What’s In The Blood: Why Trans Persons Can't Be Blood Donors In India

India has had an official ban on blood donations by transgender persons since 2017, and an unofficial one since the HIV/AIDS epidemic, experts say.

Santa Khurai, a trans activist from Manipur, has challenged the ban through a writ petition in the Supreme Court in 2021. “People have shared their stories with me as to how they were bullied, and faced discrimination at blood donation centres because of their trans identity,” said Khurai. “Trans people, especially trans women, are easy targets because they are visible.”

In her petition, Khurai challenged the constitutional validity of Clauses 12 and 51 of the Guidelines on Blood Donor Selection and Blood Donor Referral, 2017, issued by the National Blood Transfusion Council (NTBC) and the National Aids Control Organization (NACO) under the Ministry of Health and Family Welfare.

Clause 12 says that a “donor shall be free from any disease transmissible by blood transfusion, as far as can be determined by history and examination”. It prohibits donation by a person considered to be “at risk” for HIV, Hepatitis B or C infections, and specifies that this includes transgender people, men who have sex with men, female sex workers, injecting drug users and persons with multiple sexual partners.

Clause 51 states that transgender persons, men who have sex with men and female sex workers are considered ‘at risk’ and are permanently deferred or prohibited from being eligible as donors for blood or plasma, because they are “at risk for HIV infection”.

In March 2023, the government responded to Khurai’s petition by saying that the ban is based on “scientific evidence”. The issue should be judged “from the lens of a public health perspective and not merely from an individual rights perspective, being mindful of the practical

realities of unequal access to quality healthcare in a vast and diverse nation”, the government told the court in an affidavit. Scientific evidence clearly shows that transgender persons, MSM and female sex workers “are globally recognised as a population group with a higher prevalence of HIV and other TTIs [Transfusion Transmitted Infections]”, the government told the court.

In court, the government also said that the best test for blood testing is expensive, and not widely available. The lawyers representing Khurai, Anindita Pujari and Jayna Kothari, question that if these tests are not readily available, “it only suggests that you're making others prone to such diseases,” rather than as a reason to restrict transfusions from transgender persons. Pujari adds that trans and queer persons should be tested for HIV/AIDS, Hepatitis B and Hepatitis C, so that they should be able to donate blood if they are free from these illnesses.

‘Insinuating that our blood is dirty’

India’s first international trans beauty queen, Naaz Ali Joshi, 38, is a model in Delhi, who met this reporter at a talent and beauty pageant in June.

Joshi said that whenever she has felt sick, whether it was a cold or cough, the doctors told her to get an HIV test done, assuming that because she’s trans, she must be a sex worker and hence may have HIV infection.

She called it a “gross generalisation” that impacts their access to medical care.

“I got infectious mononucleosis [an infectious viral] this year and due to that, my blood cells, mainly platelets and WBC [white blood cells], were very low. I told the hospital authorities that since my haemoglobin was fine, I should be allowed to exchange my blood for platelets so that I won’t have to pay for it but they told me that I cannot do it because I’m trans.”

“I had to buy the blood units for Rs 16,000, pay for my spleen surgery [the disease can cause an enlarged spleen] which cost me another Rs 1 lakh. Trans models don’t have such money lying around. Even with my achievements, often people don’t pay us, so where do we go for the money? I had even told them to do an HIV test on me but they told me that ‘we think you are from a very high risk category’. They did not just take away my right but also my dignity insinuating that my blood is dirty.”

Santa Khurai, a trans woman from Manipur, is fighting a legal battle against guidelines that ban blood donations by transgender persons.

These incidents are common for transgender persons.

“During the second wave of the Covid-19 pandemic, two trans women who are my friends went to donate blood in a private hospital in Manipur but were not allowed to do so,” Khurai says. “In fact, there was a trans doctor at that hospital and when he tried to talk to the staff about it, he was mocked by the rest of the medical staff saying that he is an Ayurvedic doctor.”

The other instance, she said, happened in 2013, when her friend’s aunt needed blood in a severe medical condition. While a friend’s blood matched with the relative and they wanted to donate blood, the government hospital in Manipur refused to let them donate, as the friend is transgender.

“Hospitals are a terrible place for us, the attitude from healthcare service providers, there is no space dedicated to trans persons, whether it’s a room or washroom,” says Khurai, who now travels to Thailand for her medical issues.

Khurai, who belongs to Nupi Maanbi, an indigenous trans community in Manipur, said that there is a large need for blood donations in Manipur. “It is a sensitive and conflict area. Even now, with the violence in the state, members of the [transgender] community have tried to go to hospitals and donate blood but they're still not allowed to do so,” she said. “Some trans folks are living with their family, but if they want to support a family member by donating blood for them, they aren't allowed to do so.”

It's even harder for trangender people to get blood when they need it because many do not live with their blood relatives. “It's important to understand that most of the people do receive blood donations from their family. When trans folks are not allowed to donate blood and many of them may be living with their ‘chosen’ family members and friends who may also be trans, it becomes extremely difficult for them to get voluntary donors for their own sake,” says Aqsa Shaikh, a trans doctor and founder of Human Solidarity Foundation, and NGO supporting gender and sexual minorities.

Having a rare blood group, AB negative, Shaikh said, “If I require blood, none of my own trans friends and folks will be allowed to donate blood for me and that puts me into grief.”

Aqsa Shaikh, a trans doctor, who advocates for access to all healthcare services for the transgender community.

In addition, it is expensive to source blood, and many transgender persons might not be able to afford it.

“I had a trans friend, Rupali, who required dialysis quite frequently back in 2015-16. No one from my community who was close to her or knew her could give her blood. She had to then buy blood units which were very expensive for her,” says Rudrani Chhettri, 45, a trans activist, who runs a garima greh, a safe space for transgenders, in west Delhi’s Dabri. Rupali died in 2017 because of multiple organ failure. “If a trans person is not financially sound and they need blood urgently, they can’t even source it from the people they are connected to in the community. What do they do?”

The trans community comprises people from different socio-economic strata, explains Chhettri. “Some may be privileged but 80-90% trans folks who are visible are below the poverty line which makes donating or getting blood a luxury as they don’t have any donor card to use if they require blood in an emergency.”

The history of the ban on blood donations by transgender persons, scientific evidence

Rudrani Chettri, a transgender woman, in her house in Delhi. She says, “80-90% trans folks who are visible are below the poverty line which makes donating or getting blood a luxury as they don’t have any donor card to use if they require blood in an emergency.”

During the 1980s when the HIV/AIDS epidemic outbreak occurred, in many countries, such a similar lifetime ban on blood donations from transgender persons and MSM (men who have sex with men) was implemented.

In 1986, India diagnosed its first official cases of AIDS; the first two cases were because of blood and blood product transfusions abroad.

Research by Prema Ramachandran of the Nutrition Foundation of India, published in 2012, says that data from sero-surveillance in the 1980s showed the presence of HIV infection in all the known high-risk groups and in the general population, and that HIV was getting “transmitted through all the known modes of transmission.” “In most states heterosexual transmission was predominant”, while in “Manipur intravenous (iv) drug use was the most common mode of transmission,” the survey had found.

The World Health Organization (WHO) says that transgender persons are around 13 times more likely to be HIV-positive than other adults. “In some regions, transgender women account for disproportionally large shares of new infections, including Asia and the Pacific (7%),” the WHO says, adding that however, “little data is available for transgender men and other transgender populations regarding HIV epidemiology. Even less data is available regarding prevalence and incidence rates of viral hepatitis and other sexually transmitted infections (STIs) in transgender people.”

The US Centers for Disease Control and Prevention (CDC) notes that "annual HIV infections among gay or bisexual men have been stable in recent years, an encouraging sign after more than a decade of increases”.

"The ban that forbid (sic) men who have sex with men from donating blood was implemented more than 30 years ago. During the '80s, the epidemiology was different and it seems not only hypocritical but also naïve to rely on guidelines that are far outdated and old-fashioned," an opinion piece published in 2017 by researchers from Greece and the UK, asking for blood donation guidelines for gay, lesbian and the transgender population, to be re-evaluated.

Now, many countries have changed their guidelines, such that they do not have a permanent ban based on identity. For instance, the US and the UK have revised their policies to not make deferrals identity-based, but based on either a 3-5 month or 45-day deferral from the last high-risk sexual contact.

Rohin Bhatt, a human rights litigator, queer rights activist and founder of the Indian Bioethics Project, an independent project under Gujarat National Law University on the intersection between law and bioethics, says that the stigma rooted in the AIDS epidemic is still being used to leave queer people out.

Public health experts in India point to the difficulty in widespread pre-testing before blood donations in India and the higher risk of HIV in transgender people. Transgender activists say that blood is anyway tested before being given to a recipient, that there are quick tests that can be done even before the blood is donated, and that the risks of infections exist even for other populations.

“The nature of the practice, the test and disease is such that there is a blanket ban to rule risk out. For a country like ours, it is not possible to keep track and check with every patient one-on-one; many times, these decisions are taken in a way to minimise any chance of risk,” said a doctor who worked on the national guidelines, and spoke on the condition of anonymity.

He explained that when a person is exposed to an STI or to HIV, there is usually an incubation period or a window before the disease develops and before it will show up on tests. “If in the window period, they transmit or give blood to someone else, we wouldn't know; the recipient would not know and of course it is not limited to transpersons.”

When questioned on why other countries are changing the rules, the official said that because India is a large country, even a low rate of a disease [0.2% for STIs] results in a large number of people suffering from it, thus increasing the chances of a blood donor having the disease. “Moreover, you see how well the implementation and management are in Canada and the USA.”

He said that the ban is needed because of the state of India’s healthcare system and its population. “There are some tests but they are expensive, and in a public health system like ours, in a country of millions, it doesn't serve the purpose.”

Desh Deepak, Rotary’s blood bank’s medical official, also emphasised on this window period for developing a disease, and said that while taking blood, there is a comprehensive screening process. “Past and present history, including childhood, injuries, medical conditions and relationships, all are asked about,” he said, adding that anyone who recently received a Hepatitis B or C vaccine is also not considered for donation.

He added that trans persons are among the ‘high-risk’ and ‘most-prone’ groups when it comes to HIV/AIDS, Hepatitis B and C. As blood banks would not know if a trans person is in a monogamous or polyamorous relationship, and because the likelihood of anal sex is higher in the population, they prefer to avoid blood donations from them.

Deepak says that if a trans person is not able to give blood for their family member or friends in an emergency, then the rotary blood bank will give the blood to them for free.

“If you think about the trans community, then the ban on blood donation is wrong, but if you think about the person who could possibly be infected due to receiving infected blood, then that's also wrong,” said Amit Harshana, a clinician and public health expert.

Transgender persons and activists disagree, saying that tests need to be made accessible to transgender persons who want to donate blood.

Saher Ali Naaz, a cardiovascular perfusion specialist and microbiologist, says that nothing should stop transpersons from donating blood if they don’t have a disease.

“We need to understand that now there are enough technological advances available by which we can detect HIV in the window period also. This cannot be a reason good enough to stigmatise an already marginalised group,” said Shaikh, the doctor and founder of Human Solidarity Foundation.

Saher Ali Naaz, a 34-year old cardiovascular perfusion specialist and microbiologist from Kanpur said, “There are rapid tests done for all kinds of blood diseases wherein the result also arrives in two hours and then one can donate blood. Many options such as ELISA and HBsAg tests, among others.”

Ban is selectively enforced on trans people

As a standard procedure, say blood bank officials and doctors, every blood donor is screened or counselled, and all blood units are tested to check for infection. Chhettri questions why this cannot be done for transgender persons too.

“If there's a migrant who is among the high risk or prevalence group, or a farmer who works six months in one place and then goes to a metropolitan city for casual sex, should they also not be allowed to give blood? If there's a male homosexual person but they don’t reveal it or talk about it, you would still take their blood. For a trans feminine or trans person in general, your visibility makes an impact.”

Chhettri raises a question on the automatic belief that a cis-heteroperson is not HIV-positive, such as when donating at a blood camp. She said that NACO organises medical and blood donation camps on AIDS day, December 1, and otherwise, in which many sex workers and transgender persons participate. But even at these events, where “they talk about equality and helping these marginalised communities, we can’t even donate blood and help our friends and families. How can you be so sure that a cis-heteroperson’s blood is not HIV positive in that camp?”

Saher, the microbiologist from Kanpur, had transitioned five years ago. However, as she looks feminine, she had been allowed to donate blood in the hospital she earlier worked in.

She says that gay or bisexual couples, who hide their sexual preferences, can easily donate blood. Hence, it’s the transgender persons in particular who are visible, and not allowed to donate. “In small cities, there is little awareness about the government guidelines or orders, they usually don't care so a lot of people in queer groups probably donate blood except the Hijra community.”

Shaikh adds that a risk-benefit analysis of the policy on restricting trangender people from donating blood shows that the policy risks stigmatising a vulnerable group more than it can benefit anyone.

“All we want is for the Indian government to accept and understand the reality, do a comprehensive study and amend the current guidelines or remove them so trans folks can also help other people and their families,” Khurai said.

Chettri asks for an inclusive team to decide on the guidelines, asking the government, “If you make such policies, how inclusive was your team who formulated the laws? If the community in question has not participated in that exercise, then how is it for everyone? Why shouldn’t you call us and reason with us?”

The government official who worked on the guidelines said that more does need to be done. “In three-five years, they should change the guidelines, for the better, making sure that there is no loophole. I hope in the coming years, there is more discussion on this and we see a change.”

We reached out to Anil Kumar, the additional director general in the Directorate General of Health Services (DGHS), and to Megha Pravin Khobaragade in the DGHS, but neither have responded to our queries. We will update the story when they respond.