Adapting Psychiatric Case History Taking Practices for Indigenous Transgender Communities

Abstract

While there is ample sociological or anthropological insight into the lives of Hijra persons in India, very little of it has been utilized in praxis for making mental health-care spaces Hijra-inclusive. Dominant discourses in Western psychiatry fail to tend to this community, predominantly because of its colonial gaze, inability to think beyond binaries, fancy to put “gender nonconformity” into diagnostic labels, and lack of intersectional focus and culture sensitivity. This is corroborated with remarkable service underutilization in this group as a parallel reality. Case history taking is an important part of any mental health intervention. In this article, the author shall attempt to delineate how psychiatric case history taking may be adapted to the needs of potential Hijra clients through ethnographic input from their lives. These provocations were initially shared by the author at the virtual Criposium Conference, 2020, organized jointly by King’s College London Disability+Intersectionality Reading Group and SOAS Crip Feminist Reading Group.

There is very scanty literature that documents what constitutes good praxis when working with indigenous transgender communities in non-Western mental health-care systems. Western psychiatry fails to address these issues effectively because Euro-American gender binaries do not replicate strictly in these communities. This article tries to brainstorm some reflections on how psychiatric case-history taking procedures may be tailored to meet the needs of indigenous transgender communities by taking the Hijra community as a case in point.

Who Are the Hijras

The Hijras represent a native queer subculture of South Asia that lies at diverse intersections of (a) gender nonconformity, (b) parallel sexualities, (c) nonmetropolitan and indigenous identifications, (d) low socioeconomic status, (e) lack of conventional sociocultural capital, and (f) unique kinship networks. The Hijra subculture houses a spectrum of transgressions, mostly performed by the queer male-assigned-at-birth body. Common identifications include: (a) effeminate gay men, (b) transsexual individuals (usually male to female), and (c) transvestite and intersex individuals.^1–3 Mal ⁴ also mentions “Chhibris” who are biologically fit females with “fake” Hijra identity.

Context in Which the Hijra Client Comes to the Mental Health Clinic

Hijras face a lot of discrimination and violence in their daily lives which might impair their mental health adversely. Meyer’s minority stress framework posits how minority status and resultant routine conflict with dominant culture may be a driving factor for pathogenesis and is associated with high levels of distress and mental health outcomes. ⁵ This understanding can be expanded to the Hijra population in India as they face unique, chronic social stressors that can only be rendered intelligible in the light of ethnographic inputs from lived realities. In parallel, the lack of utilization of mental health services in this population is highly discouraging while the singularly important context for consultation is for sex reassignment surgery. ⁶ In this case, the mental health professional’s opinion on the Hijra individual’s fitness to seek surgical interventions (for affirming gender identity) is sought as per World Professional Association for Transgender Health (WPATH) guidelines. ⁷ Usually these consultations are at NGO-based and community-based frameworks outside the purview of public hospitals. ⁶ Often, there is fear of maltreatment and ridicule by doctors and hospital stuff. ⁸ Ground-level sensitization regarding the Hijra community is lacking in professionals. Therefore, there is a dire need to make mental health-care systems Hijra-friendly to facilitate smooth navigation and increase service utilization of this vulnerable population. This article is an affirmative effort in that direction.

Need for Focus on Case History

In mental health care, case history taking is the only plausible means to reach a diagnosis. ⁹ It is often the entry-point of conversation with a mental health professional. By essence, case history taking involves communication between the client and mental health professional. Empathic listening is a hallmark of such communication and is largely responsible for patient satisfaction. ¹⁰ Considering the systemic invisibility of the Hijras in mental health care, an affirmative history taking protocol is an essential development. The report of the United Nations Development Programme reflects how mental health of this community is grossly neglected and this calls for systemic reforms. ¹¹

Toward a Hijra-Inclusive Case History Taking

In adapting history-taking protocol for Hijra clients, there is a need to talk back to conventional history-taking practices. The first step forward would be to break out of the clinical illusion of the Hijra individual as a living embodiment of pathology. Alternately, efforts must be made to know the community outside the clinical space and to let praxis be driven by experiences and ethnographic input from the community.

The author’s provocations are presented in the form of pointers. These provocations are colored by the author’s own queer/trans self-identification and prolonged association with queer rights activism. For logistical constraints, the author shall hereafter refer to mental health professional as MHP.

1. The Hijra individual may present with a feminine name, which may not fit the normative expectations that flow from their sex assigned at birth. This name might also differ from their official documents. Feminine names are taken up by or given by guruma to individuals in the Hijra clan as recognition and appreciation of their personhoods. ⁶ The MHP must respect that and take note of it, rather than downright demanding to know their “real” name. The name assigned at birth can be elicited by way of further conversation for record-keeping.

2. Common health-care practice in India is to address Hijra individuals using male pronouns which is derogatory and transprejudiced. ¹¹ Gender identity of Hijra individuals should be asked and not assumed. Pronouns are to be enquired and used accordingly.

   The best way is through an emic approach, through the individual’s self-determination. ² Many Hijra individuals may consider themselves to be of the third gender, as neither male nor female. This not only challenges Western binaries of gender but also training in Western psychiatry that is based on such assumptions. Respecting the selfhood of the person and affirming it must be upheld at all costs.

3. Even when referencing the sexual orientation of the Hijra person it is essential to frame it in intersection with their gender identity. Ideally, the MHP must ask and not assume in this regard and be wary against being swept away by cultural stereotypes of Hijra sexuality.

   In case of third-gender identification, sexual attraction toward men may be regarded as being androphilic. However, if the Hijra individual self-identifies as a woman who is attracted to men, she may be deemed to be straight or heterosexually inclined. Often the Hijra individual may be in a marital union with a woman and that needs to be indexed accordingly. It is also essential to clearly elucidate these nuances so that they are communicated with clarity, precision, and affirmation.

4. The MHP must be familiar with regional/vernacular vocabularies for parallel sexualities and/genders to self-identify from. Some examples may be Khoja/Chhinni ⁴ (a castrated Hijra through the removal of penis, testicles, and scrotum), kothi ¹ (the effeminate male with feminine dressing, speech, and behavior, who is often sexually passive).

5. Hijras often have secret code language (such as Hijra Farsi, Ulti) that helps maintain privacy, discreteness, and distinctiveness. ¹² Elements of the same might come up in casual conversation with an MHP, in which case the MHP might ask for clarification from the person themself.

6. The potential psychosocial stressors of the Hijra community must be well-known to the MHP beforehand so that they can serve as effective trajectories for taking the conversation forward. This prompts an understanding of their unsustainable and informal sources of livelihoods: income is mostly through begging (mangti), sex work (khajra), blessing newborns, and dancing at weddings/festivals (badhai). Constant migration stress ² (from natal families to “clandestine” “cultural family,” from one identity to another) is an important area of probing. So is vulnerability to violence; violence might be multi-modal. ¹³

7. It is also imperative to have an understanding of the “gharana” ⁴ or organizational structure of living of the Hijras. The MHP must take cognizance of the lifelong reciprocal bond in the guru (teacher/leader)-chela (follower) relationship in Hijra samaj or, instances of camaraderie and sisterhoods among several different chelas under the same guru.^{6, 14} When eliciting family history, this “cultural family” must be equally stressed upon for it is a source of resilience and belonging. Relationship with the guru and other peers are effective areas of probing. Community access and belongingness must comprise an important strand of case-history taking procedures.

8. Fellow Hijra peers must be recognized as credible informants in the clinical setup as the Hijra individual may be divorced from their natal family and may visit the clinic with a peer.

9. It is also good to take a clinical note of how the sexual health of Hijras might intersect with their mental health considering the high prevalence rates of HIV (and other sexually transmitted diseases) in this population. ¹⁵ However, the MHP must be careful not to engage in oversexualization and sidetrack important focus areas.

10. Poor endocrinal health must additionally be taken into account often due to the traditional emasculation practice of “Nirvaan” that is performed by a Hijra senior sans medical supervision.^{4, 6}

11. Double-consciousness of the Hijra individual can be probed into during history taking for they have to behave as men at natal home vs as complete women in community spaces. ⁴ Therefore, the Hijra client may present at the clinic in conventionally male attire too and the gap between gender identity and expression must not be used in their disfavor.

12. It is also prudent to check whether basic essentials of regular food, shelter, and livelihood are available to the Hijra client as many may be lacking in the primary facets of maintaining a healthy life. Mental health must be situated in this context.

13. Elements of community living and lifestyle choices are not to be pathologized and blanket, uninformed snap statements are best avoided. If need be, it may be useful to glance at the contextual realities that maintain these choices and frame assessment and interventions accordingly.

Most importantly, the burden to educate about the Hijra lifestyle must not fall on the client; the MHP must have a prior understanding of Hijra realities to guide the conversational flow.

Conclusion

The way to indigenize case-history taking practices for indigenous transgender communities lies through ethnographically informed praxis that takes into account their distinct contexts in terms of community lifestyle, livelihoods, and unique-psycho-social stressors. It is crucial to be connected with vernacular vocabularies for self-identification and respect pronouns and personhoods of the individual over biomedical reductionism on the basis of assigned sex. There is also an immediate need for MHPs to be trained in affirmative counselling protocol when rendering services to this population so that they can critically locate the deficits in existing case-history taking practices when dealing with indigenous transgender communities and make mental health services comfortable for this section of historically deprived individuals. ¹⁶ Affirmative protocols must in fact be designed in collaboration with local community stakeholders so that it caters to their specific needs.