|Year : 2015 | Volume
| Issue : 1 | Page : 24-29
Assessment of oral mucosal lesions among eunuchs residing in Bhopal city, Madhya Pradesh, India: A cross-sectional study
Nilesh Arjun Torwane1, Sudhir Hongal2, Pankaj Goel3, Byarakele Chandrashekar4, Vrinda Saxena3
1 Post Graduate Student, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
2 Guide and Reader, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
3 Professor, Head of the Department, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
4 Reader, Department of Public Health Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
|Date of Web Publication||9-Mar-2015|
Nilesh Arjun Torwane
Department of Public Health Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The present cross-sectional study following the STROBE guidelines was conducted to assess the prevalence of oral mucosal lesions among males, females, and eunuchs residing in Bhopal city, Madhya Pradesh India. Materials and Methods: Based on convenient non-probability snowball sampling technique, all the self-identified eunuchs residing in the city of Bhopal who were present at the time of examination and who fulfilled the selection criteria were examined. A cross section of the general population (males and females) residing in the same locality where these eunuchs live was also examined. The World Health Organization (WHO) oral health assessment proforma (1997) was used to collect the information on oral mucosal lesions. All the obtained data were analyzed by using a Statistical Package for Social Sciences version 20. Results: Overall prevalence of oral mucosal lesions was 127 (19.9%) among the study subjects. Fifty-nine (28.5%) eunuchs, 56 (25.7%) males, and 12 (5.6%) females were observed to have some oral mucosal lesions. Oral submucous fibrosis (6.4%), leukoplakia (5.5%), and traumatic ulceration (4.2%) were the major oral mucosal conditions observed. Conclusion: The information presented in this study adds to our understanding of the common oral mucosal lesions occurring in the eunuch population. Efforts to increase patient awareness of the oral effects of tobacco use and to eliminate the habit are needed to improve the oral and general health of eunuchs.
Keywords: Eunuchs, Oral cancer, Oral mucosal lesions, Transgenders
|How to cite this article:|
Torwane NA, Hongal S, Goel P, Chandrashekar B, Saxena V. Assessment of oral mucosal lesions among eunuchs residing in Bhopal city, Madhya Pradesh, India: A cross-sectional study. Indian J Public Health 2015;59:24-9
|How to cite this URL:|
Torwane NA, Hongal S, Goel P, Chandrashekar B, Saxena V. Assessment of oral mucosal lesions among eunuchs residing in Bhopal city, Madhya Pradesh, India: A cross-sectional study. Indian J Public Health [serial online] 2015 [cited 2020 Jun 1];59:24-9. Available from: http://www.ijph.in/text.asp?2015/59/1/24/152851
| Introduction|| |
Oral malignancies are the sixth most common cancer around the globe.  In South-central Asia, 80% of head and neck cancers are found in the oral cavity and oropharynx. , Notably, oral cancer is one of the few cancers whose survival rate has not improved over 30 years, while during the past three decades, a 60% increase in oral cancer in adults under the age of 40 has been documented. , Prognosis of intra-oral cancer is generally poor, with a 5-year survival of less than 50%. 
Several oral lesions such as leukoplakia, erythroplakia, and lichen planus carry an increased risk for malignant transformation in the oral cavity. Similarly, the incidence of oral submucous fibrosis (OSMF), a potentially oral malignant condition, has increased manifold, especially among the younger generation in South Asia.  In India, about 5 million people suffer from this disease. ,
Oral mucosal lesions could be due to infection (bacterial, viral, fungal), local trauma and or irritation (traumatic keratosis, irritational fibroma, burns), systemic disease (metabolic or immunological), or related to lifestyle factors such as the usage of tobacco, areca nut, betel quid, or alcohol. 
For planning of national or regional oral health promotion programs as well as to prevent and treat oral health problems, baseline data about the magnitude of the problem is required. India has a vast geographic area, divided into states, which differ with regard to their socioeconomic, educational, cultural, and behavioral traditions.  These factors may affect the oral health status.
Eunuchs are one of the neglected special vulnerable groups in India who need to be given special attention. The word "eunuch" is derived from a Greek word meaning "keeper of the bed."  These transgender communities historically exist in many cultural contexts, and are known as bakla in the Philippines, xaniths in Oman, serrers among the Pokot people of Kenya, and kinnars, jogappas, jogtas, or shiv-shaktis in South Asia. 
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.  According to a report in Telegraph, India has an estimated 1.5 million eunuchs.  But the census data on them does not exist; so, to make an accurate enumeration is impossible as they continue to persist as a marginalized and secretive community. 
Unlike in other parts of the world, the attitude toward a hijra in the Indian society is discriminatory and biased in general.  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 related problems which can make their lives worse.
To the best of our knowledge, there is no data on the oral health status of this community. So, the current cross-sectional study was conducted to assess the prevalence of oral mucosal lesions among the eunuch (transgender) community and to correlate the various risk factors with the lesions found.
| Materials and Methods|| |
A cross-sectional study following the STROBE guidelines was conducted among males, females, and eunuchs of Bhopal city, Madhya Pradesh India.
The study protocol was approved by the ethics committee of People's University, Bhopal. A brief study protocol was explained and written informed consent was obtained from each study subject before the oral examination.
Source of data
The study subjects consisted of self-identified eunuchs residing in the Bhopal city. A cross section of the general population residing in the same locality was also examined.
Sampling design and sample selection
Based on convenient non-probability snowball sampling technique, all the self-identified eunuchs residing in the city of Bhopal who were present at the time of examination and who fulfilled the selection criteria were examined. Based on interviews with local informants, four prominent localities of the city where most of the eunuchs reside were identified. All the identified areas were visited and eunuchs residing in these areas were contacted. The eunuchs who consented to become part of the study guided us to similar samples they knew about. The subjects were explored till saturation occurred and no new cases were identified.
Furthermore, a cross section of the general population residing in the same localities where these eunuchs live was also examined to have an idea about the disease trends in eunuchs in comparison to the general population. For this purpose; male and female subjects of the same age group as that of eunuchs were chosen randomly.
- Eunuchs: All the self-identified eunuchs available during the study period were considered for the study.
- A cross section of the general population of the same locality selected by simple random method.
- Participants who gave informed consent to participate at the time of study.
- Participants with history of medication for any systemic illness (medically compromised patients)
- Participants affected with mental retardation, physically and mentally handicapped patients, those with orthopedic defects, etc.
A total of 639 subjects consisting of 207 eunuchs, 218 males, and 214 females residing in the city of Bhopal, Madhya Pradesh, India were considered for the study.
Schedule of the survey
The survey period extended for a period of 3 months from April to June 2013. During this period, visits were made every day, except during holidays, from 11 a.m. to 3 p.m.
Method of collection of data
Information on the demographic characteristics like age, sex, occupation (the principal business of one's life), educational level, and socioeconomic status (an individual's or group's position within a hierarchical social structure) along with habits (an acquired behavior pattern regularly followed until it has become almost involuntary) and the extent of knowledge about the risk factors of oral cancer of the surveyed subjects was collected using an interviewer-based, predesigned, structured, close-ended questionnaire which had been designed based on the primary objective of the study. The questionnaire was prepared in English, translated into local (Hindi) language, and then back-translated to English to check for consistency. The subjects were asked to respond to each item according to the response format provided in the questionnaire. Response format included multiple choice questions in which the subjects were asked to choose an appropriate response from the provided list of options. The completed response format was carefully checked by the investigator.
The World Health Organization (WHO) oral health assessment proforma (1997)  was used to collect the information on oral mucosal lesions. The clinical examination through the survey was carried out by the principal investigator. The investigator read, understood, and standardized his method of operation so as to minimize error and have reproducible data. A recording clerk was trained to assist in the recording procedure throughout the survey. Clinical examinations were carried out in the living environments; these included deras (for eunuchs) and private and rented out rooms (for controls) where subjects reside.
Clinical examination was performed using a plane mouth mirror and CPI probe under adequate natural light. An examination of the oral mucosa and soft tissues in and around the mouth was made on every subject.
All the obtained data were entered into a personal computer on Microsoft Excel sheet and analyzed by using the software, Statistical Package for Social Science (SPSS; IBM, Chicago, USA) version 20. Data comparison was done by applying chi-square test. The association of different variables with mucosal lesions was analyzed by using step wise multiple linear regression analysis. The statistically significant level was fixed at P ≤ 0.05.
| Results|| |
A total of 639 subjects were examined. Of these, 218 (34.1%) were males, 214 (33.5%) were females, and 207 (32.4%) were eunuchs. The mean age of the study subjects was 37.7 years and no significant difference was observed in the distribution of age among genders.
Majority of eunuchs, i.e., 149 (72%), were illiterate. The highest number of males, i.e., 47 (21.6%), had attended high school and 54 (25.2%) females had attended middle school. The difference in the distribution of educational level among the genders was statistically significant (P < 0.05).
Among the study participants, 146 (68.2%) females, 52 (23.9%) males, and 2 (1%) eunuchs were unemployed. Also, 205 (99%) eunuchs, 49 (22.5%) males, and 12 (5.6%) females were unskilled workers. The difference in distribution of occupation among the genders was statistically significant (P < 0.05).
In a reply to the question related to the cause of cancer, 134 (62.6%) females, 132 (60.6%) males, and 88 (42.5%) eunuchs responded that usage of tobacco is the main cause of cancer. This difference was statistically significant (P < 0.05) [Table 1].
While assessing the adverse habits like chewing and smoking tobacco, it was found that majority of eunuchs, i.e., 113 (54.6%), were having the habit of chewing smokeless tobacco containing products such as betel nut, betel quid, gutkha, etc. This was followed by 66 (30.3%) males and 58 (27.1%) females having the habit. Most of these causes were statistically significant (P < 0.05) [Table 2].
Overall prevalence of oral mucosal lesions was 127 (19.9 %) among the study subjects. The prevalence of oral mucosal lesions was high among eunuchs (28.5%) and males (25.7%) compared to females (5.6%). OSMF (6.4%), leukoplakia (5.5%), and traumatic ulceration (4.2%) were the major oral mucosal conditions observed. OSMF was the most prevalent among eunuchs (10%) followed by males (8.7%) and females (1.4%). Prevalence of leukoplakia was highest among males (8.3%) compared to eunuchs (7.7%) and females (0.5%). Traumatic ulceration was seen in 5.8% eunuchs, 4.1% males, and 2.8% females. However, one eunuch was suffering from malignant tumor in the form of squamous cell carcinoma. The difference in distribution of oral mucosal conditions among the genders was statistically significant (P < 0.05) [Table 3].
In 41 (18.8%) males, 37 (17.9%) eunuchs, and 6 (2.8%) females, buccal mucosa was found to be the most affected site with oral mucosal lesions. Alveolar ridge/gingiva was affected in 13 (6.3%) eunuchs followed by 3 (1.4%) males and females. The difference in distribution of locations for oral mucosal lesions among the genders was statistically significant (P < 0.05) [Figure 1].
|Figure 1: Graph showing the distribution of locations of oral mucosal lesions according to gender|
Click here to view
| Discussion|| |
The current cross-sectional, epidemiological survey was the unique, first of its kind, pioneering study which revealed the oral health related information of eunuch/hijra/third gender community.
The major problem we faced while comparing the data was lack of literature on eunuchs. So, we have made sincere efforts to compare the results of other studies on the general population.
It can be observed that majority of eunuchs (58.5%) were unaware of tobacco being a cause of cancer. The low awareness of tobacco as a risk factor among eunuchs could be attributed to their low level of education. A similar factor was assessed in studies conducted by Lawoyin et al.  and Horowitz et al.  Awareness of the risk factors of oral cancer requires wide-ranging educational interventions which need to be directed toward the less-educated eunuch population.
This study revealed an important finding that there was a marked rise in the consumption of tobacco (smoked and smokeless) and associated products (gutkha, pan masala, khaini, areca nut, etc.) among eunuch (90.3%) and male (56.9%) population. The higher usage of tobacco among eunuchs and males can be correlated with occupation. It has been shown that occupation influences individual's tobacco use. A large proportion of females in this sample consisted of homemakers, while males and eunuchs were the major working groups. Individuals working were found to be highly associated with the habit, as they felt that it reduces the tiredness and brought in excitement in the body after heavy labor work. 
The overall prevalence of clinically significant oral lesions in the total population was 19.9% which mainly comprised 59 (28.5%) eunuchs and 56 (25.7%) males. The proportion of mucosal lesions in our study was higher in comparison to that reported in previous studies from Vidisha  (8.4%) and Chennai  (4.1%). This could probably be due to higher prevalence of smoking and/or tobacco chewing observed in this study in comparison to other studies. Studies have shown that subjects who smoked or chewed tobacco in any form had a far higher incidence of oral lesions vis-ΰ-vis nonusers. , Mehrotra et al.,  on assessing the correlation of habits with the incidence of mucosal lesions, found that smokers and chewers were having an odds ratio of 4.5 and 5.6 as compared to non-users.
Of the clinically significant lesions that were diagnosed in our study, the percentage of patients suffering from OSMF was 6.4%, leukoplakia was 5.5%, and lichen planus was 0.3%, which were lower than those reported by Mehrotra et al.  (9.7%, 40.7%, and 2.7%, respectively). The prevalence of squamous cell carcinoma in our study was found to be 0.2%. The difference in prevalence of mucosal lesions observed in our study and in the study conducted by Mehrotra et al. may probably be due to the fact that Mehrotra et al. obtained most of the cases through histopathological confirmation.
On the basis of site of involvement, it was found that majority of the total 19.9% mucosal lesions, i.e., 13.1% lesions, were present on buccal mucosa, followed by alveolar ridges/gingiva (3%), tongue, lips, hard or soft palate (0.8%, respectively). Bhurgri  suggested in her report from South Karachi, Pakistan that in oral malignancy, the buccal mucosa was the most frequently involved site. This finding coincides with our results.
Most of the oral mucosal lesions found in our study, i.e., leukoplakia (85.7%), OSMF (82.4%), ulcerations (37%), and malignant tumor (squamous cell carcinoma), were located in buccal mucosa, whereas abscess (100%) was most common on alveolar ridge/gingiva. Similar findings were obtained by Mathew et al.  where buccal mucosa was found to be highly affected in conditions like leukoplakia, OSMF, and malignant tumor.
The association of oral mucosal lesions in our study was highest with variables such as frequency of tobacco consumption, occupation, and educational status. These findings are in line with the studies conducted by Dangi et al.  and Stronks et al. 
Furthermore, this study revealed that tobacco use among eunuchs of Bhopal city is an issue of significant concern which has a serious impact on their oral health status. Programs aimed at mitigation of factors affecting tobacco menace at the individual level as well as at the community level should be implemented as a part of a long-term commitment to safeguard public health. Anti-tobacco initiatives are thus warranted. Also, there is an urgent need to plan properly to meet the unmet needs of eunuch subjects as it was observed that virtually no care pertaining to oral health has been provided for this socially deprived community.
| Conclusion|| |
The results of the present study provide important information about the prevalence of oral mucosal lesions among eunuch community residing in Bhopal city. The information presented in this study adds to our understanding of the common oral mucosal lesions occurring in the eunuch population. OSMF, leukoplakia, and lichen planus were the most common types of oral mucosal lesions found. Mucosal lesions were more common in adults and were frequently associated with tobacco use.
| Recommendations|| |
This study should serve as the basis for a larger, nation-wide survey of oral lesions among socially deprived communities like eunuchs. Efforts to increase patient awareness of the oral effects of tobacco use and to eliminate the habit are needed to improve the oral and general health of the population.
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[Table 1], [Table 2], [Table 3]
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