Gender incongruent individuals (whose experienced gender does not match their birth-assigned gender) have been the focus of considerable public discourse regarding basic human rights and access to opportunities. However, from an epidemiologic perspective, this transgender (gender incongruent individual who is seeking gender reaffirmation) community is poorly understood. There are at least 4.9 lakhs transgender persons in India as per the last census and this appears a grossly underestimated figure. The transgender hijra community is one of the most marginalized communities in the Indian subcontinent. Being mentioned in many ancient Indian texts, they represent an institutionalized traditional cult and inclusive society. They are highly vulnerable to stigma, violence, and discrimination despite their historical acceptance in Indian society. Battling stigma and violence (both sexual and physical), they are often left with no livelihood options other than begging or petty extortion or sex work. Moreover, transgender people worldwide have poor lifestyle and a poor quality of life. They are a high-risk group and source population for sexually transmitted diseases and substance abuse. Research in many geographical settings, including India, has shown an increased risk of poor mental health and suicide among transgender populations.
Before independence, the British colonial-era law (377 of the Indian Penal Code, 1860) used to criminalize same-sex behavior. In 2014, the Supreme Court of India upheld the right of all Indian citizens, including the marginalized transgender community, to self-identify their gender and also their right against discrimination based on gender identity, National Legal Services Authority (NALSA) judgment. Despite progressive legislative developments, mass media often report a wide range of discrimination and inequalities faced by the transgender community of India. There are very few studies that evaluated the socioeconomic status (SES) of the transgender community of India. In this backdrop, this cross-sectional study was done to understand and estimate the social support, well-being, and SES of this population, after seven decades of independence from British colonial rule and five years after passing the NALSA judgment by the Supreme Court of India.
SUBJECTS AND METHODS
This observational study was carried out on the gender incongruent patients, enrolled at the endocrinology outpatient department (OPD) of a tertiary care hospital in eastern India. The study was approved by the Institutional Ethics Committee, Kolkata.
Inclusion and exclusion criteria
Patients who were diagnosed with gender incongruence based on Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR) diagnostic criteria, aged between 18 and 70 years, enrolled between January 2017 and December 2019 and attended endocrinology OPD at least two times during this period.
Patients with missing demographic data and/or socioeconomic data were excluded.
After obtaining written informed consent, the Transgender Health Survey questionnaire was handed over and was completed by face-to-face interviews maintaining confidentiality as a standard operating procedure of the endocrinology department. Individual's assigned sex at birth, age, gender identity, sexual orientations, relationship status, and addiction were routinely recorded in Transgender Health Survey. Dressing habits; quality of support from family, friends, or society; occupation of the head of the family; education of the head of the family; and family income were also recorded as per routinely used structured questionnaires of the department. All enrolled patients were routinely advised to attend mental health consultation at baseline for confirmation of the diagnosis of gender incongruence and to exclude other underlying psychiatric comorbidities based on the DSM-V-TR diagnostic criteria. Mental health assessment was routinely done by both a psychiatrist and a psychologist in our institute. All this information was documented in our OPD database both manually and electronically.
Transgender health survey questionnaire
Demographic data (assigned sex at birth, age, gender identity, sexual orientations, and relationship or marital status) were collected from the record of the Transgender Health Survey questionnaire. Data about addiction (smoking/tobacco use, alcohol consumption, marijuana use, and intravenous drug use) were also captured from the documentation in Transgender Health Survey questionnaire. However, the Transgender Health Survey questionnaire was not used in our department for assessment of income as the annual household income categories were based on the US dollar rather than income structure based on Indian currency.
The mental health consultation document
The following assessments were routinely done for each subject to assess mental health status: projective test (by Thematic Apperception Test), personality test (by Draw-a-Person test and Eysenck Personality Questionnaire), and Bem Sex-Role Inventory test. Data regarding psychiatric comorbidities were captured from the mental health consultation document.
Structured questionnaire (Annexure 1)
The data regarding dressing habits, social support, occupation of the head of the family, education of the head of the family, and family income were collected from the structured questionnaires administered in our department. Support (both financial or psychological and full or partial) was assessed and captured with the structured questionnaire and entirely depends on the perception of the subject.
Kuppuswamy's socioeconomic status scale
Ses of each patient was calculated based on the Kuppuswamy's socioeconomic status (KSS) scale which takes consideration of the head of the family for calculation. The decision-maker in the family was regarded as the head of the family in this study. This scale was extensively used in the Indian urban population, for assessment of the SES by a simple method of scoring.
Scoring for the occupation was independent of the scoring in the education category and was based on the occupation of the head of family only. Occupation levels were categorized as per the KSS scale [Table 1]. Scoring for education also considered the maximum level of education that was attained by the head of the family. Literate and illiterate members were considered as per the definition by Census of India where a person aged ≥7 years who can read and write with understanding in any language was considered as literate and a person who can only read but could not write or could not read or write with understanding in any language was considered as illiterate. Education levels were categorized as per the KSS scale family income, not per capita income was assessed for categorization of the level of income in the KSS scale. As per KSS scale, the subject himself was considered as head of the family when living away from the family. The income categories used for the scale were determined using the interactive online calculator provided at http://www.scaleupdate.weebly.com. The updated consumer price index value of industrial workers (CPI-IW) was used in the interactive online calculator. For this cross-sectional study where the study population was assessed only once, the latest CPI-IW value available in 2017 before the data collection was used. The final score was calculated adding the score of the individual determinant heads (occupation score, education score, and family income score) of the individual and socioeconomic class was categorized as per the KSS scale.
We provided data on demography [Table 1], social support [Table 2], mental health status [Table 3], and Kuppuswamy score [Table 4].
The demographic characteristics of the study population (N = 120) were reported by the sex assigned at birth [Table 1]. Based on reported gender identity, the study population was categorized into (1) transfeminine (who were assigned male sex at birth but have a strong female gender identity), (2) transmasculine (who were assigned female sex at birth but have a strong male gender identity), (3) bigender (who report that their gender identity is equally male and female), and (4) male cross-dresser (who were assigned male sex at birth, have a male gender identity, and cross-dress in public or in private). One hundred and nine participants were transfeminine and only eleven were transmasculine. There were no subjects who were bigender or did cross-dressing.
Based on the reported social support, the study population was evaluated regarding support from family, support from friends, and support from society and also the level of support (no support, or full support or partial support) [Table 2]. The study population reported receiving more support from their transgender or nontransgender friends and families than from society.
Most of the study population (almost two-third) had completed the mental health evaluation and the counseling process and were evaluated for psychiatric comorbidities [Table 3]. Rest one-third were yet to complete the mental health evaluation and the counseling process. However, all other evaluation processes were completed to include them in this study. The mental health of the study population was very satisfactory with only 3 out of 80 study population having psychiatric comorbidities in the form of depression/anxiety. However, we are unaware about psychiatric comorbidities among the one-third who were yet to complete the mental health evaluation process.
KSS scale [Table 4] assessed the socioeconomic standing and the characteristics of the study population. Most of the population belonged to the upper middle or lower middle class SES according to the modified Kuppuswamy classification system.
This study represents a comprehensive analysis of the lives and well-being of self-identified gender incongruent adults in India The number of transfeminine individuals was 10 times more (109 vs. 11) than transmasculine, a fact observed in our earlier studies as well. In most of the Western studies, the prevalence of transfeminine and transmasculine individuals are balanced. Transmasculine individuals are largely invisible in India. It is difficult to explain such a huge imbalance between the two groups. However, gender practice in Indian culture, absence of transman as a role model, and the patriarchal nature of society are few possible barriers that transmasculine individuals have to cross before reaching a tertiary care center for gender-affirming therapy. Moreover, caste, language, class, education, family, and religious issues may inhibit display of gender identity of transmales. High rates of substance abuse have been consistently demonstrated among gender incongruent individuals. Gender-based harassment at school possibly influences substance use behavior patterns. While alcohol, tobacco, cigarette smoking, and electronic cigarette use (vaping) are common, marijuana and non-marijuana illicit drugs are also documented in Western countries. Prevalence of addiction among the study cohort (44.9% of transfeminine and 63.63% of transmasculine) was restricted to smoking and alcohol only [Table 1].
Gender incongruent populations are exposed to a variety of social stressors, including stigma, discrimination, and bias and are at a greater risk of depression, anxiety, suicide, substance abuse disorders, and general distress. Social support, as a coping resource, has been shown to reduce psychological distress from gender identity-related stigma, discrimination, and violence. Most of our study population (67.88% transfeminine and 90.90% transmasculine) acknowledged receiving adequate support from their biological family and even more from their friends (80.73% transfeminine and 100% transmasculine) [Table 3]. These findings are important, as they demonstrate the unique role of social support in reducing the social stressors contributing toward psychosocial ill health. Many studies have demonstrated that social support plays an important role in reducing depression, anxiety, and general distress associated with gender identity-related stigma and discrimination and suicidal ideation. In our previous 2015 study, 9.26% of transfeminine and 16.63% of transmasculine persons had support from their family. The present cohort received much more full family support (67.88% for transfeminine and 100% for transmasculine). However, 20% of 2015 study cohort were included in the present study cohort also.
A high prevalence of depression and suicidal ideation is reported in Western studies. Though the mental health evaluation report was wanting from one-third of the study population, only 2.7% of the transfeminine subjects seen by a psychiatrist had psychiatric comorbidities. In 66.97% of transfeminine and 63.63% of transmasculine subjects, no mental problem was identified with the mental health questionnaire and evaluation [Table 2]. Indian culture has a general attitude of acceptance and tolerance toward the transgender community. Rising social awareness has improved matters further. Psychiatric comorbidities were looked for using the psychiatric record review and not by a unified screening questionnaire. This constitutes a limitation of our study perhaps contributing to the low rate of identified psychiatric comorbidities. Moreover, we are unaware about psychiatric comorbidities among the one-third who were yet to complete the mental health evaluation process and further contribute to the low rate of identified psychiatric comorbidities.
Most of the transgender studies reported poor well-being, self-reported disability, poor general health, and lower quality of life. The exposure to physical and sexual violence was repeatedly reported among transgender persons. Violence seems to have long-lasting detrimental effects on mental health, substance abuse, and depression, leading to a high prevalence rate of suicidal ideation and attempts. Thus, gender incongruent people constitute a vulnerable group and need to be targeted for multifaceted interventions. Assessment of the SES is widely recognized as one of the important tools for health evaluation. To classify the communities and people, varied socioeconomic scales are used in India. SES should be a measure of the economic and social position of an individual in the wider community. Usually, profession, education, and income are taken into consideration to determine SES. KSS scale is the most extensively used scale in India. Most of the study population belong to the lower middle (41.28% transfeminine and 45.45% transmasculine) and upper middle (30.27% transfeminine and 45.45% transmasculine) SES [Table 4]. A population-based door-to-door survey in four geographically adjacent semi-urban slums in South India (covering 2.2 sq. km and 7925 households) showed that the majority (72.7%) are in the upper–lower socioeconomic stratum. Transgender persons appear to have higher SES [Table 4]. Our observation of optimum SES among the transgender population is not consistent with the previous studies done in different parts of the world. Our cohort lived primarily in urban areas, had better education, and showed enterprise in attending a tertiary care hospital for gender-affirming therapy. This cohort had strong social support, from family and friends, and may not be representative of the larger transgender community in India. Cohorts similar to ours were reported by some other Indian studies.
There are several studies from the Indian subcontinent, attesting to the discriminatory and exclusionary environments in which transgender people continue to live. The recent international commitment toward sustainable development goals presents an opportunity to enhance social and medical targets, prevent human rights violations, and promote social inclusion for the gender incongruent community.
Indian culture tolerates and even embraces contradictions at social, cultural, and sexual levels. The gender incongruent community of India receives adequate support from their biological family members and their friends. This support provides many gender incongruent individuals improved for self-esteem, gender recognition, and self-realization.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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