Psychiatric morbidities and associated psychosocial factors among adult transgender population in Dhaka city, Bangladesh

Abstract

Background

Nearly half a million transgender Bangladeshi are unable to access basic education, healthcare, and employment due to their gender identification. Social exclusion and marginalization make this community more susceptible to undiagnosed mental health issues. This study aimed to assess the range of undiagnosed psychiatric disorders and psychosocial factors among transgender adults attending outreach centers in Dhaka City.

Methods

A cross-sectional study was conducted over a 12-month period from January to December 2022 among transgender adults aged 18 to 65 years in Dhaka City, Bangladesh. Participants were initially screened using the Bengali version of the Self-Reporting Questionnaire-20 (SRQ-20). Those who screened positive underwent further assessment using the Mini-International Neuropsychiatric Interview (M.I.N.I.). English version 7.0.0, based on the Diagnostics and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria. Data were analyzed using SPSS version 27.0.

Results

Of 157 participants, 73.25% were aged 18–30 years; 86.62% were assigned male at birth, though 54.14% identified as transwomen, 38.85% as genderqueer, and 7.01% as transmen. Most participants were from urban (44.59%) or semi-urban (32.48%) areas. Among the psychosocial stressors, 36.94% reported blackmail, and 29.30% had attempted suicide. Overall, 61.8% were diagnosed with psychiatric disorders, of which Generalized Anxiety Disorder (GAD) (17.20%) was the most common, followed by Minor Depressive Disorder (12.10%), Bipolar I Disorder (6.40%), and Major Depressive Disorder (6.40%). Suicide attempts (p = 0.018) and life dissatisfaction (p = 0.031) were positively associated with psychiatric illness. When comparing GAD with the rest of the psychiatric illnesses, emotional bullying (p = 0.007), physical abuse (p = 0.018), and sexual abuse (p = 0.032) were positively associated with the development of GAD.

Conclusion

The study reported a high rate of psychiatric disease in transgender individuals in Dhaka, highlighting the vital need for equitable mental health treatment through tailored approaches and specialist clinics.

Clinical trial number

Not applicable.

Introduction

‘Transgender’ is an overarching entity that encompasses variations in gender expression, identity, or behavior, as well as an individual’s overall sense of self, diverging from societal expectations based on their sex given at birth. Various transgender identities fall under this category, including transgender men, transgender women, cross-dressers, and transsexuals [1]. Transgender communities have historically existed across different cultural contexts [2]. Although the government of Bangladesh recognized this group of individuals as “third gender” in 2013, transgender individuals are still looked down upon and treated inhumanely due to their lack of a “socially accepted” gender identity [3]. Due to their gender identity, they are denied access to fundamental education, healthcare facilities, and employment opportunities [4].

Transgender people represent an estimated 3–5% of the global population and remain among the most marginalized groups worldwide, facing profound health and social inequities [3]. Research consistently indicates an elevated prevalence of psychiatric disorders within transgender populations in comparison to cisgender individuals [5]. For example, in the United States, the prevalence of psychiatric morbidity among hospitalized transgender individuals is documented at 77%, in contrast to 38% within the general population [6]. In a comparable manner, systematic reviews indicate increased risks of depression, anxiety, substance use, and suicidality among transgender individuals across various regions [5]. In South Asian countries such as India, there exists an alarming prevalence of mental health disparities within transgender populations. Approximately 38% of transgender individuals in India have reported experiencing a mental illness at some point in their lives, with alcohol abuse identified as the most common issue, affecting 26% of this population [7]. Further study from the region underscores vulnerabilities including stigma, discrimination, violence, and exclusion, which together intensify psychiatric morbidity [5, 8]. Despite these challenges, the scope of research in South Asia is limited, with the majority of studies concentrating on HIV or sexual health, resulting in significant gaps in comprehending the wider mental health issues encountered by transgender communities [7, 9].

In Bangladesh, the transgender population, commonly known as Hijra, is inadequately represented in official documentation. The Ministry of Planning documented a total of 12,629 transgender individuals in the year 2022 [10]; however, alternative estimates indicate that the actual figure could surpass half a million [4]. One reason for this disparity is that national censuses have not clearly defined or properly included transgender people, which has led to undercounting [11]. This phenomenon is exacerbated by cultural barriers and entrenched stigma, which complicate both self-identification and engagement in research significantly [12, 13].

The structural and societal challenges faced by the transgender community in Bangladesh contribute to their significant marginalization, resulting in restricted access to education, employment, and healthcare services [13, 14]. Social exclusion is exacerbated by incidents of bullying, sexual and physical abuse, and pervasive discrimination, which collectively elevate the risks associated with suicidality and self-harm [15]. Although a few studies in Bangladesh have examined stigma, socioeconomic status, and risk behaviors among transgender individuals, comprehensive research on psychiatric disorders in this community remains scarce and inconclusive [16].

Psychosocial stressors play a crucial role in comprehending the mental health of transgender individuals on a global scale [17]. The minority stress model highlights that persistent stressors, including stigma, discrimination, rejection, and violence, contribute to elevated psychiatric morbidity rates among transgender individuals [18, 19]. In developed countries, research consistently highlights family rejection, social isolation, insufficient access to gender-affirming care, and workplace discrimination as significant predictors of depression, anxiety, and suicidality [5, 19]. In Bangladesh, transgender people face poverty, unemployment, social exclusion, and widespread violence, which exacerbate poor mental health outcomes [13, 15, 20]. Recent studies also highlighted the impact of COVID-19, which worsened livelihood insecurity, health access, and psychological distress among the Hijra community [20]. Gender stereotypes and persistent labeling further contribute to identity struggles and distress [21]. Notably, Bondhu Social Welfare Society (BSWS), one of the few organizations working with this community in Bangladesh, has documented high rates of suicidality and self-harm [12, 13].

The evidence shows that transgender people worldwide have a high rate of psychiatric illnesses, but research in Bangladesh is scant and disconnected due to cultural invisibility, the lack of systematic surveys, and methodological issues. Understanding psychiatric diseases and psychosocial aspects in this group is essential for culturally relevant therapies and policy. This study examines transgender individuals’ mental problems and psychosocial stresses in Dhaka to fill the gap.

Owing to the significant prevalence of psychosocial stressors and the insufficient research on mental health within this demographic, the prompt recognition of psychiatric morbidity is essential [4, 15, 22].

This study aimed to assess the prevalence of psychiatric morbidities among transgender adults in Dhaka City and examine their socio-demographic profiles and psychosocial factors contributing to these conditions. A secondary objective was to investigate the factors specifically associated with the onset of the primary psychiatric disorder in comparison to those related to other psychiatric conditions.

Methods

Study site & settings

BSWS is a non-governmental organization that is committed to enhancing the well-being of stigmatized and socially excluded individuals and their partners. The organization provides mental, physical, and sexual health services, as well as advocating for human rights and sustainable livelihoods [22]. BSWS maintains around 30 outreach facilities throughout the country. Three of these outreach centers were selected for study sites located in Mohammadpur, Jatrabari, and Sadarghat, all of which are located in Dhaka city. Mohammadpur center is located in Dhaka North City, while the Sadarghat and Jatrabari are under the Dhaka South City Corporation. The National Institute of Mental Health and Hospital (NIMH), which is near all three locations, offers free consultations for suspected mental illnesses and operates as a specialized research institute with multidisciplinary resources to provide comprehensive mental health care.

Study design

We conducted a cross sectional study between January 2022 to December 2022 in the outreach facilities of BSWS.

Study participants

The study participants consisted of adult transgender people who voluntarily visited the BSWS located in above mentioned area in Dhaka metropolitan city. In Bangladesh, due to social stigma, this group remains hidden and can only be reached via the affiliated transgender networks. The enrollment criteria were participants aged between 18 and 65 years and living in Dhaka city. Participants having severe medical conditions require hospitalization, or unable to communicate, or any pre-existing psychiatric illness with or without medication, were excluded from the interview. Participants willingly participated in the study without any incentives. All participants were informed about the aim and objectives of the study. Written consent was taken from those who agreed to participate in this study.

Study tools

A pre-designed structured questionnaire was prepared, pre-tested, and validated before using it for the research to accommodate the socio-demographic information, personal behavior, physical status, co-morbidity, protective factors or risk factors for developing mental illness. The questionnaire was pretested on 18 transgender individuals to assess its clarity, comprehensiveness, and completeness.

The Self-Reporting Questionnaire-20 (SRQ-20) was administered in the native language to screen for potential mental health conditions among participants. The scale has acceptable internal consistency and strong psychometric qualities; Cronbach’s alpha values are usually higher than 0.80 [23]. The SRQ-20 was originally developed by the World Health Organization (WHO) for use in low- and middle-income countries (LMICs) [24] and has been adapted and validated by the National Institute of Mental Health (NIMH), Dhaka, for use in the National Mental Health Survey of Bangladesh [25]. The tool consists of 24 items, with the first 20 questions addressing non-psychotic disorders and the last 4 questions for screening psychotic symptoms. A participant was considered screen-positive if they scored ≥ 6 on the first 20 items and ≥ 1 on the last 4 items. The SRQ-20 serves as a rapid screening instrument to identify individuals who may have mental health conditions; however, it is not designed to provide a definitive psychiatric diagnosis.

The Mini International Neuropsychiatric Interview (MINI) 7.0.0 is a short, structured diagnostic interview with established validity and reliability for identifying DSM Axis I psychiatric disorders. The M.I.N.I. has well-established psychometric qualities. Excellent inter-rater reliability (kappa >0.80) and test-retest reliability (kappa >0.90) are reported by previous validation studies, proving its applicability for diagnosing mental illnesses in a variety of groups [26]. Its standardized format ensures consistent administration, and previous studies have demonstrated excellent inter-rater and test-retest reliability, supporting its reproducibility [27]. In this study, the English version was administered by the principal investigator, a trained psychiatrist, who verbally translated and explained each question in the participants’ native language in a consistent manner. This approach ensured both clarity and cultural relevance while preserving the diagnostic integrity of the instrument.

Study procedure

Prior to commencing data collection, we visited the study location accompanied by a personal communicator who was well-regarded by the community. We collaborated with community leaders and individuals to build rapport, explained the study’s objectives, and underscored its potential advantages for the community. Data collection followed a convenient and purposive sampling approach. Since simultaneous presence at the three outlets was not feasible, the investigator visited each outlet on alternate days during official working hours (9:00 AM–1:00 PM) to recruit and interview adult transgender participants upon fulfilling the inclusion criteria.

Patients were interviewed by the principal investigator after taking proper written informed consent. Data were collected through a face-to-face interview session lasting 20–30 minutes by using a structured sociodemographic questionnaire. The SRQ-20 questionnaire was used for every participant, and then the MINI 7.0.0 scale was applied subsequently in the same interview. Diagnosis of mental disorders was done by applying MINI 7.0.0. on the basis of DSM-5. Data were gathered anonymously, with stringent protocols to guarantee privacy and confidentiality.

After administering the SRQ-20 for initial psychiatric screening, a screen-positive result was defined as an SRQ score ≥ 6 in the first 20 items and ≥ 1 in the last 4 items. The researcher implemented a quality control step to ensure accuracy. Specifically, every four participants who screened negative and every two participants who screened positive were reassessed. This approach was used to detect any cases that might have been missed during the initial screening or assessment, minimizing errors and improving the reliability of the study’s findings. Essentially, this re-evaluation step served as a validation measure to ensure that psychiatric conditions were not overlooked in either screen-negative or screen-positive participants.

Statistical methods

For this observational study conducted over a 12-month period (January to December 2022), the required sample size was calculated based on an estimated 20% prevalence of psychiatric illness in the general population of Bangladesh, with a 95% confidence level and a 5% margin of error. This yielded a target sample size of 250. The transgender population, being a marginalized and hard-to-reach group, was accessed through the outreach clinics of BSWS. Despite sustained efforts by the principal investigator throughout the study period, only 175 individuals could be approached. Of these, 18 declined to participate, resulting in a final sample size of 157 participants enrolled over 12 months.

Descriptive statistics were used to summarize the characteristics of transgender participants. Categorical variables were expressed as frequencies and percentages, while continuous variables were reported as means with standard deviations or medians with interquartile ranges, as appropriate. Logistic regression models were employed to analyze the association between socio-demographic factors, predisposing conditions, and psychiatric illness, yielding Odds Ratios (ORs) with 95% Confidence Intervals (CIs). A p-value of < 0.05 was considered statistically significant. All statistical analyses were conducted using SPSS 27.0. The model was adjusted for potential confounders, including age, sex, and the presence of comorbidities. A p-value of < 0.05 was considered statistically significant.

Copy right of M.I.N.I instrument

M.I.N.I International Neuropsychiatric interview English Version (7.0.0) for DSM 5 © copyright 1992–2014 Sheehan DV.

All rights reserved: No part of the document may be reproduced or transmitted in any form, or by any means, electronic or mechanical including photocopying or buy any information, storage or retrieval system, without permission in written from Dr Sheehan. Individual researchers, clinicians and students working in non-profit or publicly owed settings (including universities, non profit hospitals and government institution) may make paper copies of M.I.N.I instrument for their personal clinical and research use, but not for institutional use.

Consent for publication

Consent for publication was received from the participants

Results

A total of 157 transgender adults were enrolled from three BSWS centers, with participants residing across different areas of Dhaka city. The refusal rate was 10% due to a lack of consent. When applying the SRQ-20, 110 participants (70%) scored above the predefined cutoff, indicating a high likelihood of a mental illness, while 47 participants (30%) scored below the cutoff, suggesting no significant symptoms of mental illness. All participants (n = 157) then underwent further psychiatric evaluation using the M.I.N.I. 7.0.0 diagnostic tool, which confirmed that 62% (97/157) of those who had scored above the SRQ-20 cutoff received a positive diagnosis for a psychiatric disorder. On the other hand, the remaining 13 participants who scored above the SRQ-20 cutoff found no psychiatric illness. None of the participants who scored below the SRQ-20 cutoff were diagnosed with a psychiatric disease, supporting the tool’s utility in initial mental health screening (Fig. 1).

Fig. 1.

Differences of detecting psychiatric illness by MINI 7.0.0 and SQR

Among the positive psychiatric illnesses, the frequency of Generalized Anxiety Disorder (17%) and Minor Depressive Disorder (12%) was the commonest. Other psychiatric conditions identified included Bipolar I Disorder and Major Depressive Disorder, each affecting 6.4% of the participants. Substance use disorder was observed in 5.7%, Obsessive-Compulsive Disorder (OCD) in 3.8%, and Schizophrenia, Post-Traumatic Stress Disorder (PTSD), Antisocial Personality Disorder, and Panic Disorder were also noted (Fig. 2).

Fig. 2.

Spectrum of psychiatric disorders by using MINI-7.0.0

The age distribution of the participants showed that 73% (n = 115) were between 18 and 30 years old, while 27% fell within the 30–65 years age range. The mean age of all respondents was 27 years with a standard deviation of 7.71 years. In terms of education, 15% (n = 24) of the participants were illiterate. A significant proportion, 20% (n = 32), had completed higher secondary education (up to 12th grade), and an equal percentage, 20% (n = 32), had pursued education beyond higher secondary. Economically, a substantial portion of participants, 37% (n = 58), reported having no monthly income source. Approximately 49% (n = 78) earned less than 10,000 BDT (< 82 USD) per month, while 13% (n = 21) earned more than 10,000 BDT (> 82 USD) per month. Occupationally, 37% (n = 58) of the participants were students. Service holders and businessmen accounted for 17% (n = 27) and 8% (n = 12) of the participants, respectively. Additionally, 16% (n = 26) relied on begging, and 8% (n = 12) engaged in prostitution. The total number of unemployed participants was 12%. Regarding place of birth, 13% of participants were from urban areas, 45% from semi-urban areas, and the remainder from rural and slum areas. At the time of the interview, 78% of the participants were unmarried (Table 1).

Table 1.

Socio-demographic characteristics of transgender participants (n = 157)

Socio-demographic characteristics	Frequency	Percentage
Age category (in years)
18–30	115	73.25
30–65	42	26.75
Religion
Islam	142	90.44
Hinduism	15	9.56
Educational status
Illiterate	24	15.29
Primary	18	11.46
Secondary	32	20.38
Higher secondary	51	32.48
Graduate	24	15.29
Post-graduate/ Higher	8	5.1
Occupation
Student	58	36.94
Service holder	27	17.2
Panhandling (Begging/Seeking help)	26	16.56
Unemployed	19	12.1
Commercial Sex work	12	7.64
Business	12	7.64
Group performance at marriage and birth	3	1.91
Income category in BDT (USD)
1000–10,000 (8–82 USD)	78	49.68
10,000–30,000 (> 82 USD)	21	13.38
No income	58	36.94

Among the participants, 87% were biologically male at birth, while 13% were biologically female. However, a significant proportion, 54%, identified themselves as transwomen during the interview. In terms of sexual orientation, the majority of the participants, 36%, identified as bisexual. This highlights a diverse range of sexual orientations within the cohort (Table 2).

Table 2.

Gender related issues of transgender participants (n = 157)

Gender related issues	Frequency	Percentage
Biological sex
Male	136	86.62
Female	21	13.38
Gender identified by the person
Trans man	11	7.01
Trans women	86	54.14
Gender queer	61	38.85
Sexual orientation
Gay /Lesbian	38	24.2
Heterosexual	27	17.2
Bisexual	56	35.67
Asexual	17	10.83
Unlabeled/prefer not to be labeled	16	10.19
Others	3	1.91

The proportion of different associated factors among participants, like presence of conflict with family members (42%), facing emotional bullying (55%), victim of blackmailing (37%), victim of physical abuse (49%), and attempted suicide (29%) was higher (Table 3).

Table 3.

Distribution of associated factors among transgender participants (n = 157)

Associated factors	Frequency	Percentage
Conflict with family member	66	42.04
Experiences emotional bullying	86	54.78
Faced in Childhood	45	52.33
Faced in Adulthood	41	47.67
Exposure to blackmail	58	36.94
Perpetrator of blackmail
Partners	19	32.76
Friends	30	51.72
Both (partners & friends)	3	5.17
Others	6	10.34
Experience of being physically abused	77	49.04
Previous suicidal attempt(s)	46	29.3
Experience of sexual abuse	66	42.04
Family history of psychiatric illness	29	18.4
Intimate relationship	67	42.68
Family affirmation & acceptance	58	36.94
Perceived no satisfaction towards life	80	50.96

Table 4 highlights the logistic regression analysis of associated factors among transgender participants revealed that previous suicidal attempts and perceived dissatisfaction with life were significantly associated with psychiatric illness. About 36% of participants with psychiatric illness had a history of suicidal attempts compared to 18% of those without psychiatric illness (p = 0.018; OR = 2.51, 95% CI: 1.16–5.45), and 58% reported low life satisfaction versus 40% of those without psychiatric illness (p = 0.031; OR = 2.05, 95% CI: 1.06–3.94). Other psychosocial factors, including conflict with family members, emotional bullying, exposure to blackmail, physical or sexual abuse, family history of psychiatric illness, and family affirmation, were more common among participants with psychiatric illness but did not reach statistical significance.

Table 4.

Distribution of associated factors in transgender participants with or without psychiatric illness (n = 157)

Associated factors	Psychiatric illness (n = 97) (%)	No psychiatric illness (n = 60) (%)	P value (chi)	OR (95%CI)
Conflict with family member	43(44.33)	23(38.33)	0.460	1.28 (0.66, 2.47)
Experiences emotional bullying	57(58.76)	29(48.33)	0.202	1.52 (0.80, 2.91)
Exposure to blackmail	38(39.18)	20(33.33)	0.461	1.29 (0.66, 2.53)
Experience of being physically abused	51(52.58)	26(43.33)	0.260	1.45 (0.76, 2.77)
Previous suicidal attempt(s)	35(36.08)	11(18.33)	0.018	2.51 (1.16, 5.45)
Experience of sexual abuse	42(43.30)	24(40.00)	0.684	1.15 (0.60, 2.20)
Intimate relationship	43(44.33)	24(40.00)	0.594	1.19(0.62,2.30)
Family history of psychiatric illness	20(20.62)	9(15.00)	0.378	1.47(0.62, 3.49)
Family affirmation & acceptance	36(37.11)	22(36.67)	0.955	1.02(0.52, 1.99)
Perceived no satisfaction towards life	56(57.73)	24(40.00)	0.031	2.05(1.06, 3.94)

Fig. 2 shows that GAD was the most frequently diagnosed psychiatric disorder among participants. To better understand factors specifically associated with the development of GAD, all diagnosed cases were divided into two analytic groups: those with GAD (n = 27) and those with other psychiatric disorders (n = 70). This comparison, presented in Table 5. The logistic regression analysis revealed that experiences of emotional bullying, physical abuse, and sexual abuse were significantly less common among participants with GAD compared to those with other psychiatric disorders (emotional bullying: 37.0% vs. 67.1%, p = 0.007, OR = 0.29; physical abuse: 33.3% vs. 60.0%, p = 0.018, OR = 0.33; sexual abuse: 25.9% vs. 50.0%, p = 0.032, OR = 0.35), suggesting a negative association between these factors and GAD. Other factors, including conflict with family members, exposure to blackmail, previous suicidal attempts, family history of psychiatric illness, family acceptance, perceived life dissatisfaction, and experience of sexually transmitted infections, did not show statistically significant differences between the two groups.

Table 5.

Associated factors related with generalized anxiety disorder (GAD) and other psychiatric disorder (n = 97)

Associated factors	Overall (n = 97), n (%)	Generalized anxiety disorder (n = 27); n (%)	Other psychiatric disorder (n = 70); n (%)	P value (Chi)	OR (95% CI)
Conflict with family member	43(44.33)	10(37.04)	33(47.14)	0.369	0.66(0.27, 1.64)
Experiences emotional bullying	57(58.76)	10(37.04)	47(67.14)	0.007	0.29(0.11,0.73)**
Exposure to blackmail	38(39.18)	8(29.63)	30(42.86)	0.232	0.56(0.22,1.45)
Experience of being physically abused	51(52.58)	9(33.33)	42(60.0)	0.018	0.33(0.13, 0.85)*
Previous suicidal attempt(s)	35(36.08)	6(22.22)	29(41.43)	0.078	0.40(0.15, 1.13)
Experience of sexual abuse	42(43.3)	7(25.93)	35(50.0)	0.032	0.35(0.13, 0.93)*
Experience of sexually transmitted infections	27(27.84)	11(40.74)	16(22.86)	0.078	2.32(0.90,5.99)
Family history of psychiatric illness	20(20.62)	2(7.41)	18(25.71)	0.053	0.23(0.05, 1.07)
Intimate relationship	43(44.33)	14(51.85)	29(41.43)	0.354	1.52(0.62, 3.71)
Family acceptance as transgender	36(37.11)	9(33.33)	27(38.57)	0.632	0.80(0.31, 2.03)
Perceived no satisfaction towards life	56(57.73)	12(44.44)	44(62.86)	0.100	0.47(0.19, 1.16)

Discussion

Our study examined psychiatric disorders among transgender individuals in different areas of Dhaka city, revealing that more than two-thirds (62%) of adult transgender participants experienced psychiatric illnesses. The most prevalent conditions included Generalized Anxiety Disorder (17%), Major Depressive Disorder (6%), and Minor Depressive Disorder (12%). Additionally, we identified Bipolar I Disorder (7%), Substance Use Disorder (6%), Obsessive-Compulsive Disorder (4%), along with cases of Schizophrenia, Post-Traumatic Stress Disorder, Antisocial Personality Disorder, and Panic Disorder.

Given the similar religious and conservative social cultural structure that influences public acceptance of transgender people, Bangladesh’s status is similar to that of countries like Turkey and Iran [28–30]. Significant family rejection and social stigma are prevalent in all three countries, and they contribute to poor mental health outcomes [31]. To isolate the impact of common geographical vulnerabilities, we compare our cohort’s distress rates with published studies from these similar settings. This comparative viewpoint helps us go past straight Western parallels and develop more context-appropriate findings by acknowledging the comparable pressures and customizing public health policies to the region’s cultural and conservative realities. In comparison, the National Mental Health Survey of Bangladesh reported a much lower prevalence of psychiatric disorders (20%) in the general adult population, with Depressive Disorders (7%) and Anxiety Disorders (5%) being the most common [12, 25]. The unique vulnerabilities of transgender individuals, such as stigma, discrimination, marginalization, and limited healthcare access, are well-known risk factors for poor mental health that likely explain the higher prevalence observed in our study compared to national estimates [13, 22]. Additionally, the national survey may have been influenced by methodological differences, as it encompassed the general population without disaggregating data for transgender individuals. The lower prevalence reported may be partially attributed to the underrepresentation or omission of many transgender individuals in Bangladesh, who remain concealed due to stigma and fear of disclosure [4]. Our research thus addresses a critical knowledge deficit by offering a perspective on a marginalized population that is frequently excluded from national estimates. Our participants were predominantly younger, with a mean age of 26.8 years and nearly three-fourths aged 18–30, compared to only 36% in the same age group in the National Mental Health Survey, indicating a younger transgender cohort in our study [25]. Studies from other developing countries also report high rates of depressive disorders among transgender subgroups, with prevalence of 24% in male-to-female individuals, 31% in female-to-male individuals, and 38% in genderqueer individuals, underscoring the substantial mental health burden and the urgent need for targeted interventions [24, 32]

Regarding educational status, 15% (n = 24) of participants in our study were illiterate, while 20% (n = 51) had studied up to the higher secondary level (12th grade), and 20% (n = 32) had education beyond higher secondary. Aligning with the national survey, which reported that 16% of respondents were illiterate [33]. Additionally, 38% had completed primary education, 32% had secondary-level education, while 9% had reached higher secondary, and 6% had attained graduation or above. The overall literacy rate in the national survey was 85% [12]

Among participants, 37% had no fixed income, 49% earned 1,000–10,000 BDT(8–82 USD) monthly, and 13% earned over 10,000 BDT (>82USD). Regarding occupation, 37% were students, 17% worked in government, private, autonomous, or self-employed roles, and 8% ran small- or large-scale businesses. Notably, 17% relied on begging, 8% on prostitution, and 12% were unemployed. These findings reflect the limited access to stable and dignified employment opportunities within the transgender community, often driven by pervasive social stigma and marginalization [2, 4, 34]

Our study considered several past experiences that may predict mental illness among transgender adults. Since most participants were young adults, these factors were likely experienced in the recent past. Individuals with diverse sexual orientations and gender identities have historically faced stigma, discrimination, and marginalization [19]. Transgender, intersex, and queer individuals are often deprived of basic rights, self-dignity, bodily autonomy, and access to healthcare, resulting in adverse health outcomes [34]

Amidst the vast spectrum of gender diversity worldwide, our study has successfully highlighted the prevalence, distribution, and associated psychosocial factors of psychiatric illness among transgender adults in Dhaka city. The findings reveal a significantly higher burden of psychiatric illnesses in the transgender community compared to the general population in Bangladesh. Key contributing factors include a history of suicidal attempts, emotional bullying, physical and sexual abuse, and a family history of psychiatric disorders.

Strength and limitation of the study

Our study is not without limitations. Firstly, we were unable to interview members of the floating transgender population due to trust issues, which may have introduced selection bias. Secondly, we did not utilize the Minority Stress Model to better predict mental stress and associated factors, which could have provided a more comprehensive understanding of the underlying stressors. Thirdly, due to the difficulty of reaching the transgender population and the time and resource constraints that constrained recruitment, the total sample size was rather small. This might have decreased the statistical power to identify some correlations. Lastly, we used the English version of the M.I.N.I. 7.0.0. Due to constraints of time and resources, we were unable to formally translate it into the native language. Although the principal investigator explained and translated the questions during interviews to aid participants’ understanding, the possibility of linguistic and cross-cultural biases cannot be entirely ruled out.

Conclusion

This study highlights the prevalence of mental illnesses among transgender adults, which is enormous and mostly ignored. Comprehensive mental health measures adapted to this vulnerable population are urgently needed due to the high prevalence of mental disease and the substantial influence of psychosocial stressors. Enhancing mental health services, including the setup of specialized clinics for gender-diverse individuals within government hospitals, would constitute an essential measure toward achieving equitable physical and mental health care.

Author contributions

NAA and MS contributed to the study concept and design. Data collection and project administration were carried out by NAA, SRR, and MRI. NAA and MMM did the data analysis under the guidance of MS and LS. NAA, MS, and LS drafted the manuscript, with critical revisions from MHUA, MTA, and MMM.

Funding

This study was funded by the National Institute of Mental Health as part of the primary author’s research requirements for the Fellowship of the College of Physicians and Surgeons (FCPS) Psychiatry program. The funding agency had no role in the study design, data collection, analysis, interpretation, or manuscript preparation.

Data availability

This manuscript includes original data collection and analysis on psychiatric illnesses among transgender adults in Dhaka. Upon publication, authors will make de-identified individual participant data and a data dictionary available for sharing, accompanied by a signed data access agreement.

Declarations

Ethics approval and consent to participate

The study protocol was submitted to two separate committees for ethical review and approval. Ethical clearance was obtained from the Ethical Review Committee of the National Institute of Mental Health on 28 August 2021 (Ref: NIMH/ERC/2021/1428), and subsequently from the Research Committee of the Bangladesh College of Physicians and Surgeons on 12 December 2021 (Ref: BCPS-712/2021/PSN-0073). Informed consent was obtained from each participant through a consent form written in native language “in accordance with the Declaration of Helsinki”. The document explicitly defined the study's aim, objectives, processes, potential risks and benefits, and confidentiality protocols.

Consent for publication

Informed consent for publication was received from the participants ensuring deidentified data will be used in the manuscript.

Competing interests

The authors declare no competing interests.