Social strain, distress, and gender dysphoria among transgender women and Hijra in Vadodara, India.

Background: There is immense diversity among transgender people in India with respect to ethnicity, sub-culture, and gender expression. Aim: This study examines psychological distress, gender dysphoria, transgender congruence, and social strain among transgender women, and explores their reflections on self and community using a mixed-method approach. Method: Gender dysphoria, psychological distress, and transgender congruence were assessed with standardized scales while the participants' reflections were captured using semi-structured interviews. A total of 20 transgender women and Hijras were included in the study using convenience sampling. Data was analyzed using quantitative and qualitative techniques. Results: A positive correlation was found between psychological distress and social strain, but no correlation was found between psychological distress and gender dysphoria. Half of the participants fell into the range of gender dysphoria, five of them underwent gender affirming surgery, while two could not undergo the surgery and the rest did not express any discomfort with their gender. While all participants experienced psychological distress due to psycho-socio-cultural stressors, Hijra reported additional stressors related to the Hijra tradition. Discussion: Findings reveal that the psychological distress experienced by transgender women and Hijra had a significant, positive relationship with social strain rather than gender dysphoria. Participants reported various psycho-socio-cultural factors causing psychological distress, which impacted their lives more negatively than gender identity conflicts. These findings support the recent advances by the World Health Organization in ICD-11 to extract transgender conditions from the Mental and Behavioral Disorders category. Limitations of the study are elucidated by authors and the need for a culturally relevant and nonbinary gender dysphoria scale, and implications are discussed.