Religious experiences of Iranian transgenders: A qualitative study.

BACKGROUND: Gender identity disorder and its treatment with sex reassignment surgery is a profound experience, which can affect the mental, interpersonal, social and religious aspects of one's life.
METHODS: This was a qualitative content analysis study focusing on the various dimensions of the experiences of seven patients suffering from gender identity disorder in a female-to-male subgroup. This study presents a report concerning the religious aspects of their experience.
RESULTS: The findings of this study were categorized into the four following conceptual categories: sense of guilt; accomplishing a sense of submission to God's will as well as God's pleasing; practical commitment to religion; and rejection by the religious communities.
CONCLUSION: Diminishing religion to spirituality comprised the core experiences of these patients having intimate relations with such concepts as secularism, stigma, and technocracy.

Introduction

Transsexuals face fundamental challenges (1). Religion is one of the important aspects of this experience. Transsexuality has a different trend in Iran where different social factors are at work (2).

Religious experiences engage different issues in a country like Iran, with a religious context. Issues including meaning of sex appeal to the (biologically) same sex, type of cover and veil, form of worshipping rites, location separation of men and women along with a higher valuation for men are important in this context.

The formal religious interpretations in Iran have a supportive role, comparing the same sex intercourse. Se x reassignment surgery was legalized in Iran in 1980 following the fatwa of Imam Khomeini (3). However, no qualitative study has been conducted on the religious experiences of these patients in Iran. The aim of this study was to attempt to understand the deep and sophisticated, culturally differentiated aspects of this phenomenon in this society.

Methods

This was a qualitative content analysis study. This method was selected due to the lack of knowledge on the subject of transgender as the specific research topic of the religious experience after the surgery in Iran. This method provides an opportunity for the participants to freely speak of their unique experiences and express the hidden aspects of their thoughts and feelings (4).

Participants and Procedure

In this study, a group of transsexuals was considered who had submitted their request for evaluation and obtained SRS permission of Tehran Psychiatric Institute and the forensics; they also passed the required psychotherapy period, experiments and medical commission and succeeded in receiving the permission. They had already passed the stages of cross-sex clothing, hormone therapy and had already started reassignment surgery, but they were in different stages. No specific period was set between the surgery and the interview. However, it was attempted to select the individuals who were more heterogeneous from this respect and other significant aspects (5).

Data Collection

As the rehabilitation Unit of Tehran Psychiatric Institute was continuously in contact with these patients, we asked them to contact the patients and ask them to participate in this study to express their experiences and concerns and problems. Those individuals, who were primarily called, were expected to be most cooperative. As the social worker of the institute stated, these individuals were mostly from the female-to-male groups; the study was restricted to this group.

The first individual who was invited for an interview was the one who was in contact with most of the patients and had continuously assisted and supported them and announced his cooperation with this study in attracting the cooperation of the others. Nevertheless, selection was done according to the patients register list. Finally, eight individuals participated in the interviews. One of the interviews was incomplete as the interviewee did not cooperate, and no other interview was arranged in the study because we found that the patient had bipolar disease. As a result, this study was a summary of the information of seven individuals.

The table 1 demonstrates the demographic characteristics of the participants.

Table 1

Demographic Characteristics of Participants (N = 7)

Participant	Age	Education	Date of Surgery	Conducted Surgeries
R.R.	29	M.Sc. in civil engineering	2007	Breast discharge and ovariohysterectomy
M.P.	28	M.Sc. in physical education	2012	Breast discharge and ovariohysterectomy/ metoidioplasty
A.D.	22	B.Sc. student in physical education	2013	Breast discharge and ovariohysterectomy
Y.J.	26	B.Sc. in civil engineering	2009	Breast discharge and ovariohysterectomy
Sh.B.	29	M.Sc. student in sociology	2011	Breast discharge and ovariohysterectomy/first stage of metoidioplasty
A.E.	22	High school diploma	2011	Breast discharge and ovariohysterectomy/ metoidioplasty
A.Sh.	23	High school diploma	2012	Breast discharge and ovariohysterectomy/ metoidioplasty

Data Analysis

In this study, in-depth interviews were conducted to attain the experiences of the participants. Based on the consensus of the interviewers, a list of questions was prepared before the interview. These questions were arranged under the topics of gender identity, sexual relations, marriage, having a child, and religious experience. This study reports the findings concerning the last topic: Religious experience.

The interviews included individualized questions, which were asked uniquely in each interview to reach a concept closer to what the interviewee was trying to express. To attain trustworthiness, Guba's criteria were employed including credibility, transferability, dependability and confirmability (6).

The study lasted until the context was clear and the categories and sub-categories were identified. In each interview, the interviewer, using the MAX QDA 10 software, implemented open coding. Two advisors evaluated the extracted codes separately and discussed the analysis and initial conceptualization. Important remarks were recorded in the Memo section in the software and in a paper. The initial concepts and categories were collected and concluded after four interviews. A discussion was held about the concepts and categories. Considering the temporariness and tentativeness of the concepts, three other interviews were conducted, codified, and discussed using the same method. Finally, data were saturated based on the group opinion. The interviews were terminated, and consensus was reached on the final summary of the extracted concepts. To define the findings, samples from participants’ dialogues were extracted from the text and presented against the codes (7).

Results

The findings of this study were categorized into four categories: Sense of guilt; accomplishing a sense of submission to God’s will and pleasing; practical commitment to religion; and rejection of the religious community.

The first category, sense of guilt, included the following subcategories: Sense of guilt from the sexual relation, sense of guilt from the sex change surgery, sense of guilt from masturbation. Second category, reaching to submission to God’s will and pleasing, included the following subcategories: Surrender to fate, surrender to anger before the sex change, feeling God’s support during sex reassignment stages, reaching a friendly relation with God, becoming closer to God, transsexualism as a sign of a miracle, the possibility of real and sincere pilgrimage only after the sex change. The subcategories of practical commitment to religion were as follows: No bond to the veil before the operation (“hijab”) despite commitment; having no bond to the conventional cover at the presence of the opposite sex before the operation; avoidance from biologic same sexes due to elusion from the possible sin; avoidance from obligatory usage of chador as a womanly cover before operation; internal and external religious ambivalence in conjunction with internal ambivalence about the identity; and the test of achieving virile identity by wearing the veil. The last category included the following subcategories: Rejection by religious authorities, rejection of the desired gender identity by the family due to piety.

Discussion

Overall, in this study, the participants’ experiences about their sex change led them to move to some degree from religion to spirituality. Before the surgery, commitment to religion was based on the perceived identity not the biological identity; and after sex reassignment, which could be considered a trauma, they found a profounder and closer belief in God. Stigma imposed by the religious community on the one hand and the need for a superior power to protect them against the gap in their identity on the other hand helped the participants maintain a spiritual faith rather than commitment to religion.

Transgenders’ religious and spiritual experiences could be examined from two aspects: First, the origin of gender identity disorder is sexuality concept and sexual orientation. Thus, they may be categorized in the group of sexual minorities (homosexuals, bisexuals, and in total LGBTs or queers) and may inquire the religious experiences of these people. Nevertheless, due to the burden of stigma and interpersonal social conflicts, it can be compared to such diseases as AIDS.

The testimonies of the application of religion as a protector for the health in general and mental health in particular have been shown in different studies. Nonetheless, those studies reflect that religion functions in a more complicated and paradoxical manner among the sexual minorities such as homosexuals and transsexuals. Several studies such as that of Hatzenbuehler revealed that religious beliefs enhanced healthy behaviors and decreased risky ones in these groups even more than the effect it exerted in the group of heterosexuals. Nonetheless, other studies revealed that sexual minorities (the study was mainly on homosexuals), who were raised in religious families had a more severe sense of guilt and probability of suicide. This fact was more evident in younger ages and especially in adolescents (8).

Rejection by religious communities was experienced by our participants especially those who had more intimate relations with the institutions associated with religion. So far, this experience has been studied in the sexual minorities in Christian societies.

A substantial number of studies have been conducted on the view of Islamic religious institutions on the issue of transsexualism and sex reassignment surgery. The studies conducted by religious sociologists revealed that some Islamic cults, the Islamic society in general, are facing homosexuality among men with more overlooking attitude than heterosexuality (no article was found on homosexuality, which had a closer association with the topic at hand among women). In a study by Assad Abukhalil, it was found that the fact of religious authorities tackling homosexuality through Islamic penal codes and aggression toward pious people arises from the Christian tradition, not the Islamic one (9). Still, the official Islamic authorities, at least in some countries such as Iran, have taken a supportive position on gender identity disorder and surgical operation. The fatwa (religious order) of Imam Khomeini in which he permitted surgery for sex reassignment and the associated medical measures was a testimony to this contention. The comprehensive study of Mohd Shuhaimi Bin Haji Ishak in Malaysia verifies this status of religion (10).

In a qualitative study conducted in Turkey as a secular country and a country with a Muslim society and traditional family structure concerning gender identity disorder, stigma, insult, and isolation from the family and friends were reported. This condition is commingled with the social values of this secular society. In another study, the negative feelings from the families of male-to-female subgroups were higher compared to the families of the subgroup, which was ascribed to the higher social valuation of boys with respect to the girls in the society (11).

Distancing from practical commitment, but replacing it with the sense of submission to God’s will were two core concepts in our results. Studies in the field of social sciences demonstrate that sexual minorities show various reactions and choose different strategies against rejection and stigmata by the religious communities. Andrew K.T. Yip, an author who has conducted a specialized research into the spiritual and religious experiences of the sexual minorities, reports the strategies as follows (12):

Concealing perceived gender for fear of stigmatization‏

Discard religion totally to reduce psychological distress

Avoiding practicing their sexuality through, among others, and seeking spiritual assistance from the groups who better accept their sexual alteration‏

Distancing from religious communities but still keeping a personalized religious faith, trying to minimize stigmatization

Remaining in religious communities of the people, despite the sense of stigmatization, with the hope of reaching positive change from inside

In our study, it was observed that the experience of maintaining spirituality with the cost of fading away from the practical commitment to religion was prioritized. In summary, more spirituality and less religion, which has a closer relation with the fourth strategy, was observed. It seems that the perceived stigma is so overwhelming that they need to rely on a source of universal power to reject the practical commitment.

Another considerable finding in this study, parallel the formers, is reaching for the sense of submission to the God’s will. Sex reassignment surgery is perceived as a process, which in sum leads to the elimination of intermediary and having a closer and more sincere and even a friendly relation with God. The intermediaries mentioned in this study are the sources of emulation (denial of the need for asking questions), religious rites (prayers and pilgrimage), and female organs (breasts). Former studies may explain how and why for this process.

In a qualitative study, the role of inner homophobia in the formation of belief in God independent of the religion and church was mentioned (13). This is a finding, which Miller has also mentioned: the homosexuals take advantage of religious, spiritual, and cultural abilities to resist against the internalized homophobia (14).

The phrase “spiritual but not religious” (SBNR) is referred to a spectrum of beliefs and behaviors along with varying intensity in which the belief to the superior power of the universe is maintained, but the connection to and obeisance from a religious institution as an authoritative source is abandoned (15,16). Woods believes that the ones who are committed to the religion believe in a judgment-central God, whereas the spirituality offers loving aspects, forgiving, and non- judgmental (17).

The spiritual but not religious view is also criticized by other authors like James Martin, who considered the denial of connectedness to a religious institution as a type of rejection of the collective wisdom (18). The defect in the person’s identity is beyond the defect in the gender identity, which verifies Martin’s theory. An individual with low self-confidence and a gap in his/her identity needs a metaphysical power to rely on. In as much as the experience of rejection by religious communities and religion authorities is perceived concurrently, the individual resorts to build spirituality free of religion for him/herself.

The relation between being religious and reaching a higher level of psychological-social performance was investigated in a qualitative study (19). In this study, the two folded effect of religion in sexual minorities were examined; religion was considered as a developmental asset on the one hand and as a source of risk on the other. This study as a testimony to this view cites various groups of studies in this category:

Higher self-esteem was observed in the group of churchgoers

Religious commitment can be a reflection of the degree of stress experienced by the person who is a member of a sexual minority‏.

According to this study, the themes related to reaching a positive and negative social-psychological performance resulting from growing in a religious context in sexual minority groups were extracted as follows: “feeling of inadequacy, religious-related guilt, depressive symptoms, and social strains associated with negative outcome, among which the last one had the most significant role”. The extracted themes associated with positive results were as follows:” increased sense of self, acceptance of others, incorporation of religious values and social support” (19‏).

The sense of guilt, which was clearly observed in a sexual desire towards a person of the same sex, was diminished by acquiring the opposite gender identity and finding a proper justification.

Conclusion

Diminishing religion to spirituality is similar to considering religion only in the personal level not in the scale of a social structure concordant with the secular view to the religion which allows the belief to God only in the personal life. The experience of sex reassignment surgery, both because of a gap in the person’s identity beyond the gender identity and as a trauma in the person’s life, is generally in conjunction with the secularization of the religion. It seems that one of the justifications for the expansion of this viewpoint is the technocratic view on the human beings.

The delineation of these processes from the social and cultural perspectives, in parallel with anthropological and religious aspects, can pave the way to a deeper understanding of view of the present-day human to their relation with the creator and their origin and resurrection, assisting them to achieve spiritual growth and mental health.

Table 2

Question List Used in Interviews

What problems did you have with religious matters after sex change with respect to religious practice?
What is your experience concerning the veil and having contact with an outsider “namahram”?
How did you resolve your problems?
Which doubts or senses of guilt did you feel concerning sexual relations?
How did you feel when you entered religious institutions such as mosques?
What do you think of God? How do you see God?
Practical commitment to religion	Having no bond to veil(“hijab”) despite commitment before the operation	-
	Having no bond to the conventional cover in front of the opposite sex before the operation	-
	Avoidance from biologic same sexes due to elusion from the possible sin	-
	Avoidance from obligatory usage of chador as a womanly cover before operation	-
	Rejection by religious communities	Internal and external religious ambivalence in conjunction with solidarity or no solidarity inside the oneself
The test of achieving virile identity by maintaining the veil by women		-
Rejection by religious authorities		-
Rejection of the desired gender identity by the family due to piety		-

Table 3

Extracted Categories

Category	Subcategories	Participant’s quotations
The sense of guilt	Sense of guilt from the sexual relation	-
	Sense of guilt from the sex change surgery	-
	Sense of guilt from masturbation Surrender to fate	-
Reaching to submission to God’s will and pleasing		R.R.: “It may be something you don’t really want, by you will see later that it would become something you wouldn’t want it by heart. This is why I do not take a vow so that something I want happens”M.P.: “…some people don’t believe in fate and kismet, find it ridiculous; but I say that Faezeh was a part of your life puzzle; she should have come and maybe gone. She came so your works sped up. Faezeh was the reason my work was done earlier.A.D.: “The works of God are all wisdom. The fact that I’m a TS is a result of wisdom or kismet. I strongly believe it…”
	Surrender to anger before the sex change	-
	Feeling the God’s support during sex reassignment stages	-
	Reaching to a friendly relation with God	M.P.: “I say: O God well done! You’re so wonderful. It like he has been my friend who is seven, or eight, or five, or six or twenty five year-old.”
	Becoming closer to God	A.D.: “It’s really like I’ve got closer to God, when my breasts were removed (he puts his hand on his chest), I got closer to him, got much closer to God…the voice of heart…I touch it; I hear it; I become calmer. I got far closer to God. I feel him more, love him more..”
	Transsexualism as a sign of the miracle of God	-
	The possibility of real and sincere pilgrimage only after the sex change	-