From birth until death societal structure provides individuals with acceptable and unacceptable behaviours in society based on whether they are male or female (Dietert & Dentice, 2009). As per 2011 Indian census it was reported that total population of transgender is around 4.88 lakh (Transgender in India, 2011). Despite this, there is little research in India exploring the transgender people’s experience of therapy and Mental Health Services. Since transgender population is itself varied in nature in terms of their identity, seeking mental health and lack of federal protection, there is need for more research (Stocking, 2016). Transgender issues are beginning to come to the attention of many health professionals and researchers (Lombardi, 2001).
Transgender are likely to face violence or discrimination at some point in their lives (Lombardi, 2001). In a study it was reported that 60% of transgendered people in USA had faced some form of harassment and discrimination and 37% had experienced some form of economic discrimination (Lombardi, Wilchins, Priesing, & Malouf, 2002). Many transwomen are at risk mainly because of risky sexual behaviours (Nemoto, Luke, Mamo, Ching, & Patrij, 1999). These individuals may find it difficult to get through traditional prevention campaigns, as they fear discrimination in seeking HIV/ AIDS Testing and Education (Bockting, Wilkinson, Kitano, & Marx, 1993). They may also be resistant to seek help from other health professionals because other trasngenders have reported discriminatory behaviour on the part of service providers (Bockting, Wilkinson, Kitano, & Marx, 1993). Individuals who do not conform to gender norms and roles face many health related issues and discriminatory practice is common (Lombardi, 2001). In United States, 41% of transmen and transwomen attempted suicide which is 9 times more as compared to cisgender. It was also reported that LGBT adults who have experienced discrimination have average stress levels of 6.4, compared adults who are non-LGBT, stress levels are 5.5 for those who have experienced discrimination (American Psychological Association, 2016)
It was also found that trasngenders felt that therapists are not well-informed about the needs of transgenders and in the process they start seeking information from the transgenders. They also showed concerns for therapists’ inadequate training to deal with their issues. Transgenders also expressed concerns related to stereotyping and being misunderstood by the therapist (Benson, 2013). In 2015, a research was conducted where 65% transgender reported being on the receiving end of discrimination by mental health professionals (Cahill, Reisner, Hughto, Dunham, Heflin, & Begenyi, 2015) Distress and impairment are main characteristics of any Mental Health Disorder that arise from discriminatory behaviour, stigma, lack of acceptance, and abuse they face on a regular basis. It was also reported that people who feel stigmatised shy away from healthcare professionals and reach for addictive substances to reduce aloneness and anxiety or risk-prone behaviours, which further degrades their health and chances of seeking help again. (Robles, et al., 2016) Other than difficulties accessing mental health services, it has been found that transgenders face discrimination in every aspect of life.
Workplace discrimination is also well-documented with regard to transgender population. Barcley & Scott (2006), studied how male-to-female transition at workplace affects transgenders. They found one issue amongst others was the restriction to use the opposite sex washroom after transitioning, significant drecrease in pay and status for MTFs (Dietert & Dentice, 2009). Whereas, on the other hand, FTMs received more benefits after transition, where they were treated better at workplace and given more respect with the same skill set (Schilt, 2006). It was also seen how transitioning on job may impact the way they negotiate their gender identities within workplace, participants reported they had to deal with the reactions from their colleagues and upper management. Transgenders often report the experience of being harrased after transitioning which leads to them quitting their job or an underlying fear of losing their job (Dietert & Dentice, 2009). Overall, these forms of discrimation makes it difficult for them to function well at their wokrplace. Literature has shown how transitioning to a new identity may impact different aspects of an individual’s life. Gender binary discourse enforces norms for two exclusive categories either male or female. Societal expectations require individuals to be in a certain manner, where their gender aligns with their sex (Dietert & Dentice, 2009). Bockting et al., 2013, found out that trasnwomen are subjected to environmental provocative experinces which are not specific to transgender but may increase depressive rates; transwomen may experinence a loss of status as they transition to a female role and trasmen may experience the opposite.
Discrimination in school setting by peers and teachers is another aspect that can hinder transgender mental health. Given the transphobia in our society, adolescents who are struggling with the issue of gender identity and sexual orientation face many challenges and lack the fundamnetal support system as compared to cisgenders and heterosexuals (Gonsiorek, 1988). researches have focused how lack of support sytem for LGBT people within schools can comprise of one of the most homophobic and transphobic social institutions (Elia, 1993). It was also found that instead of family members, LGBT youth in high school percieved support from peers and non-family adult members which they specified as emotional and instrumental in nature. They also reported LGBT peers and adults provided valuable informational and appraisal support (Plaza, Quinn, & Rounds, 2002). With increasing LGBT population, schools, workplaces and other social institutions can no longer ignore this population but instead needs to be better prepared to provide guidance and assist them in order to make them better equipped to deal with situations in a healthy manner.
In addition to this, lack of parental support increases the mental health risks in sexual minority individuals. Lack of parental support in acceptance and supporting children who are trasnitioning or non-conforming to gender roles is linked to poor mental health. Olson, Durwood, DeMeules & McLaughlin (2016) found out that transgender children who were supported in their identity showed typical rates of depression and slighlty elavted rates of anxiety (which were no different than control groups) which suggested that familial support may be associated with better mental health among transgender children, as compared to children without any familial support. Similarly, it was found that lack of parental support is inversely associated with higher quality of life and may serve as a risk factor towars depression (Simons, Schrager, Clark, Belzer & Olson , 2013).
Meyer’s (2003) Minority Stress Model postulates how minority stress factors like expectation of rejection, prejudice, hiding,concealing and ameliorative coping processes result in occurrence of psychological problems in Transgenders. Stressors which arise from the environment like social stigma or homophobia may require an individual to adapt to the surrounding at the same time causing significant distress which in turn affects the mental health and physical health outcomes. (Dohrenwend, et al., 1992) Meyers found that the psychological disorders which are prevalent in LGBT group is especially a result of stressful and hostile social environment.
He proposed 3 ways through way transgenders are subjected to minority stress. First stressor which is present in transgenders is external and environmental in nature which occurs because of their minority status and which can create even more stress. Second factor overlaps with the previous factor where transgender individuals anticipate likeliness of being discriminated against and expect other individual to react to them in a certain manner, as a result of which LGBT people may receive rejection because of their sexual minority status and in turn may hide their identity to protect themselves from physical and psychological harm. Third, negative attitudes and prejudice from the society are internalised which may result in internalised homophobia for LGB people and internalised transphobia for Transgenders.
He also observed that the third factor of internalising society’s beliefs can be the most damaging for these individuals because it has direct negative effects on their ability to cope with external stressful events and may reduce their resilience when negative situations arise. He identified various ways through which these processes contribute to increased levels of psychopathology which may include mood disorder, substance abuse, suicidal ideation and attempts. The present study aims to explore the transgenders’ perception regarding the nature of mental health services provided by mental health professionals.
In transgender literature it is acknowledged that LGBT (lesbians, gay, bisexuals and transgendered individuals are subject to minority stress as a result of prejudice, stigma and discrimination which places them at higher risk of experiencing mental health difficulties. (as cited in Hunt, 2014) The term “transgender” cover a variety of atypical gender experiences and expressions like transsexuals, transgenders, gender queer and who cross-dress or perceive themselves as gender variant. (Stryker, 2006)
However, there have been few empirical studies exploring what specific issues transgender people seek therapeutic help for and what their experience of therapy has been. ( Hunt, 2014) One major study that aligns with the present research was done which explored transgender people’s experience of seeking and receiving counselling and psychotherapy outside of gender identity clinics in UK was studied. This study used a mixed method approach where they used an online survey and a semi-structured interview. It was found that participants sought help on two or more occasions and had psychological concerns like gender identity and coming out ( Hunt, 2014). It was also reported that transgendered people faced two barriers while seeking help; fear of being discriminated and exploring gender for the first time. This study majorly emphasised on the clients experience while seeking counseling services, the need for these professionals to develop a greater understanding to deal with the issues brought up by transgenders and competence and knowledge while working with them. In a similar study, Stocking (2016) studied perceived discrimination at Mental Health Clinics and reported there is an association between gender identity and reports of discrimination at mental health clinics. National Transgender Discrimination Survey (2008) was used to understand the extent to discrimination in this population, sample included 6456 respondents and bivariate analysis was used to understand the associations.
Association varied depending on which gender term individual identified with and form of discrimination (verbal harassment, being denied services or physical assaults). FTM and MTF reported contrasting experiences of discrimination where a person identifying as FTM was denied services or equal treatment and MTF were physically assaulted at mental health clinics. (Stocking, 2016) Contrasting rates of psychological distress were also seen in transgendered and non-transgendered population. Survey used to assess participants’ socio-demographic characteristics, substance use, transgender identity, sexual behaviour. It was found that transgender had disproportionate rates of anxiety, depression, somatization and overall psychological distress as compared to cisgender. (Bockting, Miner, Romine, Hamilton & Coleman, 2013) Association between felt stigma and peer, family support and identity pride were negatively related which confirmed these as protective factors. On the other hand, felt stigma and psychological distress were positively related. An interesting finding was reported in the same study, where transgender felt investment in passing (concealing identity) lead to felt stigma and outness (coming out) lead to enacted stigma especially for transmen. Specific types of enacted stigma were higher for transmen than transwomen which included getting a job, verbal harassment and access to health services.
The predictors of psychological well-being in treatment seeking transgender individuals were investigated, which included psychopathology and quality of life in transgenders and cisgenders. This research employed 6 tools; SCL-90-R, SF36v2, RSE, IIP-32 and HBDS to assess 6 factors of psychological distress. It was found that transgendered people had greater levels of psychopathology, interpersonal problems, lower self-esteem and body dissatisfaction compared to cisgenders. It was also found that younger transgender people may be more vulnerable to more mental health difficulties as they have less experience in managing stress as compared to older transgendered people.