, among several interventions, one method to control health-care costs is to make sure that medicines are reasonably priced and
affordable to the general population. However, affordability of medicines seems to be of low importance to policy makers in Pakistan. In recent months, prices of hundreds of essential and lifesaving medicines have increased greatly in Pakistan, making them unaffordable to residents with low and middle incomes. For some of these medicines, a price increase of over 100% has been observed. For example, the price of the frequently prescribed antispasmodic drotaverine has increased by 218%, while that of commonly used cough syrup dextromethorphan hydrobromide, chlorpheniramine, and pseudoephedrine increased by 105%. Additionally, the price of an injection of vitamins B1, B6, and B12 increased by 85%.2 Numerous medicines have recently increased in price over 2–3 months, making them unaffordable for patients. The situation is getting out of hand for the people of Pakistan because there is no national health insurance, and most of the health-associated expenditure is an out-of-pocket expense. A major reason for this uncontrollable price hike is the unsatisfactory performance of the Drug Regulatory Authority of Pakistan (DRAP) and other associated agencies. Medicine prices in Pakistan were officially permitted by DRAP to increase four times between June and August, 2016; however, pharmaceutical companies ignored DRAP’s notification and instead raised the prices five times over the 3 months. Shockingly, this illegitimate increase in price was not acknowledged or acted upon by DRAP in Pakistan. Despite the fact that the Ministry of National Health Services, Regulations, and Coordination (NHSRC) admitted that the medicines of some multinational companies were overpriced, no action was taken. Notably, the issue of the price increases was highlighted at the federal parliament of Pakistan in February, 2016, whereby the parliamentarians instructed NHSRC and DRAP to take strict action against pharmaceutical companies who were plundering the masses by increasing prices of medicines unilaterally.
Furthermore, a subsidy of medicines that had increased in price was proposed. The price hike was strongly condemned and the Senate’s Standing Committee on National Health Services, Regulations and Coordination instructed that no second chances should be given to these companies.3 However, no action was taken and patients were left at the mercy of the pharmaceutical companies, so they had no choice but to pay exorbitant prices for medicines that were affordable just a few months before. Within this context, surely pharmaceutical companies in Pakistan are using various tactics to avoid scrutiny from the regulatory authorities. At the same time, the leniency of the regulatory authorities is also evident. It is time for health authorities in Pakistan to start learning from past experiences. An amendment in the relevant schedule appended to the Drug and Pricing Act is needed that will allow the government to place stern policies on price control, and actions to be taken in case of illegitimate price hikes. Instead of listening to the demands of the pharmaceutical industry, the Pakistani Government should start listening to the people, who are now faced with unaffordable medicines. We declare no competing interests.
*Fahad Saleem, Mohamed Azmi Hassali, Qaiser Iqbal, Marvi Baloch, Pathiyil Ravi Shanker [email protected] Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta 87300, Pakistan (FS, QI, MB); School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia (MAH); and Xavier University School of Medicine, Oranjestad, Aruba (PRS) 1
2
3
UN. Sustainable development goals. Ban establishes eminent panel to help broaden access to quality medicines at affordable costs. UN. Nov 25, 2015. http://www.un.org /sustain abledevelopment/blog/2015/11/ban-establish es-eminent-panel-to-help-broaden-access-toquality-medicines-at-affordable-costs/ (accessed Sept 2, 2016). Chaudhry A. Authorities fail to check steep drug price hike. Dawn. Aug 22, 2016. http://www.dawn.com/news/1279112 (accessed Sept 2, 2016). The Express Tribune. Price hike: legislators call for action against pharma companies. Feb 20, 2016. http://tribune.com.pk/story/1050702/pricehike-legislators-call-for-action-against-pharmacompanies/ (accessed Sept 2, 2016).
www.thelancet.com Vol 388 November 26, 2016
Addressing transgender health in a Lancet Series and in The Lancet Psychiatry1 constitutes a milestone for health professionals and social scientists. I draw conclusions from some of these papers on how we consider health, disease, and gender, and on the purpose of the nomenclatures we have developed and use. Given that transgender people have very common experiences of social rejection and violence, these factors are strong predictors of distress and mental illness.1 The proposal to shift descriptive elements of transgender identity from mental health and behavioural disorders (International Classification of Diseases [ICD]-10) to sexual health categories (ICD-11) represents an opportunity to combine public health with clinical objectives and promote health care as a human right.2,3 In many ways, this achievement results from the process that has also helped to combat violence against women. The long-lasting efforts of social (feminist) movements and the way epidemiology has addressed interpersonal violence as a public health issue4 have progressively converged, making violence a target for public health and human rights policies. The relation between feminism, human rights, and public health, although not fully understood, illustrates a broader endeavour in public health and epidemiology that the new proposals on the health of transgender people also show: reformulation of various social issues that involve health in social terms to provide pragmatic public health implementations. These approaches propose renewed definitions: debiologisation of sex by giving gender a social meaning and a reflection on what disease is. However, our social use of nomenclatures related to transgender people needs further discussion. The Lancet Series on transgender health helps us to www.thelancet.com Vol 388 November 26, 2016
understand that a binary dividing line between men and women might not be sufficient to provide transgender people with appropriate access to health care and their rights. The contentious debate about hyperandrogenism in female athletes reminds us that pursuing health care and human rights goals at the same time is difficult. Moreover, the possible new status for transgender identity in the ICD-11 could be ambiguous. On one hand, the new classification could provide better health care and give transgender people a diagnosis, which could be helpful from a social perspective. On the other hand, it might also lead to repathologisation of gender status as a dysfunction that is exceptionally tolerated by society.5 As continuums, gender and health still require our research and political efforts. I declare no competing interests.
Catherine Cavalin [email protected] Centre for European Studies, Sciences Po, Paris, France 1
2
3
4
5
Robles R, Fresán A, Vega-Ramírez H, et al. Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. Lancet Psychiatry 2016; 3: 850–59. Lo S, Horton R. Transgender health: an opportunity for global health equity. Lancet 2016; 388: 316–18. Winter S, Settle E, Wylie K, et al. Synergies in health and human rights: a call to action to improve transgender health. Lancet 2016; 388: 318–21. Rosenberg ML, Mercy JA. Assaultive violence. In: Rosenberg ML, Fenley MA, eds. Violence in America: a public health approach. New York, NY: Oxford University Press, 1991: 14–50. Parsons T. Social structure and dynamic process: the case of modern medical practice. In: Parson T, ed. The social system. London: Routledge & Kegan Paul Ltd, 1951: 428–79.
Transgender health in India and Pakistan Sam Winter and colleagues (July 23, p 318 and p 390)1,2 reported a much neglected health issue of transgender people, who have been officially recognised as a third gender citizen registration category in Nepal, Pakistan,
India, and Bangladesh, since 2010. Locally known as hijras (hijra), this civil recognition is profound for their social rights because it translates into confirmed allocation into government and education quotas. Despite the legal recognition, access to quality health care is alarmingly scarce compared with their cisgender counterparts. More concerning is their reduced engagement in health promotion and disease prevention activities especially related to sexual health, putting them at a higher risk of sexually transmitted infections, including HIV. The prevalence of HIV among transgender people in India is estimated to be 14·5%.3 In Pakistan, the HIV incidence among transgender people contributes up to 17·5% of the entire HIV population.4 Moreover, in Pakistan, approximately 71% of transgender sex workers who use injectable drugs have sexual relationships with other drug users and up to 33·7% of them did not use a condom in the last coitus with their clients.5 Similarly in India, the use of condoms during anal sex remains low and almost two-thirds of transgender people have no access to treatment of sexually transmitted infections. Of the interviewed respondents,6 only 59·2% (of 277 transgender people) had been referred for HIV testing and up to 67·1% had not been given proper counselling on antiretroviral therapy adherence even though the medication had been given. Additionally, because of social discrimination and stigma, most transgender people in India and Pakistan have no opportunity for schooling or access to higher education, eventually leading to poor health literacy. Even though transgender people in Pakistan and India have been given their civic identity, they are still vulnerable to verbal and psychological abuse by medical personnel. Unsurprisingly, HIV prevalence among transgender sex workers is eight times higher compared with their cisgender counterparts in Pakistan. Also, there are hardly any anti-discrimination laws in place to safeguard equality in health-care access
For more on The Lancet Series on transgender health see http://www.thelancet.com/ series/transgender-health
Getty Images
Gender and health: between nomenclatures and continuums
2601
Correspondence
for transgender people in Pakistan and India. Albeit with a prominent visibility of hijras in the community such as in contesting for local, provisional, and national legislative assemblies, there is still a long way to go before they can elicit political support and destigmatise their former identity to receive proper medical care and prevention measures against sexually transmitted infections and HIV. We declare no competing interests.
Long C Ming, Muhammad A Hadi, *Tahir M Khan [email protected] Unit for Medication Outcomes Research and Education (UMORE), School of Medicine, University of Tasmania, Hobart, TAS, Australia (LCM); School of Healthcare, University of Leeds, Leeds, UK (MAH); and School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia (TMK) 1
2
3
4
5
6
Winter S, Settle E, Wylie K, et al. Synergies in health and human rights: a call to action to improve transgender health. Lancet 2016; 388: 318–21. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016; 388: 390–400. Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence. Glob Public Health 2016; 11: 849–65. Singh S, Ambrosio M, Semini I, et al. Revitalizing the HIV response in Pakistan: a systematic review and policy implications. Int J Drug Policy 2014; 25: 26–33. Melesse DY, Shafer LA, Shaw SY, et al. Heterogeneity among sex workers in overlapping HIV risk interactions with people who inject drugs: a cross-sectional study from 8 major cities in Pakistan. Medicine (Baltimore) 2016; 95: e3085. Shaikh S, Mburu G, Arumugam V, et al. Empowering communities and strengthening systems to improve transgender health: outcomes from the Pehchan programme in India. J Int AIDS Soc 2016; 19 (suppl 2): 20809.
Uncontrollable medicine prices in Pakistan Published Online November 7, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)32120-1 For the Lancet Commission on essential medicine policies see Online/Commission http://dx.doi.org/10.1016/ S0140-6736(16)31599-9
2602
The Sustainable Development Goal 3 presented by the UN1 emphasises that there is an urgent need to ensure that everyone has access to quality treatment at affordable costs. Therefore, among several interventions, one method to control health-care costs is to make sure that medicines are reasonably priced and
affordable to the general population. However, affordability of medicines seems to be of low importance to policy makers in Pakistan. In recent months, prices of hundreds of essential and lifesaving medicines have increased greatly in Pakistan, making them unaffordable to residents with low and middle incomes. For some of these medicines, a price increase of over 100% has been observed. For example, the price of the frequently prescribed antispasmodic drotaverine has increased by 218%, while that of commonly used cough syrup dextromethorphan hydrobromide, chlorpheniramine, and pseudoephedrine increased by 105%. Additionally, the price of an injection of vitamins B1, B6, and B12 increased by 85%.2 Numerous medicines have recently increased in price over 2–3 months, making them unaffordable for patients. The situation is getting out of hand for the people of Pakistan because there is no national health insurance, and most of the health-associated expenditure is an out-of-pocket expense. A major reason for this uncontrollable price hike is the unsatisfactory performance of the Drug Regulatory Authority of Pakistan (DRAP) and other associated agencies. Medicine prices in Pakistan were officially permitted by DRAP to increase four times between June and August, 2016; however, pharmaceutical companies ignored DRAP’s notification and instead raised the prices five times over the 3 months. Shockingly, this illegitimate increase in price was not acknowledged or acted upon by DRAP in Pakistan. Despite the fact that the Ministry of National Health Services, Regulations, and Coordination (NHSRC) admitted that the medicines of some multinational companies were overpriced, no action was taken. Notably, the issue of the price increases was highlighted at the federal parliament of Pakistan in February, 2016, whereby the parliamentarians instructed NHSRC and DRAP to take strict action against pharmaceutical companies who were plundering the masses by increasing prices of medicines unilaterally.
Furthermore, a subsidy of medicines that had increased in price was proposed. The price hike was strongly condemned and the Senate’s Standing Committee on National Health Services, Regulations and Coordination instructed that no second chances should be given to these companies.3 However, no action was taken and patients were left at the mercy of the pharmaceutical companies, so they had no choice but to pay exorbitant prices for medicines that were affordable just a few months before. Within this context, surely pharmaceutical companies in Pakistan are using various tactics to avoid scrutiny from the regulatory authorities. At the same time, the leniency of the regulatory authorities is also evident. It is time for health authorities in Pakistan to start learning from past experiences. An amendment in the relevant schedule appended to the Drug and Pricing Act is needed that will allow the government to place stern policies on price control, and actions to be taken in case of illegitimate price hikes. Instead of listening to the demands of the pharmaceutical industry, the Pakistani Government should start listening to the people, who are now faced with unaffordable medicines. We declare no competing interests.
*Fahad Saleem, Mohamed Azmi Hassali, Qaiser Iqbal, Marvi Baloch, Pathiyil Ravi Shanker [email protected] Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta 87300, Pakistan (FS, QI, MB); School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia (MAH); and Xavier University School of Medicine, Oranjestad, Aruba (PRS) 1
2
3
UN. Sustainable development goals. Ban establishes eminent panel to help broaden access to quality medicines at affordable costs. UN. Nov 25, 2015. http://www.un.org /sustain abledevelopment/blog/2015/11/ban-establish es-eminent-panel-to-help-broaden-access-toquality-medicines-at-affordable-costs/ (accessed Sept 2, 2016). Chaudhry A. Authorities fail to check steep drug price hike. Dawn. Aug 22, 2016. http://www.dawn.com/news/1279112 (accessed Sept 2, 2016). The Express Tribune. Price hike: legislators call for action against pharma companies. Feb 20, 2016. http://tribune.com.pk/story/1050702/pricehike-legislators-call-for-action-against-pharmacompanies/ (accessed Sept 2, 2016).
www.thelancet.com Vol 388 November 26, 2016