Being in a different world: a phenomenological study of life with gender dysphoria

Abstract

Background

Individuals with gender dysphoria are exposed to greater health risks and are increasingly seeking medical care. In pursuit of gender equity and improved healthcare outcomes, this study aimed to explore the lived experiences of individuals with gender dysphoria in Iran, where the ‘traditional’ gender binary constitutes an integral aspect of Islamic social ethics.

Methods

We employed a qualitative approach using a phenomenological hermeneutic framework. Fourteen individuals with gender dysphoria were recruited to participate using purposive sampling. Face-to-face and semi-structured interviews were used to collect data, which was subsequently analysed using the seven-stages of Critical Hermeneutic Analysis.

Results

Our findings revealed how people living with gender dysphoria experienced a lack of social and cultural support and distressing psychological experiences. Theme (1) lacking social and cultural support included the following sub-themes; rejection by family and society; lack of legal support and being victims of cultural taboos. Theme (2) distressing psychological experiences included the following sub-themes; disgust in relation to sexual characteristics and gender conformity, fear, and anxiety about disclosing one’s authentic gender. In this study, a constitutive pattern emerged of “being in a different world”. Participants experienced being beaten, abused, suicidal ideation and death threats.

Conclusions

This research was carried out in a unique cultural and religious context in which government jurisprudence is implemented. In Iran, individuals with gender dysphoria require social, familial support along with legal and medical frameworks which enable access to gender affirming care. The experience of gender dysphoria is deeply influenced by cultural factors. Thus, cultural and educational interventions are required in Iran to change both attitudes and perceptions. These may include endorsement of change by law and policy makers through public and television appearances.

Background

The term “gender dysphoria” replaced the arguably more pathologized “gender identity disorder” in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The term refers to a general sense of unease with one’s gender/sex assigned at birth, and an incongruence between that which has been assigned and their gender identity. Individuals in this group often choose to reject their assigned gender and live in alignment with their own gender identity [1]. Gender dysphoria is also often accompanied by a sense of unease with one’s physical characteristics [2]. Feelings and experiences of being ‘different’ in society can be overwhelming for those with gender dysphoria [3], to the extent that some experience suicidal ideation [4]. The prevalence of problematic substance use, mental and physical illnesses including sexually transmitted diseases is higher among individuals with gender dysphoria than in the general population [4, 5]. In Iran, the phenomenon of gender dysphoria has contextual psychosocial aspects, and is often compounded by emotional deprivation and early maladaptive schemas [5]. Recent research conducted in Iran demonstrates that gender dysphoria can be comorbid with psychological and psychiatric disorders [6]. In Iranian society, those who are open to new experiences tend to be more receptive to new ideas, and thereby demonstrate more tolerant and accepting attitudes towards marginalized groups [7]. Nevertheless, people with gender dysphoria can face multiple challenges in life, often beyond their control [8]. Moreover, people with gender dysphoria often lack visibility in society [9] and are thus marginalized [10]. This marginalized status can lead to social stressors and hindered access to healthcare, meaning those with gender dysphoria experience greater health risks [11]. Furthermore, due to their experiences of harm in healthcare settings, individuals with gender dysphoria often choose to conform to gender norms for protection [10]. Disclosing their gender dysphoria and gender identity to healthcare providers can prevent them from receiving adequate and standard care [12]. Contrariwise, recent research in Iran has illuminated a positive association between help-seeking among those with gender dysphoria and satisfaction of basic psychological needs, considered fundamental for psychological well-being, motivation, and optimal functioning [13]. Encouragingly, there has been a recent noticeable trend of individuals with gender dysphoria seeking medical care [3]. Still, transphobic, anti-trans, and nonbinary attitudes remain, even in countries considered more progressive [14].

In response, studies involving individuals with gender dysphoria and the challenges they experience have been conducted internationally. Latin immigrants residing in the United States of America (USA) have reported facing discrimination in accessing mental health services [15]. Further in the USA, individuals seeking gender-affirming surgery expressed that this surgery was the most significant event in their lives, though inequalities in accessing healthcare services and inadequate insurance coverage remained [16]. Individuals with gender dysphoria in Mexico City report having had no professional help or positive feedback from healthcare workers since their gender dysphoria began in childhood [17]. In India, individuals with gender dysphoria have faced discrimination in education, employment, and healthcare services [18]. Equally in Spain those with gender dysphoria have reported difficulties in accessing healthcare systems due to therapists’ attitudes towards them and the paternalistic behaviors of healthcare staff [19]. In the Netherlands, ethical and therapeutic decisions for gender-affirming purposes have been promoted for those with gender dysphoria, who are recognised as needing active participation in the decision-making process [20].

Gender dysphoric people also continue to suffer deeply in the majority of Muslim societies due to generalized unawareness, neglect, cultural and religious boundaries on this issue [21]. Islamic perspectives appear particularly concerned with issues related to gender dysphoria, as the ‘traditional’ gender binary constitutes an integral aspect of Islamic social ethics. Such perspectives thus play a key role in shaping religious obligations and interpersonal judgments within Islamic countries. In response, recent years have witnessed challenges aimed to dismantle the concept of the gender binary within Islamic communities, driven by growing social libertarianism, highlighting gender fluidity and choice [22]. Iran is one such Islamic country, where the treatment of transgender citizens is complex, with contradicting legal support and societal judgement [5]. Those with gender dysphoria in Iran often conform to gender roles and norms in order to be able to coexist with their peers in society, even though they experience a disparity between their authentic identity and the one with which others associate them [23]. They can also experience increased sexual abuse, social discrimination, and a lack of family, and social support due to increased societal stigma [24]. Nevertheless, these sentiments are not universally shared, and further understandings are required to achieve gender equity in all areas.

Our scoping review of the literature indicated that gender dysphoria is a phenomenon based on the context of societies [8, 21]. Whilst some studies have been conducted in Iran to explore this phenomenon [25–28], we identified a paucity of studies aiming to explore the lived experiences of those with gender dysphoria in Iran. As the concept of gender diversity in Iran is juxtaposed with Islamic social ethics, the dignity, health and wellbeing of people with gender dysphoria is at risk [8], and further research in this area is urgently required. Considering the above, this research aimed to broaden understandings by answering the following question: What does it mean to live with gender dysphoria in Iran? We aimed to answer this question by garnering insights from individuals’ lived experiences of gender dysphoria in Iran using hermeneutic phenomenology. This study ultimately aimed to explore the lived experiences of individuals with gender dysphoria.

Methods

Study design

The present qualitative study adopts a phenomenological hermeneutic approach inspired by Heidegger [29]. Essentially, this approach enables the interpretation and uncovering of people’s beliefs, convictions, interests, values, and lived experiences which in this case relate to gender dysphoria whilst living in Iran.

Setting and participants

Individuals with gender dysphoria were invited to participate if they had visited the legal medical center in Zahedan, located in southern Iran, to obtain gender reassignment surgery where their sex assigned at birth did not align with their gender identity in Cisheteronormative terms. The inclusion criteria were as follows: currently experiencing gender dysphoria, verification of gender dysphoria through diagnosis by a psychiatrist, willingness to participate in the study, and ability to provide appropriate data. We used purposive sampling to achieve maximum variation in variables such as age, educational level, sex assigned at birth, age at which conflicts regarding gender identity were identified, and duration under legal medical supervision until data saturation was reached. We considered that reasonable sample size may range from 3 to 25 participants for a phenomenological study [30].

Overall, participants (n = 14) were aged between 18 and 45. Over half were assigned female at birth (n = 9) and others were assigned male at birth (n = 5). Participants were aged between 7 and 15 at the time they began to experience conflicts regarding gender identity. The number of months participants had been under the supervision of the medical centre ranged from 3 to 28. The level of education participants had ranged from Bachelor’s degree to less than diploma level. Full details regarding participant characteristics are outlined in Table 1.

Table 1.

Participants’ demographic data

Participant code	Age	Education	Sex assigned at birth.	The age at which gender dysphoria began. (years old)	Duration under the supervision of the medical centre (months)
1	29	Bachelor’s degree	Female	10	8
2	35	Diploma	Female	12	12
3	19	Diploma	Male	7	7
4	26	Bachelor’s degree	Female	8	8
5	35	Bachelor’s degree	Male	10	15
6	20	Diploma	Female	8	22
7	24	Diploma	Female	9	14
8	43	Less than diploma	Female	10	5
9	40	Bachelor’s degree	Male	9	3
10	23	Less than diploma	Female	10	9
11	23	Diploma	Female	10	8
12	18	Less than diploma	Male	9	12
13	45	Diploma	Female	14	12
14	44	Diploma	Male	15	28

Data collection

Data were collected over a period of 3 months (August to October 2023) using semi-structured face-to-face interviews. Questions posed were developed by the research team and based upon findings from existing literature. The main questions included; “Based on your experiences, what does gender dysphoria mean?”;“What experiences do you have living with gender dysphoria?“; “How do you feel and think about living with gender dysphoria?“; and “What is life like for you?” Additionally, sub questions and phrases such as “What do you mean by…?“; “Please elaborate further.” and “Can you provide an example to clarify your point?” were used as appropriate during interviews to garner deeper insights and clarity from participants. The duration of interviews ranged from 45 to 60 min following the collection of basic demographic information. Interviews were conducted in a confidential interview room based within the legal medical center. Prior to interviews taking place, participants received comprehensive information about the study and given their written consent to participate and have their interviews audio recorded. We recognised that talking about bad memories can be uncomfortable for participants. Thus, the corresponding author, a psychiatric nurse facilitated the interviews using compassion and empathy to support participants throughout. Furthermore, participants were given access to mental health professionals such as psychologists should the need arise either during or after the interviews taking place.

Data analysis

Data collection and analysis were conducted concurrently. Quantitative data were analysed using descriptive statistics. The seven stages of Critical Hermeneutic Analysis proposed by Diekelmann, and colleagues was used to make sense of the qualitative data collected and subsequently transcribed [31]. This method guides the researcher to the highest level of interpretation and includes the following stages: (1) Reading all interview transcripts to become familiar with the data, (2) Writing interpretive summaries for each interview, (3) Group analysis of selected excerpts from interview texts and identifying themes, (4) Returning to interview texts or participants to clarify discrepancies and contradictions in interpretations and writing a comprehensive analysis of each interview text, (5) Comparing interview texts to identify, determine, and describe common meanings, (6) Identifying and extracting constitutive patterns that connect themes, and (7) Presenting the final findings in the form of main themes. Accordingly, after each interview, the transcript was reviewed several times. Subsequently an interpretive summary was written for each interview, and efforts were made to understand and extract hidden meanings. The research team also discussed the extraction of sub-themes and themes, which were formed through an iterative succession of refinements. As more interviews were conducted, previous topics became clearer and/or evolved. New topics also occasionally emerged. Moreover, to clarify and resolve any discrepancies and contradictions in interpretations, there was frequent back-and-forth between the texts and the participants throughout the analysis. A sample of our data analysis is presented in Table 2.

Table 2.

A sample of data analysis

Themes	Sub-themes	Meaning units	Narratives
Lacking social and cultural support	Rejection by family and society	- Living in an unbearable home - Not being understood by family members	“The home environment became unbearable for me. No one understood me.“(Participant 6)
	Lack of legal support	- Lack of necessary support from the government	“In the legal procedure of gender reassignment, there is a lack of necessary support from the government.” (Participant 2)
	Being victims of cultural taboos	- Give a sideways glance - Having a peculiar and meaningful look	“Whenever anyone sees me or someone like me anywhere, they give a sideways glance, a look that’s peculiar and meaningful as if they’ve seen a ghost.” (Participant 11)
Adverse psychological experiences	Disgust in relation to sexual characteristics and gender conformity	- Hatred of genitals	“I despise my genitalia.” (Participant 3)
	Fear and concern about disclosure	- Afraid to have intimate relationships - Afraid to have sexual relationships	“I’m afraid to have intimate relationships, for example, sexual relationships; because our situation is special, and our sexual preferences are different.” (Participant 14)

To establish the rigor of our findings, criteria such as credibility, dependability, confirmability, and transferability were employed [32]. For credibility, prolonged engagement, rich and comprehensive descriptions, member-checking, triangulation, and reflexivity were used. Thus, the positions of the research team were drawn from in connection with the process of data collection and analysis. As researchers without lived experience of gender dysphoria, we acknowledge that our interpretations are shaped by our cisgender perspectives and theoretical frameworks. Final findings were discussed and reflected upon with some of the participants as well as two people external to the research team holding doctoral nursing degrees. For dependability, the opinions of an external supervisor, who was familiar with both the phenomenon and qualitative research but was not a member of the research team, were sought to ensure there was congruence in the findings presented. To determine confirmability, all activities were documented, and a report on the research process was compiled. Lastly, to establish transferability, our findings were ‘sense checked’ with two individuals who had experience of living with gender dysphoria but were not participants. Their insights and confirmation of the findings were used to further enhance the credibility and applicability of the findings beyond the study participants.

Findings

Our analysis revealed that people living with gender dysphoria in Iran experienced a lack of social and cultural support and distressing psychological experiences. Theme 1) Lacking social and cultural support’ included the following sub-themes; rejection by family and society; lack of legal support and being victims of cultural taboos. Theme 2) Distressing psychological experiences’ included the following sub-themes; disgust in relation to sexual characteristics and gender conformity along with fear, and anxiety about disclosing one’s authentic gender. These themes and sub-themes reflected the meaning of life with gender dysphoria based on the lived experiences of the participants. In this study, a constitutive pattern emerged as follows; “Being in a different world.”

A - Lacking social and cultural support

This theme describes how participants found themselves in the absence of social and cultural support due to experiences of rejection by their family and society, a lack of legal support, and being victims of cultural taboos.

A-1 - Rejection by family and society

According to participants, both family and society are intolerant of accepting their behaviors and way of life. Families resist their children’s desires and inclinations, leading to conflicts and tensions, eventually resulting in the expulsion of individuals with gender dysphoria from their families along with abuse and even death threats. In many cases, this leads to forced escape and abandonment of participation in society.

One of the participants expressed their family’s opposition to their gender reassignment and the consequences of this opposition as follows: “My family is against my surgery. When they found out I was trying to get legal permission for gender reassignment surgery, they resisted a lot. They said inappropriate things to me, even threatened to kill me. I had to leave home. I went to the house of one of my old classmates who lived alone.” (Participant 4).

Another participant was forced to run away due to harassment at home. “The home environment became unbearable for me. No one understood me, and they tortured me more every day; that’s why I escaped. I was displaced for almost a month, but because I had nowhere to go, I returned to our home!” (Participant 6).

In addition to rejection from home and family, participants also experienced rejection from society. “They kept me locked up in a room at home, like a prisoner, and closed the door on me. They didn’t let me talk to anyone… I had to sit alone in class at university all the time; I couldn’t have relationships with others. Other students found it hard to tolerate me, so I had very few friends.” (Participant 1).

A-2 - Lack of legal support

According to participants, judicial institutions lack sufficient information about people with gender dysphoria and do not support them. Obtaining gender reassignment is a lengthy process that often results in individuals abandoning their gender reassignment. The following exemplary quotes outline this lack of information, support, recognition and legal frameworks, all of which would enable comprehensive gender reassignment in Iranian society at large.

“I went to the judge to follow up on obtaining legal permission for gender reassignment, but when I went, the judge didn’t know what this issue was and said, ‘I don’t accept it! It’s better not to do this!’ Well, when the judge assigned for the gender reassignment case has no information about this issue, it prolongs the process… In my opinion, the most significant problem could be the lack of legal framework to support us.” (Participant 5).

Individuals with gender dysphoria believe that the government does not provide them with sufficient support. “The government does not support us at all until this condition exists and it is perceived that this issue is insignificant, no problem will be solved.” (Participant 12).

According to participants, medical organizations also do not provide the necessary support for their gender reassignment needs. “The process of gender reassignment is difficult, and the necessary permissions through legal medical channels are scarcely granted. For example, in the civil registry, when an individual undergoes gender reassignment, only their new name is mentioned in the ID card, but what matters is the legal procedure of gender reassignment, which lacks necessary support from the government in this regard.” (Participant 2).

A-3 - Being victims of cultural taboos

Individuals with gender dysphoria encounter stigma and disdain as their existence disrupts social and cultural norms in everyday encounters. Negative attitudes, inappropriate language, mockery, and ridicule shape the everyday lived experiences of individuals with gender dysphoria, who in turn often feel forced to conceal their gender nonconformity.

Participants experienced being humiliated by members of society as a cultural pain. “Once when I went out to buy something, I overheard the shopkeeper saying, ‘It’s not clear what these people are… It’s not clear if they’re men or women.’ They really belittle us… These are cultural pains that we have to deal with.” (Participant 7).

Another way one participant became a victim of a cultural taboo was in experiencing insulting looks and ridicule by the public. “Many people look at us very disdainfully. Whenever anyone sees me or someone like me anywhere, they give a sideways glance, a look that’s peculiar and meaningful as if they’ve seen a ghost. Sometimes people mock us and say anything that comes to their minds.” (Participant 11).

In talking about gender dysphoria, participants often clashed with cultural taboos and societal norms, which in turn lead to secrecy. “Unfortunately, discussing gender dysphoria is difficult in our culture, and it’s not easy to talk about it openly. Most of the time, we’re forced to stay silent on the matter and conceal it, which is rooted in our cultural norms because our situation and the fact that we want to undergo gender transition are considered taboo in our culture.” (Participant 8).

B - Adverse psychological experiences

Disgust in relation to sexual characteristics and fear and anxiety about disclosing their gender identity led to adverse psychological experiences for individuals with gender dysphoria.

B-1 - Disgust in relation to sexual characteristics and gender conformity

These participants with gender dysphoria often experience distress at the sight of their own bodies and sexual organs, and some want to remove their genitalia or have their genitalia changed in some way. They strive to live a different life. One where they can live freely and express their gender identity and/or nonconformity.

“To be honest, I feel a lack of breasts. I want to shave my facial hair. It’s really tormenting for me. Most importantly, I despise my genitalia. I wish to be free of it through surgery… I feel like I’m in a cage, like a bird trapped in a cage!” (Participant 3).

These participants with gender dysphoria often detest their assigned gender to the extent that they loathe wearing clothes and exhibiting behaviors associated with it (e.g., feminine or masculine). They feel obliged to engage in gender conformity in public, and so often engage in other gendered behaviours and nonconformity in private.

One participant assigned male at birth expressed their dislike of ‘boyish’ clothes and behavior and their ‘girly’ tendencies:“I want to do makeup, but I have to endure and wear boyish clothes because of my situation, which is very difficult, and I really hate it… When I’m alone and in private, I do girly things, put on makeup, dance… But when my mom, dad, and others are around, I have to act like a boy, I have to behave like someone I’m not, I have to play a role… I’m tired of it, I feel tired from within.” (Participant 12).

Likewise, a participant assigned female at birth expressed hating ‘girly’ behavior and wearing ‘girly’ clothes and described how their ‘boyish’ behaviours led to punishment: “I do boyish things and have no interest in girly stuff at all. I hate girly things and run away from them. I don’t even wash my own teacup; that’s why I’m heavily criticized. I’ve been beaten and punished, but despite all the beatings, I never wore a skirt, and I always wear a short-sleeved shirt with pants.” (Participant 10).

B-2 - Fear and concern about disclosure

Individuals with gender dysphoria experience fear and concern about disclosing their gender identity. This fear may stem from feeling trapped in a gender identity unaligned with their true gender identity.

“I’m afraid to have intimate relationships, for example, sexual relationships; because our situation is special, and our sexual preferences are different, we can’t have sexual relationships with anyone. But if we undergo gender transition, we’ll no longer face this gender identity crisis and can interact with society without fear.” (Participant 14).

The fear of their true gender identity being exposed ultimately leads participants to feelings of abandonment and suicidal ideation.

Participants had experienced fear of revealing their gender identity while communicating with others, friends and acquaintances. This fear had led to extreme restlessness in them. “I always have this fear accompanied by abandonment within me about how to share with friends and acquaintances that I want to undergo gender transition. I’m restless and uneasy… When I go outside, I’m afraid that someone might figure out exactly what gender I am. I’m afraid of it being revealed.” (Participant 13).

The fear of appearing in public and having their gender dysphoria exposed was ultimately associated with suicidal thoughts for some participants. This is outlined by one participant who said: “I’m afraid to appear in public because someone might overhear something and realize that I’m not comfortable with my gender and that I want to be a girl… I thought about these things so much that they became so distressing to me that I even thought about suicide several times.” (Participant 9).

The constitutive pattern

Being in a different world.

The meaning of life with gender dysphoria emerges within the cultural and social context of Iran as ‘being in a different world’. Indeed, the world of an individual with gender dysphoria is vastly different from that of someone without it in this context. This difference arises from the marginalized position of individuals with gender dysphoria, who experience the deprivation of social and cultural support including, along with being ostracized by their families, society, and lawmakers, while also being victims of taboos rooted in culture. At the same time as being abused, beaten, and receiving death threats they strongly despise their assigned gender and experience fear and anxiety about disclosing their true gender identity. Such fears can be accompanied by suicidal thoughts. Ultimately, these participants with gender dysphoria live in a different world.

Latent meanings within these themes that emerged include widespread social and cultural isolation. The cultural taboos and lack of legal support further contribute to this isolation, forcing individuals to conceal their true identities and suffer in silence. Participants are often marginalized and/or ostracized, further contributing to a profound sense of loneliness and disconnection from their communities. Moreover, the disgust that individuals feel towards their bodies and expected gender roles may be reflective of a deep internalization of the societal stigma and shame they have been exposed to. Similarly, the fear of their true gender identity being exposed highlights the pervasive nature of this stigma and the potential consequences of not conforming to societal expectations in this context. Participants’ call for reforms and desire to live authentically demonstrates a powerful sense of resilience and resistance despite challenges. Their experiences illuminate how systems and norms in this context enforce rigid gender roles and how those who deviate from them are punished.

Discussion

This study was conducted in a context where the ‘traditional’ gender binary constitutes an integral aspect of Islamic social ethics, and challenges aimed to dismantle the concept of the gender binary within Islamic communities are currently driven by growing social libertarianism. It aimed to explore the lived experiences of individuals with gender dysphoria. Our findings indicate that these individuals experience a comprehensive entrapment and isolation of ‘being in a different world’. In this regard, they struggled with the lack of social and cultural support, experiencing rejection from their families and society, as well as the absence of legal protection and being victims of cultural taboos. Hermeneutic phenomenology enabled us to reveal interpretive insights into these particular phenomena. Our analysis of participants’ lived experiences revealed that rejection and neglect by family and society are significant issues, which may pave the way for various forms of inequality [33]. Similar experiences have been reported among non-white trans women in the USA, who also experienced rejection and isolation in society [34], along with those with gender dysphoria in Italy who also experienced social isolation [35]. Earlier studies in Iran have revealed how a lack awareness in relation to gender dysphoria in both families and society can also lead to rejection and ostracism [36]. Likewise, in the present study, the nonconforming behaviors of participants resulted in negative reactions from peers. Family members and society were unable to accept them. This ultimately led to them being rejected beaten, receiving death threats and suicidal ideation. They were not easily able to establish relationships with others and were misunderstood by Iranian society. This often resulted in them opting for isolation. In pursuit of gender equality, gender diverse individuals must be seen and accepted as equal to cisgender people in a context where no single gender is favored or centered above another.

Our findings underscore the importance and indispensable role of legal and governmental support in shaping and solidifying the status of gender diverse individuals. The legal process of gender transition was challenging, as judges are often reportedly uncooperative or uninformed, and sometimes even attempt to dissuade individuals from undergoing gender-affirming procedures. Likewise, those in Australia with gender dysphoria are rarely able to access medical and surgical gender-affirming interventions [37], and those in Greece have expressed dissatisfaction with similar legal frameworks [38]. Future legal frameworks will require unbiased responses to requests from citizens requiring legal gender recognition, and gender-affirming interventions must be made as easily available to gender diverse individuals as they are for cisgender individuals [14]. In Iran, current legal support for trans people remains contradictory, and both legal and societal judgements continue to be harsh [39].

Our participants became victims of cultural taboos associated with living with gender dysphoria in Iran. Consequently, these individuals experienced stigma, ridicule, and cultural inequalities in this regard, effectively becoming cultural pariahs to the extent that discussing gender dysphoria became challenging for them. In an Islamic country such as Iran, stigma and discrimination of those with gender dysphoria can result in significantly more psychological complaints when compared to those in non-Islamic countries, suggesting that socio-cultural factors may increase the likelihood of psychopathology in this context [40]. In Nigeria, stigma related to gender dysphoria has similarly been identified as being prevalent [41], as they have been elsewhere in Iran [42]. Those in Norway who experienced similar stigmas attempted to conceal themselves to prevent stigmatization [2]. Healthcare professionals in the United Kingdom (UK) considered that gender diverse individuals also remain marginalized and stigmatized as they too seek to conceal their gender identity in pursuit of healthcare [14]. However, those in Iran with gender dysphoria are known to experience more challenges compared to those in the global north as they experience increased discrimination, violence, and other forms of stigma more frequently [43]. From the analyses presented here, Iranian culture and the beliefs that arise from it were observed to shape understandings relating to gender dysphoria in various ways. In Iranian society, individuals with gender dysphoria experienced stigma, deprivation, and social isolation largely as a result of the cultural and social impacts imposed upon them, alongside the rigid beliefs about the gender binary exposed in this context. Iranian society’s intolerance of gender nonconformity further compounded the marginalization of those with gender dysphoria in this context, perhaps because they ultimately challenge the status quo in relation to the rigid binaries imposed.

Sexual characteristics and in particular, genital organs had an impact upon gender identity and were the cause of emotional distress in some cases, particularly with regards to the building of relationships. The metaphor “a bird trapped in a cage” depicted the peak of their gender aversion and dysphoria, ultimately resulting in psychologically distressing experiences accompanied by suicidal ideation. In South Korea, the most significant challenge reported in the lives of individuals with gender dysphoria was similarly related to their interpersonal relationships. This challenge, particularly in romantic relationships, was associated with distress related to their physical appearance and dissatisfaction with their bodies [44]. Another study conducted in Iran also illuminates how individuals with gender dysphoria experienced fear of disclosure, secrecy, depression, hopelessness, and suicidal ideation in these circumstances [42]. Indeed, Iranian transgender women are known to be at increased risk of psychological distress related to their reduced quality of life in this context [25]. Moreover, Iranian individuals with gender dysphoria experience higher rates of mental health disorders [26–28]. Again, our analyses demonstrate that people with gender dysphoria in Iran are subject to great psychological pressure. In Iran, society does not accept those who do not conform to gender norms. Those who live beyond this continuum are subject to psychological issues and deprivation of access to resources and social benefits. Also, our findings demonstrate how, in Iran, negative attitudes toward people with gender dysphoria and a lack of effective cultural and social awareness campaigns have caused many of these people to suffer from several stressors, including lack of support from their families and society. In response, there is a need for psychological therapies such as personal, group, and family therapy and for educating the public about these vulnerable groups. In future it will also be important to increase access to gender affirming healthcare and enhance societal attitudes and education (e.g., via public and television appearances) in respect of gender diversity to address such inequities. The societal context plays an essential role in shaping the health landscape for individuals with gender dysphoria. Some social determinants affecting health such as persistent discrimination, exclusion, and heteronormative expectations contribute to a sharp increase in stress levels, anxiety, depression, and suicidality within the community. The cumulative effect of these social determinants affecting health has a negative impact upon the health of individuals with gender dysphoria. The identification of these social determinants opens up possibilities to create more supportive atmospheres that foster more optimistic health outcomes for everyone, regardless of their gender identity [45]. As such, future research could usefully explore these with larger sample sizes.

Whilst this study has contributed to the body of knowledge in relation to the lived experiences of gender diverse individuals in Iran, we acknowledge some limitations. For example, whilst we have taken steps to establish the rigor of our findings along with criteria such as credibility, dependability, confirmability, and transferability, our analysis was interpretive and therefore open to alternate sensemaking. Future studies could be conducted to explore the lived experiences of individuals with gender dysphoria in other contexts.

Conclusions

Life with gender dysphoria in Iran is akin to living in a different world. It includes being beaten, abused, experiencing suicidal ideation and receiving death threats. The cultivation of both familial and societal support is urgently required, along with the legal frameworks to support gender affirming care as required. The experience of gender dysphoria in Iran is deeply influenced by cultural factors, including integral aspects of Islamic social ethics. Thus extensive cultural interventions are also required. These may include endorsement of change by law and policy makers and changing attitudes through public and television appearances. By dismantling discriminatory structures, fostering understanding, and providing targeted mental and social support, society can contribute to the health promotion of all people with gender dysphoria. The path to mentally healthier people with gender dysphoria is one that aligns with broader goals of societal development. Full consideration of mental, cultural, and social challenges for people with gender dysphoria underscores the need for comprehensive societal understanding. The distinctive stressors arising from cultural discrimination, stigma, and marginalization have tangible effects on the mental, cultural and social health of people with gender dysphoria. Identifying these challenges is not only vital for fostering capacity but also for actively supporting a community that faces exclusive struggle.

Author contributions

Study design: MG, MMH. Data collection: MG, MMH, NR. Data analysis: MG, MMH. Study supervision: MG, MMH, SP, NR, ZG. Manuscript writing and interpretation: MG, MMH, SP, ZG. All authors have read and approved the final manuscript.

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the confidentiality and the traceability of the qualitative data but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines and regulations. This study was registered with the Ethics Committee of Zahedan University of Medical Sciences under the code IR.ZAUMS.REC.1401.438. Written informed consent was obtained from the participants, and their right to withdraw at any stage of the research was respected. Interviews were recorded with the participants’ permission and emphasized confidentiality, adhering to the principle of confidentiality.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.