Promoting and Protecting Human Rights in relation to Sexual Orientation, Gender Identity and Sex Characteristics A Manual for National Human Rights Institutions Permanent hair removal is frequently a high priority for transgender women, as having coarse facial hair or stubble can be a significant barrier to being recognised as female.230 For transgender men, the most common surgery is a mastectomy and chest reconstruction to create a male chest. When transgender men do not have access to this surgery, often they tightly bind their chest to create a flatter contour. In some circumstances, this can result in breathing difficulties, back pain, skin conditions or, less commonly, rib fractures. 3.6.4. Regional situation In the Asia Pacific region, public health systems or private health insurance cover medical transition costs only in Hong Kong, mainland China, parts of India (particularly for hijras, aravani and thirunangai), to a certain extent in Australia and to a very minimal extent in New Zealand. Most transgender people in the region have to pay to access counselling, diagnosis assessment, laboratory tests, hormone treatment, hair removal, surgeries and other treatments. Self-medication of hormones is common among transgender women in the region, including in the Philippines, Laos, Thailand, Malaysia, China and Nepal. This means they have no prior medical advice in relation to monitoring of doses and potential side effects. In the Pacific, there is often no access to specialist advice and the most commonly used hormones are oral contraceptive pills that are not ideal for transgender women. There is no access to hormones for transgender men in the Pacific. When they are denied access to existing services or when those services are not available, transgender people are at the mercy of unregulated and potentially unqualified practitioners. Transgender women who cannot obtain hormones or afford surgeries may view injections of silicone and other soft tissue fillers as their only accessible form of body modification. These practices are very dangerous and potentially fatal. Castration has been the most common surgery for hijras in South Asia. It is associated with indigenous rituals and is referred to as nirvani. Until recently, it was largely performed outside the formal medical sector and resulted in deaths or serious complications. As a result, in India the hijra community is increasingly approaching health professionals to perform the nirvani surgery in private clinics and some operations take place in public healthcare settings.231 There is very limited research about the health experiences of transgender men in the region. The information that does exist suggests that many have no information about gender-affirming health services and that they may not have the same access as transgender women to peers who can help fill ‘information gaps’. Transgender people are frequently not treated with dignity and respect when they approach health services. Furthermore, health professionals do not have the necessary information and training to assess and respond to the health needs of transgender people. The Asia and Pacific Trans Health Blueprint, published in October 2015, helps to address some of these information gaps and promote good practice.232 There are no health professionals specialising in transgender health in the Pacific and limited expertise is available in some parts of Asia. Yet hormone treatment and some surgeries required by transgender people are available for other medical conditions. These means that some transgender health needs could be mainstreamed within other health services. Denying medically necessary treatment to transgender people, when it is available to other population groups, leaves health providers open to potential claims of unlawful discrimination. 62 230 Plucking hair with tweezers or traditional implements, such as chimta in India, only temporarily removes hair. 231 Health Policy Project et al, 2015, p. 54. 232 Health Policy Project et al 2015.