Oral health‑related knowledge,

Attitude and practices among

Eunuchs (Hijra’s) residing in
Hyderabad City, Telangana, India:
A cross‑sectional study.

Author: K.Jayasurya
Co-Author: John Jims.V
Guided by:
Dr. P.V. Bhagirathi, Head of the Department
Dr. Bhargavi Krishna. A, Professor,
Department of Oral Pathology
Panineeya Mahavidyalaya Institute of Dental Sciences and
Research Center, Hyderabad.
 INTRODUCTION:
• THE TERM EUNUCH GENERALLY REFERS TO A MAN WHO
HAS BEEN CASTRATED,TYPICALLY EARLY ENOUGH IN HIS LIFE
FOR THIS CHANGE TO HAVE MAJOR HORMONAL
 CONSEQUENCES.
• IN INDIA, EUNUCHS ARE ALSO CALLED AS ‘HIJRA’, WHICH
ACTUALLY REFERS TO THIRD GENDER OR ‘MALE‑TO‑FEMALE’
TRANSGENDER PEOPLE, MOST SEE THEMSELVES AS NEITHER
MEN NOR WOMEN.
HISTORY:
• EUNUCHS WERE FREQUENTLY EMPLOYED IN IMPERIAL PALACES
BY MUSLIM RULERS AS SERVANTS FOR FEMALE ROYALTY, AS
GUARDS OF THE ROYAL HAREM, AND AS SEXUAL MATES FOR
THE NOBLES. SOME OF THESE ATTAINED HIGH-STATUS
POSITIONS IN SOCIETY.
• AN EARLY EXAMPLE OF SUCH A HIGH-RANKING EUNUCH
WAS MALIK KAFUR,A HINDU BOY CAPTURED AND ENSLAVED,
DURING THE RAIDS OF THE DELHI SULTANATE INTO GUJARAT.
• THE EUNUCHS OF KOREA, CALLED ”NAESI” WERE OFFICIALS
TO THE KING AND OTHER ROYALTY IN TRADITIONAL KOREAN
SOCIETY.
EUNUCHS IN INDIA:
• HIJRA, A HINDI AND URDU TERM TRADITIONALLY TRANSLATED INTO
ENGLISH AS "EUNUCH", ACTUALLY REFERS TO WHAT MODERN
WESTERNERS WOULD CALL TRANSGENDER WOMEN
AND EFFEMINATE HOMOSEXUAL MEN.
• THEIR SOURCES OF LIVELIHOOD MAINLY INCLUDE PERFORMING AT
MARRIAGE AND BIRTH CELEBRATIONS,BADHAI (RITUAL
PERFORMING) BASTI/MANGTI (BEGGING) FOR ALMS AND
PROSTITUTION.
• MANY HIJRA COME FROM OTHER SEXUALLY AMBIGUOUS
BACKGROUNDS: THEY MAY BE BORN INTER‑SEXED, BE BORN MALE
OR FEMALE AND FAIL TO DEVELOP FULLY AT PUBERTY, OR BE
MALES WHO CHOOSE TO LIVE AS HIJRA WITHOUT EVER
UNDERGOING THE CASTRATION PROCEDURE.
• THEY GENERALLY LIVE TOGETHER BY FORMING A GROUP CALLED
AS ‘GHARANA’ (FAMILIAL HOUSE TO WHICH THEY OWE
ALLEGIANCE), WHICH IS HEADED BY A GURU (MOST SENIOR
MEMBER) AND OTHER MEMBERS ARE AS ‘CHELAS’ (FOLLOWERS).
ATTITUDE TOWARDS THEM:
• UNLIKE IN OTHER PARTS OF THE WORLD, THE ATTITUDE TOWARD
A HIJRA IN INDIAN SOCIETY IS DISCRIMINATORY AND BIASED IN
GENERAL.
• THE HIJRA CLAIM THAT MAINSTREAM SOCIETY DOES NOT
UNDERSTAND THEIR CULTURE, GENDER, AND SEXUALITY.
• THEY ARE CONSIDERED AS THE MOST VULNERABLE,
FRUSTRATED, AND INSECURE COMMUNITY OF THE COUNTRY.
THEY ARE ALSO DENIED GENERAL, ORAL HEALTH AND
PSYCHOLOGICAL ASSISTANCE.
• IN INDIA, THE ACCESSIBILITY TO MEDICAL AND DENTAL
FACILITIES FOR THE EUNUCHS IS NEARLY NON‑EXISTENT. THERE
IS EVERY POSSIBLE CHANCE THAT THIS NEGLECTED SPECIAL
GROUP OF POPULATION MAY HAVE HEAVY STRESS AND INDULGE
IN ALCOHOLISM, GUTKHA‑PAN CHEWING AND OTHER PERNICIOUS
HABITS. THESE FACTORS MAY CAUSE MANY ORAL HEALTH
PROBLEMS ESPECIALLY THOSE RELATED TO PERIODONTAL
OBJECTIVE OF STUDY:
• THE COMPLETE ABSENCE OF PUBLISHED LITERATURE ON ORAL HEALTH-
RELATED ASPECTS OF THIS SPECIAL GROUP HAS PROMPTED US TO TAKE
UP THE PRESENT STUDY TO EXPLORE THE ORAL HYGIENE-RELATED
KNOWLEDGE, ATTITUDE AND PRACTICES OF EUNUCHS (HIJRAS) RESIDING
IN THE HYDERABAD CITY, TELANGANA, INDIA.

STUDY DESIGN
• A cross‑sectional questionnaire survey was conducted among the eunuchs of
HYDERABAD CITY.

• Based on interviews with local informants, different prominent localities of the city
where most of the eunuchs reside were identified.

• The eunuchs who consented to become part of the study guided us to the similar
samples they knew about.
• ELIGIBILITY CRITERIA
• INCLUSION CRITERIA
• EUNUCHS: ALL THE SELF-IDENTIFIED EUNUCHS AVAILABLE DURING THE STUDY
PERIOD WERE CONSIDERED FOR THE STUDY
• THE MATCHED CONTROLS WITH THE EUNUCHS FOR CERTAIN PERTINENT VARIABLES
LIKE AGE, SOCIOECONOMIC STATUS AND GEOGRAPHICAL DISTRIBUTION
• PARTICIPANTS WHO GAVE INFORMED CONSENT TO PARTICIPATE AT THE TIME OF
STUDY.

• EXCLUSION CRITERIA
• PARTICIPANTS WITH HISTORY OF MEDICATION FOR ANY SYSTEMIC
ILLNESS (MEDICALLY COMPROMISED PATIENTS)
• PARTICIPANTS NOT WILLING TO PARTICIPATE IN THE STUDY

SAMPLE SIZE : 40 PARTICIPANTS

• ASSESSMENT AND STRUCTURE OF A QUESTIONNAIRE

TO ASSESS THE ORAL HEALTH-RELATED KNOWLEDGE, ATTITUDE

AND PRACTICE OF STUDY SUBJECTS AN INTERVIEWER BASED,
PREDESIGNED, STRUCTURED, CLOSE-ENDED 18 ITEM
QUESTIONNAIRE, WHICH HAD BEEN DESIGNED BASED ON THE
PRIMARY OBJECTIVE OF THE STUDY WAS USED.

THE INTERVIEW WAS CONDUCTED IN REGIONAL LANGUAGES

HINDI AND TELUGU
DETAILS OF QUESTIONNAIRE
• DEMOGRAPHIC DETAILS : LIKE AGE, OCCUPATION, EDUCATION
LEVELS WERE TAKEN.

• ORAL HEALTH KNOWLEDGE: THE ASSESSMENT OF PARTICIPANT’S

ORAL HEALTH KNOWLEDGE INCLUDED 5 QUESTIONS (ITEMS) ON IMPORTANCE
OF ORAL HEALTH, CAUSE OF TOOTH DECAY, IDENTIFICATION OF TOOTH
DECAY, CAUSE OF CANCER, DENTAL FACILITIES AVAILABLE IN THE AREA

• ORAL HEALTH ATTITUDE: 4 QUESTIONS (ITEMS) ON ATTITUDE

TOWARD CONDITION OF MOUTH, REGULAR DENTAL VISITS, REASON OF VISIT
AND PREFERRED TREATMENT FOR DEEPLY DECAYED TEETH

• ORAL HEALTH PRACTICE: THE ASSESSMENT OF PARTICIPANT’S ORAL

HEALTH BEHAVIOR INCLUDED 11 QUESTIONS (ITEMS) ON BRUSHING HABITS,
FREQUENCY OF SUGAR CONSUMPTION, TOBACCO-RELATED HABITS.
 RESULTS
• THE POPULATION UNDER STUDY (EUNUCHS)
CONSISTED MAINLY OF INDIVIDUALS LIVING IN
ISOLATED SETTLEMENTS AWAY FROM THE GENERAL
POPULATION
1. THE POPULATION MAINLY BELONGED TO THE AGE
GROUPS BETWEEN 22-40 YEARS.
EDUCATION LEVELS
2. MAJORITY OF THE EUNUCHS WERE ILLITERATE (75%)
Professional course

Intermediate

High school certificate

Middle school certificate

Primary school certificate

ILLITERATE

0 10 20 30 40 50 60 70
 ORAL HEALTH
KNOWLEDGE:
Good oral health can improve general health Main cause of tooth decay
60

50

40

30

20 40
35 DON’T KNOW(8)
10
30
25 TOBACCO(16)
0
20
15
FRUITS(0)
10
YES (22) NO(8) 5
0 SWEETS(16)
Category 1
DO NOT KNOW(10)
 Tooth decay
60 Dental facilities available in area

50

40

30

20

10

0 5 10 15 20 25 30 35 40
0

GOVERNMENT HOSPITAL(22) Tiny black spot in tooth(6)

PRIVATE CLINICS(12) Large hole in tooth(12)

DON'T KNOW(4) Pain(8)

NONE(2) Don't know (8)

 CAUSE OF MOUTH CANCER

0 10 20 30 40 50 60 70

BETEL QUID(4) TOBACCO(24) ALCOHOL(8) DON'T KNOW(8)

ATTITUDE OF SUBJECTS TOWARDS ORAL HEALTH AND HYGIENE

Condition of mouth DID YOU EVER VISIT DENTIST

35

30

25

60 DON’T KNOW(0)
20
50
FAIR(6)
40
15
30
GOOD(10)
20
10 10
EXCELLENT(0)
0
Category 1
5

0
YES(3) NO(37)

EXCELLENT(0) GOOD(10) FAIR(6) DON’T KNOW(0)

 Would like to treat the deep painful decay by
Visit to dentist in last year
80

70
35
60
30
50
25
40
20
30
15
20
10
10
5
0
0 Category 1
Category 1

ONCE(3) TWICE(0) ROOT CANAL(0)

EXTRACTION(6)

POSTPONE TREATMENT(4)
THRICE(0) NOT VISITED(37)
DON’T KNOW(30)
ORAL HYGIENE PRACTICES AMONG SUBJECTS
Cleaning of Material use for cleaning of teeth Frequency of brushing
teeth with

PASTE/POWDER(38)
TOOTH BRUSH(32) ONCE(20)
FINGER(0) CHARCOAL(2) TWICE(16)
NEEM STICK(8) AFTER MEALS(2)
LIME SALT
OTHER(0) DON’T KNOW(2)
OTHERS
 Use of any other oral hygiene aid Use of tobacco
100%
70
80%
60
60%
50
40%
40
30 20%

20 0%

10
0
) ) ) ) 2)
(0 R(8 S(4 (0 (3
SS E K H E
O AN IC AS N
FL E P W N
O
CL TH TH
E O U
G
U TO M
O
N
TO Frequency of sugar intake
60

40

20

0
 Apprehensions faced to visit any dentist? Why would you not visit a Dentist?

20
80

18
70
16

60
14

50 12

10
40
8

30
6

20 4

2
10

0
outcasted economic lack of knowledge don’t know
0
yes no doesn’t matter Series 1
DISCUSSION:
 CONCLUSION
• THE RESULTS OF THE PRESENT STUDY PROVIDE IMPORTANT
INFORMATION ABOUT ORAL HEALTH-RELATED KNOWLEDGE, ATTITUDE
AND PRACTICES AMONG EUNUCH COMMUNITY
• THE INFORMATION PRESENTED IN THIS STUDY ADDS TO OUR
UNDERSTANDING OF THE COMMON ORAL HYGIENE PRACTICES WHICH
ARE PERFORMED AMONG EUNUCH POPULATION.
• IT WAS FOUND THAT, EUNUCHS HAVE POOR ORAL HEALTH-RELATED
KNOWLEDGE, ATTITUDE AND PRACTICES ALONG WITH HIGHER
PREVALENCE OF TOBACCO-RELATED HABITS.
• EFFORTS TO INCREASE THE AWARENESS OF ORAL EFFECTS OF
TOBACCO USE AND TO ELIMINATE THE HABIT ARE NEEDED TO IMPROVE
ORAL AND GENERAL HEALTH OF THIS POPULATION
• THE RESULTS OF THIS STUDY SHOULD SERVE AS THE BASIS FOR A
LARGER, NATION-WIDE SURVEY OF ORAL LESIONS AMONG SOCIALLY
DEPRIVED COMMUNITIES LIKE EUNUCHS
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