Abstract
Background: Transgender is an umbrella term, used to encompass people who have a gender identity or gender expression, which differs from their sex assignment at birth. Being independent of sexual orientation, they have often been classified as the “third sex.” Based on various sociocultural traditions and beliefs, they are frequently “othered,” discriminated, and stigmatized against. This has led to their limited social inclusion and participation. In the social diversity of a populous country like India, transgenders are termed as “hijra’s,” belonging to a separate social community. Their experiences, perceptions, and unmet needs are rarely evaluated.
Methods: Qualitative approach was used to explore the “lived experience” of 4 individuals who are part of the “hijra” community in Kolkata. These individuals were born with ambiguous primary sex characteristics. In-depth interview was conducted with these participants with subsequent transcription. Interpretative phenomenological analysis (IPA) was used for analysis.
Results: A total of 2 superordinate themes (identity issues, relationship issues) and 6 subordinate themes emerged from the analysis (identification with feminine gender, perceptions regarding caregivers, perception regarding siblings, perception regarding childhood peer groups, identification with the hijra community, societal rejection). The findings have been discussed in terms of identity process, social and cultural construal of hijras in this part of the world.
Conclusion: In India, the transgenders (hijra community) represent a unique subculture besides the heterosexual groups. Understanding their relationships, sexuality and societal interactions are vital for their psychosocial well-being and related interventions. This study adds to the shared understanding of their marginalization and lived experiences, in their own voices.
Introduction
In India, transgenders (termed as “hijras”) are those people who are born as hermaphrodites or mixed unformed biological sexual characteristics. The uniqueness of hijras is that they exist beyond the sanctified social or familial structure but, paradoxically, in the Indian society, the hijras find place in the history and mythology. For example, many Hindu deities manifest as both males and females or as a merging of the 2 sexes in their different incarnations, eg, Lord Vishnu as Mohini, an enchantress with the task of luring away the demons from the elixir of life (Amrita), or Ardhanarishwara (merging of Shiva and Parvati), respectively. In South India, Aravan is worshipped as a deity of the hijras as he had communion with Lord Krishna prior to his sacrifice for his father Arjuna. In the contemporary context, the hijra community is heterogeneous and is composed of not only people who are born as hermaphrodites but also men, who voluntarily undergo emasculation and join the community. However, in contemporary India, the gender nonconformity of transgenders makes them marginalized in terms of lack of a gender recognition, sexual expression, employment, decent housing, subsidized health care services, and as well as the risk of violence and various forms of transgressions they suffer. Therefore, in India, the hijras represent a controversial and miniscule community, the term itself having a pejorative context. As a result, their unique psychological and social experiences often do not find a voice or space in academic forums. In order to recognize the hijras’ space in the gender continuum and to address their rights as citizens of the subcontinent, it is pertinent to explore their psychological journey, in their own social context.
Methods
Aims and Objectives
The aim of the present study was to explore the subjective experience of “living” as a “hijra” in Kolkata. The term “hijra” is used in the indigenous language (Bengali) to describe people who are born with incompletely matured primary sex characteristics of both the sexes and also follow gender roles that are different from socially sanctioned gender norms. The present study adopted a qualitative approach of data collection and analysis as these experiences (lived experience of being a hijra) can be thought to be relative to each individual and specific to the social context under study. Rich data exploring their lived experiences could be best collected using qualitative methods.
Operational Definition of Key Constructs
For the purpose of this study, “hijra” has been construed as individuals who have been born with incomplete sex organs of both sexes thereby making the individual incapable of sexual reproduction and presenting with abnormal or undifferentiated external genitalia. The authors provide a disclaimer that the term is just used to describe their community (as it is called in the local sociocultural context) and has not been intended to label or stigmatize them in any way.
Selection Criteria for Participants
As is already known, hermaphroditism in humans represents a disorder of sexual differentiation and is an extremely rare condition with a prevalence ranging from 0.05% to 0.06%. 1 In India, these individuals with intersex attributes often lead their life in a closed community, which also consists of people who are not born as hermaphrodites but have chosen to be a part of this community because they have unique sexual preferences, different from main stream social norms; chief livelihood being begging or participating in certain social rituals like birth of a child, marriage, etc, and also asking for alms in these occasions. These activities are often enforced as a part of social obligation, due to lack of alternative ways of earning, compounded by the social prejudice.
Sampling Technique and Participants
As has been already stated, in terms of prevalence, hermaphroditism is an extremely rare condition and it is very difficult to get acquainted with a hijra in Kolkata. Also, the livelihood of majority of hijras in Kolkata is moving around in public spaces, like bus, train, crossroads, etc, in groups comprising also of transgender and asking for alms from public. For this research, the researchers approached few of them and briefly explained them the nature of the study and requested them to help the researcher identify individuals who are born as intersex. At first, the researcher got acquainted with one of them who was willing to participate in the study. Subsequently, a sampling technique akin to snowball sampling was used where in 1 participant refers the researcher to another participant. The final sample consisted of 4 participants:
Participant 1 (56 years) Participant 2 (23 years) Participant 3 (22 years) Participant 4 (43 years)
All the participants were conversant in Bengali and so the interviews were conducted in their mother tongue.
Tools Used
the psychological and social appraisal of biologically determined sexual identity,
sexual identity and its incongruence with preferred gender identity,
reactions from family and society for being born as a hermaphrodite,
Decision of leaving home and choosing a profession solely belonging to persons with ambiguous biological gender,
Trauma and tribulations faced for being a hijra.
Interpretative Phenomenological Analysis
Interpretative phenomenological analysis (IPA) is an approach to qualitative research, which is concerned with exploring and understanding the lived experience of a specified phenomenon (in this case, “the experience of being a hijra”).
3
IPA was introduced by Smith
4
as a means of analyzing data, but it has evolved to be a methodology in its own right. To be more precise, IPA involves the detailed examination of participants, such as
their lifeworlds, their experiences of a particular phenomenon, how they have made sense of these experiences, and the meanings they attach to them
The other distinctive feature of IPA is the concept of “double hermeneutic.” Smith and Osborn
5
used the term “double hermeneutic” to emphasize that 2 layers of interpretation are imbued in IPA, namely,
the first is the participant’s meaning-making (interpreting their own experience), the second is the researcher’s sense-making (interpreting the participant’s account),
2
and thus, there is an inevitable circularity in the process involving questioning, uncovering meaning, and further questioning; this circular process of understanding a phenomenon is called the “hermeneutic circle.”2, 6, 7
Procedure
The interview schedule was prepared keeping in mind that members of the hijra community prefer not to disclose much information about themselves and require a sensitive handling because of their unique sexual identity and are mostly recipient of callous and uncaring responses from the general society. The interview schedule tried to elicit information in a nonthreatening manner from the participants regarding their early life, socioeconomic status of family of origin, realization related to their biologically determined ambiguous sexual identity, the age when they took the decision to relocate to a community composed of people like them, educational and occupational training, etc. Another purpose of using the interview schedule was to develop rapport with the participants before going over to the in-depth interview where they are expected to talk about personal issues, which are more significant from an emotional point of view. During this process only, the participants were debriefed about the research and asked to consider carefully whether they were willing to share their personal thoughts with the researcher.
Triangulation and Determination of Trustworthiness of Data
The data was transcribed by the first author, but simultaneously and independently coded and interpreted by the other authors. Only those codes and/or themes were sustained that were corroborated by all the 3 researchers.
Ethical Issues
Formal ethical clearance was obtained from the University of Calcutta, Kolkata. The data was maintained as strictly confidential, including the identity of the participants. Since the participants would be discussing about life experiences that are extremely personal and might evoke unpleasant emotions at times, participants were told that they can opt out of the research at any point even if they had given prior consent. This was done to ensure that the well-being of the participants is not affected.
Results and Analysis
Data was analyzed in 3 steps. At first, rudimentary themes were listed chronologically, and then subordinate themes were emerged by clustering these rudimentary themes, at last superordinate themes were extracted by clustering the subordinate themes.
Superordinate Theme 1: Identity Issues
Subtheme 1: Identification With Feminine Gender and Sexuality
“What about our life? Neither we could be a mother nor will anyone marry us and let us be a part of their family… We have to live our life alone. There is nothing to do, so we spend our life with public entertaining them. This is our life…. We had only one grief in our live that we could never hear the word ‘maa’….”
“…every human being has a wish that he/she would have a family. I used to brood about this earlier…. Now I have stopped brooding about these things…. In my earlier life, I wished that if I would be just like you people, I could have a child, would have a husband….”
“It is true that I have a wish that I will stay with my boyfriend, together. I don’t need any child that is not possible also. I just want to stay together. I will wash my boyfriend’s clothes, will cook for him. I have a dream that he will love me very much. But I don’t know whether my dream will be fulfilled or not. I truly loved the 3 guys but everyone cheated me. They have broken my heart….”
“Before I came into this ‘line’, I used to sing and dance, and I used to play with my friends. I used to spend most of the time with girls. Everybody used to humiliate and call me ‘meyenyakra’, ‘mogra’ (slang languages applied for those, who behave like a female). What else would I do? I didn’t like being with boys, so I used to play more with girls.”
Subtheme 2: Identification With “Hijra” Community
“there were some other people just like me, but they are not hermaphrodite (hijra), they are gay. Do you understand the meaning of gay?? They were made friends of me. They are my very good friends. I used to share all my feeling, emotion with them freely, they also have shared their feelings with me freely….”
“kinnars never harm others. If anyone tease her, then they use slang. They never harm others. They always want well for other people. We always pray to the God. Why God has sent us in this world? For the prayer (‘dua’ in their term).”
“No, I have told you before, we do all the things among ourselves, I have my guruma, she treats me like her child so she can obviously scold me. If she wouldn’t rebuke me, who else will? Like when I feel sad, I would tell guruma, or else who will listen to my sorrows. Because even if I tell others, they would say, ‘go solve your problems on our own’.”
“I don’t have friends’ related trouble. My friend is my own self; my friends are those who work in this ‘line’. I love them, they love me. I fight with them; they fight with me. We quarrel among ourselves. We do all the things among ourselves, because we know today we may fight, but tomorrow we can work out things between ourselves. But if we fight with others, they would not resolve with us.”
Superordinate Theme 2: Relationship Issues
Subtheme 1: Exploitative Relationship With Males
“Many people told me they would be with me, they would marry me, but I think if they would even marry me, after they got to know about my particular self, would then also they want to be with me, spend their life with me? They never would. I live silently with this pain burying in my mind.”
Subtheme 2: Perception of Caregivers
“Neither I’m a boy nor a girl. I was born as a kinnar. When my parents got to know about me, they didn’t tell anything to the masis who used to come in my neighborhood. When I got my consciousness, I understood about my true-self. I left my home at the age of 13…. …No, my parents didn’t give consent of my leaving. I came out forcibly. Because, no parents would ever leave their child no matter what the child will be; a boy, a girl, or a kinnar. No guardian would ever leave….”
“…there is very much suffering in parent’s home. Father worked in bank. Suppose we have 7 to 8 brothers. When father died suddenly, our family started suffering. I have worked as a maid servant in other’s house, picked cow-dung, wood, etc. I have saved my family members by doing very hard work. Then I met with some hijras in our locality. They took me with them.”
“My mother did not allow me to go outside … in my childhood…. I never understood why my mother kept me inside the home. She never allowed me to mix with others. My father did not like me at all. He does not love me….”
“I was not allowed to go outside, my father used to behave with me very badly. He did not talk with me. My father said that my face is very unlucky for him. But my mother always used to say, whatever she may look like, she is my child. I have kept her in my womb for 10 months 10 days. She may be blind, may be lame, or may be a kinnar whatever he/she is, he is my son, she is my daughter. She used to say in this manner….”
Subtheme 2: Perception Regarding Siblings
“I have sisters. I need to take care of them. I have learnt to earn now. I work hard for them only and I pray to god that my luck has turned out to be this, but at least my sisters could lead a good life and my mother would be in good health. One of my sisters got married while my father was alive…. I took the responsibility of marrying of another sister…. There is one more sister who is yet to get married…. I am trying to find out a match for her….”
“…My sisters might look after me. Everyone should understand that they cannot be self-reliant for the entire life…. As god has made me like this that is why I’m bearing all these sufferings in my life….”
“I have 8 siblings. Then there was so much poverty, suffering. Elder brother did not get a job…. I fell on the feet of the barokorta (Supervisor) to let my brother work….”
Subtheme 3: Perception Regarding Childhood Peers
“When my friends got to know about me, they started to avoid me as I grew up and became different from them. Their families told them not to talk with me and that had devastated me.”
“When I grew up … other girls as well as boys used to stay away from me. Nobody talked with me. I spent my childhood all alone. Nobody wanted to mix with me…. Nobody played with me. After growing up, I found that I don’t have any friends….”
Subtheme 4: Rejection and Exploitation by Society
“About the government? Yes, they also don’t want us to work on road. When we used to work on road, ‘they’ (the politicians) prohibited our road work. But at the time of vote, they want us; kinnars’ votes. So, are we counted on for election purposes only? Because if the government didn’t get our votes, they wouldn’t even probably have had won the election.”
“When people have used the term ‘hijra’ naturally it was very hurtful. There is a sympathy, kindness, and love in every human being both in male and female. We also have the same thing. Everybody has a heart….”
“…There was a child who used to beg at the railway track. One day I took her with me into my house. I have reared her. She used to do household task, used to be at home. I have reared her as my own daughter. All I have done alone. I reared her up, extravagantly married her to a good match, gifted ornaments. Everything I did by myself. The husband is very good. But now she doesn’t talk to me….”
“I gave exams in private from Ramakrishna Mission…. I gave exam from there. I did not go to school the whole year, used to read at home. I went outside once in a year but wearing burka….”
“I went to a company for a job once or twice, where boys and girls both work. The manager of that company said to me, I can’t work there. The boys will discuss about me. So, we can’t give you the job…. Then I went to the factory of inner garments, they also told me the same thing….”
“There is no government that would give us money or work. People say government has money, but they never give us a goddamn penny, I have seen that since I was born. There is no one to look after us, take care of us. There is no law for us, nothing.”
Discussion
This study is unique in conceptualizing the “lived” experience of those people who have been born with an ambiguous biological sex and belong to the “hijra” community. These people in this part of the world are primarily engaged in badhai and badhni (a dialect within hijra community where badhai refers to the dance performance during wedding and birth of a baby and badhni refers to begging). It is interesting that all the participants share some similarities in the manner they describe their lived experiences, which also reflected their psychosocial status. Wandrekar and Nigudkar, in their detailed review of mental health related to the LGBT community from 2000 to 2019, mentioned the dearth of research regarding their societal needs, lived experiences, and factors related to their well-being. 8 This study essentially attempted to explore that under-stated area. On the basis of the analysis of the transcripts, mainly 4 subordinate themes and 2 superordinate themes could be identified.
Identity Issues of Hijras
As is evident from the transcript, all of the participants reported that they were born with an intersex condition. It was evident from the transcripts that most of them had an intense need to be a “female” and to lead the life of a female, like marrying a male, setting up a family, bearing children, etc. But, because of their biological constitution, they were incapable of reproduction and are also bereft of secondary sex characteristics unique to a female. However, they dressed up as females and adopted feminine behavior such as having long hair, putting up makeup, plucking facial hair, etc. Other researches have also pointed out that most of the hijras have an intermediate gender identity which lean toward feminine identity. 9 There is a social convention that hijras do not marry. The hijras who were the participants of the study also confirmed that they were not married. There has been ambiguity related to transgender marriages in the Hindu Marriage Act, 1955. However, after the historical “Section 377” judgment of the supreme court, thoughts were rekindled about rights of the LGBT community, and discrimination against them were condemned. 10 In fact, in one of the recent landmark judgments, the Madurai bench of Madras high court upheld the rights for transgender marriage, stating that a person who is born as an intersex but identifies herself as a “women,” should be considered to be a “bride” under the Hindu Marriage Act, 1955. 11 It was reaffirmed that transgender rights fall within the “rights to equality” granted by article 14 of the Indian Constitution, which is a “fundamental right.” However, unfortunately these laws rarely transit into common understanding and community practice. This creates agony and sense of purposelessness in hijras. These participants have repeatedly expressed their cravings for a so called “normal” family, ie, where they play the role of a wife or a mother. It is possible that this adoption of feminine identity may help to restructure their cognitive framework and, somehow, give them a sense of satisfaction. These participants have also spoken about their seemingly unsettling emotional experience of being sexually attracted toward males and the coercion of the society to suppress such feelings. The pressure of the heteronormative society makes these people (hijras) develop a self that is unsure, insecure, and over compliant, show a constant expression of docility and abjection in search of intimacy. Interestingly, the interviews are abundant with examples of their obsequiousness toward unworthy people in search of a “family” or “conjugal” life. It is possible that these hijras in their struggle to fill the vacuum created by their inability to play the role of a “mother” or a “wife” and to search for natural intimacy fall prey to exploitative and abusive relationships dominated by males.
A very important finding was the manifested need of the hijra participants to be “mothers” and their attempts to take care of other vulnerable children in the community as a way of satisfying unfulfilled maternal desires. A different study had also found out that her respondents (hijras) put special emphasis on motherhood, in their daily life, eg, guruma and chela relationship and initiation rituals all of which supposedly attempt to construct a sense of identity, characterized by filial bondage. 12
Identification With the Hijra Community
Another interesting observation was that all of the participants preferred to use a dichotomous pattern of referral where “them” refers to people who have normative sexual and gender identity and “us” are people who are non-normative (mostly hijras and also other people who deviate from this norm, eg, transgenders, homosexuals, etc). These hijras clearly state that the people belonging to the “them” category treat the hijras in a demeaning manner. Hence, to maintain their dignity, they (hijras) try to maintain a distance from these people. This “we versus they” dichotomy has been the basis for their “othering” in society. According to the hijra participants, their sense of belongingness with the hijra community helped them cope with feelings of deprivation and vulnerability. Also, it is in this group that they could openly discuss their emotions, pains, needs, etc, without the fear of being negatively evaluated or discriminated. These participants were of the opinion that though our society has witnessed a lot of progress in various matters, the society is still largely dominated by the concept of an essentialist binary gender. From a psychological point of view, the striving for identification with the hijra community is in line with the concepts 13 that all have a basic need to be loved and accepted. Ghosh had also obtained similar findings from her ethnographic study of hijras of Bankura, a district in West Bengal, India. 14 Her respondents have repeatedly articulated the importance of these relationships within the community to develop a stable sense of identity. Such identification with the community also serves to strengthen the social position of being identified as a hijra. Shawkat 15 had described a complex social network system within the hijra community, which acts as a buffer against the discrimination of the larger society. Bakshi 16 had also talked about the distinctive social system of the hijras characterized by unique forms of communication, initiation, and death rituals, which help them to deal with stigma and marginalization.
Relationship Issues
Most of the participants stated that their relationship with parent and siblings was very positive. At the same time, they also reported that they have independently taken the decision to leave their home once they attained puberty. So, apparently their engagement in this profession is a choice freely made by them. Puberty is a universal developmental stage, which is accompanied by significant physical, cognitive, and emotional changes. In many parts of the world, the onset of adolescence is marked by autonomy and sexual freedom. In the Indian social context, individuals have an extended period of social and economic dependence on the parents or the family of origin. As a result, adolescents in this part of the world have a lesser share of autonomy with respect to various psychosocial issues. Hence, even in economically backward families, adolescents are not expected to leave the “cocoon” of parental protection and start earning. Hence, the self-disclosure of all the hijra participants that they have left the parental home on attaining puberty warranted further explanation regarding the following questions:
Why their parents accepted their decision of leaving home, moving to a foster family (hijra community) and taking care of their financial well-being, without any apparent emotional resistance? How could their parents not urge them to lead lives at par with their siblings?
This brings forth a very critical and sensitive question—“Were the decisions taken by the participants to move out of the family of origin, actually voluntary?”/Were these decisions shaped by circumstances and societal apathy. The participants had also shared similar vague thoughts regarding their relationship with siblings and peers. On one hand, these participants reported of having an affectionate relationship with their contemporary figures; but, on the other hand, they also report of experiences of neglect, bullying, and shaming from their peers and siblings along with feelings of loneliness. Late childhood is typically referred to as “gang age” by developmental psychologists and such interactions with members of the same age is crucial for the social as well as identity development of the child. It is likely that these individuals (hijra) experienced alienation from their contemporaries during this age, which had a lasting impact on their psyche. But, for some reason, all of them (4 hijra participants) refuse to acknowledge the experience of lack of love and trust with their peer and siblings.
Such an ambivalent attitude on the part of the hijras toward their early life relationships seems to portray their need for acceptance from the conventional family. There is no denying the fact that family is the crucial most source of nurturance and positive self-appraisal, and obviously it is not possible to accept the extreme rebuff from the family, without detrimental psychosocial consequences. It is noteworthy that more than 1 participant reported of having compromised their education for the sake of their siblings. At the same time, it was obvious from their unspoken words that they do not share a very congenial relationship with these siblings. Such events are also suggestive of the widespread nature of social discrimination directed toward intersexed people. Research findings are also abundant with regard to the fact that the marginalization of the hijras usually starts at the family level and subsequently spreads to the society at large. 17
Rejection From Society
The findings of the present research are consistent with earlier research findings, 17 which reflect that hijras are mostly alienated from their families and society. In spite of the fact that there are some lingering beliefs that hijras bring good luck at weddings or after birth, there is widespread fear and mistrust associated with hijras. All 4 of the participants affirmed that they had been stigmatized and remained underprivileged throughout their life. One of the participants shared the story of being forced to wear a burka while appearing for Board (Secondary) examinations. Though the Board granted her a transgender status, it is obvious that she was not sure whether the attitude of the invigilators or coexaminees would be favorable. The same participant shared her experience of being unduly rejected from jobs because of her marginalized gender identity. Shakwat 12 had interviewed 5 hijras from Bangladesh and reported that often family members such as elder siblings or fathers would bully, assault, or lock up the individual (hijra) as a means of displacing the frustration of being shamed by their peer for having a “deviant” offspring/sibling. In fact, one of the hijra participants of this study also reported of being abused and assaulted by the father. So, it is reasonable to assume that the stigma of being a hijra is initiated within the family of origin forcing them to seek a life outside the biological family constellation. According to Reddy 18 in a traditional Indian society, when the siblings reach marriageable age and one sibling is entering the institution of marriage, the presence of the other sibling who is not supposed to marry becomes conspicuous. So, these people (hijras) are often left with no choice other than moving out of the family to protect the latter from social wrath and stigma. In that way, they seek their own group for inclusion and connectedness. Peer validation has shown to improve their self-identity and psychological well-being. A queer affirmative cognitive behavioral therapy based group-therapy intervention had shown to improve the distress, reduce the social isolation, and enhance knowledge and skills related to self-sustenance in the transgender community. 19
This study had a small sample size, owing to the difficulty of accessing and interviewing people from the transgender communities. They often are apprehensive to share their inner feelings or consider it as another “social shaming” attempt. However, rich data from in-depth interviews can be rigorous, irrespective of sample size in qualitative studies. 20 Also, the inherent limitations of a qualitative study are to be considered, like the subjectivity bias and generalizability. However, triangulation was used to improve the data rigor.
Conclusion
In India, hijras represent a unique subculture existing alongside the heterosexual family. One of the difficulties in writing about the transgenders is the disjunction that exists between the cultural definition of “hijra” role and the variety of individually experienced social roles, gender identities, sexual orientation, and life histories of people who become the “third sex.” Sexual identity is a complex and heterogeneous concept, and thus involves experience and expression of each unique group to shape their attitudes, beliefs, and practices. 21 This study is thus a unique attempt to understand the subjective experience of 4 such individuals born with intermediate primary sex characteristics and leading the life of a hijra. All the participants have retold their experiences of living based on their “third gender.” The shared understanding that has emerged reflects that hijras in this part of the world have not been able to come to terms with their inimitable sexual identity because of the subversive pressures from the heteronormative society; their experience of social discrimination starts from the family, forcing them to leave the family of origin; they try to reconcile with their needs for love and acceptance by partially denying the role of their family in marginalizing them, and by giving in to abusive and demanding relationships. But they also reconstruct their sense of self by developing a committed relationship with their community members and trying to take care of children who are vulnerable. They mostly have inclination toward a feminine identity. However, the cascade of rejection and discrimination from an early life has a ripple effect on the lives of these people; wherein they are less educated, less privileged, less empowered, polarized, and “othered.” This study could have been enriched, if the ambivalence or disjunction in the biological, social, and cultural constructs of a hijra and the associated agonies that plague such individuals were explored. Qualitative studies using grounded theory and ethnographic approach would be necessary to further explore their societal roles, relationships, unmet needs, and hence shape awareness, understanding, and administrative decisions regarding their care and safety.
Footnotes
Acknowledgment
The authors would like to thank all the participants of the study.
Author Contributions
All authors have contributed equally in conceptualizing the study, analyzing and curating the data, and preparing and reviewing the manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Statement
Written informed consent was taken from the participants, in accordance with prescribed ethical standards.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
