Suicidal ideation, suicide attempts and sexual harassment among transgender people in Puducherry, South India: a cross sectional analytical study

INTRODUCTION

In India, the population of transgender people is 4, 88,000. Around 252 of them reside in Puducherry.¹ Access to this population group is difficult for the health care providers because of their different cultural background. To reach this population, better understanding, culture specific, sensitive interventions and a different approach is required.² Transgender people are stigmatized, victimized and often driven towards attempting suicide by reinforcing institutional discrimination.³ With increase in the urbanization and change in social structures, now most of the transgender people have become sex workers and are begging in the streets for their daily needs. They leave their families to live with transgender people’s community leaders who in local terms are called “Guru”. These Gurus perform all the rituals related to their community.⁴ Compared to the general population, transgender people are at greater risk of suicides and sexual harassments.² In India, due to the sensitivity of the topic, this has been a relatively neglected area for research and very few studies are available regarding stigma experienced by transgender people, but none in the published literature on their suicidal behaviors. But there are many studies on perceived stigma, sexual harassment, suicide attempts and associated factors globally. The major risk factors identified in those studies for suicide and suicide attempts among transgender people were depression, gender discrimination, social exclusion, low economic status, low educational attainments, childhood abuse, homelessness and other mental health conditions. More often they experience violence which increases the number of suicide attempts in their entire lifetime.^5,6 In a recent study conducted by William institute, USA that compared transgender population with the general population, transgender people were found to be more depressed and therefore attempted suicide.³ In spite of having poorer mental health status, they usually do not seek help or access health services because of unfriendly behaviour from the health personnel.⁷ Few studies done in India are from Maharashtra and Tamil Nadu. Puducherry is a Union Territory in southeast coast of India with a French cultural connection and is a major global tourist attraction, which might have an impact on the health of the transgender people. Puducherry also has very good health infrastructure including mental health services, but the mental health issues of the transgender population especially suicidal ideation and attempt has not been studied yet. To address this lack of knowledge on the number of transgender people who attempt suicide and the factors associated, especially sexual harassment, this study was undertaken in Puducherry to find out the proportion of transgender people who had faced sexual harassment, had suicidal ideation in the past one year, had ever attempted suicide and the factors that drove them to do so.

METHODS

This was a cross-sectional analytical design. The study was conducted in a Non-governmental Organization (NGO) in Puducherry called Sahodharan community oriented health development (SCOHD) Society between April and December 2018. This is a Community Based Organization in Puducherry and Tamil Nadu which exclusively works among transgender community. Hence we chose SCOHD Society NGO as our study setting. There were 130 transgender people registered in the Puducherry SCOHD NGO. The list of transgender people was obtained from the NGO and all were approached for the study purpose. All the adult consenting transgender people were finally included in the study. The study was conducted after ethical committee approval from JIPMER and official approval and permission from the NGO. Written informed consent from the participants was obtained after explaining the purpose and procedure of the study in detail. The participants were interviewed using a pre-tested questionnaire consisting of questions on socio-demographic characteristics like age, gender, occupation, place of residence, suicidal attempts, C-SSRS – Columbia Suicide Severity Rating Scale for assessing suicidal ideation and TGISS- transgender identity stigma scale for identifying transgender people facing sexual harassment. The number of persons to be interviewed per day was based on the availability of study participants in the NGO at a pre-defined allotted time. Each participant was given a unique id number to keep their identity confidential. Data was entered in EpiData manager software version 4.2.0.0 and analyzed using IBM SPSS software version 20 and STATA version 14. Continuous variables like age, income were categorized and analyzed for the descriptive analysis. For outcome variables like number of suicide attempts, number of suicidal ideations and sexual harassment results were expressed in simple proportion. Association between the outcome variables and independent variables was tested for statistical significance using Chi-square/Fishers exact test and multivariate analysis was done to find the independent association of the predictor variables with the outcome using adjusted prevalence ratio.

RESULTS

Among the 130 transgender people registered in the NGO, 119 (91.53%) accepted to participate in the study, out of them 95.8% were assigned as male at birth and 86.6% were recoded as Transwomen. About 80.7% of the population belonged to age category of 18-30 years, 64.7% people lived in urban areas of Puducherry and 86.6% population lived away from their families with the other transgender population. Almost 50% of them were unemployed and were begging on the streets whereas 28.6% involved in sex work for earning their daily living. Their income ranged between INR 3447 and 6892 with 45.4% of them belonging to class II of BG Prasad’s Classification (Table 1).

Overall, 31.1% (95%CI 23.3%-39.8%) of the transgender people had suicidal ideation in the past one year. It was higher in the age category of 18-30 years (89.2%), among the transgender population living in urban areas (73%) and in those living with other transgender people (81.1%). Within the employment and income categories, suicidal ideation was found to be highest among commercial sex workers (37.8%) and those with income of above INR 6893/ month (56.8%) (Table 1). Out of 31.1% who had suicidal ideation 86.6% were Transwomen. There were only five transmen and 3 (60%) out of them had suicidal ideation (Table 2).

Association of suicidal ideation was found to be statistically significant with employment status and monthly income in univariate analysis. Socio demographic factors were included in the model for the adjusted analysis. In the multivariate analysis, monthly income was statistically significant, prevalence of suicidal ideation being 2.23 times higher among the transgender people who had monthly income above INR 5000 compared to low income category (<INR 5000) (Table 3). Overall lifetime suicidal attempts was found in 46.2% (95%CI 37.4%-55.2%) of the transgender people.

It was higher in the age category of 18-30 years (83.6%), among the transgender population living in urban areas (69.1%) and in those living among the transgender people (89.1%). Within the employment and income categories higher proportion of commercial sex workers (43.6%) and those with income of above INR 6893/ month (50.9%) had attempted suicide (Table 1).

Of all those had attempted suicide at least once in their lifetime, 89.1% were transwomen. Among the five transmen, one had attempted suicide at least once in his lifetime (Table 2). Lifetime suicidal attempts was found to have statistically significant association with employment status and monthly income in univariate analysis. After inclusion of socio demographic factors in the model for the multivariate analysis, employment status was still statistically significant. The prevalence of lifetime suicidal attempts was 1.85 times higher among the employed transgender people compared to unemployed transgender people (Table 4). Overall, more than four-fifths (84.87%) of the transgender people were facing sexual harassment, 18-30 years (86.1%), those living in urban areas (68.3%) and those living with other transgender people (93.1%) the most. Within the employment and income categories highest proportion was in unemployed people (52.5%) and with income range INR 3447- 6892/ month (48.5%) (Table 1).

Out of 84.87% who had faced sexual harassment, 93.1% were Transwomen. 1% were male cross dresser. Among the transmen, one (20%) had faced sexual harassment (Table 2). Factors associated with experience of sexual harassment is shown in Table 5. Risk of having experienced sexual harassment was found to be significantly associated with age and inhabitation status in univariate analysis. The prevalence of sexual harassment was 1.5 times higher among the younger population aged 18- 30 years compared to those aged 30-55 years. The prevalence of sexual harassment was twice more common among those who lived away from family compared to those who lived in family. Other socio-demographic factors such as place of residence, employment status and monthly income were not significantly associated with sexual harassment.

DISCUSSION

The prevalence of suicidal ideation and suicide attempts in this study was found to be 31.1% (95%CI 23.3%-39.8%) and 46.2% (95%CI 37.4%-55.2%) respectively. Suicidal ideation among transgender people ranges from 10.0% in the study conducted by Mustanski et al to 35.1% in the study done by Bauer et al.^8,9 Prevalence of lifetime suicide attempts among transgender people across the world also has a wide range from 11.2% to 50%, highest of 50% found in India and Australia.² The wide variations may be because of differences in study design, racial, ethnic and cultural beliefs. Suicidal ideation and suicide attempts were higher in the younger population and decreased with increasing age. In this study very high proportion of transgender population belonging to the age category of 18-30 years of age had both suicidal ideation (89.2%) and suicide attempts (83.6%). Similarly in the study conducted in William Institute by Ann P. Haas et al, Suicide attempts was high in the age category 18-24 years (45%).³ In the study done by Kristen clement- nolle, 32% of participants who had attempted suicide were below 25 years of age.¹⁰ This may be due to the higher vulnerability of the younger transgender people to sexual harassment. In our study, suicidal ideation and suicidal attempts among commercial sex workers were 37.8% and 43.6% respectively. Contrary to the findings of studies done elsewhere (William institute), the proportion of suicidal attempts in our study was higher among participants from higher socio-economic status.³ One possible explanation could be that majority (86.6%) of our study participants lived separately from their family and hence had a higher per-capita income (class II & II of modified BG Prasad’s classification of socio-economic status).

In our study the proportion with suicidal ideations and suicidal attempts were more among transwomen than transmen. In the current study about 1.8% of transmen and 89.1% of transwomen had suicidal ideations. Toomey et al also reported that suicidal attempts are common among transwomen (50.8%) compared to transmen (29.9%).¹¹ However, in the study done at William Institute, the proportion of suicidal attempts was higher among the transmen (46%) than among the transwomen (42%).³ Another study done by Gold et al showed that 32.1% of transmen and 26.5% of transwomen had attempted suicide during their lifetime.⁵ These differences in the findings could be attributed to lower proportion of transmen (4.2%) being included in our study. The prevalence of self-reported sexual harassment among transgender population was 84.87% in our study. In this current study, the distribution of sexual harassment with sociodemographic and gender related characteristics was analyzed and it was found that participants aged less than 30 years and those living away from the family were at higher risk of experiencing sexual harassment. There was no significant difference in the experience of sexual harassment among different socio-economic groups. In this current study 93.1% of the transwomen had faced sexual harassment. Another study done in Spain had also reported that the transwomen faced more harassment than transmen in any form.¹²

The National transgender discrimination survey by Grant et al conducted in USA also reported that 64% were sexually harassed at some point of time in their life. About 12% of the survey participants had faced sexual harassment at school and about 90% had faced sexual harassment at workplace.⁷ Another study done by Kimberley J. Mitchell et.al. showed that 42.85% had faced sexual harassment in any form.¹³ Shaw et al in Karnataka, India reported that 17.5% of the participants had ever faced sexual harassment.¹⁴ The reason for higher proportion of sexual violence in our study could difference in employment opportunity, family and peer support, stigma and discrimination associated with transgender population, socio-cultural beliefs, sample size and sampling strategy etc.^15-17 In our study, younger transgender population, living in urban areas, living away from family with other transgender population and involved in commercial sex work were more exposed to sexual harassment and also had higher suicidal ideation and attempts.

Limitations

Current study is subject to certain limitations. First, due to the nature of our study sample, we could not compare equal numbers of transwomen and transmen, which could have led to an underestimation of the problems faced by the latter group.

CONCLUSION

Transgender population face many problems in Indian society as compared to the normal population. Almost half of them have attempted suicide at least once in their life because of family rejection, stress and stigma and most of the transgender population had experienced sexual harassment at some point of time in their lives. But the younger transgender population had higher exposure to sexual harassment, suicidal ideation and attempts as compared to the older transgender population. The reasons for the associations between these phenomena and specific demographic variables need to be explored further. It is important to address negative societal attitudes towards this population. Therefore, this group should be focused in provision of mental health services and protection against abuse or harassment. Community-based approaches, which have already been tested in some parts of India with good results may facilitate this process and reduce the risk of suicide in this vulnerable population. Transgender people wish to be treated as equals and normal but, most of them have been denied their rights to live in the society. The general community needs to be sensitized to the plight of the transgender population to reduce stigma against them.

ACKNOWLEDGEMENTS

The authors would like to thank Dr. Palanivel C, Additional Professor, Dr. Shanthosh Priyan, and Dr. Gilbert, Senior Resident, Department of Preventive and Social Medicine, JIPMER, for their valuable inputs. We also thank Dr.Jilisha G, Mr. Saravanan.E, Master of Public Health Scholars, JIPMER, for their technical support throughout the study. We would like to express our gratitude to all the study participants and Head of the SCOHD society, Puducherry for their valuable co-operation during data collection. Timely assistance from the faculties is also greatly acknowledged.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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