Mental health and challenges of transgender women: A qualitative study in Brazil and India

Abstract

Background: Transgender women from low- and middle-income countries (LMICs) are understudied, their coping strategies and struggles underrecognised.

Aims: This study aimed to explore the lived experiences of transgender women from two major cities located in Brazil and India, LMICs with high rates of transphobia and gender-based violence.

Methods: We conducted a mixed-methods, exploratory study, including focus group discussions (FGDs) and brief survey interviews with 23 transgender women from Hyderabad, India and 12 transgender women from Rio de Janeiro, Brazil. Herein we present the combined (qualitative and quantitative) results related to discrimination, stigma, violence, and suicidality in transgender women’s lives.

Results: Three major themes emerged from FGDs: stigma and discrimination; violence, and suicidality. Lack of education and working opportunities influence high levels of poverty and engagement in survival sex work by transgender women in both cities. Study participants live in large cities with more than 6 million inhabitants, but transgender women reported chronic social isolation. Participants disclosed frequent suicide ideation and suicide attempts. Brief surveys corroborate FGD findings, identifying high prevalence of discrimination, intimate partner violence, suicidality and low social support.

Discussion: Multiple layers of stigma, discrimination, violence and social isolation affect transgender women’s quality of life in Hyderabad and Rio de Janeiro. Strategies sensitive to gender and culture should be implemented to tackle entrenched prejudice and social exclusion reported by transgender women. Additional social support strategies, better access to education and employment opportunities are also urgently needed. Improving the availability of evidence-based mental health interventions addressing the high prevalence of suicidality among transgender women from Hyderabad, India and Rio de Janeiro, Brazil should be prioritized.

Introduction

Throughout history, many societies did not stigmatize or marginalize transgender and gender nonconforming (TGNC) persons, including in low- and middle-income countries (LMICs) as diverse as Nigeria and Mexico, among many others (Bartlett & Vasey, 2006; Bullough, 1974; Herdt, 1996; Mendoza-Álvarez & Espino-Armendári, 2018; Salamone, 2005; Stephen, 2002). TGNC persons in Native American communities filled multiple social roles (Nanda, 2000), such as the Two-Spirit who fulfill ceremonial gender variant roles (Burks et al., 2011). Among the Mohave Native American, TGNC female identified ("Alyha") and TGNC male identified ("Hwame") were allowed to change their names and adopt desired societal roles (Roscoe, 1996). However, with European colonization, TGNC persons faced increasing discrimination, criminalization, harassment and violence (Jacobs et al., 1997).

European colonization and Christian education highly influenced the two diverse countries studied herein: Brazil and India. Brazil was a colony of Portugal until 1882, and Portuguese traders started bringing slaves from Africa to Brazil by the end of 16^th century (Stefflova et al., 2011). British colonial rule ended in India in 1947. Both countries had a rich and inclusive culture pre-colonization, where TGNC persons were respected, and held important societal roles (Chakraborty & Thakurata, 2013; Picq & Tikuna, 2019). In pre-colonial Brazil and almost all Latin America, TGNC persons were respected by their communities and frequently had an important role as community members and healers, traditionally seen as blessing from the gods (Picq & Tikuna, 2019). The recognition of travesti as a Brazilian cultural identity goes back to colonial Brazil, identified as a practice of femininity, and is currently frequently used as a pejorative term for transgender women (Vartabedian, 2016). The practices of travesti, visibly exercised within groups representing African and Indigenous people, and religious variants such as Candomblé may or may not include body modification (Elbein, 1986; Fry, 1982; Mott, 1999; Trevisan, 2007). In India, hijras were a revered and a protected minority referenced in Hindu scriptures and oral traditions, frequently invited to dance at weddings and bless people, bringing joy and health to newborns (Chakraborty & Thakurata, 2013). However, colonization and cultural globalization also influenced fast changes in social structures, decreasing the traditional role and importance of hijras (Kalra, 2012). Until the Supreme Court ruled in NALSA v. India in 2014, TGNC had few legal rights, experienced blatant discrimination and mistreatment influening their healthcare, poor educational and employment opportunities. Those aspects act in synergy, influencing poverty and requiring them to engage in sex work, beg, or perform on the streets for donations (Jayadeva, 2017; Mal, 2019). Afterwards, TGNC including hijras, were granted a third gender option, equal protection of the law, and the right to decide their self-identified gender.

Portuguese and British colonization regulated TGNC persons’ experiences and freedom in both countries. In Brazil, the social, cultural and religious mixture of African and European traditions highly influenced the relationship between Brazilian society and the transgender population, a mix of fascination and respect brought by African religions and abjection brought by European values and Catholicism (Jesus, 2018, 2019). In recent years, highly conservative groups and representatives from Neopentacostal Churches have increased their political influence in the country, within a growing scenario of intolerance and violence toward TGNC persons (Malta et al., 2019). In 2018, the Brazilian Supreme Court recognized the constitutional right of TGNC persons to rectify their official documents, adapting them to their gender identity (Brazilian Supreme Court, 2018). However, while TGNC persons in Brazil can change their name and gender on civil documents without the need of any medical evaluation or gender-affirming medical interventions, they face constant discrimination and inadequate access to education, employment and healthcare (Malta et al., 2019). That same year in India, the section of the Indian Penal Code, created in 1864 by the British government, which criminalized sexual and gender minorities, was retired (Supreme Court of India, 2018). Unfortunately, despites these shifts in national policies, alarming numbers of transgender women in India still experience stigma, discrimination, and violence (Bharat, 2011; Chakrapani & Bharat, 2014; Kalra & Shah, 2013). In 2019, India’s parliament passed the Transgender Persons (Protection of Rights) Bill, upholding the rights of transgender persons and prohibiting discrimination, but unlike Brazil, requires TGNC to document gender-affirming surgery to obtain a certificate of identity.

Herein we report the results of a qualitative study conducted with transgender women from those two historically distinct cultures: Rio de Janeiro, Brazil and Hyderabad, India. We describe their lived experiences, current challenges and their efforts to build resilience in the face of hardship. We also try to understand how these factors might be related to transgender women’s mental health. Both countries share a history of religious and spiritual beliefs that were accepting, inclusive and even revering of TGNC persons in the past, but currently experience increasing intolerance and violence toward this population. This study is important in order to expand our knowledge about the impact of stigma, discrimination and violence on transgender women’s lives. Our findings could contribute to inform the development and implementation of evidence-based interventions addressing the specific needs of transgender women from LMICs with similar contexts.

Methods

We conducted a mixed-methods exploratory study in 2017 with transgender women in Brazil and India. A brief quantitative survey was conducted, followed by focus groups with representatives of the transgender community from Rio de Janeiro, Brazil, and Hyderabad, India. Participants were identified and recruited in close collaboration with community leaders. All of the participants from Hyderabad identified as hijra, and participants from Rio de Janeiro identified as travesti, or as transgender women. This study focuses on descriptive statistics from survey items that measured social support, experiences with discrimination, stigma, and violence; and results from the focus groups. IRB approval of this study was obtained from Duke University, and the Oswaldo Cruz Foundation.

The quantitative surveys were administered in person and at a time prior to the focus groups so that focus group discussions would not bias the results of the quantitative surveys. The surveys were administered on paper with participants electing to complete the surveys on their own, have the questions read to them or to ask for assistance from the interviewer when needed. Quantitative items included questions assessing demographic characteristics such as gender identity, living arrrangements (i.e., alone or with someone else), and relationship status. Discrimination events in the past year were measured using an adapted version of the Multiple Discrimination Scale (MDS), sexual orientation subscale (MDS-Gay) (Bogart et al., 2013). The ten-item scale, which measures perceived interpersonal (close others, partners, strangers), institutional (employment, housing, healthcare), and violent forms of discrimination (insults, physical, property damage) associated with sexual orientation, was modified to assess these forms of discrimination based on sexual orientation and/or gender identity. In addition, two questions used in previous studies assessed intimate partner violence (IPV): “Have any of your partners ever tried to hurt you?” and “Have any of your partners ever used physical force or verbal threats to force you to have sex when you did not want to?” (Finneran & Stephenson, 2014). Six items from the World Health Organization World Mental Health Composite International Diagnostic Interview (WHO WMH-CIDI) - Suicidality (SD) subscale were used to identify lifetime and recent thoughts of suicide (i.e., last 12 months), lifetime and recent plans to commit suicide, and lifetime and recent suicide attempts (Kessler & Üstün, 2004).

Focus groups, used as a data collection methodology in this study, have some advantages for generating data in the field of health. Focus groups can be an efficient and nondiscriminatory way to improve communication and participation with people who may fear being interviewed alone or cannot read or write while allowing researchers to gather information from several people simultaneously (Kitzinger, 1995; Robinson, 1999; Twohig & Putnam, 2002; Wilkinson, 1999). The focus groups at both sites were semi-structured, lasted 60-90 minutes and used a script that included probes about: (1) key structural challenges faced by members of the population (e.g., legal system, employment, violence); (2) physical and mental health challenges, including substance use; (3) status of interpersonal relationships including experiences of stigma and discrimination; (4) challenges in accessing overall health and gender transition care; and (5) perspectives about local and national policies that influence health and wellbeing of transgender women. The questions were designed to permit discussion to emerge, with a moderation that managed the group dynamics with a low degree of control. Study participants were interviewed by a local investigator (JGJ in Brazil and GKK in India). The focus groups were audio-recorded, with consent of the participants, who were initially asked to speak one at a time to avoid overlapping voices on the recordings. The discussions were transcribed for later analysis.

All transcripts were reviewed and independently analyzed by two investigators (JGJ & MM). Coding and theme discrepancies were discussed and reconciled. During this process, the domain structure was continually reassessed and underwent subsequent revisions. Quotes were identified to illustrate major research findings reported by the interviewees. The selection of quotes aimed to cover all expressed viewpoints while avoiding redundancy. Investigators used previously published domains of mental health adapted from the minority stress to draft a preliminary framework of analysis (Hendricks & Testa, 2012). After reviewing the focus group transcripts, the team reached three major domains: (1) stigma and discrimination experiences (family discrimination, discrimination in health services, social isolation); (2) violence (bullying, harassment and physical violence); and (3) suicidality.

Results

We collected quantitative surveys and conducted 2 focus groups with a total 35 transgender women participants: 12 in Brazil and 23 in India. Brazilian transgender women had a median age of 30 (Range: 20 to 49) compared with 31.66 for Indian transgender women (Range: 23 - 50). One form of continual discrimination is in the everyday terms that are used to “other,” objectify and stereotype gender minorities. The focus groups found belittling terms for gender minorities in both countries and the focus group members had developed their own terms to affirm their gender identities. “Pajubá” or “Bajubá” is Brazilian queer slang that uses some words originally from Yoruba and Bantu languages that are commonly used in Afro-Brazilian religions, like “Candomblé.” Pajuba was designed by transgender women to protect the community in certain circumstances, especially from police violence. Herein we preserved slang words to illustrate their specific language, followed by an English translation. Table 1 presents specific words of Pajubá expressed by the Brazilian participants, followed by their approximate meaning in English. Hijra use words more closely related to the general Hindi (Indian language), and eventually some adapted English words (Table 2).

Table 1.

Pajubá expressions and their meaning.

Pajubá	Meaning
Amapô	Cisgender woman
Aqué	Money
Aquendar	Call attention to something. To look. To flirt. To catch. To hide. Sex.
Bafão	Synonims: Bafo, babado, basfon. Variation of French “Bas-fond”. May refers to a quarrel, confusion, something very good or significant. News. A novelty.
Bofe	Man with masculine appearance. In the context of sex work refers to the client.
Carão	Usually spoken as “to do carão”: To pose. To be snobbish, arrogant.
Equê	Lie. Trick. Mistake. False thing. In specific contexts means that something is artificial, substituting a natural thing.
Gravação	Oral sex
Picumã	Hair. Wig.
Uzê	Really bad thing. A prominent variation of the usual word “Uó”, which refers to something or somebody bad, ugly, disgusting, despicable.

Table 2.

Hindi expressions and their meaning.

Hindi	Meaning
Akka	Older sister
Amma	Mother
Athamma	Aunt
Chakka	Very derogative term to refer to Hijra.
Chela	Rookie. Disciple.
DD	Meaning “Double Ducker”. Sexually active and passive.
Guru	Teacher.
Haveli	House. Community.
Hijra	Also Hijda. Indian transgender woman, understood as a third gender person.
Hizda	Hijra.
Kinner	Derogative term to refer to hijra.
Kojja	Derogative term to refer to hijra.
Kothi	Sexually passive. Receiver. Refer to hijra when related to theirselves. Derogatively, in sexual context, means bitch.
Lathi	Stick
Nayak	Head of the house.
Nirvan	Traditional castration. Different from Sexual Reassignment Surgery (SRS).
Panthi	Sexually active. Doer. Man.

Stigma and discrimination

For transgender women in Brazil and India, stigma and discrimination began in home, school, and public environments and continued into adulthood (Table 3). All 35 (100%) participants reported experiences of someone insulting or making fun of them because they are gender minorities. Nearly all participants in India (n = 22, 96%), and most participants in Rio De Janeiro (n = 9, 83%) reported being ignored, excluded, or avoided by people close to them. Similar results were found for being treated with hostility or coldness from strangers, and experiencing someone acting as though they could not be trusted because they are a gender minority.

Table 3.

Experiences with Stigma and Discrimination.

In the past year, because you are a sexual or gender minority?	Hyderabad			Rio De Janeiro
	India (N = 23)			Brazil (N = 12)
Have you been treated withhostility/coldness by strangers?	Yes	22	96%	10	83%
	No	1	4%	2	17%
Have you been ignored/excluded/avoided by people close to you?	Yes	22	96%	9	75%
	No	1	4%	3	25%
Have you been rejected by a potential sexual/romantic partner?	Yes	10	43%	5	42%
	No	13	57%	7	58%
Have you experienced someone acting as if you could not be trusted?	Yes	21	91%	10	83%
	No	2	9%	2	17%
Have you experienced someone insulting/making fun of you?	Yes	23	100%	12	100%
	No	0	0%	0	0%
Have you been treated poorly/made to feel inferior when receiving health care?	Yes	15	65%	10	83%
	No	8	35%	2	17%
Have you been denied a job/lost a job?	Yes	11	48%	8	67%
	No	12	52%	4	33%
Have you been denied a place to liveor lost a place to live?	Yes	23	100%	4	33%
	No	0	0%	8	67%
Have you experienced personal property damage/stolen?	Yes	11	48%	4	33%
	No	12	52%	8	67%

We are bullied everywhere. It starts at our home, with our family. Then at school. I hated my school, I hated all the ‘jokes’ about me, I hated the looks, I hated how my teachers never protected me… And then it keeps going on, when I’m walking at the street, or at the shopping mall, I know that everyone is staring at me. If I go inside a store, security folks follow me. If I’m getting out of the market, or bookstore, they will probably stop and ask to check my bags. As if I was a constant threat. That’s why we are always reacting with ‘carão’ [staring back, mocking cis folks]. They bully us, we bully back. But it’s a hard life. (Brazil).

Our family members say that [because] we are like this [our] other siblings will not [be able to] get married so they will not support us, they will not allow us to [be part of the] family (India).

At the age of 15 to 16 years my parents did not accept me like this so I consumed phenol to die but they saved me. Later when they started putting more pressure, I ran away from home so my parents booked a case against me, I also filed a case against them and I moved away from home. When I ran away from home I was caught by them, they shaved my head, they tied me with iron chain like a dog. I faced all these problems. Now, also, if I want to visit my parents they insist that I arrive like how I was before leaving home, like a boy but not like what I am (India).

Our family people feels that it [being transgender] is shameful and brings down their social status, so they will not allow us to live with them. No one [in the family] will even talk to us or meet us (India).

Interpersonal discrimination, expressed through insults or impeding participants’ ability to move freely or access services from close others and strangers was discussed.

We don’t feel bad if someone call us hijra, but we feel so bad if anyone calls us Kojja (India).

If we are going on the streets, two or three boys will surround us and ask us to do sex like this, they torture us with their bad words (India).

Okay… I’m gonna give you back this question, right? Like, you’re “Amapô” [cisgender woman], white, fancy “Amapô”. Think about the last time you went to a grocery store, or to the shopping mall, or to a restaurant, anything that you do every day. Do you remember seeing someone that you could tell it was a travesti? No? Exactly, if you are not passable [transgender woman who looks like a cis woman], you hide in the shadows… You go to the grocery at night, you avoid the daylight, you don’t go where the ‘perfect-traditional-family’ is. We are ghetto, we are unwelcome, we don’t belong. (Brazil).

When I am going on my bike, people used to make fun by saying “see the chakka driving,” they bully us by coming in front of us trying to obstruct the way (India).

All ‘travesti’ [transgender women] that you will interview have the same story. We are all kicked out of our family, or we just ran away after years of violence… I hate Christmas, I hate Mother’s day, I hate Father’s day. My family is here. My family is my sisters, my blond mom [famous transgender women and activist who have a shelter for homeless LGBTQ + in Rio]. Those are the persons I can count with, those are the ones who accept me for who I am. Who give me food, shelter, hugs whenever I need. No questions asked. Here I can be me, I can dress the way I want. I can dance, I can smile, I have a shoulder to cry when I need. That’s my safe spot, and those persons here (points to her transgender women friends) made me want to live when I couldn’t even get out of bed. I was soo depressed, I even wanted to kill myself. They were there for me when I needed the most… I’m sorry. They are the reason why I am alive, why I am strong and why I wanna live. Red lipsticks, “Picumã do equê” (long wig), all produced and ready. Yeah, baby! (Brazil).

Baby, we are isolated. Society don’t wanna see a bunch of travestis in the Shopping Mall, or seating nearby them at the movies. We are not welcomed. Not at all. They look at us and it feels like we have some sort of disease… So, I usually stay home during the day. At night I feel more free, that’s when I work, I hang out with my friends, I drink, I have fun, I get my “aqué” [money], find my “bofes” [hot guys] (Brazil).

Systematic discrimination and barriers to inclusion in general society are highlighted by high levels of employment discrimination and being denied or losing a place to live. Nearly half of participants in Hyderabad (n = 11, 47%) and two-thirds in Rio De Janeiro (n = 8, 67%) reported being denied a job, or losing a job because they are a transgender woman.

Basically we do three types of activities: one is begging in the city, go to the shopkeepers in some locality and ask for money; some will do sex work they go to hotspots and get the clients; and some people will go to trains to beg. With all three types of activities we have problem with police. Beggars will be stopped by the police to not to disturb the business people. … Police will come to hotspots and catch the clients and demand money from them or they will harass us for money. If we don’t give them money they will beat us until we leave that place. For people who do sex work, they also have a problem with Goonda’s, roudies (Gangsters). When we have a problem we approach the police for help, but they will not help, but rather they mingle with them [the roudies] and take away all of our money and belongings (India).

Among us we have people who have completed their graduation [from school] but will not be given employment (India).

We do have educated people in the [hijra] community, still we have no option but to choose sex work or begging as means of livelihood (India).

I did my BSc-Nursing, but I cannot get the job. They say that “you have studied as a boy now you are transgender, so you cannot get job. They say that “even if we are ready to give you a job, people will object to use your services (India).

One in three (n = 4, 33%), and all 23 (100%) participants from Hyderabad reported housing discrimination, such as being denied a place to live, or losing a place to live.

Even when we get a room for rent, neighbors put pressure on the owner to evict us…how much discipline we will maintain, people have one or the other objection (India).

We will not get the residence: if someone wants to rent out their rooms they will think 10 times before giving us a house to rent (India).

Owners also take advantage by charging or increasing rentals (India).

Violence

Almost 1 in 5 (16.7%) Brazilian transgender women reported intimate partner violence in the past 12 months, compared with 96% for Indian transgender women. One-quarter of transgender women in Brazil (25%) reported physical or verbal threats for sex, compared with 61% for India. Focus group participants reported experiences with a broad range of violence. Verbal abuse was very commonly reported, followed by physical assault. There was a broad range of violence reported, from people in streets, family members, sex clients, occasional and stable partners, but also the police. Fewer participants from Rio De Janeiro reported intimate partner violence (17%), but nearly all participants from Hyderabad reported having a partner try to hurt them in the past year (96%), and over half reported a partner using physical force or verbal threats to force them to have unwanted sex (61%) (Table 4).

Table 4.

Experiences with intimate partner violence.

In the past 12 months, have any of your partners ever tried to hurt you? This includes pushing you, holding you down, hitting you with a fist, kicking you, attempting to strangle you, and/or attacking you with a knife, gun, or other weapon.
	Hyderabad, India			Rio De Janeiro, Brazil
	Yes	22 (96%)		2 (17%)
	No	1 (4%)		10 (83%)
In the past 12 months, have any of your partners ever used physical force or verbal threats to force you to have sex when you did not want to?
	Hyderabad, India			Rio De Janeiro, Brazil
	Yes	14 (61%)		3 (25%)
	No	9 (39%)		9 (75%)

We walk in groups because: one we protect each other and two ‘Travesti não é bagunça!’ ‘Travesti are not to be messed around with.’ This is a quote from a late and famous transwoman activist, Luana Muniz]. Like, if we walk alone in the daylight, people laugh at us, call us names, and it’s always in the news, we are dying. They kick us, they beat us, they laugh while they are killing us. Nobody cares… We are the country that kills more trans in the world! And baby, if we wanna stay alive, we gotta protect one another… I mean, we fight A LOT. It’s always ‘Bafão’ [messy] around here (Brazil).

I was raped sooo many times, you know? By family members, clients, partners, the police… And it’s not only rape, it is like… everyone feels like they can touch our bodies without consent. I had guys touching my butt when I was walking in the street with a friend, or on the bus, everywhere. It’s crazy, even if you are not a prostitute, or when you are not working on the street, it seems like we are always ‘for sale,’ you know what I mean? Like, if you’re not ‘Amapô’ [cisgender woman], you are for sale (Brazil).

Those guys who come here every night, who wanna pay less to get ‘gravação’ [oral sex] or ‘aquendar’ [sex] without condom, they don’t want their families, their wives, to know what they are up to… So, if they feel threatened, or if they are high, drunk, or if we don’t agree with some weird thing, they just beat us really bad… It’s like a ‘pressure cooker’, ready to explode any minute (Brazil).

One day [name of transgender woman] was attacked, a guy stabbed her. We ran to the ER, like, she was bleeding okay? I was screaming, and everyone there, freaked out. As if we were inside the ER to steal the docs, or something like that… So, they asked for her documents. She doesn’t have them, I mean, it’s the wrong name [on the documents], she doesn’t carry it. ‘Uzê’ [swear]. And she was bleeding, okay? I was making a scene, screaming, she could die there and they wanted the f* document with male name! Long story short, they left her in the hall for one hour or even more. No one wanted to touch her! The only nice person was this cleaning lady who offered her a glass of water. Can you imagine? And after they finally saw her, she had to be admitted at the ER and guess what? She was assigned to the male ward! My blood boils just remembering it. Of course she left the hospital. Of course she didn’t finish the treatment. But is it her fault? (Brazil).

Participants from Hyderabad made several comments about challenges with law enforcement:

We have lot of issues, when we are walking on the streets people will beat us from behind (India).

We have lot of problem from police, they say when you go for begging they tell us not to demand money and accept and take what ever they give (India).

Recently two of our community boys [transgender women] caught in the “hotspot” when they were doing sex work. They argued with police and said if at all us something wrong took us while wearing this dress to police station. What police did is that they brought the boys pants and shirts and forced them to wear those clothes and took them to the police station and charged them with being drunk and doing non-sense on the road. They will make up different charges (India).

When we go for sex work and are caught by police they tear our clothes, if we have the organ [penis] they say you are a male, so you cannot do this, then they charge us with different things (India).

When we go to the people to bless them like on special occasions like shop openings, new born baby’s presentation ceremony, that time we demand for money, Police will have a deal with them and take some of the amount and give us the balance. If we say anything they will take us to police station and beat us (India).

Suicidality

Suicidal thoughts were common among transgender women in both Brazil and India, with 58.3% and 60.9% having ever seriously thought about killing themselves, respectively. Furthermore, 50% of Brazilian participants made a plan to commit suicide at some point in their lifetime compared with 60.9% for India. Almost half of participants in Brazil (41.7%) reported a lifetime suicide attempt, with a slightly higher reported proportion in India (52.2%). When asked about seeking help for a mental health problem in the future, 40% of the participants from Brazil reported they were very likely to seek help compared with 4% in India. In the qualitative discussions, there were identified discourses related to hopelessness, tending to have no sense of a future, indications of depression, as well as suicidal ideations and attempts.

I already buried too many friends, too many sisters… First, it was AIDS, killing everyone. I carried so many coffins… And they keep beating and killing us. Every f* day… Those horrible events all over the news, on facebooks, twitter, everywhere. I feel like I don’t have tears anymore, I’m drying from the inside out. Our sisters are dying, and nobody cares. Every night, when I go out with a ‘bofe’ [sex client], I kinda ask myself: Am I gonna be the next? Like, you really don’t know if you are getting inside the car of a murder, a crazy guy that just wanna kill you… When I’m done for the night, I walk home slowly… And almost every morning, I cry. Until I sleep, exhausted… To wake up and work on the other night again… (Brazil).

Questions on suicidal ideation and attempts were asked in the surveys (Table 5), and suicide was mentioned in both Hyderabad and Rio focus groups.

Table 5.

Suicidality.

	Hyderabad			Rio De Janeiro
	India (N = 23)			Brazil (N = 12)
Have your ever seriously thought about killing yourself?	Yes	14	61%	7	58%
	No	9	39%	5	42%
Have you had thoughts about killing yourself in the last 12 months?	Yes	2	9%	2	17%
	No	12	52%	5	42%
	NA	9	39%	5	42%
Have you ever made a plan for committing suicide?	Yes	14	61%	6	50%
	No	1	4%	1	8%
	NA	8	35%	5	42%
Have you made such a plan in the last 12 months?	Yes	3	13%	2	17%
	No	11	48%	5	42%
	NA	9	39%	5	42%
Have you ever attempted suicide?	Yes	12	52%	5	42%
	No	3	13%	2	17%
	NA	8	35%	5	42%
Have you attempted suicide in the last 12 months?	Yes	2	9%	2	17%
	No	10	43%	3	25%
	NA	11	48%	7	58%

We have no one in the world, any mother, father, brother or sister; we cannot marry like any other person so feel frustrated and cut hands or try to die (India).

Early age we will have more struggles that time we start cursing god why you have created me like this I am neither a man nor a women. We feel it is better to die than living like this.” (India).

It’s a hard life… Sometimes I cry all day long and don’t wanna get out of bed. I remember my mom… I miss her so much! But then you gotta put yourself together to work every night, you gotta look sexy, then you get inside a car but you just don’t know where he [sex client] will take you… You just hope to be alive, hope for a night without beating, rape, fear… And you think about all your sisters going on the same anxiety, night after night. Until someone’s face is on the news, X. beaten to death… I tried to kill myself. And I might do it again. Our life is pointless…(Brazil).

Discussion

Transgender women in these two cultures were once historically accepted, and even revered by some, then marginalized and ostracized. It is critical that we improve our understanding of the multiple layers of stigma, discrimination, and violence transgender women experience in order to select and implement appropriate evidence-based interventions to address those layers. In addition to coldness, hostility, exclusion, and distrust, all of our participants reported being verbally insulted in the past year. Nearly half of transgender women in Hyderabad, India and over half in Rio de Janeiro, Brazil reported being denied a place a live; and the majority of transgender women in Hyderabad and Rio reported being treated poorly while receiving health care. Policies can be implemented to reduce housing discrimination, programs have been developed to train clinicians and staff at health facilities to improve care for transgender populations, and interventions can be developed and implemented to address suicidality.

Whereas transgender women at both study sites experience discrimination and stigma across the life course, we found remarkable disparities between transgender women from Hyderabad and Rio De Janeiro, regarding reported experiences of intimate partner violence in the last year, and forced sex in the last year. Our finding in Rio De Janeiro is slightly lower than the 25% of participants from a cross-sectional study of 16 transvestites and transsexual individuals in Cajazerias/Paralba, Brazil reporting lifetime sexual violence (Silva et al., 2016); but it appears that intimate partner violence may be particularly widespread among transgender women in India. Studies of sexual and gender minorities in India report substantial variation in rates of physical and sexual violence (Chakrapani et al., 2017; Shaw et al., 2012; Thompson et al., 2019). A study of 543 MSM and transgender individuals from four districts in southern India by Shaw et al. (2012) found an 18% prevalence of sexual violence in the past year; whereas Chakrapani et al. (2017) found that 84% of their 300 transgender participants reported physical or sexual violence. This is very alarming, however, our results should be considered in light of a recent systematic review finding that a median of 41% of cisgender women in India reported any lifetime domestic violence; and 30% reported domestic violence in the past year (Kalokhe et al., 2017), combined with results from a 2009 study comparing acceptability of intimate partner violence using Demographic and Health Surveys from Armenia, Bangladesh, Cambodia, India, Kazakhstan, Nepal, and Turkey finding that acceptability of “wife beating” in India was very high (Rani & Bonu, 2009). Results from this study suggest that acceptability of “transgender woman beating” in India may be even higher. Taken together these results indicate that policy interventions in India are necessary to address physical and sexual violence as a matter of urgency. For example, policies that support heavy punishment when a woman or child is sexually abused should align with policies regarding sexual offenses against transgender women.

Although estimates are likely conservative because transgender murders are not well recorded in many countries, information collected by the Non-Governmental Organization TransGender Europe (Trans Murder Monitoring, 2017) recorded 2,609 murders of transgender people in 71 countries, between January 1, 2008 and September 30, 2017. The majority of recorded crimes occurred in Latin America (2,048 - 78.5% of the total), with Brazil accounting for 52.3% of the reported murders of transgender people in the world between 2008 and 2017 (1,071). In 2018, the National Association of Travestis and Transsexuals (ANTRA) and the Brazilian Trans-Institute of Education (IBTE) identified 163 murders, of which 158 were Transgender Women, 4 Transgender Men and 1 Gender Non-Conforming Person (Benevides & Nogueira, 2019). In response to growing concern with the disproprortionate lethal violence experienced by transgender women, the Brazilian Supreme Court criminalized acts of discrimination and hate against TGNC persons in 2019. Future studies will be necessary to evaluate the impact of this law, and addressing frequent exposure to lethal violence suggests a critical need for scale-up of trauma-informed mental health care for transgender populations, and innovative approaches tailored to improve physical security. Adaptation and promotion of interventions with mobile health apps that increase direct participation from transgender women in the generation of data about local personal safety conditions, self-reporting what they know and live everyday may be effective and empowering.

Our results with regards to suicidality are also alarming, and there were differences between Hyderabad and Rio de Janeiro with regards to willingness to seek help for mental health issues in the future. Research has consistently demonstrated the relationships between gender-based discrimination, violence, and suicidality among sexual and gender minorities (Clements-Nolle et al., 2006; House et al., 2011; Perez-Brumer et al., 2015; Rood et al., 2015). Findings from a meta-analysis in the US by Herbst et al. (2008) suggest that transgender women have high rates of suicidal ideation (53.8%), and attempts (31.4%); and those rates are associated with structural transphobia, lack of social support and mental healthcare experienced by this particular population. The majority of transgender women participants in Hyderabad, and half of participants in Rio de Janeiro reported ever planning to commit suicide; and over half of participants from Hyderabad, and nearly half of participants from Rio de Janeiro reported lifetime attempts at suicide. Perhaps salient for future interventions to address suicidality among transgender in Hyderabad and Rio de Janeiro is a recent study in the US from the National Transgender Discrimination Survey (N = 4,190) investigating the impact of discriminatory experiences in health care settings (doctors offices, emergency rooms, mental health clinics) (Romanelli et al., 2018). Results using structural equation modeling also demonstrate associations between service denial, substance use, and attempted suicide. Discriminatory experiences in healthcare such as denial or negative treatment might explain both the lower likelihood of hijra to access care, and future studies are needed to explore if discriminatory experiences in healthcare precipitate suicidality among transgender women in Brazil and India. With regards to seeking help for anxiety, the majority of participants in Hyderabad reported not reaching out for help, because they did not know where to get help, or did not think the anxiety was serious enough to get help. This finding may highlight an opportunity to implement programs with community-based organizations to increase culturally-appropriate screening tools for both anxiety and depression, and scale-up of interventions directly targeting suicidality and training programs for members of health facilities in providing appropriate care for TGNC persons.

A major limitation of this study is that the recruitment methods did not allow for a larger selection of participants, and differences seen between the cities and rates of reporting may be due to recruitment differences in who the focus group facilitators had access to in this exploratory study. However, facilitators worked with advocacy groups that were trusted by the participants. As such, we would expect that the direction of the participant bias would be toward those who are more open and supportive. Regardless, the study provides hypotheses for future larger scale multi-country studies that can provide information necessary to understand the importance of cultural and political differences in the experience of transgender persons. An additional limitation is the lack of information on the participants’ racial and sexual orientation diversity. These aspects may have an impact on achieving resources for confronting limitations, like access to health care. This study only focused on transgender women, and future studies should measure locally appropriate racial identity, gender identity and sexual orientation as independent variables in order to more accurately assess important and address unique nuances physical and mental healthcare needs for TGNC who may also benefit from similar study.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Disclosure of potential conflicts of interests

The authors declare they have no conflicts of interest. Ethical approval was received from the Institutional Review Boards (IRB) at Duke University, Protocol: 2019-0507 and the Oswaldo Cruz Foundation IRB (CAAE 87564618.0.0000.5240).

Funding Statement

This work was supported by the Sanford School of Public Policy, and the Duke Global Health Institute, Duke University, North Carolina, USA.