Social strain, distress, and gender dysphoria among transgender women and Hijra in Vadodara, India

Abstract

Background: There is immense diversity among transgender people in India with respect to ethnicity, sub-culture, and gender expression.

Aim: This study examines psychological distress, gender dysphoria, transgender congruence, and social strain among transgender women, and explores their reflections on self and community using a mixed-method approach.

Method: Gender dysphoria, psychological distress, and transgender congruence were assessed with standardized scales while the participants’ reflections were captured using semi-structured interviews. A total of 20 transgender women and Hijras were included in the study using convenience sampling. Data was analyzed using quantitative and qualitative techniques.

Results: A positive correlation was found between psychological distress and social strain, but no correlation was found between psychological distress and gender dysphoria. Half of the participants fell into the range of gender dysphoria, five of them underwent gender affirming surgery, while two could not undergo the surgery and the rest did not express any discomfort with their gender. While all participants experienced psychological distress due to psycho-socio-cultural stressors, Hijra reported additional stressors related to the Hijra tradition.

Discussion: Findings reveal that the psychological distress experienced by transgender women and Hijra had a significant, positive relationship with social strain rather than gender dysphoria. Participants reported various psycho-socio-cultural factors causing psychological distress, which impacted their lives more negatively than gender identity conflicts. These findings support the recent advances by the World Health Organization in ICD-11 to extract transgender conditions from the Mental and Behavioral Disorders category. Limitations of the study are elucidated by authors and the need for a culturally relevant and nonbinary gender dysphoria scale, and implications are discussed.

Introduction

Transgender is an umbrella term to define individuals whose gender identity or expression differs from the traditional gender role associated with one’s assigned birth sex. It refers to those who transgress gender norms, and culturally prevalent stereotypical gender roles (Chakrapani, 2010; Craig & Heith, 2014; Davidson, 2007; Valentine, 2007; WHO, 2017). Although transgender and gender non-conforming individuals are a part of cultures around the world, these individuals encounter several unique psycho-social, economic, and legal obstacles. This study examines transgender individuals’ experiences of psychological distress, social strain, and gender identity in the contemporary Indian context. In doing so, it also aims to deepen our understanding of their experiences with gender identities and dysphoria.

Transgender identities in India

According to the 2011 Census, 4.88 million people in India (0.04% of the total population) identified as transgender (Census, 2011). Experts and activists estimate that these figures are under-reported, as many transgender individuals choose to remain invisible given the social stigma and discrimination (Chakrapani, 2010; Jayadeva, 2017).

The transgender community in India is a culturally recognized group that is diverse, distinct, and includes a variety of gender identities (Jayadeva, 2017; White Hughto et al., 2015). There are transgender individuals who express their gender identity by making lifestyle changes to transition socially, including changing one’s name or appearance, or cross dressing (Chakrapani, 2010). Some transgender individuals also transition medically, taking cross-sex hormones, and/or undergoing gender affirming surgery. It should be noted that these gender identities are fluid: for example, few urban transgender individuals prefer to identify themselves as a transgender man (i.e., a man who was assigned female at birth), transgender woman (i.e., a woman who was assigned male at birth) or simply transgender. In India, there are a host of socio-cultural groups of transgender women who identify themselves as Hijra, Kinnar, Aravani, Jogta or Jogappa, and Shiv-Shakti (Chakrapani, 2010; Satpathy et al., 2017; Sawant, 2017). Some transgender women choose to be a part of these groups on their own free will (Swain, 2006), whereas others (particularly, intersex children) are often handed over to the Hijra groups by their parents (Kalra, 2012; UN-OHCHR, 2015).

Hijras are devotees of the Hindu goddess Bahuchara Mata (whose lore is associated with transgender and intersex individuals) and are commonly found in Western India, where many belong to a unique subculture known as the Hijra gharana (Nanda, 2015). Ancient Indian myths bestow Hijras with special powers to bless people with luck and fertility (Kalra, 2012). Some, though not all, Hijras undergo an initiation rite into the Hijra community called nirvaan, involving castration or emasculation (Kalra, 2012; Kalra & Shah, 2013; Nanda, 2015). Kinnar is an identity for Hijra in Northern India as well as Maharashtra and Gujarat. More recently, educated Hijras who are not associated with Hijra gharana have begun to describe themselves as Kinnar. Aravanis, and Jogtas or Jogappas, found in Karnataka and Tamil Nadu, are devotees of Lord Aravan (Mahalingam, 2003). Shiv-Shakti, commonly found in Andhra Pradesh, are devotees of Lord Shiva who typically work as spiritual healers or astrologers (Chakrapani, 2010).

For the transgender individuals described above, feeling like one is born in the wrong body can be a part of their experience (similar to transgender individuals in Western society), however “many transgender individuals with socio-cultural identities claim of not belonging to either of the sexes, but to the third sex – the true Hijras” (Schultz & Lavenda, 2001, p. 238). Furthermore, transgender individuals belonging to these socio-cultural groups are commonly visible in Indian society, even when many transgender individuals refuse to come out openly due to fear of ridicule and ostracism.

About the Hijra tradition

Amongst all transgender groups, Hijras have a dominant and respected position in India. Hijra culture has existed since the 9th century BC (Michelraj, 2015). Hijras may either stay alone or with their live-in or married partners. Alternatively, they may live within a Hijra commune, or with other Hijras of the same clan staying nearby. The Hijra community is composed of a strict hierarchy with large groups of Hijras from different areas forming different houses or clans called Gharanas (Kalra, 2012). Each of these gharanas is headed by a Nayak, who is the primary decision-maker for that house (Nanda, 1997, p. 40) and leads a number of Gurus (literal translation of mentor) under them. These gurus rule over the community members chelas – followers or mentees, who learn about various Hijra customs and rituals from the guru and regulate their day-to-day life. An experienced chela can become a guru. Hijras refer to each other as women, forming relations such as that of a daughter with their chelas, a sister with contemporaries, a maternal aunt (Maasi) with their seniors, a mother (Maa) with their guru, and a grandmother (Naani, i.e., the guru of one’s guru). In its structure, the Hijra community is not dissimilar to that of India in general: a collectivist society that promotes social cohesion and interdependence (Chadda & Deb, 2013) and that uses hierarchical structures of power to prioritize group goals over individual goals (Kurman & Sriram, 2002; Wong et al., 2018). The Hijra community creates bonds just like an Indian joint family, encouraging interdependence and strict hierarchies.

Though they are revered and considered worthy to bless a newborn, or a new house, ironically, they have poor living conditions due to their exclusion from society. Hijras are discriminated against, as they do not conform to the predominant social norms (Chakrapani, 2010; Mal, 2018). Their primary source of earning remains begging, makeup artistry, and sex work (Bhattacharya & Basu, 2017; Chakrapani et al., 2020; Kalra, 2012). This results in stigma and discrimination. In order to end such discrimination faced by transgender people, the Indian parliament enacted the Transgender Persons (Protection of Rights) Bill (TGP (PR)) 2016 and revised it in the year 2018 (Transgender Persons (Protection of Rights), 2018). The bill provides a mechanism for facilitating legal recognition of their gender as “transgender.” Although the bill aims to provide protection and welfare to the transgender community, it has been heavily criticized for its shortcomings (Venkatesan & Kaur, 2019). The definition of a transgender person in the bill does not discriminate between transgender and intersex individuals, despite these two groups being distinct from one another. In denying this distinction, the law contradicts the voices of the transgender community, experts, and international organizations such as The World Professional Association for Transgender Health who describe gender as existing on a spectrum, rather than in mutually-exclusive categories (Venkatesan & Kaur, 2019). The bill also requires transgender individuals to obtain a certificate of identity (Ghia, 2019) and to undergo gender affirming surgery in order to assert their gender identity as male or female. These requirements further otherization of transgender individuals and violate the 2014 NALSA judgment that accorded rights of self-identification to all transgender individuals regardless of medical transition (National Legal Services Authority v. Union of India and others, 2014).

Social strain and distress among transgender women and Hijra

Transgender individuals in India experience immense psychosocial stressors, stigma, and violence. A few Indian studies have reported social strain among transgender individuals as a result of social transphobia, fear of adjusting or not adapting to social norms (Sullivan, 2006), harassment, verbal bullying, and sexual violence often perpetrated by parents, teachers, peers, and society (Bund, 2013; Reddy, 2005). In addition, studies have highlighted psychological distress characterized by fear related to the potential loss of relationships, internalized transphobia, identity disclosure, and coming out (Chakrapani, 2010; Satpathy et al., 2018). These multiple oppressions reinforce social inequities in terms of economic and housing insecurity, employment discrimination, and poverty (Ganju & Saggurti, 2017) and, not surprisingly, make transgender women and Hijras vulnerable to mental health problems.

Several studies have revealed a high prevalence of mental health problems among transgender women and higher vulnerability to substance abuse (such as alcohol) compared with the general population (Bund, 2013; Chakrapani, 2010; Goyal et al., 2014; Shivakumar & Yadiyurshetty, 2014; Virupaksha et al., 2016; Virupaksha & Muralidhar, 2018).

Gender dysphoria

The limited literature on issues of gender identities highlights transgender women’s felt discordance between their internal and external identity (Agoramoorthy & Hsu, 2015; Kalra, 2012; Kalra & Shah, 2013; Reni, 2010); persistent need for sex change and gender change, and the need to find a community of similar people (Shivakumar & Yadiyurshetty, 2014). Indeed, according to the research, many transgender individuals report facing great challenges in coming to terms with their gender identity and/or gender expression (Chakrapani, 2010). In studies, a few transgender individuals have reported seeking psychiatrists’ help and were diagnosed with gender dysphoria – feeling of an incongruence between sex and gender – which is an essential requirement for hormone therapy or gender affirming surgery in India (Ahuja & Bhattacharya, 2001; Gupta & Murarka, 2009). Considering the dominant transgender identities and groups, the present study attempts to examine the experience of psychological distress, social strain, and gender dysphoria in transgender women, and their reflections on their gender identities.

Material and method

Researchers used a mixed-method research approach combining established scales and semi-structured interviews. Given that the study focused on a hard-to-reach, marginalized population, the sample was selected using a non-probabilistic convenience sampling technique. Twenty transgender women with different gender identities were selected for the study. Individuals were considered eligible to participate in the study if they were 18 years of age or older; identified as transgender/hijra/nonbinary; had received a formal diagnosis of gender dysphoria from a psychiatrist; or had undergone gender affirming surgery. Intersex individuals, people with a severe degree of chronic illness (such as cancer, HIV) and those who could not read or understand Gujarati, Hindi, or English were excluded.

Participants

All participants were residents of the city of Vadodara, in the state of Gujarat. Out of 20 participants, 15 identified as “Hijra”. Two of the Hijra identified as a guru (head of local Hijra gharana), and the rest were chelas (followers). Four participants exclusively identified as “transgender woman” and one identified as “transgender.” Twelve of the Hijra participants had undergone nirvaan (castration). Five participants had successfully undergone gender affirming surgery, and 10 expressed a desire to do so but were unable to pursue it due to financial constraints. Three participants did not feel a need for gender affirming surgery.

Table 1 presents the participants’ demographic profile. Participants ranged in age from 18-42, with a mean age of 27.5. Participants represented a range of educational attainment, including post-graduate work (n = 3), graduation (i.e., 15 years of schooling; n = 1), higher secondary schooling (i.e., 12 years of schooling; n = 8), and no formal schooling (n = 9). Most participants (n = 13) were engaged in unskilled religious community activities known as “Yajmanvruti,” earning approximately INR 5000 to 8000 per month. Some were in skilled labor (e.g., tailoring, cooking [n = 4)]) and were making about INR 8000 to 10,000 monthly. Three participants were in highly skilled occupations such as media studies (n = 1) and social work (n = 2) with a monthly income in the range of INR 15,000 to 20,000. More than half of the participants (n = 12) were cohabiting in transgender communes, while others were living with their families (n = 6), or were living on their own (n = 2).

Table 1.

Participant demographic profile.

Characteristic	N(%)
Age
18–20	1(5%)
21 − 25	9(45%)
26 − 30	5(25%)
Over 31	5(25%)
Current Gender Identity
Hijra	15(75%)
Transgender	1(5%)
Transgender woman	4(20%)
Education
No formal schooling	9(45%)
Secondary	8(40%)
Under graduation	1(5%)
Post-graduation	2(10%)
Occupation
Yajmanvrutti – Unskilled work	13(65%)
Tailor/Cook/Dancer – Semi-Skilled work	4(20%)
Social sector service or media sector job – Skilled work	3(15%)
Gender affirming surgery status
Desired Gender Affirming Surgery but could not get it	10(50%)
Did not undergo any medical procedure	3(15%)
Underwent Gender Affirming Surgery	5(25%)
Underwent Penectomy	12(60%)
Monthly income
INR 1,001 − 5,000	4 (20%)
INR 5,001 − 10,000	10(50%)
INR 10,001 − 15000	5(25%)
INR 15001 − 20000	1(5%)

Research instruments

The study used four scales: Kessler’s Psychological Distress Scale, Utrecht Gender Dysphoria Scale, The Everyday Discrimination Scale and Transgender Congruence Scale. These scales were not standardized in the Indian context, and alphas reflect the individual scales.

Kessler’s Psychological Distress Scale (K10)

This is a 10-item questionnaire used as a brief screening tool to identify levels of distress based on questions about anxiety and depressive symptoms (Kessler et al., 2002). The reliability scores (kappa and weighted kappa score) ranged from 0.42 to 0.74, indicating that the K10 is a moderately reliable instrument.

Utrecht Gender Dysphoria Scale

This is used to measure the intensity of gender dysphoria. It has 12 statements related to gender dysphoria. Answers are marked on a five-point scale to indicate to what extent one agrees or disagrees with each statement. The scale has a Cronbach’s alpha score of 0.92 (Steensma et al., 2013).

The Everyday Discrimination Scale

This scale aims to identify everyday social strain and unfair treatment based on responses to nine questions. The Cronbach's alpha score for this scale is 0.74 and the test-retest reliability coefficient is 0.70 (Krieger et al., 2005).

Transgender Congruence Scale

This scale provides a quantitative assessment of the extent to which a person’s outward expression matches their internalized identity. The scale was developed by Kozee et al. (2012) and has 14 items. The Cronbach’s alpha of this scale is 0.93.

Semi-structured interview schedule

The semi-structured interview schedule was used to gather study participants’ reflections on their gender identity. It contained the following key questions:

1. Can you share your experiences of being transgender or Hijra?

2. When and how did you discover your gender identity?

3. Many people think “transgender identity” is unnatural and equate it to an illness. Can you share your thoughts on the same?

4. Can you share your experience of transitioning? (i.e., your experience of gender affirming sugery or emasculation)

5. Can you share factors that cause social strain and psychological distress among transgender women or Hijra?

The scales and semi-structured interview schedule were translated and back-translated into Gujarati (the native language of the study setting). The tools were shared with team members including a counselor from the community-based organizations (CBOs) who facilitated data collection, one team from the Project Wajood implemented by the CBO, two faculty members from the Department of Psychology at the Maharaja Sayajirao University of Baroda, and two postgraduate research students for their feedback. Scales and semi-structured interview protocols were pre-tested with three participants to check the appropriateness of these tools, which also provided key first-hand experience of data collection to researchers. Based on the feedback received, research instruments were modified. These participants were not included in the main study.

Data collection procedure

Data were collected by researchers after the appropriate approval from the University and the CBOs. A member from the appropriate CBO accompanied the researchers and introduced them to the participants for the study. The interview was conducted privately after receiving the participant's consent. First, the responses of the participants on the scales were recorded by the researchers on the scale itself, followed by a semi-structured interview, which was recorded in the data collection notebook. In addition, researchers have maintained field notes to record observations during the interview. Overall, the entire session (administration of scales and interview) took around 120-200 minutes per participant.

Data analysis

Quantitative data was analyzed using descriptive statistics such as mean and standard deviation, as well as Pearson correlation using the Statistical Package for Social Sciences version 22. Qualitative data were analyzed using thematic analysis techniques consistent with the recommendations of Corbin and Strauss (Chapman et al., 2015; Corbin & Strauss, 2014). These techniques allowed for the identification of common themes within the qualitative data inductively by researchers who collected the data. The data was then independently examined for identification of themes. Themes were then discussed amongst the researchers and the discrepancies in themes were resolved. Quotations from participants are included in italics with their gender identity and age.

Ethical considerations

The objectives of the study were explained to the participants. Written consent was obtained prior to the session which contained all necessary information regarding participation in the research. It emphasized that the participation in the study is voluntary and they could withdraw anytime without any consequences. They were informed that the results of this study would be used in publication after removal of personally identifiable information.

Results

The results section is divided into two sections, quantitative analysis and qualitative analysis.

Quantitative analysis

Psychological distress

Half of the participants (n = 10) responses were categorized as not experiencing any psychological distress while others responses indicate experiences of mild (n = 3) moderate (n = 2), and severe (n = 5) psychological distress (M = 21.8, SD = 7.81; Table 2). It should be noted that a lack of mental health literacy among the participants may have contributed to the low rates of reported psychological distress.

Table 2.

Results of psychological distress.

Variables	Categories	f (%)
Psychological distress (Mean = 21.8, SD = 7.81)	Well	10 (50%)
	Mild mental disorder	3 (15%)
	Moderate mental disorder	2 (10%)
	Severe mental disorder	5 (25%)

Social strain

Just over half of the participants (n = 11) reported a higher than average level of social strain (M = 25.25, SD = 7.91; Table 3). Apart from discordance between birth sex and gender identity, participants experienced several sociocultural stressors like family pressures to conform to gender norms, coming to terms with their sexual and gender identity, and migration to Hijra communities.

Table 3.

Results of social strain.

Variables	Categories	f (%)
Social strain (Mean = 25.25, SD = 7.91)	Higher than average social strain	10 (50%)
	Less than average social strain	3 (15%)

Transgender congruence

A majority of the transgender individuals (n = 13) reported experiencing a high level of transgender congruence (M = 3.13, SD = 1.13; Table 4).

Table 4.

Results of transgender congruence.

Variables	Categories	f (%)
Transgender congruence (Mean = 3.13, SD = 1.13)	High transgender congruence	13 (65%)
	Low transgender congruence	7 (35%)

Gender dysphoria

Scores for half of the participants (n = 10) fell into gender dysphoric range while rest scored below the gender dysphoric range (M = 45.9, SD = 11.04; Table 5).

Table 5.

Results of gender dysphoria.

Variables	Categories	f (%)
Gender dysphoria (Mean = 45.9, SD = 11.04)	Gender dysphoria range	10 (50%)
	Below the range for gender dysphoria	10 (50%)

Correlation between psychological distress, gender dysphoria, social strain and transgender congruence

Results from the test that was conducted showed a positive correlation between psychological distress and social strain (r = 0.592, p = 0.06) while no significant correlation was found between psychological distress and gender dysphoria (r = 0.399, p = 0.82) and psychological distress and transgender congruence (r=-.393, p=.086; Table 6).

Table 6.

Results for correlation between psychological distress, social strain, gender dysphoria, and transgender congruence.

Dimensions	Pearson correlation		Level of significance
Psychological distress and gender dysphoria	r value	.399	p value	.082 NS
Psychological distress and social strain	r value	.592	p value	.006**
Psychological distress and transgender congruence	r value	–.393	p value	.086 NS

^**Significant at 0.01 level.

Qualitative analysis

The qualitative data from the semi-structured interviews provided insights into participants’ formative experiences of gender identity development, gender transition experience, perspectives on Gender Dysphoria, and psycho-socio-cultural stressors.

Formative experiences of gender identity development

Participants were aware of the incongruence between sex assigned at birth and their gender identity at early ages (M = 12, SD = 3.04) yet they did not disclose that information to their families until much later. Nine participants stated that they were aware of the incongruence in their childhood (between 7-8 years of age), whereas others realized it around 9 to 12 years of age. Four participants reported having been disowned by their parents because of gender incongruency at the age of 9 years. Gender incongruence was reflected in cognitive-behavioral characteristics such as the desire to cross-dress, inclination to behave in feminine ways, preferring to play with girls over boys, and discomfort around males and masculine clothing. One participant said,

I always felt I was born inside the wrong body…always felt like I was female inside. I enjoyed feminine activities more [like wearing feminine attire, jewelry, dancing, cooking, –culturally expected as a feminine job]. In school, I had to wear a boy’s uniform…[that] was very uncomfortable. (Hijra, 20 years)

Gender incongruence was heightened by feelings like discomfort, disgust with one’s male physique, penis, and facial and/or body hair. Conversely, they were feeling proud to have less facial hair, seeking breast augmentation, or hormone therapy to feminize and castrate their penis. Many participants stated in Gujarati that "Manne Maasi banvu chhe [I want to be Hijra]”. The term “Maasi” is used for Hijra. This indicates that body image is a vital determinant for gender identity expression among transgender individuals. Some participants reported realizing their gender identity in adolescence (n = 2) or early adulthood (n = 3). For example, one “Hijra” (22 years) explained that after being “married [for] four years… I felt something was not right…one day, I wore my wife’s clothes out of curiosity…[It] made me realize that this is what I am…Since then [my desire] to live life as a woman [has grown stronger].”

Since the Hijra community has a formal support system within the broader socio-cultural context, many participants explained that they chose to join the Hijra tradition to help them to come to terms with their gender non-confirmative feelings and behavior. However, alternatives to Hijra tradition are also emerging as a potential lifestyle choice in Indian culture. Two transgender women contemplated joining the Hijra but decided not to join as they felt comfortable being transgender even without joining them.

Gender transition experience: normalizing gender incongruence

Individuals with gender non-conformity accept themselves, once they realize that there are others who feel the same way. Participants explained that once they realized there were others who experience the same incongruence between their assigned gender and their felt gender, they were able to accept themselves. Participants believed that some people are transgender when they are born while others realize it later in life, emphasizing that it was not something that they could choose but what they are, which is integral to them. Religious beliefs such as being “God’s special child,” or a “Gift of God,” and paranormal experiences such as “Goddess coming to their dream and beckoning them” aid them in normalizing and accepting their gender non-conformity and adapting to their transgender identity. One “Hijra” (26 years) said, “Mataji ka sapna aata hai toh jana padta hai;”, i.e., when the Goddess [name the goddess if possible!] comes to one’s dream, one has to join the Hijra community to serve the Goddess. This finding validated previous research wherein there were reiterations of the sentiment that most Hijras were “called” by the Goddess, either by a dream or some other omen that clearly signifies the desire of the goddess for the person to become a Hijra or even to remove male genitalia (Dynes & Donaldson, 1992).

Many participants (n = 17; 5 transgender women and 12 Hijra) underwent gender affirming surgery and/or emasculation (removal of male external genitalia). Those participants shared positive feelings and satisfaction with their bodies after surgery and emasculation. One transgender woman explained,

I’m a man [who is undergoing gender affirming surgery] … soon going to be a [trans] woman …I’m satisfied and excited with my life … I love being on my own and I am a proud transgender woman. (Transgender woman, 25 years)

Participants’ perspectives on gender dysphoria

Participants expressed discomfort with their bodies, clothes, masculine gender expression, activities, and hobbies performed as men earlier. They were happy and content with clothing and behavior of the opposite gender. All participants had adopted feminine attire. However, their gender identities were not universal. Hijra participants strongly identified themselves as Hijra. While a few (n = 2) preferred to be identified as transgender women, one individual identified and labeled themselves as “Transgender” or “TG”. Notably, the qualitative results related to gender dysphoria contradict those of the gender dysphoria scale. Most participants expressed comfort with their present gender identity. Furthermore, participants indicated their preference for not being labeled as having “gender dysphoria” or being “mentally ill.” They seemed to be defensive when one interviewer used the term “jaati olakhni bimari,” i.e., illness related to gender identity, and “manasik samasya,” i.e. mental illness, for their condition. Participants explained:

We are not mentally ill. We need acceptance in society as we are. Let us be what we feel and what we are. Don’t impose illnesses on us. (Hijra, 27 years)

I am a happy being. I am a proud transgender woman. People perceive us as ill because we are not comfortable with the gender we were born with…but if society allows us to be what we are, we are absolutely fine with our lives.” (Transgender woman, 25 years)

Psycho-socio-cultural factors/stressors causing psychological distress

Participants’ experiences of living as a transgender or Hijra highlighted key psycho-socio-cultural factors, namely: stigma and discrimination, family and social rejection, and limited educational and economic opportunities. These factors impact their lives negatively more than gender identity issues. Moreover, Hijra reported additional stressors like dissatisfaction with the Hijra tradition.

Stigma and discrimination

The transgender individuals encounter a variety of discriminatory attitudes. One “Hijra” (23 years) shared that she realized her identity as transgender after marriage. Upon coming out she faced hostility from her spouse (resulting in a difficult divorce), abusive family members, and ultimately, difficulty living in her village. Migrating from the village and joining the Hijra community was her only resort since they accepted her as part of their family.

Half of the participants experienced discriminatory attitudes and behaviors, including physical abuse after they identify as transgender individual. For example, two participants reported sexual abuse by peers and family members during their childhood. Three participants expressed statements indicating the internalized stigma of being transgender. One participant shared,

…at the age of 25 years I left my job as a housekeeper…I did not want to be a bad influence [as a transgender] on the children belonging to that household, who were close to me. (Transgender woman, 45 years)

Internalized stigma and its impact on their well-being can be explored in future research.

Family and social rejection

Nearly all participants (n = 19) stated that they were not accepted by their families. Rather, they described being threatened or assaulted by family members for behaving in a way that was incongruent to their expected gender role. Fourteen participants walked out of their families during childhood, while three ran away from their home in their adulthood when they realized they could not continue to live the life of a man. Some parents outrightly rejected, disowned or evicted their own child for not fulfilling expected gender roles. One “Hijra” explained that her “…parents evicted [her] to the Hijra community at the age of nine years.”

Most participants echoed that few people ridicule them for being “different”. A transgender (18 years) voiced that she left home at 14 years of age due to discrimination and torture by her neighbors and relative’s family. Non-acceptance by family members and stress as a result of being mocked, cast out, and/or treated with hostility were the sources of psychological distress among trans women and Hijra. Because of these experiences, many participants reported that they preferred to avoid public interactions.

Limited educational and economic opportunities

Many of the participants were unable to start or complete their education. Pervasive stigma and discrimination were the primary reasons for not pursuing education. Seven participants reported negative experiences (being teased, called derogatory labels such as ‘chhakka’, which is used for the third gender), including discrimination (such as being kept at a distance or being avoided) by peers and teachers at schools. Since fifteen participants ran away or were evicted from home, they did not receive support from their family and faced numerous challenges including limited economic opportunities. Thirteen participants were engaged in begging while only three were working in the social sector.

Dissatisfaction with Hijra tradition

Of the fifteen participants who identified as Hijra, four expressed dissatisfaction in the way of life of the Hijra community, specifically that it mandates interdependence at the cost of independence. One transgender woman reported that she had left the Hijra gharana because she could not adjust to the intrusive and controlled way of life. When she tried to leave the gharana, she was physically attacked by the other Hijras, ultimately requiring help from a CBO to extricate herself from the community.

The people at the CBO found me, helped me leave the Hijra community, and helped me understand my gender identity and build my life. I am happy living as a transgender woman. (Transgender woman, 18 years)

Hijra tradition as a source of psychological distress

Social order within the Hijra community is maintained by the Nayak through regulation of internal councils, called the Hijra panchayats or Jamaats. The Nayak has the authority to order punishment, include or expel Hijras from the houses when rituals are not followed or for unexpected behaviors. Punishments can include fines, additional work, or isolation in a room. Expulsion of Hijras from the communities is called “huqqa-pani band” (meaning cast out or ostracize). During the expulsion, an outcast Hijra finds it difficult to re-initiate themselves into the Hijra community in any city. The Hijra tradition has strict rules that control every aspect of the members’ lives and these are a source of distress for many of the hijras. This can be seen in the requirement that each member surrenders their earnings from begging to the guru, and a meager monthly allowance is allotted to the members, which is regulated. One participant stated,

…it is customary to deposit all our earnings from begging to our guru, we are provided with money for daily expenses like travel and so. (Hijra, 22 years)

Another Hijra expressed the wish to study and work including the desire to buy her parents a house, but living in the Hijra tradition, given their rules, it was not possible. Further, all members of the Hijra tradition are only allowed to visit their native home (to see their parents) once a year, which was restrictive for many members. Upon violation of rules, members are either punished or expelled by the Nayak. One Hijra explained:

I was not happy to live among the Hijras. They were forcing me to get nirvaan (emasculation) so I tried to run away. They caught me, and then they cut off my hair and beat me and tortured me. I was charged with fifty thousand Rupees as a punishment. (Hijra, 36 years)

Certain similarities can be noted in the trans women's responses, wherein they took a disliking to the Hijra way of life, which requires one to accept a certain level of interdependence, to lose autonomy in taking personal decisions, to beg for a living, and to forfeit all earnings to the Nayak. In contrast, the responses given by some Hijra participants indicated that their original preference was to live exclusively as a woman, but due to social pressure from their community, including certain incentives in being part of the community (such as safety and protection from their community network) they adjusted their expectations and accepted living in the Hijra tradition.

Validation of Utrecht Gender Dysphoria Scale in India

The Utrecht Gender Dysphoria Scale is based on a binary gender identity framework (either male or female). The challenge was to measure the discomfort associated with the body and gender expression within a gender binary framework. More than half of the sample (n = 13) reported experiencing a high level of transgender congruence. This could be attributed to the fact that the entire sample reported a desire to transition via gender affirming surgery or penectomy.

Discussion

The results of this study illustrate that although psychological distress showed a significant positive relationship with social strain, it did not show a significant relationship with gender dysphoria, or transgender congruence. Notably, transgender women and Hijra reported distress due to social strain as well as enacted and internalized stigma that forced them to walk out of their families during childhood. These results largely support the findings by Reed et al. (2016) that distress among transgender individuals was predicted largely by the experiences of social rejection or violence that transgender people had, rather than by gender incongruence itself (Reed et al., 2016). Gender incongruence was experienced mostly during participants’ childhood; after which it gradually normalized and was accepted by most participants as integral to them. The expression of self-identified gender and acceptance of oneself in the transgender community significantly reduced the discordance between their internal and external identity and these findings have echoed with the results of a similar study conducted in Bangalore (Shivakumar & Yadiyurshetty, 2014). Most participants who experienced gender dysphoria were able to resolve gender incongruence over a period of time with self-acceptance of gender identity and through support from the transgender community. This finding contradicts the basic classification of “transgender” as mental illness, which states that “distress and dysfunction” is an essential element of the condition. Recent expert consensus is that transgender identity is a non-pathological condition, which is reaffirmed by the removal of gender dysphoria from the mental and behavioral disorder (WHO, 2017).

Most conceptualizations of gender identity among transgender individuals in the global literature are based on the gender binary framework, leaving little room for fluidity or flexibility (Galupo et al., 2017). Perhaps limitations of the binary framework of the scale could have contributed to inconsistencies in reporting gender dysphoria. The Utrecht Gender Dysphoria Scale used in this study did not capture experiences of gender fluid or gender diverse individuals with cultural gender identities. The qualitative data indicate higher adaptability of transgender identities and behaviors. However, findings on the Utrecht Gender Dysphoria Scale identify half of the participants meeting the criteria for gender dysphoria. Therefore, there is inconsistency in the findings as the participant’s report gender dysphoria, but not identity incongruence. This study echoes the perspectives of other researchers on the inclusion of nonbinary transgender identities for measurement of experiences of gender dysphoria (e.g., Budge et al., 2014; Farmer & Byrd, 2015; Galupo et al., 2017, 2020; Galupo & Pulice-Farrow, 2019; Harrison et al., 2012; Lykens et al., 2018).

In India, transgender individuals have long been part of the broader culture and, in the past, were treated with great respect (Chakrapani, 2010). Yet today, they face immense stigma and societal discrimination, which often results in psychological distress that affects their mental health (Sadiq & Bashir, 2015). Furthermore, certain cultural norms of the Hijra tradition cause distress, especially vertical collectivism and perceived hegemony. This may mean that even after gender affirming surgery, emasculation or other interventions, transgender individuals may continue to feel distressed due to social stigma and societal discrimination.

Individualism conflicting with vertical collectivism

Collectivism is a basic cultural element for cohesion within social groups, stressing on the priority of group goals over individual goals in contrast to individualism (Brewer & Chen, 2007). Singelis et al. (1995) described vertical collectivism as a system where people sacrifice their personal goals for the sake of in-group goals but the members of the in-group are different from each other, some having more status than others. It refers to a system of decision-making by hierarchical structures of power in a collectivistic family (Chadda & Deb, 2013), which was dominant in the Hijra tradition. Some Hijras were dissatisfied with strict norms and vertical collectivism in terms of dominance in decision-making during “Jamaat” and control in their day-to-day lives. Hijra norms need further exploration to understand how these rules are evolved, operate and affect the lives of Hijra.

Perceived hegemony of Hijra community

Hegemony is the social, cultural, ideological or economic influence exerted by a dominant group (Szymanski et al., 2008). Those who identify exclusively as trans women have expressed a sense of disconnection from belonging to the transgender community since they do not have a strong group to represent them and have no visibility in Indian culture. Due to the absence of concepts like ‘transgender woman’ in public discourse in India, low-income, uneducated trans women are led to think that life in the Hijra community is the only way of life open to them. As a result, some of them join the Hijra tradition, restrict their gender expression resulting in experiencing discontent.

Program implications

Educational anti-stigma interventions presenting factual information about diverse gender identities in the Indian context can correct myths, inaccurate stereotypes, and misinformation among the public. It can effectively decrease public stigma—including self-stigma as experienced by transgender individuals—as well as sensitize health professionals, educators, social workers, etcetera on Hijra and transgender identities. Similarly, a gender affirming approach needs to be incorporated into the training curricula for primary mental and allied health care providers. Existing sexual health programs for HIV (e.g., prevention, management) can incorporate transgender mental health literacy as one of its components. Mental health literacy programs specifically targeting this cohort can improve awareness, knowledge, and attitudes toward mental health and illness, and promote help-seeking behavior. Peer support can act as a counterbalance to the discrimination, rejection, and isolation that transgender women and Hijra may encounter while seeking healthcare services. Moreover, community empowerment is an important part of care, especially in the Indian context. A rights-based approach to programs may help in reducing violation of human rights within the transgender community. Although there is increasing awareness of sexual health among this cohort, there is scope for integrating psychosocial interventions and promotion of healthy norms among transgender women and Hijra within existing sexual health programs.

Clinical implications

These findings emphasize the importance of understanding psycho-socio-cultural factors as experienced by transgender women and Hijra. The way gender dysphoria is experienced and how gender incongruence is resolved may differ among those who identify as Hijra, as transgender women, and as persons with diverse transgender identities. Mental health professionals must learn to support transgender women and Hijra in exploring their beliefs, thoughts, and feelings related to gender incongruence, and allow self-determination of gender without imposing notions. Mental health assessments, therefore, should be informed by an understanding of diverse gender identities and community practices. Counseling or therapy (especially gender-affirming therapy) may assist individuals in dealing with distress and/or gender-fluid identities, and identify an individual’s specific needs and desires while deciding gender-affirming health care services (particularly hormone therapy, penectomy, and other irreversible methods of gender affirming medical interventions). For individuals who are undergoing gender-affirming care, counseling can prepare them to adapt to their changing life; transgender support groups can be leveraged for restoring their sexual and gender identity.

Considering the cultural context, Hijra clients may prefer group therapy and insist on the involvement of someone from their adopted family (such as guru, aunt or sister). Therapists need to consider the problems they face in their socio-cultural context (such as issues adjusting with norms, rituals, interpersonal, and group dynamics) and encourage positive norms in their community. There is a need for adapting standard operating procedures for counseling diverse transgender identities within Indian context and for awareness among primary care providers, and specialists toward referral for gender-affirming care (e.g., hormone therapy, hair removal, speech therapy). Application of gender-affirming counseling and psychotherapy practices for transgender individuals in the Indian context need further scholarship.

Limitations and direction for future research

The study was conducted with a small sample size and our participants represented a convenience sample. Hence, the generalizability of the findings is limited. Furthermore, the sample does not represent educated, middle class, English- speaking transgender individuals proportionately. The majority of the sample comprised of transgender women and Hijra from low-socio-economic strata of the society and do not represent experiences of transgender men. Thus, interpretation of this data should be noted within the sample demographics. Researchers have contextualized the research scales, but these were not originally developed for use in an Indian context. Therefore, the scales may be less likely to capture the nuanced experiences of dysphoria in an Indian setting.

The results of this study suggest that not all participants who experienced gender incongruence can resolve it. Thus, future research should identify factors that impede resolving gender incongruence and psychological distress in some Hijra and transgender women. Prospective studies on a similar topic should consider a larger sample size as well as a diverse transgender population. There is also a need to develop scales that better resonate with Indian transgender individuals’ experiences of distress, gender incongruence, and gender dysphoria in a diverse cultural context. At the same time, it is important to ascertain factors that promote gender congruence, ease psychological distress, and facilitate smooth gender transition.

Conclusion

In this study, psychological distress among trans women and Hijra did not show a significant relationship with gender dysphoria or transgender congruence. However, various psycho-socio-cultural factors can cause and heighten psychological distress. These factors ultimately impact trans women’s and Hijra’s lives more negatively than gender identity issues. Although the study had a small sample size, this result backs the recent advances by the World Health Organization in ICD-11 to extract transgender conditions from the Mental and Behavioral Disorders category to a new chapter on Sexual Disorders and Conditions Related to Sexual Health.

Disclosure statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Author’s contribution

Amrita Arvind has conceptualized, coordinated the study, and prepared a draft manuscript. Lekha Amin, Mansi Aggarwal, Dhriti Agrawal, Krishma Tiwari, Saumya Singh, Merina Nemkul, and Pankhuri Agarwal have collected data, also contributed to tool development, and have reviewed the manuscript. Apurvakumar Pandya provided technical guidance, aided in the manuscript writing and ensured that all the elements of the study were reflected in the manuscript. All authors have read and approved the final version.