When doctors turn gatekeepers: Indian transgender community’s battle for mental health

Trans people are prone to mental health problems due to social stigma and the biological upheaval during medical gender affirmation process – and they suffer further when mental health professionals fail them.
When doctors turn gatekeepers: Indian transgender community’s battle for mental health
When doctors turn gatekeepers: Indian transgender community’s battle for mental health
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“I am praying at the temple now, can you come after sometime? This is the most peaceful part of my day,” says Viji* on the phone, in an apologetic tone. An hour later, as I enter an unfurnished one-bedroom house in the outskirts of Chennai where Viji lives, she explains why she won’t let her praying time be disturbed.

Viji’s day revolves around her ‘collection’ schedule; since her only income is from going around asking for money from shops, the rest of her day is traumatic. She identifies herself as a Thirunangai, member of a socio-cultural transgender group in Tamil Nadu who see themselves as women trapped in bodies assigned male at birth, and continue to face social stigma and violence.

The day I meet her, Viji is wearing a silk saree, and has a handkerchief wrapped around her hand. “A few days back, some goons attacked a few of us, and I got injured,” she explains.

As I sit down on the floor of her house, she scampers to get me water and turns the ‘Amma’ fan towards my direction. I tell her I am comfortable, and only then does she sit down to narrate her story.

“I was in third grade when I had my first sexual experience,” she says matter-of-factly. “A man used to live across from my house, and I used to approach him with ‘wrong intentions’. I was told I was a boy, but I never really felt like one fully... and I liked other men,” Viji says.

Growing up, Viji sought out several other such sexual experiences - all the time intensely aware that she was not comfortable with her assigned gender. In her early 20s, her mother wanted to find a ‘treatment’ for her ‘behaving like a woman’, and dragged her to a clinic in Chetpet in Chennai. This was Viji’s first interaction with a mental health professional (MHP) - this was her first opportunity to speak to an MHP about her gender, sexuality, and her body.

Viji* at her home in the outskirts of Chennai

Viji told the MHP about her felt gender, her struggles with societal expectations - and also about her sexual experiences.

And almost immediately, Viji’s world came crashing down.

The counsellor promptly told her mother everything that she had shared during therapy. She even went on to tell her that if Viji was not ‘reined in’, she would cause ‘embarrassment’ to the family.

“Until then, my mother did not know,” Viji says. “She used to think that I was ‘acting like a woman’ sometimes, but she had no idea that I slept with men. And that counsellor told my mother everything,” she recalls ruefully.

Viji’s relationship with her mother was never the same again, and that was the last time she ever met an MHP.

Her life is now a dizzy blend of survival and ambition. “I want to be a big businesswoman one day,” she says. “I want to be famous in society.”

But she feels depressed. She feels guilty about who she is, and bursts into phases of sadness and anxiety. “Sometimes I just sit in a corner and cry myself out. I used to drink a lot earlier, but after my close friend died of alcoholism, I stopped,” she says, making it evident that she might very well need mental health support, but she refuses to get it.

She does not trust psychiatrists or psychologists anymore. “The doctors are never willing to listen to us; they just tell us what to do, and we have to do it. I don’t want to go to such doctors.”

Viji isn’t the only transgender person who feels this way.

Struggle for a healthier mind

There has been no detailed study yet on the prevalence of mental illnesses among transgender persons in India, and their experiences with MHPs. But agencies which have worked with the community have pointed to high prevalence and a lack of a holistic approach towards mental health.

A 2010 report from UNDP India states, “Mental health needs of Hijras/TG communities are barely addressed in the current HIV programs. Some of the mental health issues reported in different community forums include depression and suicidal tendencies, possibly secondary to societal stigma, lack of social support, HIV status, and violence-related stress.”

In his 2017 academic article, ’Understanding the Mental Health of the Hijra Women of India’, Dr Vikas Jayadeva writes about available data showing that, “LGBT populations, like the hijra, have a higher prevalence of mental health issues compared with their heterosexual counterparts.”

He notes, “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. Seeking help is not a viable option for these individuals, due to perceived and real stigma from health professionals.”

The lack of empathy which the trans community faces is often rooted in MHPs’ poor understanding of gender itself, say activists.

Siva, Founder of Chennai-based NGO Nirangal. Image: Haris Manian

“Trans people face problems when they go to MHPs because the professionals have not been taught properly about gender and sexuality. They have been taught that being transgender is a psychiatric issue or an illness,” says Siva, co-founder, with trans activist Sankari, of Chennai-based NGO Nirangal, which has held at least two sensitisation programs for MHPs in the past few years.

“Those who have studied psychiatry decades ago don’t understand that gender is a construct. Doctors still don’t have complete awareness, and they don’t engage with the transgender community. There are still many who think that trans people can be ‘treated’. Younger doctors are better, they don’t judge the trans community, but even they don’t understand the issue deeply enough,” Siva says.

Understanding gender

What many doctors don’t understand even today is that none of us are born with a gender, we are assigned one at birth based on our external genitalia. In many instances, MHPs and other medical professionals themselves are unaware of who transgender people are. They routinely misrepresent transgender persons as intersex persons; ‘Intersex’ is an umbrella term used in a variety of cases, where a person’s reproductive or sexual anatomy does not match the typical definition of ‘male’ or ‘female’. 

But gender is different from biological sex - it has a lot more to do with how individuals feel about themselves, than about what the society infers on the basis of one’s genitals.

Growing up, a person may not identify with the gender they were assigned at birth. Cisgender people identify with the gender they were assigned at birth; the term is derived from the Latin meaning of ‘cis’, meaning ‘on the same side as’. Transgender people, on the other hand, don’t identify with the gender they were assigned at birth. 

So a person assigned male at birth, but grows up identifying as a woman, is a transgender woman, or a trans woman. Similarly, a person assigned female at birth, but grows up identifying as a man, is a transgender man, or a trans man. People can also be gender-fluid or non-gender-binary, which is to feel like neither a woman or a man. Essentially, gender is a spectrum. 

Being transgender is not a disease or a disorder, although transgender persons are prone to mental illnesses due to social stigma, and could suffer from ‘gender dysphoria’. Dysphoria is the distress some trans people feel due to being uncomfortable with their assigned gender.

While it’s the dysphoria that needs to be addressed by MHPs, along with the other mental health issues, in many cases, psychiatrists and counsellors view their job as that of ‘treating’ the gender of the trans person.

Experiences of trans people

The News Minute’s conversations with a wide range of people in the trans community and activists shows that often, MHPs don’t have the basic understanding of gender, or empathy for trans people.  

“There are some who are well-informed, but there are those who are spectacularly uninformed. The gulf is huge,” says Shilpi Banerjee, a clinical psychologist based in Gurugram, who has worked with several transgender people.

The gulf is not surprising, for it wasn’t until recently that even international manuals – like American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) – stopped referring to being transgender as a ‘disorder’, and decided to bring in the term ‘dysphoria.’ WHO’s International Classification of Diseases (ICD) still calls it a ‘disorder’ and is now being reworked.

The trans community is up against an education system, which has, for decades given doctors the wrong understanding of gender, and very few have been able to unlearn it.

Representative image. Transgender women at Koovagam festival. Image: Sindhuja Parthasarathy

Trans people have had to face challenges even when they approach MHPs for mental health issues which have nothing to do with their gender identity.

Bengaluru-based activist and Rumi Harish, a trans-queer person who works as a part-time consultant with Alternative Law Forum, had an emotional break-up in 2014. “I was going through severe insomnia, and I had severe myoclonic seizures during sleep. In Bengaluru, the doctors did not treat me properly. For almost 8 months, I was given sleeping pills by psychiatrists,” he narrates.

“The treatment was so horrible. I was just given sleeping pill after sleeping pill, instead of treatment for the myoclonic jerks, which was the neurological problem,” he says. “And I think the decision of the doctor to just give me sleeping pills might have been coloured by their perception of my identity, because I told them I was depressed about it.”

Rumi faced similar health issues in 2010, too, but he was fortunate to have had a good psychiatrist. Even then, he had to spend several sessions initially convincing them that his problems were not related to his gender.

“I am very comfortable with my gender, I have no problem with it. So why do I have to keep convincing them of that before getting treatment for my other issues?” he asks.

What psychiatrists feel

Leading psychiatrists, too, agree that there is a lot of work to be done on their end.

Dr Thara Srinivasan, a well-known psychiatrist and Director of Schizophrenia Research Foundation (SCARF) in Chennai, says, “I think psychiatrists don’t understand the issue very well. I have had only three people come to me for help. There are many more people out there who need help - we do know that they might need help. But the exposure of mental health professionals to this group is very limited, and they don’t take the trouble to understand the issues they face.”

Her colleague at SCARF, Dr Hema Tharoor, has had a lot more experience in dealing with transgender persons, and many in the community say they are more comfortable with her. “When it comes to psychiatrists, it’s a mixed bag,” she says.

“It’s wrong to generalise about all psychiatrists (as being unaware/transphobic),” she says. “May be a few are - just like some psychiatrists are homophobic. I think they should choose not to treat transgender persons,” she adds.

Dr Hema says that during training, psychiatrists rarely encounter transgender persons. “But we are definitely taught that these issues have to be addressed properly,” she says. “There is an awareness and understanding of the issues (that transgender persons face). Most common is depression - transgender persons face a lot of social ostracisation, and many of them feel alienated. This has a psychosocial impact. A lot of judgement is passed on by mental health professionals.”

The experience of the trans people only gets more horrifying when it comes to the process of gender affirmation.

Doctors turn gatekeepers

Gender affirmation is the process wherein transgender persons start living according to their felt gender, rather than the gender assigned to them at birth. The word ‘affirm’ is now being used instead of ‘transition’ – the idea being that trans people don’t transition to their felt gender, they already are that gender, so the process is just an affirmation.

There are three broad areas of gender affirmation, explains Dr L Ramakrishnan from the public health NGO SAATHII and volunteer with the Orinam collective.

One is social affirmation. This when a trans person starts telling people in their circles about their felt gender. They could choose to start wearing different clothing or look different, openly declaring their felt gender.

The second is legal affirmation, which is a more complicated process and involves the government. This involves changing the gender – and usually, name - of the person in official documents like ID cards, education certificates and passport.

The third area, and perhaps the most long-drawn and challenging process, is medical affirmation, which may involve surgery. This means making physical changes to the person’s body, to the extent that the trans person chooses. Surgery is usually preceded by months of hormone therapy, under the guidance of an endocrinologist. Many, but not all, transgender people seek medical procedures for gender affirmation.

Representative image. A participant at Chennai Pride, 2017. Image: Haris Manian

In 2012, Vijay*, who identified as a trans man, decided he would go in for a gender affirmative surgery.

His story, pieced together from those who knew him and were directly involved in his story, marks the sorry state of Indian psychiatry.

Vijay wanted to start hormone therapy. But in 2012, although there was no clear law mandating it, no endocrinologist or plastic surgeon would legally go ahead with the medical process unless a psychiatrist provided a certificate ‘identifying’ the gender of the person, and stating that the person is fit to undergo the hormonal therapy, and later plastic surgery.

And that’s where psychiatrists turned gatekeepers. They held the power to decide who could go ahead with medical affirmation and who could not.

Vijay visited a senior psychiatrist at a major hospital in Porur in Chennai. For close to one-and-a-half years, Vijay visited the psychiatrist regularly, paying the hefty fee. A doctor in his mid-40s, he was educated with books which perhaps considered even homosexuality to be a disorder.

“After 18 months, the doctor told Vijay to get someone from his home. Vijay informed him that his family was not supportive, so the doctor told him to bring along someone who knew him well, and was close to him. Vijay requested me to go along with him to meet this doctor,” recounts Siva.

“Once I reached the hospital, the doctor asked Vijay to wait outside while he spoke to me alone. And then he asked me: What is LGBT?” Siva recalls.

A shocked Siva decided to use the opportunity to explain the terminology to the doctor at that point. However, the doctor then asked him questions about why ‘such people’ are the way they are, and why they can’t ‘remain’ their assigned gender.

“And I thought to myself, shocked, how can this person ask these basic questions after one-and-a-half years? Even if he had asked basic questions to Vijay and done some research, he should have known this by then,” Siva says.

The doctor eventually refused to provide a certificate, and Vijay cut-off from his friends for a long time after that. “He was an MA graduate, and told me he was going to tear up all of his certificates, because he did not want anything to do with his assigned gender. I hope he never did it,” says Siva, looking away emotionally. Vijay has not responded to any requests for interview.

Varied experiences 

This is not an isolated incident.

Born in the early 80s, Bengaluru-based writer and activist Nadika, who identifies as a trans woman, has been wanting to transition ever since she was 17. That was the late 90s, and ignorance about LGBTQI+ people was rampant.

“My first few psychiatrists or psychologists were all idiots. I had a few bad experiences with both psychologists and psychiatrists, which sort of put me off them for a really long time. I was getting frustrated that I was not able to start transition,” she says.

Her psychiatrists, she says, would ask her questions ranging from insulting to stupid. “They were also coloured by the prejudice that only people from the lower class and castes go for medical transition,” she points out. “They would ask me if I was missing my mother, or if I liked men, which is why I wanted the transition. They should have been there to talk to my family and help me out; instead, they sat there judging me.”

By 32, she had had enough, and started self-medicating.

Self-medicating on hormones is rampant among people who seek medical affirmation but are unable to access hormones or surgeries, thanks to psychiatrists who don’t allow them to.

Health professionals, too, attest to that. Shilpi Banerjee says, “There is a lot of gatekeeping happening, so I know of a lot of people who are self-medicating, and they are driven to it by frustration.”

“I was self-medicating because I was depressed, frustrated and my previous attempts at doing it legally or properly did not work out,” Nadika says.

Self-medicating could lead to disastrous ends, endangering the lives of the trans person. Rumi Harish says that one of his friends, a trans man who was on hormones, killed himself, and it is highly likely that the person was unable to cope with the mood swings that come along with hormone therapy.

“He was getting ready to go through surgery, and had started hormone therapy under an endocrinologist. What was not informed to him was that he had to undergo counselling, and should have had access to mental health professionals, because the hormones can play with your moods, play with your mind, and that’s what happened with him later,” he says.

Representative Image. Transgender person at Koovagam festival in Tamil Nadu. Image: Sindhuja Parthasarathy

Rumi Harish also talks of a case where two transgender people were stripped naked at a leading mental health institution in the country by psychiatrists to ‘ascertain’ their gender.

“They were traumatized,” he says.

There is widespread dismay in the trans community with the role of the psychiatrist in the medical affirmation process.

“Psychiatrists should have no role in ascertaining gender. No male or female has to get a certificate from anyone about their gender, so why should trans people get one then? That is why we need the NALSA verdict to be implemented properly,” says Siva, who himself identifies as genderfluid.

NALSA and self-identity

On April 15, 2014, the Supreme Court of India gave out a landmark verdict which was a giant step ahead for the transgender community in the country, and has since come to be known just as the ‘NALSA judgment.’

NALSA, the National Legal Services Authority, was the petitioner in the case in which the apex court gave broad directions to the governments in India to safeguard the fundamental rights of transgender people, and to provide them with social welfare. More importantly, in this context, the judgment upheld a transgender person’s “right to decide their self-identified gender”, and told the central and state governments to “grant legal recognition of their gender identity such as male, female or as third gender.”

Meaning, only a transgender person gets to choose their gender, no one else. Further, a person can identity as the gender ‘opposite’ to their birth-assigned gender, or as a third gender. The verdict stated that it is both illegal and immoral to ask for proof of hormone therapy or surgery. However, at one place in the verdict, Dr Ramakrishnan points out, the court says that if the government must verify the gender of a person in a particular case, then it has to be a psychological assessment and not a physical one.

The NALSA judgment thus clearly separated legal gender identity from medical transitions. It  is supposed to have taken away the power of medical professionals to play god in deciding who could legally change their gender.. Yet, things have not changed, and gatekeeping continues to happen.

A participant at Chennai Pride 2017. Image: Haris Manian

Siva has conducted sensitisation programmes for at least 200 MHPs through two workshops - one of them, post the NALSA judgement. In his interaction with doctors, Siva has realised that some of them cannot digest the fact that a person would want surgery - especially in the case of trans men.

“They don’t think a trans man should have a hysterectomy,” Siva says. “They believe that the uterus  is a god-given gift, and that they cannot remove it from a person they see as a woman, despite their self identification as a man,” Siva explains.

Not only do trans men have to put up with societal stigma, they are also invisible in society, compared to trans women. Their assigned gender also reduces their mobility, as they are seen as women by their families and often forced into marriages.

“Gatekeeping happens incredibly often even now,” says Nadika, “even after NALSA. Society has deemed the MHPs to be powerful people, and the system gives them the initial power, that only when they are ok with you, do you get to go ahead. Even today NALSA has not percolated.”

“The average psychiatrist would still look at it as a ‘disease’ or a ‘disorder’, often working against the transperson and with the family, and trying to get conversion therapy etc. The community still hears of those things,” Nadika adds.

Legal grey areas

But does that mean that the psychiatrist should not have any role in the process?

“I think there is  a role for the psychiatrist in supporting the gender affirmation process,” says Dr Ramakrishnan. “I am not discounting the burning pressures imposed by gender dysphoria for those who seek medical procedures, but I also know that there can be factors which lead to trans people opting for a surgery sooner than they are prepared for, emotionally and otherwise.”

“There is definitely a lot of ignorance and prejudice among mental health professionals, which is one of the reasons for gatekeeping,” he says.

Another reason for gatekeeping, Dr Ramakrishnan adds, is fear of lawsuits. “Even when trans persons are above the age of 21 and have given consent, parents sue hospitals for going ahead with gender affirmative surgeries,” he says. And in this context, it does not help that there are still grey areas in the law which can be misused if the system decides to.

Kaushik Gupta, a lawyer based in Kolkata who has worked on several cases with transgender people and has been running sensitisation programs for lawyers in West Bengal, says that there are sections in the law which throw up challenges for doctors.

“When you read section 87 of the IPC along with section 320 of the IPC, a case could be made to argue that a plastic surgeon, by agreeing to remove the penis of a person even with consent, is being medically negligent,” Gupta says. “NALSA is silent on this, and I don’t think this should change how things are happening now, but there are such grey areas.” While even governments have gone ahead with affirmative surgeries stating medical necessities, Gupta merely points out that such contradictions do exist. 

Why we need psychiatrists

Psychiatrists, however, have their own reason for believing they are imperative to the medical gender affirmation process. “Sometimes, even in schizophrenia, you can have a delusion, you can feel you are a woman or a man (when you are not), and you want to change (gender). That person should not be allowed,” warns Dr Thara Srinivasan.

But she does agree that gatekeeping should not be allowed. “Scrap the psychiatrist’s role. All we have to verify is whether the person is delusional or not. Is the person schizophrenic? Is that why they want to change? If it is a well-functioning individual and is otherwise alright, if the person wants to have it done them let them have it done, and face the consequences later if it was the wrong decision,” she says.

Dr Hema Tharoor goes a step further. “This gatekeeping is slightly necessary, and I would say mandatory prior to surgery, because there are situations which demand it, she says, adding,  "After all, these surgeries are not reversible.” However, she does agree that MHPs should not be in a position to decide.

Rumi Harish fights the argument that psychiatrists need to be involved because of the 'irreversible' nature of these surgeries.

“The idea that the person cannot reverse a surgery is overstated. Are you saying you cannot reconstruct your penis? And why the fear? Where is this fear coming from? When you are arguing that gender is fluid, and if the person wants to reverse after a surgery, what is your problem? Why can’t you just facilitate it?”

What if certain changes in the body cannot be reversed, say if the person has had their uterus removed?

“There are all sorts of possibilities. The person can adopt children. You can have silicon surgeries. It is important to tell people what they are getting into and its consequences, but don’t overstate it,” Rumi says.

Dr Ramakrishnan says that the ideal role of MHPs is to enable the trans person achieve their transition goals, not decide for them, or nudge them towards a particular decision. “The community of mental health professionals has to educate themselves more, have more empathy and listen to diverse people from the trans community – men, women and non-binary, pre-op, post-op and non-op. We need a lot more people who are sensitive,” he says.

Online resources are being created for medical professionals to access and understand how to treat trans people with sensitivity and respect. Sappho For Equality in Kolkata has created a Good Practice Guide to Gender-Affirmative Care.

However, almost everyone agrees that the process of change has begun. Says Dr Hema Tharoor, “My take is that it is a normative process – this is something they want to do and they are going ahead with it. The reason why I think we need to be a part of it is because they do undergo mental health issues due to the stigma in the society. But I agree, that we don’t need to be in a position to decide for them.”

*Names changed to protect identity.

Edited by Ragamalika Karthikeyan

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