ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10067-0108 |
Psychiatric Morbidity among Transgender Population: A Study in a Rural Area of Bengaluru
1,2Department of Psychiatry, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India
Corresponding Author: Ume Hani, Department of Psychiatry, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India, Phone: +91 9972959545, e-mail: haani29@gmail.com
How to cite this article: Hani U, Pandiyan K. Psychiatric Morbidity among Transgender Population: A Study in a Rural Area of Bengaluru. Ind J Priv Psychiatry 2022;16(1):10–13.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Aim and objective: To study the psychiatric morbidity among transgender population.
Materials and methods: A cross-sectional study was done using convenience sampling. Sixty consenting transgenders, fulfilling criteria for gender dysphoria based on DSM-5 criteria, were included. The study was done for a period of 18 months.
Tools used: For assessing the sociodemographic profile, semi-structured pro forma was used, and for assessing psychiatric morbidities, Mini International Neuropsychiatric Interview (MINI)-plus scale was used.
Results: Among 60 participants, 36 (76.6%) had psychiatric morbidity, of which 16 (26.7%) had substance-use disorder, 10 (16.7%) among them had alcohol dependence, and 6 (10%) had nonalcoholic substance-use disorders, such as cannabis, benzodiazepines, and cocaine.
Ten (16.7%) participants qualified for the diagnosis of depressive disorder among which six (10%) had mild depression and four (6.7%) had moderate depression. Dysthymia was present in four (6.6%) individuals. Eleven (18.3%) participants had adjustment disorder. Three (5%) of them had anxiety disorder and two (3.3%) had insomnia.
Conclusion: Substance use and depression were found to be the most common psychiatric disorders among this population followed by adjustment disorders.
As this population is at higher risk of developing other psychiatric problems, regular screening and timely intervention are needed to prevent or treat their psychiatric comorbidities.
Clinical significance: The study highlights that there are various psychiatric morbidities prevalent among transgender population, mainly due to the various life adversities they face, which points toward encouraging and creating awareness toward the need for reducing discrimination and accepting the transgender persons in the families, friends, and the community groups which will help them in mainstreaming, achieve welfare, and reduce their psychosocial problems.
The findings of this study may help to inform the development of appropriately targeted and tailored mental health interventions and resilience-building programs for transgender population.
Keywords: Gender dysphoria, Psychiatric morbidity, Transgender.
INTRODUCTION
Gender dysphoria/transgender refers to distress or discomfort that is caused by a discrepancy between a person’s sex assigned at birth and that person’s gender identity (and primary and secondary sex characteristics and/or the associated gender role).
Transgender is defined by the American Psychological Association as “persons whose gender identity, gender behavior or expression does not conform to the sex to which they were assigned at birth.”1
The ICD-10 classifies transgender identity with a code of “transsexualism” under the section of “gender identity disorders” which is under subsection of the “disorders of adult personality and behavior.”
Transsexualism is defined as follows:
A sense of discomfort with one’s anatomic sex and a desire to live and be accepted as a member of the opposite sex. To make one’s body as congruent as possible with one’s preferred sex, they wish to have surgery and hormonal treatment.2
In the Census of 2011 collected in India, the transgender population was estimated to be consisting of about 4.88 lakh adults and 54,845 children.3
Accessing health care is a fundamental human right that is regularly and often denied to transgender and gender nonconforming people.
They usually have a very high tendency of postponing medical care when injured or sick. This may be due to refusal of care, discrimination or inability to afford it, violence, harassment, and lack of provider knowledge about transgenders. Resulting in marking the transgender population as high-risk to various physical and psychiatric morbidities.4
Though data are sparse, review of literature regarding people with gender dysphoria shows higher rates of psychological problems and psychiatric disorders, such as negative self-image, low self-esteem, adjustment disorders, depression, personality disorders, and suicidality compared to normal controls.5
MATERIALS AND METHODS
A cross-sectional, observational study was conducted after obtaining institutional ethical committee approval. Sixty participants who fulfilled the criteria of gender dysphoria according to diagnostic and statistical manual of mental disorders, fifth edition (DSM-5),6 were included for the study. All consenting transgenders aged between 18 and 50 years were interviewed at their locality. The sampling technique used was convenience sampling. Those having significant neurological diseases or any comorbid medical illness interfering with the interview process were excluded along with nonconsenting individuals. Each transgender was interviewed individually, after written informed consent. For assessing the sociodemographic profile, semi-structured pro forma was used, and for assessing psychiatric morbidities, mini international neuropsychiatric interview (MINI)-plus scale was used.7
It is a brief structured interview for assessing major axis one psychiatric disorders, which has an acceptably high validation and reliability scores.
Data were analyzed using SPSS software v.23 (IBM Statistics, Chicago, USA) and Microsoft Office 2007. Fisher’s exact test was used to determine the significance of differences.
RESULTS
The study included 60 transgender individuals: 33 (55%) participants were in the age-group of 18–30 years. Majority, i.e., 44 (73.3%), belonged to Hindu religion. Thirty-eight (63.3%) had successfully completed high school. Forty-five (75%) were unemployed. Forty-eight (80%) were unmarried. Thirty-nine (65%) participants belonged to lower socioeconomic status (Table 1).
| Characteristic | No. of cases | Percentage |
|---|---|---|
| Age (years) | ||
| 18–30 | 33 | 55 |
| 31–40 | 14 | 23.3 |
| 41–50 | 13 | 21.7 |
| Religion | ||
| Hindus | 44 | 73.3 |
| Muslims | 6 | 10 |
| Christians | 10 | 16.7 |
| Education | ||
| Illiterates | 5 | 8.3 |
| Primary school | 10 | 16.7 |
| High school | 38 | 63.3 |
| Bachelor’s degree | 7 | 11.7 |
| Marital status | ||
| Unmarried | 48 | 80 |
| Married | 1 | 1.7 |
| Separated | 8 | 13.3 |
| Divorced | 3 | 5 |
| Employment status | ||
| Unemployed | 45 | 75 |
| Employed | 15 | 25 |
| Socioeconomic status | ||
| Lower middle | 4 | 6.7 |
| Upper Lower | 17 | 28.3 |
| Lower | 39 | 65 |
Among 60 participants, 46 (76.6%) had psychiatric morbidity and 14 (23.3%) did not have any psychiatric illness. Out of the 46, 16 (26.7%) had substance-use disorder, 10 (16.7%) among them had alcohol dependence, and 6 (10%) had nonalcoholic substance-use disorders, such as cannabis, benzodiazepines, and cocaine.
Ten (16.7%) participants qualified for the diagnosis of depressive disorder among which six (10%) had mild depression and four (6.7%) had moderate depression. Dysthymia was present in four (6.7%) individuals. Eleven (18.3%) participants had adjustment disorder. Three (5%) of them had anxiety disorder, and two (3.3%) had insomnia (Table 2).
| Psychiatric disorders | No. of cases | Percentage |
|---|---|---|
| Nil psychiatry | 14 | 23.3 |
| Substance-use disorder | 16 | 26.7 |
| Depressive episode | 10 | 16.7 |
| Mild depressive episode | 6 | 10 |
| Moderate depressive episode | 4 | 6.7 |
| Dysthymia | 4 | 6.7 |
| Anxiety disorder | 3 | 5.0 |
| Adjustment disorder | 11 | 18.3 |
| Insomnia | 2 | 3.3 |
DISCUSSION
A study done by Bariola et al.8 reported that about 46.0% reported high or very high levels of psychological distress, and this distress was significantly greater with younger age.
A study done by Cheung et al.9 found that the median age at initial presentation of transgenders having psychiatric morbidity was 27 years. This study also found that around 32.9% of transgenders were unemployed.
Low socioeconomic status was established as a determinant of psychological distress in this group by Fredriksen-Goldsen et al.10 and Grant et al.11 reported that the income among the study population was on the lower side.
Our study found that about 55% of the participants were between the age of 18 and 35 years among which 40% of the participants had psychiatric morbidity. Our study population about 75% were unemployed. Various reasons for increased unemployment among this population exists: discrimination, sexual and physical abuse, stigma at workplace, lack of qualification due to low education status, fear of being embarrassed about their identity crisis, and experienced an adverse job outcome, such as being fired, not hired, or denied a promotion because of being transgender. Our study found that about 65% of individuals belonged to lower socioeconomic status. Many of the transgenders end up in the slash of lower socioeconomic bar; even though they have the potential, they are not accepted or offered jobs; lack of family support and lack of financial sources contribute to stress; and these difficulties have led them to often depend on others for their livelihood which makes them vulnerable for exploitation.
A study done by Hebbar et al.12 found 31.2% were suffering from depressive disorder and generalized anxiety disorder (GAD) about 37.5%. Our study found 16.6% to have depressive disorder and 5% had anxiety disorders, and the low prevalence in our study maybe secondary to stigma associated with being labeled to have psychiatric illness. Dysthymia was found to be less in our study 6.6% as compared to a study by Hebbar et al. which reported 7%.
However, our study found higher prevalence of adjustment disorders to be around 18.3% as compared to Hoshiai et al.13 which was 6.7%.
Various problems, such as a long history of suppression of transgender feelings, may result in isolation, loneliness, and feelings of hopelessness; the fear of disclosing this secret to partners, family, friends, and co-workers—risking rejection and employment discrimination—can provoke a great deal of adjustment difficulties among this population.
Reisner et al.14 found 20.6% of transgender youth to have depression. 26.7% were diagnosed to have anxiety. 11.1% had attempted on their lives.
Our study did not find any prevalence of suicidal ideation or attempted suicide in the study population, reasons being they using different defense mechanism to combat their difficulties or simply would have accepted the harshness of their life situations. Good peer support from other transgender individuals belonging to their community may be another reason for no prevalent suicide among this rural population.
Another study in 2016 by Reisner et al.15 found of the 298 transgender, 41.5% of participants mental health issue or substance dependence diagnoses; 11.2% were alcohol-dependent; and nonalcohol psychoactive substance use dependence were around 15.2%. Our study found substance use in 26.7% and alcohol use among 16.6 % and nonalcoholic substances among 10%. The prevalence of alcohol use was higher in our study compared to this study, but, however, nonalcoholic substance use was high in Reisner et al. than our study. The causes may be due to easy availability of alcohol and cheaper than other drugs in rural areas. The financial status also contributes to having difficulty in purchasing nonalcoholic substances, such as cocaine and cannabis. They use drugs or alcohol in a vague attempt to cope with their transgender feelings, mental health issues, memories of physical or sexual abuse or assault, painful situations relating to socioeconomic concerns, or stress related to work. Other reasons to use alcohol or drugs are to facilitate social and sexual interactions or due to peer pressure.
CONCLUSION
This study reports about 76.6% of the study population had psychiatric morbidity. Substance-use disorders, adjustment disorders, and depression were found to be the most common psychiatric disorders among this population according to our study.
As this population is at higher risk of developing other psychiatric problems, regular screening and timely intervention are needed to prevent or treat their psychiatric comorbidities.
Limitations
Our study had various limitations, to begin with we had a small sample size.
Our study was a cross-sectional observational study, which limited further follow-up and identifying psychiatric disorders which did not come forth in one single interview.
Transgender individuals who are in the process of undergoing gender reconstruction or hormonal therapy and those who have already undergone gender reconstruction or hormonal therapy were not distinguished between. Whether the prevalence of psychiatric disorders was due to hormone imbalance was not assessed.
Clinical Significance
The study highlights that there are various psychiatric morbidities prevalent among transgender population, mainly due to the various life adversities they face, which points toward encouraging and creating awareness toward the need for reducing discrimination and accepting the transgender persons in the families, friends, and the community groups which will help them in mainstreaming, achieve welfare, and reduce their psychosocial problems.
The findings of this study may help to inform the development of appropriately targeted and tailored mental health interventions and resilience-building programs for transgender population.
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