What has the internal stigmatisation and isolation of trans persons led to?
It is now a widely recognised and accepted fact that trans persons and gender non-conforming individuals are a part of most cultures all over the world. This, however, has not completely worked towards their advantage. Unique hurdles are always thrown in their way, whether when they’re at the workplace or are accessing basic health care.
Apart from an already deteriorated physical and sexual health, their mental health has also emerged to be a major cause for concern — the vitality of which has been severely undermined throughout the years, leading to little progress, especially in India. The internal stigmatisation and isolation of trans persons in India has made this patient cohort tragically vulnerable to a plethora of mental illnesses; the most common being depressive spectrum disorders, anxiety and substance abuse.
Personal and social barriers such as lack of family support, community-level barriers like discrimination of HIV-positive trans persons within their own communities, and institutional barriers including difficulty in obtaining voter identity cards and ration cards have only proven to be destructive to the mental health of trans persons.
Rejection and lack of support from family and society, gender dysphoria associated with extreme stressful experiences, child sexual abuse, early discontinuation of schooling, forced marriage, lack of opportunities of livelihood, sexual and financial exploitation by the police, and lack of legal measures for protection are some of the characteristic hurdles that transgender persons face.
Health Care Barriers:
However, the root cause of the problems and disadvantages encountered by trans persons are the health care barriers, which do not make seeking help a viable option for them. Acknowledging these barriers are pivotal to understanding their individual needs. Due to prevailing poor mental health awareness, trans persons in India are not even aware of the available intervention and management techniques.
Apart from inferior services, health care barriers also prevent trans persons from receiving timely treatment due to insensitive hospital policies, outpatient registration and admission procedures. Regular operating hours are also inconvenient for trans persons as a majority of them are involved in sex work.
In a recent study, about 62% of the transgender respondents had problems with their family members, 56% of them had discontinued their education at either the primary level or secondary level; a majority of the transgender persons opted to make a livelihood through sex work, 54% of them had the habit of consuming alcohol and 26% of them had severe depression. A cross-sectional study of 50 trans persons in Mumbai showed that 84% of participants met the criteria for gender identity disorder according to DSM-IV-TR.
Self-harm as well as suicidal behaviour has been extremely common amongst trans persons as a consequence of poor mental health. 31% of trans persons in India end their life by committing suicide, and 50% of them have attempted suicide at least once before they have reached the age of 20. They are at risk for forms of self-harm such as cutting of one’s wrists and other areas, excessive drinking, eating and drug use, harmful sexual behaviour, etc. Causes of suicidal behaviour include psychological distress caused by low self-esteem, emotional fatigue, gender dysphoria, bullying and victimisation, as well as concerns regarding physical conditions such as sexually transmitted disorders.
The psychological autopsy of suicides among transgender persons has revealed that factors such as the end of a relationship (64.3%), serious altercations with family members (14.3%), refusal of gender/sex reassignment by the family members (9.5%), financial problems (9.5%), being diagnosed as HIV positive in the past few days/weeks (2.4%) have triggered the act of suicide among the victims.
Intervention and Management:
Healthcare professionals must focus on designing tailor-made interventions and coping strategies for trans persons in India. There must be non-discriminatory and trans-friendly policies that allow trans persons to fully utilise any and every kind of help available to them. An all-inclusive policy should be maintained on behalf of the health care system in India which will act as a catalyst for trans persons to achieve better mental health.
In the recent past, multiple organisations like Sangama, Samara, Jeeva, Aneka, IDF and the Karnataka Women Development Corporation of Bengaluru, Sahodari in Tamil Nadu, The Humsafar Trust in Maharashtra, etc. have risen to actively support and provide assistance to trans persons in India in the form of helpline services, clinical services, information and referral services, legal and advocacy support, drop-in-centers, alternative employment services and financial assistance, soft-skills training, and self-help group formation.
The transgender population has always been perceived as a difficult population to reach. This does not have to necessarily be the scenario if health care professionals become more involved in equipping themselves with population-specific data. An understanding of the social plight of trans persons in India, which has contributed to their deteriorated mental health, will help to dissolve real and imagined barriers.
1. 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; 19:20809
2. Kalra G, Shah N: The cultural, psychiatric, and sexuality aspects of hijras in India. Int J Transgenderism 2013; 14:171–181
3. Transgender Suicide Rates Continue to Rise. The Soft Copy -An IIJNM Web Publication. 2012.
4. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. J Homosex. 2006;51:53–69.
5. Haas AP, Eliason M, Mays VM, Mathy RM, Cochran SD, D’Augelli AR, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations. J Homosex. 2011;58:10–51.
6. Reback CJ, Shoptaw S, Downing MJ. Prevention case management improves socioeconomic standing and reduces symptoms of psychological and emotional distress among transgender women. AIDS Care. 2012;24:1136–44.
7. Suicide Risk and Prevention for Lesbian, Gay, Bisexual, and Transgender Youth. Newton, MA: Education Development Center, Inc.; 2008. Suicide Prevention Resource Center.
8. Budania SK. Rapid Assessment of Mental Health Needs and Planning of Mental Health Services for the Transgender (Hijras) Community. Bangalore: National Institute of Mental Health and Neuro Sciences (NIMHANS); 2012.
9. Sridevi Sivakami PL, Veena KV. Social Exclusion have a negative impact on the health of the Transgender. Indian Streams Res J. 2011;1:1–4.
Shruti Venkatesh is a Research Associate (Mental Health) at One Future Collective.
Featured image: Markus Spiske
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