An Observational Study of the Quality of Life Among Gender Incongruent Individuals From "Hijra" Community of India.

BACKGROUND: The term "hijra" is used to describe eunuchs, intersex, and gender incongruent individuals from hijra community people in the Indian subcontinent. Various adversities, violence, and discrimination experienced by many of them might have adverse consequences on their quality of life (QOL). The present study was conducted to assess the QOL among adult gender incongruent individuals from the hijra community.
METHODS: Data of thirty-seven hijra enrolled in the Endocrine outpatient clinic (hijra group) and thirty-seven healthy employees of the hospital (control group) were analyzed with regard to QOL. QOL was assessed by using the physical and mental health Short Form-36 (SF-36) health survey questionnaire. Results on continuous measurements were presented as mean ± SD and results on categorical measurements were presented in number and percent. Mann-Whitney U test or Student t-test was used to find the significance of study parameters between the two groups according to the data distribution.
RESULTS: In the domain namely role limitation due to emotional problem, the hijra cohort had a statistically significantly lower score (66.4 ± 20.2) versus the control cohort (83.4 ± 23.7), P = 0.002. No difference was observed between two groups with regards to other QOL domains namely general health perception, physical functioning, role limitation due to physical problem, bodily pain, general mental health, social functioning, and vitality.
CONCLUSIONS: QOL of the gender incongruent individuals from the hijra community included in this study and the control group comprising of hospital employees were almost similar, though the former had reported lower levels of emotional health issues than the latter. Copyright:

Glossary

Cisgender: Denoting to a person whose sense of personal gender identity corresponds with their assigned birth sex.

Gender identity: Internal sense of being male or female or identifying with both or neither.

Intersex or DSD (disorder of sexual differentiation): Denoting to a person born with reproductive or sexual anatomy that does not fit typical definitions of female or male.

Transfeminine: Denoting to a transgender person who were assigned male at birth, but identify with femininity to a greater extent than with masculinity.

Transmasculine: Denoting to a transgender person who were assigned female at birth, but identify with masculinity to a greater extent than with femininity.

Transgender: Denoting to a person whose sense of personal gender identity does not correspond with the assigned birth sex.

INTRODUCTION

Gender incongruence (the incongruence between assigned gender and expressed or experienced gender) is associated with social stigma in our country.[1] It may be observed amongst apparently normal individuals, amongst individuals suffering from a disorder of sexual differentiation (DSD), and also amongst some individuals known as “hijra". Most of the hijra are gender incongruent individuals. Hijra has great traditional significance in India. As per the last census in 2011, there are about 5 lakh transgender individuals in India, which is most likely an underestimation. Despite their long-standing presence, the social circumstances faced by them to date, are quite deplorable and they live as a disadvantaged minority.[2] They are found living along the fringes of society and the term “hijra” by which they are labeled, is considered derogatory in the societal perspective.[3] A traditional and ritual adoption process is the gateway into the community. The societal acceptance as well as an outlook towards the hijra have been very different in India and is in stark contrast to that seen in the western world. They face discrimination in education, health, housing, employment, and bureaucratic dealings.[45] As they face discrimination in employment, they generate income from petty extortion, performing at ceremonies, begging, or working as sex-workers.[6] In general, most Indians consider hijra to be sex workers and they face discrimination and are subject to physical, verbal, and sexual abuse since their teenage years.[7] Among the numerous issues faced by transgender people, harassment, perceived discrimination, verbal and physical abuse, and perceived healthcare discrimination still remain important challenges in the western world also.[8] Many of them experience abuse since childhood and also through the rest of their life.[7] Accordingly, these might have adverse consequences on their quality of life (QOL). The QOL among the hijra community of India is understudied and in this context the present study was conducted to fill this knowledge gap by analyzing self-rated health and overall quality of life among gender incongruent individuals from the hijra community of India. The term “hijra” is used as both plural and singular in this article.

SUBJECTS AND METHODS

Study participants

This was a retrospective case-control study and the case group (hijra cohort) comprised participants from the hijra community who were enrolled in the Endocrine outpatient department of a tertiary care hospital at Kolkata as gender incongruent individuals seeking gender reaffirmation as female. The diagnosis of gender incongruence was reconfirmed using The Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR) criteria. From June 2018 to December 2019, gender incongruent patients coming from the hijra community were automatically enrolled in the study. Individuals were excluded from the study if they had an inability to respond to, or an unwillingness to participate in the study or were suffering from severe psychiatric disorders or any limiting chronic disease or DSD. Thirty-seven gender incongruent individuals from the hijra community (hijra cohort) were compared to a control group (control cohort) of 37 apparently healthy volunteer employees of the hospital.

Data collection

After obtaining written informed consent from all the voluntary participants, a detailed history regarding the socio-demographic data was routinely recorded using a semi-structured format. The following variables were acquired by an interview and a self-administered questionnaire regarding age, gender, educational level, and relationship status. All 74 individuals (37 cases and 37 controls) were interviewed face to face in the local language (Bengali) by a trained person using a health survey questionnaire. The data was processed and analyzed by an authorized person and was anonymized and deidentified before analysis.

Main outcome measures

To measure QOL of the case group and the control group, we used the validated version of the self-reported physical and mental health Short Form-36 (SF-36) health survey questionnaire.[9] This questionnaire has 36 independent questions and cover eight domains: general health perceptions (determines the overall sense of well-being), physical functions (evaluates the presence and severity of limitations to physical activities), role limitations due to physical health problems (assesses the limitations to work or other daily activities), role limitations due to emotional problems (assesses the impact of emotional problems in performing daily activities), pain (determines the impact of pain in daily activities), general mental health (evaluates the presence or severity of mental health indicators: like anxiety and depression), social functioning (measures the impact of health in engaging in social activities), and vitality (evaluates the influence of health on energy level and fatigue).

Statistical methods

Descriptive statistical analysis was carried out with Statistical Analysis System (SAS, version 9.2 for Windows, SAS Institute Inc. Cary, NC, USA) and Statistical Package for Social Sciences (SPSS Complex Samples, Version 21.0 for Windows, SPSS, Inc., Chicago, IL, USA). Microsoft Word and Excel were used to generate graphs and tables. Results on continuous measurements were presented as mean ± SD and results on categorical measurements were presented in number percent (%). Significance was assessed at a level of 5%.

The following assumptions were made of the data:

1) Cases of the samples were independent.

2) he populations from which the samples were drawn had the same variance (or standard deviation) and

3) The samples drawn from different populations were random.

The normality of data was tested by the Anderson Darling test, Shapiro–Wilk, Kolmogorov–Smirnoff test, and visually by QQ plot. Mann–Whitney U test or Student t-test was used to find the significance of study parameters between the two groups (hijra and control group) according to the data distribution.

RESULTS

A total of 37 gender incongruent individuals from hijra community (hijra cohort) and 37 apparently healthy employees (control cohort) of the hospital were enrolled in the study. The mean age of the control group was 25.25 years and that of the hijra group was 26.77 years. Age, gender, educational level (post-graduate/professional, graduate, high-school, secondary-school, class eight standards, literate or illiterate), and relationship status (married, unmarried-single or unmarried in relationship) of both the group are shown in Table 1. Out of the 37 control cohort, 40.54% were straight heterosexual male and 59.45% were straight heterosexual female. The study population of the hijra cohort was gender incongruent individuals from hijra community. The education level of control group was much better compared to hijra group. The study population of the hijra cohort was either unmarried or unmarried in relation.

Table 1

Demography, Education,and Relationship status for Control Cohort and Hijra Cohort

Demography	Control Cohort (n=37)	Hijra Cohort (n=37)
Age (average)	25.25±5.92	26.77±4.12
Gender
Male	15 (40.54%)	0
Female	22 (59.45%)	0
Gender incongruent individuals from hijra community	0	37 (100%)
Education
Postgraduate/Professional	5 (13.51%)	4 (10.81%)
Graduate	20 (54.05%)	8 (21.62%)
High-school	7 (18.91%)	11 (29.72%)
Secondary-school	1 (2.20%)	4 (10.81%)
Class 8	1 (2.20%)	4 (10.81%)
Literate	2 (5.40%)	5 (13.51%)
Illiterate	1 (2.20%)	1 (2.70%)
Relationship status
Married	28 (75.67%)	0
Unmarried, Single	9 (24.32%)	12 (32.43%)
Unmarried in relation	0	25 (67.57%)

Perceived QOL characteristics of the 37 gender incongruent individuals from hijra community and 37 controls are shown in Table 2. Both hijra cohort and control cohort, rated their QOL equal in the dimensions of general health perceptions, physical function, role limitations due to physical health problems, pain, general mental health, social functioning, and vitality. The domain of role limitation due to emotional problems deals with the aspects of emotional health issues interfering with routine activities as experienced by both the groups. Hijra cohort rated their emotional health problems less than the control group (P value 0.003).

Table 2

Crude means and standard deviations for the SF-36 domains for control cohort and hijra cohort

QOL Domains	Mean±SD		P
	Control Cohort (n=37)	Hijra Cohort (n=37)
General Health perception	69.3±27.2	70.96±20.2	0.671
Physical Functioning	86.1±19.8	89.8±14.3	0.799
Role Limitation due to physical problem	79.1±26.5	79.12±28.6	0.836
Role limitation due to emotional problem	83.4±23.7	66.4±20.2	0.002
Bodily Pain	74.8±26.2	73.8±28.9	0.902
General Mental Health	72.9±20.1	75.6±21.7	0.702
Social Functioning	81.1±30.12	80.3±28.3	0.392
Vitality	54.3±22.9	56.1±21.5	0.837

DISCUSSION

Transgender people face considerable challenges in their life. Challenges can be physiological (development of secondary sexual characteristics), social (rejection, discrimination, victimization, transphobia), and psychological (anxiety, depression, low self-esteem). These challenges have a profound negative impact on QOL. A systematic review and meta-analysis, looking at the different dimensions of QOL, suggest that treatment-seeking gender incongruent people display poorer QOL than the general population, independent of the QOL domain investigated.[9] QOL is a complex concept and can be described in different ways and can be considered as a way of quantifying the level of functioning and perceived wellbeing of people's lives.[10] The QOL should be assessed based on different physical and psychosocial domains. SF-36 health survey questionnaire[11] (a shortened version of a battery of 149 health status questions) as a measure of patient outcome, seems acceptable to the patients, internally consistent, and a valid measure of the health status.[12] The SF36 health survey questionnaire is often used to measure the QOL of transgender people,[1314] and this questionnaire is used in this study also.

Most of the studies showed that the QOL of transgenders is lower in the physical function subscale.[1516] A systematic meta-analysis of the studies on QOL in transgender people, found poorer QOL than the general population, particularly before the gender-affirming treatments.[9] However, there is a significant difference between transmasculine and transfeminine individuals in mental health outcomes.[16] Keeping in the background the cultural preference and the desire to have male children by most of the parents of India, males who seek to change gender have poor family and community acceptance. Not only mental health but all dimensions of the QOL get affected because of this lack in family and social support. Most of the studies carried out in different parts of the world show a similar trend and lower QOL in MTF (male to female) compared to FTM (female to male) transgender.[161718]

We have a cohort of gender incongruent individuals seeking gender reaffirmation as female (hijra cohort) in this study, and they are at different stages of the treatment protocol in our institute. The gender incongruent individuals from hijra community of our study cohort reported similar QOL in most of the dimensions (general health perceptions, physical functions, role limitations due to physical health problems, pain, general mental health, social functioning, and vitality) compared to the control group (Table 2- P values were not significant). Unexpectedly, the hijra group reported less emotional health problems (P-value 0.002). These people, usually were shunned by their families in their early adulthood, and they left their homes and moved to a new location to live with the hijra community, as members of a rundown section of the society. They were given new names and new identities in the community. A sense of isolation drove them towards the hijra community, as an association of like-minded souls. They forgot their past and accustomed themselves to the course of hijra life and emerged with a new name and a new gender role. Hijra have a recorded history in the Indian subcontinent from antiquity onwards and have served as a traditional support group since then, in sharp contrast to the professional modern support group system of western countries formed in the last few decades only.

Gender affirming treatments (long-term hormone therapy, upper and lower sex reassignment surgical interventions) in transgenders are associated with improvement in QOL and improvement in a sense of general health.[91417] However, all hijra in the study population were in the nascent stages of the gender-affirming process. Age, better educational status, better socio-economic status, obtaining jobs, presence of family, and community support have a positive correlation to the overall state of the physical and mental health in the transgenders. Nevertheless, family and social support are a very important aspect affecting the transgender QOL.[192021]

The human rights of lesbian, gay, bisexual, and transgender people (LGBT) are coming into sharper focus around the world, with advances in the adoption of new legal protections. In April 2014, the Supreme Court of India (NALSA judgment) granted legal recognition of the third gender and upheld the fundamental rights (the right of equality and equal protection) of the LGBT community as is guaranteed in Articles 14 and 21 of the Indian Constitution.[22] Since the judgment laid the framework for better protection from discrimination based on gender identity, the Government's approach on LGBT has evolved considerably. Now, the Government has directed to provide medical care to transgender people in the hospitals, planned to include the community in various social welfare schemes, promoted the creation of jobs in Indian companies, and are taking steps to create public awareness about the LGBT community, so that these people from weaker sections of the society, feel that they are also a part and parcel of normal societal structure. All these measures have a positive impact on the Hijra community and are possibly reflected in QOL assessment process.

Limitations

Although this study reveals several results that served towards the goal of a better understanding of the hijra community of India, it has some limitations also. The study is a case-control model and is limited in its ability to elucidate causal relationships. The study exclusively included gender incongruent individuals from the hijra community who were seeking medical help for their gender incongruence and hence did not include the hijra who could not access medical interventions but form a large majority within the class. Socio-economic status, which can be scored on the basis of occupation, education, and income (Kuppuswamy scale) has a significant effect on QOL. As these confounding factors weree not considered for QOL assessment, it remains a major limitation of this study. The relatively small sample size in this study is also a potential limitation. A large sample should, therefore, be analyzed before reaching the conclusion. The control group in this study was recruited from volunteers among the employees of our hospital and not from the community. In particular, the control group was not matched in socio-demographic characteristics, although we tried to match in age. Hence, our data cannot be generalized to the large hijra community of India.

CONCLUSION

QOL of gender incongruent individuals from the hijra community are similar to the present control group in all dimensions but is better with regards to emotional health issues. This can be partially to the recent legislation passed and social upliftment measures adopted by the Indian Government in favor of the hijra community.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.