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Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 282-284

“Family intervention” – A key to unlock the psychiatric morbidities in transsexuals: A case series

Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission18-Jun-2021
Date of Decision12-Sep-2021
Date of Acceptance29-Oct-2021
Date of Web Publication31-Oct-2022

Correspondence Address:
Dr. Vinoth Krishna Dass
No 14, Associate Professor Quarters, Sri Manakula Vinayagar Medical college and Hospital, Kalitheerthalkuppam, Madagadipet, Puducherry - 605 107
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_74_21

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Transsexuals, who form a part in LGBT community, face a great amount of distress due to social stigma and lack of family support. This case series emphasizes the effect of family stigma in three such transsexuals, who presented with psychiatric complaints. A definitive need for scientific research and its application exists to address this stigma and discrimination. ICD-10 criteria were used to diagnose the psychiatric morbidities. Standard scores (Hamilton Depression Rating Scale and Suicidal Affect Behavior Cognition Scale) were used to assess the severity. Familial, individual, and interpersonal level interventions were administered. Significant improvements were seen in two patients (received family therapy) and one patient who did not receive therapy continued to be distressed. Psychological interventions resulted in reducing the family stigma and psychiatric morbidities suffered by them. This is an effort to show the need for implementation of such standard protocols in health-care facilities to address the stigma faced by transsexuals.

Keywords: Family therapy, psychiatric comorbidities, stigma, transsexuals

How to cite this article:
Sanjay L, Selvaraj A, Dass VK, Perarul S. “Family intervention” – A key to unlock the psychiatric morbidities in transsexuals: A case series. Ann Indian Psychiatry 2022;6:282-4

How to cite this URL:
Sanjay L, Selvaraj A, Dass VK, Perarul S. “Family intervention” – A key to unlock the psychiatric morbidities in transsexuals: A case series. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Dec 10];6:282-4. Available from: https://www.anip.co.in/text.asp?2022/6/3/282/360082

  Introduction Top

Gender dysphoria according to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition is defined as a marked incongruence between their experienced or expressed gender and the one they were assigned at birth.[1] Among transgenders, transsexuals are those who desire to have the body of opposite sex. There is paucity of data about the prevalence of gender dysphoria in Indian population, which could be mainly due to the social stigma attached to queer youth. A recent study reported up to 5–6 million eunuchs living in India.[2] Studies prove that familial conflicts of LGBT queer youths, social stigma, and other psychosocial factors result in a negative health outcome in transsexuals.[3],[4] Comparative studies of family, friends, and other supports revealed that family support was more needed for mental health among transsexual adolescents and their self-acceptance of sexual orientation.[3],[4] They are prone to have various psychiatric morbidities such as depression, anxiety, substance use disorders (prevalence of 28%), personality disorder (52% prevalence), and increased risk of self-harm and suicidality (48.3% prevalence).[5] In India, the mental health problems associated with the social and family stigma need more awareness and active intervention at various levels. The clinical importance of intervening at family and individual level will be discussed here and can be adapted to improve the quality of life at a community level.

  Case Scenario 1 Top

A 24-year-old biological male with desire to change to a female, a diploma graduate and currently unemployed, was brought with history of being hit by random men, as she was strolling in the streets and making inappropriate sexual advances. Her desire to change to a female started as early as 8 years of age. She had very low family support and was restricted both emotionally and physically. She had depressive symptoms fulfilling the criteria for depression for more than 6 months. Mental status examination revealed depressed affect with restricted range, preoccupation with suicidal and guilt ideas. The Hamilton Depression Rating Scale (HAM-D) score was 23 which amounted to very severe depression. Thyroid-stimulating hormone (TSH) and testosterone levels were in normal level of the biological sex. Following psychoeducation of the patient and her family, she attended 12 sessions of cognitive behavioral therapy (CBT) paced weekly to address her guilt ideations and negative thoughts, along with antidepressant therapy. Gradually, her family was also involved in attachment-based family therapy. Out of the planned 12 sessions, they attended only 6. The patient's mother was more supportive to the patient after attending the sessions. By the end of individual sessions, the patient had expressed his desire to undergo sex reassignment surgery to the family members and took responsibility of her dad's business. Her HAM-D score came down to 6. After 6 months of regular treatment and follow-up, she was referred to an endocrinologist and a surgeon for further planning on sex reassignment treatment.

  Case Scenario 2 Top

A 23-year-old biological male, educated up to higher secondary, currently unemployed was admitted by his father, with history of poisoning by paracetamol overdose. The patient had strong desire to be a female and was already under hormonal replacement therapy for 2 months. She occasionally cross-dressed when not living with the family. On detailed psychiatric evaluation, she was diagnosed with adjustment disorder with brief depressive reaction and impaired familial relations. HAM-D score was 11. Testosterone was low, and thyroid function test (TFT) levels were normal. Suicide attempt was an impulsive act committed as a result of the family stigma. Unemployment, which played a major role, was addressed through individual psychotherapy. She also attended 14 sessions of CBT to address her suicidal ideas and behavioral disturbances of frequent anger outbursts. Her family was psychoeducated and advised to attend family therapy aiming at interpersonal level intervention. The patient's father attended 12 sessions, but her mother was reluctant and wanted to try spiritual ways. Still with her father's support, the patient came for regular follow-up, got a job, and was then referred to an endocrinologist consultation. HAM-D score then reduced to 4. The Suicidal Affect Behavior Cognition Scale (SABCS) assessment showed a significant reduction from low suicidal risk to nonsuicidal risk at the end of therapy sessions. Effects of psychotherapy on the patient's father perspective helped in breaking the vicious cycle caused by the familial stigma.

  Case Scenario 3 Top

A 19-year-old biological male, an engineering student, was admitted due to poisoning by diabetic and hypertensive medicines. On detailed evaluation, she expressed desire to be a female. Due to familial conflicts and extreme restrictions faced by her, she decided to dress like a male until she became independent financially. She had depressive symptoms lasting for short duration. On physical examination, multiple self-injurious cuts were seen on the wrists. Genital examination was appropriate for the biological sex. Testosterone and TFT levels were normal. She was diagnosed with adjustment disorder with brief depressive reaction, borderline personality disorder, and impaired familial relations. Her SABCS assessment revealed moderate suicidal risk which predicted a high rate of future attempts. The patient and the family were psychoeducated and advised to attend family and individual psychotherapy. However, the family refused. The patient attended dialectical behavior therapy (DBT) sessions focusing on all the four basic skills of emotion regulation, mindfulness, interpersonal effectiveness, and distress tolerance. Group and individual sessions were conducted on a weekly basis. She was able to achieve stabilization of problematic behavior, experiencing emotional pain, and promoting stability and happiness. She expressed her wish to move out after getting employed due to continuing familial stigma. HAM-D showed remission, and the SABCS assessed was nonsuicidal. She is still under regular follow-up and supportive psychotherapy.

  Discussion Top

Social discrimination and family stigma caused severe distress in all three cases described above. All three of them had depressive features with varying duration and severity. Psychoeducation of the patients and their families was given focusing on evoking awareness of the mental and physical effects of social discrimination and family stigma on the transsexual individuals.[3],[4],[6] Positive attitude of family members and their positive effects were stressed in these sessions.[4] Only two among the three families were cooperative and were willing to participate in the planned interventions. Attachment-based family therapy which focuses on building attachment between family members and the patients was tried in two of the families.[7]

Family therapy helped in reducing the family stigma in two of the transsexuals significantly. Individualized therapies such as CBT and DBT were tried for the first case with severe depression and the third case with borderline personality disorder, respectively. Associated psychiatric morbidities (depressive features) and decreased functionality improved with individualized psychotherapy. This was confirmed by a reduction in HAM-D score in all three cases (case 1 – from 23 to 10, case 2 – from 11 to 4, and case 3 – from 12 to 6). In the third case, although the family stigma could not be addressed, the patient's self-injurious and maladaptive behavioral issues were addressed and she attained emotional regulation and distress tolerance skills. The SABCS assessment also showed a reduction in suicidal behavior. Modifiable determinants of family stigma (unemployment and lowered self-esteem) were fixed as target goals to be overcome. Overall, the psychological interventions addressed were found to benefit the transsexuals emotionally.

  Conclusion Top

Lack of family support, family stigma, and social discrimination of transsexuals resulted in psychiatric morbidities. Transsexuals, in the process of transforming, despite suffering discrimination express desire to reassign their sex by taking hormonal replacement therapy and gender-related surgeries.[8] High chances are there for them to undergo unplanned surgeries by unqualified persons, if psychological interventions are not started promptly. Psychiatric morbidities observed in the cases were depression, adjustment disorder with brief depressive reaction, and impaired familial relationship, and one of them had features of borderline personality disorder.[9] Awareness and psychoeducation of the family members of those affected along with psychological interventions such as attachment-based family therapy were promising in alleviating family stigma according to earlier studies.[4],[6],[7] Other interventions that have proven efficient in transsexuals are group psychotherapy and support systems at community level which are not well established in developing countries like India. Standardization of interventions and incorporation of psychotherapies into medical practice to alleviate family and social discrimination by policymakers would prevent unwarranted practices and discriminatory practices against transsexuals in India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. USA: American psychiatric publishing, Inc; 2013. p.451.  Back to cited text no. 1
Kalra S. The eunuchs of India: An endocrine eye opener. Indian J Endocrinol Metab 2012;16:377-80.  Back to cited text no. 2
Rothman EF, Sullivan M, Keyes S, Boehmer U. Parents' supportive reactions to sexual orientation disclosure associated with better health: Results from a population-based survey of LGB adults in Massachusetts. J Homosex 2012;59:186-200.  Back to cited text no. 3
McConnell EA, Birkett M, Mustanski B. Families matter: Social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth. J Adolesc Health 2016;59:674-80.  Back to cited text no. 4
Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend 2012;13:165-232.  Back to cited text no. 5
White Hughto JM, Pachankis JE, Willie TC, Reisner SL. Victimization and depressive symptomology in transgender adults: The mediating role of avoidant coping. J Couns Psychol 2017;64:41-51.  Back to cited text no. 6
Parker CM, Hirsch JS, Philbin MM, Parker RG. The urgent need for research and interventions to address family-based stigma and discrimination against lesbian, gay, bisexual, transgender, and queer youth. J Adolesc Health 2018;63:383-93.  Back to cited text no. 7
St Peter M, Trinidad A, Irwig MS. Self-castration by a transsexual woman: Financial and psychological costs: A case report. J Sex Med 2012;9:1216-9.  Back to cited text no. 8
Reisner SL, Vetters R, Leclerc M, Zaslow S, Wolfrum S, Shumer D, et al. Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. J Adolesc Health 2015;56:274-9.  Back to cited text no. 9


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