Mental illnesses and related vulnerabilities in the Hijra community: A cross-sectional study from India

Abstract

Purpose:

The Hijra community is a cultural and gender grouping in South Asia broadly similar to western transgender communities, but with literature suggesting some differences in gender experience and patterns of psychosocial adversity. The present study aims to describe patterns of mental illness and psychoactive substance use in Hijra subjects and study their association with gender experience and psychosocial adversity.

Methods:

Fifty self-identified Hijras availing HIV-prevention services in New Delhi, India, were interviewed. Data on mental disorders, psychoactive substance use, quality of life, discrimination, empowerment, violence and gender identity were assessed using structured instruments.

Results:

Subjects were mostly in their mid-twenties, and had joined the Hijra community in their mid-teens. More subjects (46%) were involved in begging than in traditional Hijra roles (38%). Sex work was reported by 28% subjects. The rates of lifetime mental illness was 38%, most commonly alcohol abuse (26%); others had anxiety or depressive disorders (8% each), somatoform disorders (6%) and bulimia nervosa (n = 1). Disempowerment was mostly experienced in domains of autonomy and community participation; 52% had experienced sexual or psychological violence. Discrimination was attributed to gender (100%), appearance (28%) or sexual orientation (28%). There were negative correlations between the physical domain of WHO-QOL and physical violence and depression scores; and between discrimination and WHO-QOL environmental, physical and psychological domains.

Conclusions:

This Hijra group showed high rates of mental disorder and substance involvement, related to QOL domains and experiences of discrimination and disempowerment.

Keywords

Hijra gender-incongruence mental illness psychosocial vulnerabilities self-esteem discrimination quality of life

Introduction

Sexual minorities, including lesbian, gay, bisexual and transgender (LGBT) individuals, are disadvantaged in multiple domains. These included experiences of discrimination and social exclusion (Hatzenbuehler et al., 2008) as well as sexual and physical abuse. A related observation is of higher rates of medical illnesses including sexually transmitted diseases and HIV/AIDS (Cochran & Mays, 2009), mental illness (Marshall et al., 2011; Ramirez-Valles et al., 2008), substance use disorders, and poor overall quality of life (Math & Seshadri, 2013).

Within the larger group of sexual minorities, the Hijras of South Asia are a distinct group. This group has been recognised as such since antiquity, by cultural as well as gender signifiers (Alhawary et al., 2005; Conner et al., 1997). Although many members of this community probably have experiences that would conform to current notions of ‘gender incongruence’, the qualitative literature suggest that their gender experience is heterogeneous, covering feminised homosexual individuals and transsexuals, as well as those with gender identity concerns (Chakrapani et al., 2007; Kalra, 2012; Nanda, 1993, 1999; Rowland & Incrocci, 2008). Within the community, a majority are likely to be individuals assigned a male gender at birth, and socialised as males in childhood, and a minority may have ambiguous genitalia (Nanda, 1991). There are transgender groups across India, including the Hijras, Aravanis and Kinnars. Similar traditional communities have also been described in other countries, for example, the Waria community of Indonesia (Boellstorff, 2004), the Kathoey of Thailand (Storer, 1999), or the Mahu (or Mahuwahine) in Hawaii and Samoan islands (Ellingson & Odo, 2008).

Perspectives from within the community show that members eschew the masculine-feminine binary, and consider themselves as belonging to a ‘third gender’ (Reddy, 2010; Sharma, 2012). Group affiliation is usually by self-identification, and perhaps by participation in a formal initiation ceremony called ‘nirvana’ (Nanda, 1999) which involves castration. In addition, initiates reside in a close knit group with a specific hierarchy (Kalra, 2012; Towle & Morgan, 2002), where most dress in feminine clothes. A number of Hindu religious rites have customarily involved participation of Hijra performers, and this was the main source of livelihood for members of the community. However, with changing social norms, many members are also engaged in begging and sex work to earn a livelihood (Chettiar, 2015). Under prevailing social conditions, and despite legal protections, they face discrimination and limitations in their access to employment, housing and healthcare, and are also marginalised from social benefits provided by the public sector (Chakrapani, 2010; Morcom, 2016; People’s Union for Civil Liberties Karnataka (PUCL-K), 2003).

Being a distinct population with visible markers of identity living apart from mainstream society, Hijra individuals experience multiple vulnerabilities to their mental health. It is unclear whether these vulnerabilities overlap with those experienced by western transgender populations, in whom mental health morbidity has been extensively studied. As described above, the typical gender experience within the Hijra population is also likely to be heterogeneous, and may influence vulnerability to mental illness. The present study aimed to assess the rates and proportions of mental illness within a sample of Hijra participants. The relationship between these rates and the experience of psychosocial adversity (including stigmatisation, experienced discrimination and disempowerment), and gender roles and identity, were also assessed.

Methods

This was a cross-sectional, descriptive study of self-identified Hijra individuals receiving HIV prevention services provided by a non-governmental organization (NGO) under a programme supported by the government of Delhi, India. A purposive sample of fifty adult Hijra participants aged 18–60 years was drawn, and those who provided informed consent were interviewed either at the NGO, or at a place of the respondent’s choice. Privacy was ensured during data collection. Participants were excluded if they had a history of neurological illness, or of medical or psychiatric illness that could interfere with assessment. All interviewers were conducted by the first author, who was not affiliated to the NGO nor directly involved in providing care to the respondents. The study was approved by the ethics committee of the institution to which the corresponding author is affiliated.

Data collection instruments

Demographic information, and participants’ gender experience and experiences within the Hijra community were ascertained using a semi-structured pro forma based on the descriptive literature.

The diagnosis of mental illness were elicited using a Hindi version of PRIME-MD Patient Health Questionnaire (Avasthi et al., 2008). This is a widely used instrument developed for use in primary care, which may be used to reliably elicit common mental disorders (including anxiety disorders, depressive disorders, somatoform disorders, eating disorders and alcohol abuse). For the original version, a diagnostic accuracy of 85% (sensitivity 75%; specificity 90%) and good reliability have been recorded (κ = 0.65) (Spitzer, 1999). In addition, the instrument also provides symptom severity scores that assess the level of morbidity.

The World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test (WHO-ASSIST) was used to screen for substance use. This instrument is a brief screening tool that provides risk categorisations for ten groups of psychoactive substances (Humeniuk & World Health Organization, 2010). It has been validated extensively in a number of countries, including India, for the ability to identify problematic substance use (Humeniuk et al., 2006).

Quality of life was assessed using the 26-item WHO-Quality of Life Instrument (WHO-QOL-BREF) in its Hindi translation (Saxena et al., 1998). Hindi versions of the PHQ and WHO-QOL BREF have previously been validated in Indian populations.

Data on predetermined psychosocial factors were collected using structured instruments.

The experience of discrimination was assessed using the 9-item Everyday Discrimination Scale (Williams et al., 1997), which measures general mistreatment without reference to specific domains (such as race, age, gender, religion, physical appearance or sexual orientation), with each item measured on a 6-point scale; in addition, respondents’ subjective opinion about the reason for discrimination is also recorded from amongst multiple options. This instrument has been shown to be reliable (test-retest coefficient = 0.70, Crohnbach’s α ⩾ 0.74) with a high correlation with psychological distress. It is considered to be superior as to single-item measures of discrimination (Krieger et al., 2005).

Rogers’ Empowerment Scale (Rogers et al., 2010) is a 28-item scale that measures consumer-defined empowerment in five dimensions (self-esteem, power/powerlessness, community activism, righteous anger, and optimism and control over the future) on a four-point agreement scale (1 – strongly agree; 4 – strongly disagree), with high scores representing a low sense of personal empowerment. It was designed to be used to assess the empowerment experienced by patients with chronic mental illnesses, and their say in their own rehabilitation. It has fair to high scores for internal consistency (overall α = 0.82; adjusted α for subscales varying between 0.45 and 0.82), and the instrument has been validated in populations with mental illness. This instrument was used with the permission of the authors, in its Hindi translation.

The Indian Gender Roles and Identity Scale (IGRIS) was developed by Basu et al. in 2010, and is based on the standard Bem’s Sex Role Inventory(Pedhazur & Tetenbaum, 1979), modified for use in India. It lists 30 traits that are classified as masculine, feminine or neutral, each rated on a 7-point scale denoting the desirability of the trait in men or women, respectively.

The modified Violence Against Women Instrument (VAWI-m) was used the measure violence experienced by Hijra individuals. It assesses physical and sexual violence and controlling behaviours experienced in the past year and in the respondent’s lifetime by 11 ‘yes’ or ‘no’ questions. This instrument was chosen because it is a frequently-used measure of gender-based violence, and previous literature suggests that the Hijra community is vulnerable to similar kinds of violence. The instrument has been piloted and used in multiple countries in the developing world. It has a high internal consistency (α = 0.81, 0.66, 0.73 for the three major domains).

Self-report instruments (Rogers Empowerment Scale, VAWI-m) were used in Hindi versions, produced by a translation-back translation method, using a committee approach to resolve differences. Data was tabulated and summarised according to frequencies and measures of central tendency. Spearman Correlations were used to measure the correlation between various domains of quality of life and the scores on empowerment, discrimination, and depressive symptom severity (as measured by PHQ-9). All statistical analysis was carried out using a licensed version of SPSS, Version 21 (IBM SPSS Statistics for Windows, 2014).

Results

Sample characteristics

Sociodemographic characteristics are provided in Table 1. The participants’ age ranged between 20 and 40 years, with a mean of 28.7 (± 4.8) years. Around 88% (n = 44) reported being born male; while all endorsed ‘Hijra’ as their current gender identification. About 24% (n = 12) reported that they were either married or living with a sex partner. Of those who were married (n = 4; 8%), two reported being married to a male partner, and the other two to women. Nearly half reported earning money primarily through begging, while 28% (n = 14) were involved in sex work. About 38% (n = 19) participated in work traditionally assigned to and associated with the Hijra community (performing at marriages, births or other ceremonies). About 36% (n = 18) respondents had not been formally educated, while 6% (n = 3) had received a college education. About 44% (n = 22) respondents were living in group housing arrangements with other ‘Hijras’ (as per their tradition), while 26% (n = 13) were living with their sexual partners. Two respondents (4%) reported that they were HIV positive.

Table 1.

Socio-demographic and clinical details of transgender (Hijra) subjects.

Variables	Mean (SD) / Freq (%)
Occupation
Begging	23 (46)
Group performance at marriage and birth ceremonies	19 (38)
Commercial Sex worker	14 (28)
Others (field workers)	4 (8)
Self-employed	3 (6)
Professional	1 (2)
Student	1 (2)
Education
Illiterate	5(10)
Just literate	13 (26)
Primary	14 (28)
High school	12 (24)
Higher secondary	3 (6)
Graduate	2 (4)
Postgraduate	1 (2)
Professional	0 (0)
Residence
Urban slum	34 (68)
Urban	15 (30)
Homeless	1 (2)
Religion
Hindu	34 (68)
Muslim	6 (12)
No specific religion	6 (12)
Current living arrangement
Group housing with other Hijras	22 (44)
Living with sexual partner	13 (26)
Living alone	8 (16)
Living with parents	5 (10)
Living with friends	2 (4)

Gender transition status

Most respondents (68%, n = 34) reported that they had not undergone any gender reassignment surgical procedures. Of those who had, most respondents’ experience was of emasculation (removal of the external genitalia), which was performed by qualified medical professionals (n = 7), or by those without any such formal qualification (n = 7). The procedure was associated with a high rate (55%) of surgical complications, 90% of these from procedures by unqualified persons. These complications included both short-term (urinary tract infections, fever) and long-term complications (such as urethral strictures).

Substance use and mental illness

About 64% (n = 32) reported lifetime use of alcohol, while 54% (n = 27) reported tobacco use, and 16% (n = 8) reported cannabis use. For tobacco, most (54%, n = 27) belonged to the ‘low risk’ category as per WHO ASSIST, with 26% (n = 13) in moderate-risk, and 20% (n = 10) in the high-risk category. For alcohol, 16% (n = 8) and 14% (n = 7) were categorized respectively as belonging to the moderate or high-risk categories. Two participants were classified as being at moderate risk, and one at high risk for cannabis use. On PRIME-MD PHQ assessment, 38% (n = 19) had at least one mental illness, out of whom five had more than one diagnosis of mental illness. The mental illnesses included alcohol abuse (n = 13, 26%), anxiety disorders (n = 4, 8%), depressive disorders (n = 4, 8%), somatoform disorders (n = 3, 6%) and bulimia nervosa (n = 1). Those with alcohol abuse also had co-morbid mental illnesses: depression in three participants and panic disorder in one participant. In addition, the participant with bulimia nervosa also met criteria for other anxiety disorders. Psychiatric illnesses were more common amongst those who had undergone emasculation procedure (p = 0.01).

Associated social and psychological vulnerabilities

Assessment of gender roles and identity revealed that the respondents scored higher on the femininity scale where the mean score was 48 (±5.58) compared to mean scores of 37 (±6.96) on the masculinity scale. The mean overall empowerment score in the empowerment scale was 2.07 (± 0.19). Mean scores on the community activism and autonomy (1.78 ± 0.43) domains were less than the cut-off score of two. Table 2 provides the mean and range scores for all domains of the empowerment scale and for the WHOQO-Bref. About 52% (n = 26) respondents faced psychological and sexual violence each, and 36% (n = 18) experienced physical violence perpetrated by partners, police or clients. About 40% (n = 20) and 26% (n = 13) continued to experience psychological/sexual and physical violence in the present year. The individual scores on modified VAWI-m scales is provided in Table 3. Respondents scored a mean of 7.7 (SD = 1.83) on the everyday discrimination scale (EDSS), with all participants having experienced discrimination due to their gender, and 28% (n = 14) each attributing discrimination to their sexual orientation or physical appearance.

Table 2.

Quality of life and empowerment scores of transgender (Hijra) subjects.

	Mean (SD)	Range
WHO QOL domains
Physical	58.44 (11.63)	25–87.5
Psychological	54.19 (11.63)	(18.75–81.25)
Social	60.31 (10.00)	(25–81.25)
Environmental	39.44 (11.63)	(18.75–68.75)
Empowerment scale scores
Overall empowerment score	2.07 (0.19)	(1.29–2.43)
Self-esteem – self-efficacy	2.05 (0.45)	(1–2.78))
Power-powerlessness	2.16 (0.26)	(1.5–2.63)
Community activism and autonomy	1.78 (0.43)	(1–3.17)
Optimism and control over future	2.11 (0.47)	(1.5–4)
Righteous anger	2.12 (0.33)	(1.25–3.25)

Table 3.

Modified violence against women instrument (VAWI-m) scores of transgender (Hijra) subjects.

Domains	Range	Ever		Last 12 months
Domains	Range	Frequency (%)	Median (IQR)	Frequency (%)	Median(IQR)
Psychological	0–4	26 (52%)	1 (0, 3)	20 (40%)	0 (0, 2)
Physical	0–6	18 (36%)	0 (0, 2.25)	13 (26%)	0 (0, 1)
Sexual	0–3	26 (52%)	1 (0, 1)	20 (40%)	0 (0, 1)

Correlation analysis

Significant negative correlations were found between the physical score on the VAWI-m scale and the physical (r = −0.38; p < 0.05) and psychological (r = −0.33; p < 0.05) domains of WHOQOL. A positive correlation was seen between the VAWI-m sexual score for the past year and the WHOQOL environmental domain (r = 0.30; p < 0.05). EDDS scores correlated negatively with the WHOQOL environmental domain (r = −0.42; p < 0.05). Negative correlations were also seen in the relationship between scores on the empowerment scales and the physical (r = −0.30; p < 0.05), psychological (r = −0.29; p < 0.05) and environmental (r = −0.40; p < 0.05) domains of quality of life as assessed on WHOQOL. The depression score on PHQ also showed a negative correlation (r = −0.38; p < 0.05) with the physical domain of WHOQOL. The correlations related data is provided in Table 4.

Table 4.

Correlation between sociodemographic variables, scale scores and tobacco risk, alcohol risk, depression and quality of life.

	PHQ depression	WHOQOL physical	WHOQOL psychol	WHOQOL social	WHOQOL environ
VAWI physical EVER	−0.098	−0.027	−0.297*	−0.250	0.033
VAWI sex 12 months	−0.016	0.216	0.138	−0.137	0.296*
VAWI sex EVER	0.041	0.136	0.057	−0.072	0.282*
EDDS	0.180	−0.143	−0.017	−0.147	−0.422**
ES total mean	0.186	−0.300*	−0.289*	−0.223	−0.408**
PHQ depression	–	−0.381**	−0.328*	−0.209	−0.227

Psychol: Psychological; Environ: Environmental.

p < 0.05, **p < 0.01.

Discussion

This was a cross-sectional study to assess the rates of mental illnesses and substance use problems in a purposive sample of 50 Hijra subjects, and to correlate psychosocial vulnerabilities with mental illnesses. The study showed that the rates of common mental illnesses were high in this sample, alongside problems related to alcohol and drug use.

The Hijra community constitute a special type within the transgender community. All respondents in the study identified their gender as ‘Hijra’, suggesting that within the community, this gender specification is preferred to those arising from binary notions of gender (as male or female). In fact, a previous study had shown that a substantial proportion of Hijra respondents preferred to identify with multiple (rather an single) gender assignment (Chettiar, 2015). Hijra individuals also have been identified as a separate group, residing together in communities with other Hijra individuals from an early age (as also seen in close to 90% of our sample). These patterns have been described in studies from across the Indian sub-continent, and may reinforce the traditional roles Hijra people have been assigned in the society (Brahmam et al., 2008; Hawkes et al., 2009). With changes in social structure, Hijra individuals must resort to other illegal means to support themselves including begging or to indulge in sex work, as seen in the present study. These activities also pose additional vulnerabilities in the life of a Hijra (Kalra & Shah, 2013; Saravanamurthy et al., 2010). Even some of the activities required for confirming oneself with the group such as emasculation procedure also leads to long-term medical complications as seen in the present study (Singh et al., 2014). These also increase vulnerabilities experienced by Hijra individuals.

One-third of the respondents had undergone an ‘emasculation’ procedure that involved removal of the external male genitalia, without any provision of feminizing hormones or other transition assistance. Of those (one-third) who had undergone ‘emasculation’, that is, the removal of external male genitalia, half (n = 7) had carried out by a person without formal medical training, and these were associated with high rates of medical complication. Nearly a quarter were in long-term conjugal relationships, more often informal live-in relationships rather than formal marriages. These findings are in line with those of previous studies for example, Kalra and Shah (2013); however it is difficult to say whether these are due to norms within the community, or whether these are due to difficulties accessing formal healthcare facilities or marriages as understood by Indian societies. Indeed, where a full spectrum of publicly funded gender reassignment procedures have been made available by Indian states, these have been accepted by transgender communities over traditional procedures (Chakrapani et al., 2002).

There was a high exposure to sexual and psychological violence in around half of the participants, and physical violence in around one-third of the participants. Although high rates of violence are seen among sexual minority groups across various categories, Shaw et al (Shaw et al., 2012) reported lower rates amongst Hijra and Kothi communities, as compared to other categories of ‘men having sex with men’. In other communities, Bazargan and Galvan (2012) have found that amongst Latina transgender individuals, domestic violence and mistreatment were suffered by a majority of respondents. Hijra participants in our study also reported facing discrimination in their daily lives, and the major reason they felt for their discrimination was their gender. Their choice of appearance and community dwelling give Hijra individuals a distinct and stable identity. While this may confer protection, this also makes their identity more difficult to conceal, and may thus lead to different patterns of discrimination. Qualitative findings from one previous study have shown that this discrimination extends to multiple domains of a Hijra individual’s existence, including their interactions with structural aspects of society, namely, access to healthcare, insurance, political participation and employment (Chakrapani, 2010), as also in interpersonal relations(Bazargan & Galvan, 2012).

The present study showed that Hijra subjects have high rates of mental illnesses and substance use problems. There was a high prevalence of substance use in this sample, with 46% falling in the moderate to high risk groups for tobacco and one-third for alcohol use. These rates are substantially higher than those estimated by general population surveys of substance use in the Indian population, which have made an estimate of 13% for tobacco use (Gururaj et al., 2016). Estimates for alcohol use from the National Survey on the Extent of Substance use disorders (Ambekar et al., 2019), also estimated rates that are one-sixth of those in this population.

The most common mental disorder that could be diagnosed based on PHQ was also related to substance use (alcohol abuse) in one-fourth of the participants. These findings are broadly in line with a number of studies amongst Indian male to female transgender groups (Chakrapani et al., 2015; Hongal et al., 2014; Kalra & Shah, 2013; Saravanamurthy et al., 2010). A recent review by Reisner et al. (Reisner et al., 2016) report that most studies have assessed individual domains of mental distress (e.g. depression, suicidality, substance use) in transgender population with a variety of structured indices. The studies show that transgender populations experience higher rates of mental distress as compared to the general population. Even studies that have used diagnostic interview schedules demonstrate that these communities have higher rates of illnesses, mostly common mental disorders and substance use disorders. While the patterns of mental illness are similar to those in the general population, with anxiety- and mood disorders being the most common, the absolute proportions in this sample were approximately four times the general population estimate (Gururaj et al., 2016).

In interpreting these results, it is important to note that studies that have made use of structured screening instruments (such as ours) have shown consistently higher rates of depression even up to 50% of the sample (Chakrapani et al., 2015; Patel & Andrew, 2001), while those using clinical methods of ascertainment (Kalra & Shah, 2013) have shown rates resembling those in the general population. In these studies, depressive symptoms were found to contribute to higher rates of substance use (Nuttbrock et al., 2014). Another significant predictor for substance use in these studies was gender-related violence.

A significantly higher proportion of those who had undergone emasculation in our study had a psychiatric illness. This could be explained by overall sexual dissatisfaction, post-emasculation hormonal changes and functional loss of genitals, and to long-term complications of emasculation. Participants who were in the ‘high-risk’ category of alcohol had poor quality of life in the social domain. Participants with higher depression score had poorer quality of life in physical and psychological domains. Additionally, higher everyday discrimination correlated with lower quality of life in the environment domain. Those participants who felt less empowered had poor quality of life in physical, psychological and environmental domains. More importantly, the present study also shows that very few (4%) of those with a diagnosable lifetime mental illness had ever sought medical intervention for their illness. There is a clear need to educate this population about the availability of treatment for their mental health condition.

The study has several limitations. The sample size is small, and hence variations within this population might not have been adequately captured. Moreover, all participants were drawn from the catchment pool of a single NGO. Thus, participants are likely to belong to a more cohesive group, besides representing a sub-population that is in contact with social and medical services. The instruments used have been those that are useful to measure categorical mental disorders, and thus not fully reveal the extent of psychological distress. In multiple studies, subclinical depressive and anxiety-related conditions have been far more prevalent than the clinically diagnosable forms. As validated instruments were not available specifically for this population for some constructs (e.g. empowerment, gender-based violence), instruments used in other cultures or communities were used on the basis of their face validity. However, despite these limitations, the findings are important because they represent the experiences of community dwelling self-described Hijra individuals, a group that experiences marginalization in multiple domains, and in whom mental health morbidity has not been studied in any detail. The high levels of mental morbidity and substance use, and the relationship with psychosocial discrimination, also suggest interventions that may be useful to limit the impact of mental illness in this group.

Conclusion

Hijra subjects faced significant morbidity in terms of mental illnesses and substance use disorder. They also have high scores on various parameters that measure psychosocial adversity, such as experienced violence, empowerment, discrimination, and quality of life.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Vijay Krishnan

Ravindra Rao

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