Psychological Distress and Coping Strategies Among Transgenders

6. INTRODUCTION:
“Why compare yourself with others? No one in the entire world can do a better job of being you than you”.1
Transgender is a general term applied to a variety of individuals, behaviors, and groups involving tendencies to vary from culturally conventional gender roles.
Transgender is the state of one 's "gender identity” (self-identification as woman, man, neither or both) not matching ones "assigned sex" (identification by others as male, female or intersex based on physical/genetic sex).
A transgender individual may have characteristics that are normally associated with a particular gender, identify elsewhere on the traditional gender continuum, or exist outside of it as "other", "agender", "Genderqueer", or "third gender". Transgender people may also identify as bigender, or along several places on either the traditional transgender continuum, or the more encompassing continuums which have been developed in response to the significantly more detailed studies done in recent years.2 'Transgender ' refers to a person, male or female, who dresses, acts or presents in a manner that differs from his or her gender norm. 'Transgender ' includes transvestites (both fetish and dual-role), drag queens, drag kings, androgynes and genderqueers. It does not include transsexual people.3
The transgender community in India, known as hijras, number up to a million people and occupy a unique role in society. On the one hand, they are called upon to offer blessings during auspicious occasions like weddings and at births. The rest of the time, they are not only ignored but often ostracized from society.4
Transgender individuals are commonly viewed as a part of the lesbian, gay, and bisexual (LGB) community, forming the commonly known acronym LGBT. However, inclusion of transgender individuals within the sexual orientation political movement, and at social or cultural gay/lesbian events is highly debated. This is due to the division of sexual orientation and gender identity, which, though correlated, are different constructs. Whereas sexual orientation refers to one’s emotional, romantic and sexual attraction to others, gender identity refers to the person’s relationship to their gender and is largely independent of orientation. It is important to make the distinction between sex and gender. Sex is biological and physical (e.g., chromosomes, hormones, gonads), while gender is psychologically and socially constructed. For transgender individuals, gender is not congruent with sex. In order to align sex and gender a transgender individual may or may not undergo medical treatment, such as hormones or surgery.5
Psychological distress is the end result of factors–example, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with 'significant others '6.
Coping is the expending conscious effort to solve personal and interpersonal problems, and seeking to master, minimize or tolerate stress or conflict. Psychological coping mechanisms are commonly termed coping strategies or coping skills. The term coping generally refers to adaptive or constructive coping strategies, i.e., the strategies reduce stress levels. Furthermore, the term coping generally refers to reactive coping, i.e., the coping response follows the stressor. This contrasts with proactive coping, in which a coping response aims to head off a future stressor7.
Brief Resume of Intended Work
6.1 NEED FOR STUDY
The term transgender (TG) was popularized in the 1970s (but implied in the 1960) describing people who wanted to live cross-gender without sex reassignment surgery. In the 1980s the term was expanded to an umbrella term, and became popular as a means of uniting all those whose gender identity did not mesh with their gender assigned at birth.
In the 1990s, the term took on a political dimension as an alliance covering all who have at some point not conformed to gender norms, and the term became used to question the validity of those norms or pursue equal rights and anti-discrimination legislation, leading to its widespread usage in the media, academic world and law. The term continues to evolve.2
The population of hijras in India is estimated to be between 50,000 and 1.2 million. There is a huge disparity in the numbers because population censuses only give space to define either males or females. There are no reliable statistics. Tamil Nadu in a path breaking move has come to recognize transgenders – (the term itself is no monolith as transgender is more of an umbrella term).8
Most hijras live at the margins of society with very low status; the very word "hijra" is sometimes used in a derogatory manner. Few employment opportunities are available to hijras. Many get their income from performing at ceremonies, begging, or sex work—an occupation of eunuchs also recorded in premodern times. Violence against hijras, especially hijra sex workers, is often brutal, and occurs in public spaces, police stations, prisons, and their homes. As with transgender people in most of the world, they face extreme discrimination in health, housing, education, employment, immigration, law, and any bureaucracy that is unable to place them into male or female gender categories.9
Discrimination has prevented most hijras from obtaining decent education, jobs and housing, say transgender and human rights activists. The vast majority live in slums and, with limited job opportunities, resort to sex work or begging. They weave in and out of Mumbai’s traffic or come onto the women’s compartments of local trains, clap loudly and take money in exchange for a blessing.
While hijras continue to face discrimination, they have also made significant social and legal gains in recent years. Last July, the Delhi High Court decriminalized gay sex, and in November, transgenders won the right to be listed as “other” rather than “male” or “female” on electoral rolls and voter identity cards.4

Tamil Nadu has an estimated population of 30,000 transgender people. It has made great strides in trying to integrate transgender people into society. This includes welfare schemes initiated by the Government and acceptance of transgender people into the mainstream media and film industry.10
The Hijra of India are probably the most well known and populous third sex type in the modern world – Mumbai-based community health organisation The Humsafar Trust estimates there are between 5 and 6 million hijras in India. In different areas they are known as Aravani/Aruvani or Jogappa. Often (somewhat misleadingly) called eunuchs in English, they may be born intersex or apparently male, dress in feminine clothes and generally see themselves as neither men.
In June 2009, the Supreme Court of Pakistan ordered a census of hijras, who number between 80,000 and 300,000 in Pakistan. In December 2009, Iftikhar Muhammad Chaudhry, the Chief Justice of Pakistan, ordered that the National Database and Registration Authority issue national identity cards to members of the community showing their "distinct" gender.11
In a national school climate survey on the school related experiences of our nation’s lesbian, gay, bisexual and transgender youth, 55 percent of transgender youth report being physically attacked.33.2 percent of transgender youth have attempted suicide. 74 percent of transgender youth reported being sexually harassed at school, and 90 percent of transgender youth reported feeling unsafe at school because of their gender expression
In a survey of 403 transgender people, 78 percent reported having been verbally harassed and 48 percent reported having been victims of assault, including assault with a weapon, sexual assault or rape. A study was found that bisexual students in Massachusetts and Vermont were three to six times more likely to use cocaine than their straight classmates.12
A study conducted on fifty-five transgender youth described their gender development and some of the stressful life experiences related to their gender identity and gender expression. More than two-thirds of youth reported past verbal abuse by their parents or peers related to their gender identity and nonconformity, and approximately one-fifth to one-third reported past physical abuse. The more gender non-conforming the youth were, the more abuse they reported. Four aspects of psychological resilience were examined: a sense of personal mastery, self-esteem, perceived social support, and emotion-oriented coping. A regression model of the selected aspects of resilience accounted for 40–55 percent of the variance in relation to depression, trauma symptoms, mental health symptoms, and internalizing and externalizing problems. Emotion-oriented coping was a significant predictor of negative mental health as determined by each of the mental health variables13.
A study conducted by GLSEN found that over 85 percent of trans students reported verbal harassment based on their sexual orientation and gender identity. Nearly half (49.5 percent) reported physical harassment based on these characteristics, and a third (34.1 percent) reported being physically assaulted. Transgender students get harassed much more often than their classmates: the study found that transgender students were over four times more likely to be verbally harassed because of their gender expression. The dramatically higher frequency of such victimization among transgender people is alarming, and as one would assume, has significant effects on a student’s ability to learn.14 Psychiatric nurses are often in ideal position to assess the health and its problems and to offer education and support. Nurse needs to be knowledgeable about psychological distress and coping mechanism among Transgender people. When the nurse develops an effective plan for nursing management, she should consider family involvement, appropriate referral resources. The above studies highlight the psychological distress faced by the transgenders. As there is a dearth of research studies on transgenders in nursing, the researcher felt the need to contribute, explore and identify the psychological distress and coping strategies among transgenders.
6.2 REVIEW OF LITERATURE
A study conducted on the fear of experiencing discrimination often provokes symptoms of psychological distress. One coping resource is positive identification with one 's social group--known as collective self-esteem. This preliminary study investigated whether collective self-esteem was related to fears regarding a transsexual identity and psychological distress among 53 self-identified male-to-female transsexuals (mean age = 50.79 years). Participants were recruited from transgender events held in Arizona and California. The majority (81 percent) reported living full-time as women (mean length of time living as a woman = 6.33 years). Negative feelings about the transsexual community and fears regarding the impact of a transsexual identity were positively related to psychological distress. A regression model revealed that the fear of how a transsexual identity would affect one 's life was the best predictor of the severity of psychological distress. These results are consistent with findings from other historically marginalized groups, whereby the stress of being stigmatized by society adversely affects mental health. 15
A study used three focus groups to explore factors that affect the experiences of youth (ages 15 to 21) that identify as transgender. The focus groups were designed to probe transgender youths ' experiences of vulnerability in the areas of health and mental health. This involved their exposure to risks, discrimination, marginalization, and their access to supportive resources. Three themes emerged from an analysis of the groups ' conversations. The themes centered on gender identity and gender presentation, sexuality and sexual orientation, and vulnerability and health issues. Most youth reported feeling they were transgender at puberty, and they experienced negative reactions to their gender atypical behaviors, as well as confusion between their gender identity and sexual orientation. Youth noted four problems related to their vulnerability in health-related areas: the lack of safe environments, poor access to physical health services, inadequate resources to address their mental health concerns, and a lack of continuity of care giving by their families and communities16.
A study conducted on the sexual minority status is a key risk factor for suicide among lesbian, gay, and bisexual youth; however, it has not been studied among transgender youth. Fifty-five transgender youth reported on their life-threatening behaviours. Nearly half of the sample reported having seriously thought about taking their lives and one quarter reported suicide attempts. Factors significantly related to having made a suicide attempt included suicidal ideation related to transgender identity; experiences of past parental verbal and physical abuse; and lower body esteem, especially weight satisfaction and thoughts of how others evaluate the youths ' bodies. Sexual minority status is a key risk factor for life-threatening behaviours among transgender youth.17
A recent study undertaken to understand the level of General wellbeing of Male-to-female (MTF) Transgender population living in Chennai shed light on the mental health concerns of the transgender population in Chennai.
The study consisted of transgender (n=33), and that had been selected for the study by using Purposive sampling technique because it was a challenge to collect data from the population, given their obscurity. A standardized Tamil version of the Wellbeing Questionnaire-12 was used. As for the results of the quantitative data, 75.76 percent of the samples fell under Average Wellbeing Category, 24.24 percent of samples fell under Better Wellbeing Category and 0 percent fell under Poor Wellbeing Category. From the In-Depth Interviews it is inferred that the socio-economic status of Transgender is very poor, they feel inferior to others and are constantly humiliated and ill-treated by the society at large. However, support within the community is strong.18
A research study has documented the link between mental health disorders and discrimination. The coming-out process for an older LGBT person, who has lived most of his or her life in a hostile or intolerant environment, can induce significant stress and contribute to lower life satisfaction and self-esteem. Managing social stressors such as prejudice, stigmatization, violence, and internalized homophobia over long periods of time results in higher risks of depression, suicide, risky behaviour, and substance abuse. LGBT populations, therefore, may be at increased risk for these and other mental disorders. There may be a higher lifetime prevalence of affective disorders in LGBT persons, but no difference in current prevalence of such disorders. However, while little is known about the actual prevalence of mental health disorders in LGBT adults, even less is known about the prevalence of mental health disorders in older LGBT adults.19
A study examined the relationship between psychological well-being variables (i.e., depression, anxiety, and self-esteem) and level of outness in male-to-female (M t F) transsexuals. Participants were 105 M t F transsexual attendees at an annual transgender conference held in Atlanta, Georgia. Participants completed seven questionnaires, including the Demographics Questionnaire, the Outness Demographics Questionnaire, the Outness Attitude Scale, the Openness Scale, the Beck Depression Inventory-II, the Beck Anxiety Inventory, and the Rosenberg Self-Esteem Scale. A canonical correlation was conducted with psychological well-being variables as the predictor and the outness variables as the criterion. Results indicated that psychological well-being variables are related to outness. Treatment implications, limitations, and suggestions for future research are discussed. 20
STATEMENT OF THE PROBLEM
A study to assess the psychological distress and coping strategies among transgenders in a selected area, Bangalore.
6.3 OBJECTIVES OF THE STUDY 1. To assess the psychological distress among transgenders in a selected area, Bangalore. 2. To assess the coping strategies among transgenders in selected area, Bangalore. 3. To find out the relationship between psychological distress and coping strategies among transgenders in selected area, Bangalore. 4. To find out the association between the psychological distress and coping strategies among transgenders with selected demographic variables.
6.4 OPERATIONAL DEFINITIONS * ASSESS: In this study, assess refers to an organized and systematic way of finding out the psychological distress and coping strategies among transgender. * PSYCHOLOGICAL DISTRESS: In this study, psychological distress refers to the failure of the people to respond adequately to mental, emotional, or physical demands which will be assessed by using Kessler Psychological Distress Scale. * COPING STRATEGIES: In this study coping strategies refers to the mechanism that adapted by the transgenders to overcome the distress which will be assessed by using Coping Strategies Survey. * TRANSGENDER: In this study, transgender refers to people those are born with a particular gender but have the behaviour and characteristics of opposite gender.
HYPOSTHESIS
H1- There is a significant relationship between psychological distress and coping strategies.
H2- There is significant association between psychological distresses with selected demographic variables.
H3 - There is significant association between coping strategies with selected demographic variables.
6.5 ASSUMPTIONS * Transgenders adopt different coping strategies to overcome psychological distress.

VARIABLES UNDER THE STUDY * Research variable: * Psychological distress * Coping strategies. * Demographic variable:
Age, education, religion, marital status, cultural background, socio economic status, area of residence, past experiences.
DELIMITATIONS:
* The study is delimited to selected areas of Bangalore. * The study is limited to 100 samples.
7. MATERIAL AND METHODS:
7.1 SOURCE OF DATA
The data will be collected from the transgender in selected areas in Bangalore. RESEARCH APPROACH:
The investigator will use descriptive exploratory approach to conduct the study.
RESEARCH DESIGN:
The research design for the study will be descriptive survey design.

RESEARCH SETTINGS:
Study will be done in the selected NGO’s for transgenders in Bangalore.
POPULATION:
The target population for study is transgenders in selected area.
SAMPLING TECHNIQUE:
Investigator is using purposive sampling technique to draw the samples.
SAMPLE SIZE:
The sample size will be 100 transgenders.
SAMPLING CRITERIA:
INCLUSION CRITERIA: * People who are willing to participate in this study. * People who know English and Kannada. * People present at the time of data collection.
EXCLUSION CRITERIA: * People who are terminally ill or have critical illness.
METHODS OF COLLECTING DATA
Structured self reporting technique will be used to collect the data. Permission will be taken from samples and an informed consent will be obtained from the samples.
7.2 DATA COLLECTION TOOL * Part I – it consists of demographic variables like age, gender, education, socio-economic status, area of residence, past experiences. * Part II – the investigator will use Kessler Psychological Distress Scale for psychological distress and Coping Strategies Survey for assessing coping strategies.
DATA ANALYSIS METHOD: * The data will be analyzed using descriptive and inferential statistics. * Descriptive statistics like mean, frequency, percentages and standard deviation will be used. * Inferential statistics like “correlation co-efficient” and “chi- square” methods will be used.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMAL? IF SO PLEASE DESCRIBE BRIEFLY. * No, this is a descriptive study, it does not require any investigation to be conducted on patients or human or animals.
7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION? * Yes, the ethical clearance certificate has been enclosed.

8. REFERENCES: 1. Available from: URL: http://thinkexist.com/search/searchquotation.asp?search=self+esteem 2. Gay and Lesbian Alliance against Defamation (online). 2010 May ( cited 2011 Feb 24); Available from: URL: http://en.wikipedia.org/wiki/Transgender 3. Available from: URL: http://uk.answers.yahoo.com/question/index?qid=20070926024655AAZAbtB 4. Hanna Ingber Win. Global post. Transgender India: Banned in Bombay? (Online) 2010 April 10; 1(8). Available from: URL: http://www.globalpost.com/dispatch/india/100409/india-transgender-scandal-banned-bombay 5. Kayden Z Healy. Internalized Transphobia, Minority Stress, and Collective Self-Esteem. June 2011 6. Available from: URL: http://medicaldictionary.thefreedictionary.com/psychological+distress 7. Carver, Connor-Smith J. Personality and coping, Annual Review of Psychology. (2010). P. 61, 679 – 704. Available from: URL: http://en.wikipedia.org/wiki/Coping_(psychology) 8. Indian and Hijra (online). 2008 Nov 30 Available from: URL: http://shantanudutta.sulekha.com/blog/post/2008/11/indian-and-hijra.htm 9. Ravaging the Vulnerable: Abuses against Persons at High Risk of HIV Infection in Bangladesh (online). 2003 Aug: Available from: URL: http://en.wikipedia.org/wiki/Hijra_(South_Asia) 10. Chennai: Move on toilets for transgenders sparks off debate (online). 2009 Jun 23: Available from: URL: http://en.wikipedia.org/wiki/Transgender_rights_in_Tamil_Nadu 11. Ahmed M. Scalo Publishers (online). 2001 Sep 15: Available from: URL: http://en.wikipedia.org/wiki/Third_gender 12. Available from: URL: http://www.youthprideri.org/Resources/Statistics/tabid/227/Default.aspx 13. Arnold H G, Anthony R D, John A F. Aspects of Psychological Resilience among Transgender Youth. Journal of LGBT Youth (serial online) 2011 (cited 2011 Apr 08); 8(2): (2y screens). Available from: URL: http://www.tandfonline.com/doi/abs/10.1080/19361653.2011.541347 14. Tonei Glavinic. Student plus online academic student journal. Research Shows Lack of Support for Transgender and Gender-Nonconforming Youth in U.S. School Systems 2009 January 24; 1. 15. Sanchez, Francisco J, Vilain, Eric. Journal of Counseling Psychology. Collective self-esteem as a coping resource for male-to-female transsexuals 2009 Jan; 56(1): 202-9. 16. Arnold H. G, Anthony R. D. Transgender Youth. Journal of Homosexuality (serial online) 2006 (cited 2008 oct 17); 51(1): (2y screens). Available from: URL: http://www.tandfonline.com/doi/abs/10.1300/J082v51n01_06 17. Arnold H. G, Anthony R. D. Transgender Youth. Life-Threatening Behaviors. 2010 Dec 18. Thilakaravi. Mental Health Concerns of Transgender Population Living in Chennai, South India – A Study. MeD INDIA Networking for health January 2011. 19. Mark J Simone, Jonathan. Appelbaum. Clinical gediatrics. Addressing the Needs of Older Lesbian, Gay, Bisexual, and Transgender Adults: 2011; 19(2) p.38-45. 20. Jeffrey D Strain, I Michael Shuff. Psychological Well-Being and Level of Outness in a Population of Male-to-Female Transsexual Women Attending a National Transgender Conference. International Journal of Transgenderis: 2010 oct-dec p. 230-240.

References: 8. Indian and Hijra (online). 2008 Nov 30 Available from: URL: http://shantanudutta.sulekha.com/blog/post/2008/11/indian-and-hijra.htm 9 10. Chennai: Move on toilets for transgenders sparks off debate (online). 2009 Jun 23: Available from: URL: http://en.wikipedia.org/wiki/Transgender_rights_in_Tamil_Nadu 11