Understanding the Mental Health of the Hijra Women of India

Transgender, transsexual, and gender non-conforming individuals are a part of cultures around the world. Yet, transgender populations encounter several unique obstacles in accessing health care. These barriers are reflected in the World Health Organization reports that estimate disproportionate HIV prevalence rates ranging from 8% to 68% among transgender people (1). Despite these high HIV rates, relatively few epidemiological studies among transgender patient populations exist. Aside from poor sexual health, this patient cohort experiences perceived and internalized stigma, isolation, discrimination, and victimization that predisposes them to mental health issues, such as depression, anxiety, and substance abuse (2).

The World Professional Association for Transgender Health published international standards of care for this vulnerable patient cohort in 1979 and updated these recommendations in 2012. These guidelines emphasize the important role mental health professionals play in mitigating the negative impact of stigma and prejudice, assisting others with becoming comfortable with alternate gender expression, and facilitating the process of transitioning and coming out (3).

The transgender community in India is highly vulnerable to mental and physical illness, in large part due to limited economic opportunities, forcing many of these women to engage in prostitution (4). Despite increased health risks, these transgender individuals face an increased number of barriers to health care (2). Understanding the barriers that prevent the Indian transgender community from receiving medical care is important so that health care professionals can more adequately address the unique needs of transgender patients in India and around the world.

Who are the Hijra?

The term hijra refers to a minority group of transgender females on the Indian subcontinent. Historically, these women have held a socially protected status as a “third gender.” They held positions of power in Mughal courts and are referenced in Hindu scriptures and ancient myths as having special powers, which conferred religious and cultural authority to these women (5). This religious significance continues today, as the hijra offer blessings at weddings and births, known as badhai (6). Although hijra refers to biological males whose gender and gender expression is female (7), their identity is shaped by a range of factors outside of sex and gender, including religion, culture, and community (8).

Since Indian independence, local laws and cultural attitudes reflect blatant stigmatization, prejudice, and mistreatment of this minority group (7). In October of 2013, India’s Supreme Court directed all Indian states to establish welfare agencies to enhance the health and medical needs of these women, but despite this ruling, the hijra continue to experience discrimination with regard to education, health care, and employment. (6). With limited economic opportunities, changing Indian social structures and increasing globalization, a growing number of hijra women are turning to sex work to make an income (4), as their traditional roles are becoming obsolete (5). This situation is further exacerbated by Indian law, which makes it almost impossible to vote, own property, or obtain official identification and documentation, such as a passport or driver’s license (5).

Limitations in Defining Hijra

The hijra have evolved as a distinct cultural group on the Indian subcontinent for thousands of years and have only become marginalized in modern times (5). The hijra differ from Western transsexual identities, in that they self-identify as a “third gender” that is distinct from their female identity (5). Though they outwardly acknowledge that they are women through sexual relationships, gender roles, and clothing, within themselves they are also aware that they are separate and distinct from biological females (4). The best way to understand hijra identity is to understand the individual’s own definition of his or her identity, as the term hijra is widely encompassing of a variety of identities, including intersex individuals born with ambiguous genitalia (7) and zenanas (feminine men) who take on hijra identities to have sex with other men (9). Consequently, hijra clans, known as gharanas, consist of gender dysphoric and gender variant individuals, rather than a homogenous population, who form a community and find support after being shunned by their family and society. Cultural perceptions of gender, coupled with a diverse and heterogeneous hijra population, make it difficult to create broad generalizations about mental health issues, including gender dysphoria.

Current Mental Health Studies

There exists a paucity of medical studies on the hijra, secondary to their marginalized status. Given the high rates of prostitution among the hijra, the majority of medical studies have focused on HIV/AIDS. Few existing studies examine the mental health of the hijra population, (4), despite data from several meta-analyses demonstrating that LGBT populations, like the hijra, have a higher prevalence of mental health issues compared with their heterosexual counterparts (10–12). Furthermore, the hijra are more predisposed to mental health issues given that they are more likely to receive money for sex, have an earlier sexual debut, and have a higher prevalence of HIV compared with men who have sex with men (13). One case study also suggested that they were more vulnerable to alcohol and substance use disorders compared with the general population (14).

Forty-eight percent of hijra participants in one study suffered from psychiatric disorders, ranging from alcohol abuse and dependence to depressive spectrum disorders, but despite the presence of psychiatric disorders in participants, none had ever had psychiatric consultation for these issues (9). Seeking help is not a viable option for these individuals due to perceived and real stigma from health professionals (14).

From the limited mental health studies that exist, issues with gender identity are a reoccurring theme. A cross-sectional study of 50 hijra women in Mumbai showed that 84% of participants met criteria for gender identity disorder according to DSM-IV-TR (9). This finding was supported by a subsequent qualitative study, in which researchers interviewed eight hijra in Bangalore, India, regarding what factors and unique experiences contributed to their well-being (4). Among this small sample size, there appeared to be a persistent need for sex change and gender change because they felt discordance between their internal and external identity (4). Other contributors to well-being among this sampling were joining a gharana and finding a community of similar people (4).

Aside from discordance between gender identity and natal role, there appear to be several sociocultural stressors for the hijra that predispose them to mental health issues. These include family pressures to conform to gender norms, coming to terms with sexual identity and orientation, and migration to cities with strong hijra communities (5). Poor self- and social acceptance as a teenager, traumatic transitions, and physical, verbal, and sexual abuse from family and law enforcement were also major stressors (4). The hijra continue to be disadvantaged within society as evidenced by the barriers to obtaining voter identity cards and ration cards, as well as acceptance to educational institutions. The hijra women commonly encounter a wide variety of discriminatory attitudes and institutional difficulties in meeting their basic needs or in having their gender identity respected. This discriminatory attitude toward the hijra is extremely invasive and destructive for their mental health and has created a strong sense of loneliness (15).

Conclusions

The hijra are an integral part of Indian society but have continued to be marginalized in terms of education, economic opportunity, and access to quality health care. Although there is increasing awareness of HIV/AIDS rates among this vulnerable patient cohort, there is extraordinarily limited research into the mental health of these women. Health care professionals are less equipped to deal with the mental health issues pertinent to these communities without population-specific data. In general, the hijra community remains unaware of the psychological interventions and services potentially available to aid in management of their stress and mental health needs (14). Existing literature tells us that we need further research into the mental status of the hijra, which will allow researchers to better understand determinants of their mood. Health care professionals can build on these studies by designing interventions that can reinforce the resilience and coping strategies of these women, while ameliorating the factors that negatively affect their mental health. Available data support the need for dedicated multidisciplinary gender management services that can address the multitude of problems that these women encounter. These efforts should be backed by population-specific research data with culturally sensitive interventions and outcome measures. Consequently, these efforts can serve as the catalyst for helping the hijra community achieve a more balanced mental state.

Key Points/Clinical Pearls