TRANSSEXUALISM; A Sri Lankan experience: A descriptive study of epidemiological characteristics and management issues of transsexuals (TXLs) from a tertiary care clinic setting in Sri Lanka

Introduction: A transsexual (TXL) is an individual who seeks or has commenced a social transition from natal gender to desired gender . (1) This transition usually involves hormone treatment or sex reassignment surgery (SRS) . Epidemiological characteristics of TXLs in Sri Lanka (SL) has not been studied to date . Objective: The aim of this study is to describe the epidemiological characteristics and management of TXL clinic attendees at a tertiary care clinic setting in SL . Method: This is a descriptive cross sectional study . Data was collected retrospectively from routine clinic notes on demographic and management characteristics of TXLs registered in the psychiatry clinics of Teaching Hospital Peradeniya from their incept to 31st August 2018 . Data were analyzed using SPSS-17 . Results: Total number of TXLs were 71 with 31% male to female (MTF) TXLs and 69% female to male (FTM) TXLs  . Ratio between FTM to MTF was 2:1 . Majority were Sinhala Buddhists between 31-35yrs . Unemployment was seen in 23% . A comorbid psychiatric condition was diagnosed in 20% on presentation . The clinic has increasingly drained TXLs from almost all the provinces in SL over time . Hormonal treatment was received by 65% while 25% received some SRS . Majority were distressed due to deficiencies in organizing legal documents, hormone administration and SRS . Conclusions: There is an increasing trend in help seeking by TXL individuals . Many were unable to have SRS . There is a major gap in service provision . The study creates awareness on the distribution of the TXLs in SL, their epidemiological characteristics and deficiencies in management .


Introduction
Gender Dysphoria (GD) is the broad term used for the distress caused by incongruency between perceived and assigned genders in individuals who identify with a gender different from their gender assigned at birth .(1) A transsexual (TXL) is an individual who wishes to make the body as conformed as possible to the preferred sex through hormonal or surgical treatment .(1) Estimating global prevalence rates for GD is not easy . The cultural differences would influence behavioral expressions . TXLs with GD are the most easily countable subgroup as they present seeking help . (2) The research on TXLs is scanty and available data are mostly from the western world . Singapore prevalence rates are high with prevalence rates of 35 .2:100,000 or 1:2,900 male-to-female (MTF) and 12 .0:100,000 or 1:8,300, female-to-male (FTM) TXLs .(4) GD is more prevalent among natal males . (5) In most countries, crossing the normative gender boundaries creates moral forbiddance and censure rather than compassion . TXLs are subjected to violence and abuse more than any minority group . National Center for Transgender Equity and the National Gay and Lesbian Task Force in USA 2011 found in their survey that Lesbian, Gay, Bisexual and Transgender (LGBT) people are more than twice as likely as blacks or Jews to be subjected to violent hate crime . (6) TXLs struggle with depression precipitated by stigma, shame and isolation by the society . In a national online sample of 1,093 transgender participants in the US, 44 .1% had clinical depression and 33 .2% had anxiety . Transgender women had a significantly higher prevalence of both depression and anxiety than transgender men . (7) TXL people in Sri Lanka (SL) like their counterparts in the world are socially marginalized and deprived of basic rights . They are publicly ridiculed . They live in fear and shame from internalized transphobic issues as well as transphobia in the community . Human Rights Watch conducted a survey in 4 districts in SL among transgender and homosexual people between October 2015 and January 2016 . They reported legal discrimination towards this group, especially with regards to identification documents, health care and interaction with police . (8) There are different views among the mental health professionals themselves about the acceptance of the condition as a disorder, locally . The general public is in the dark in relation to the mere existence of GD and the other psychological hardships of this community .(9) The religio-cultural and political scene in the country too is not very conducive to identify, accept and help the gender dysphoric . (8) No published data was found on epidemiological factors associated with transgender population in SL in Google Scholar or PubMed from 1980 to date and we have addressed this unmet need . The study hopes to introduce the concept of transsexualism and report the demographic and management characteristics of the TXL population . Authors hope the results will help to formulate management guidelines for the country for this unique, ignored and maligned community .
Aim of this study is to describe the epidemiological characteristics and management of TXL clinic attendees at a tertiary care clinic setting in SL .
A second, qualitative arm of this study which is under way intends to look into the psychosocial adversities faced by the local TXL population .

Methods
Ethical clearance was obtained from the Ethics review committee, Faculty of Medicine, University of Peradeniya . In this retrospective study, clinical records of all the TXLs registered at weekly adult psychiatry clinic and sexual disorders clinic of Teaching Hospital Peradeniya (THP) were reviewed, from the time of inception on 16th of April 1985 and 15 th of June 2011 respectively to 31st of August 2018 . All the patients diagnosed with Transsexualism were included except those with a psychotic illness .
Following the registration of subjects, a detailed assessment is carried out and the psychiatrist makes a diagnosis based on the diagnostic guidelines in the International Classification of Diseases-10 th (ICD-10) version routinely .(10) Demographic information, details of gender transition, and management were extracted after careful perusal of the clinic records .  TXLs presented from all the provinces except the Uva province . Interestingly the highest percentage of individuals presented to this central province Data were entered into an Excel spread sheet and analyzed using Statistical Package for the Social Sciences-17 (SPSS-17) using descriptive statistics .

Results
The total number of TXLs studied were 71 . MTF TXLs comprised of 31% and FTM TXLs, 69 % . Ratio between FTM TXLs to MTF TXLs was 2:1 . All the patients had external and internal sex organs of birth sex . Societal gender role of all was that of the desired sex from the day they could remember and in various degrees depending on the differences in individual determinants such as the socio cultural back ground, the attitudes of family, the occupation demands and the personality traits of the patients etc . The age they recalled when they first had the awareness of living in the opposite gender's body was at 4-5yrs in 31% of patients . Mannerism, behaviours and voices were more of the desired sex .
All the FTM TXLs have attained menarche except one . All the MTF TXLs experienced the penile erections except one who has removed his penis by himself .
Though the clinic for sexual disorders was commenced in 1985 the first 3 registered patients of transsexualism presented in 2003 . The number of patients registered increased after 2012(Graph 1) . 46 .47% of the individuals were referred to the clinic by another TXL .

Graph 1: Number of TXLs registered in the clinic over the years
Age at presentation to the clinic ranged from 20 to 43 years (Table1) . The mean age of presentation is younger in MTF (28 .95yrs; SD=5 .71) than FTM (30 .71yrs; SD=5 .93) patients . There was no statistically significant difference between the mean age at presentation between FTM and MTF TXLs (p > 0 .1) . Most TXL individuals were between ages 31-35yrs .
centre was from the Western province ( Figure 1) .

Figure 1: Percentage of TXLs presented from each province in SL
Nearly one fifth of TXLs (20%) had a comorbid psychiatric condition on presentation and depression was the commonest (17%) ( Table 4) . 3% had Anxiety disorders, 3% had Mental and Behavioural disorders due to alcohol use while 1 % had Bipolar affective disorder .
The study group was in various stages of SRSs depending on the availability of a willing surgeon/ plastic surgeon or a gynaecologist, financial stability and family support (Table 4) . Legal identification documents such as national identity card, passports and birth certificates were completed by 13% . But the majority have not completed their paper work .
It is interesting to see that 63% of FTM TXLs were engaged in contact sports, athletics and martial arts and that 14% were national or district level players .
There was one FTM TXL who is a boxing player representing SL at international tournaments . Forty-five per cent (45%) of MTF TXLs engaged in music, arts or drama . One MTF TXL was a media speaker and a spokesperson for TXLs . Only one MTF reported of sexual assault . 38% were working with the NGOs Equal grounds or Wenasa .

Discussion
Determining the prevalence of TXLs has become a challenge worldwide . Social stigma and transphobia exclude them from their families, social circles and sometimes expel them from their occupations making open acceptance of their condition difficult . The high cost incurred for gender transition is also another barrier for the "coming out" process .
(4) The socio-cultural background in SL is hostile for TXLs probably due to the lack of awareness of the condition . Calculating the true prevalence of TXLs is thus impractical . But epidemiological investigations into this group at least when they present for services would give a chance to identify their needs and problems which in turn would help the medical fraternity and authorities to build services .
The number of TXLs seeking help has increased worldwide due to increased awareness through the web, social media and by TXL activists and due to expansion of services for them . FTM to MTF ratio in this sample was 2:1, which is opposite to the international figure of 1:2 .2 . (11) It is probable that FTM TXLs are higher in number as the males have higher social cultural privileges and occupational and educational opportunities than females in SL . However, this aspect needs further exploration with a more representative national sample in a qualitative analysis . The highest prevalence of TXLs presenting to the clinic was between 31-35 years of age which reflects the fact that they present when they are independent from their families as coming out is difficult as long as they are bound to their families .
The fact that 23% of the sample was unemployed is highly significant as gender transition procedures are costly and these individuals might not be in a position to access them .
The central province clinic drained the highest number of patients from the Western province . (Figure 1) . The TXL population had two choices of clinics for the whole country at the time of the study . This calls for attention to open up services in Tertiary care centers for TXLs .
TXLs seems to be engaging in leisure activities according to preferred gender as indicated by FTM engaging in sports and martial arts and MTF in aesthetic subjects .
Depression is the commonest psychiatric disorder found among TXL individuals even in a multicenter study done in 4 European countries and it is replicated in this study . (12) The TXLs of the study have the observed behavioural pattern of seeking help during the peak of requirements and not having regular contact with service providers . They also change their contact details which makes it further difficult to trace them . Therefore the progress of hormone therapy, SRS and the current status in transition is unavailable for some TXLs . This challenge is reported in international studies as well . (4) Another limitation of this study is that data on marital status, sexual orientation and parenthood of TXLs could not be elicited .
The psychosocial adversities and traumatic experiences they faced are going to be assessed in the second half of our study .
Majority of TXLs have not completed the legal transition which is a concern of their future prospects . Obtaining recognition of the preferred gender before the law is a key element in management . About 8 countries, Bangladesh, India, Pakistan, Nepal, Malta, New Zealand, Australia and Netherlands now legally recognize more than two genders . (13,14,15) Ministry of Health SL has issued a gender recognition certificate (GRC) following extensive collaborative work by major stake holders in transsexualism . (16) International professional bodies and experts have considered the importance of respecting and conforming to the gender identities of individuals . (17) Formation of National Good Practice guidelines for Sri Lanka with the participation of representatives of all the stake holders in TXL care is imperative . An attitudinal change in all relevant professional groups is quite essential with proper education of the public as well to prevent an uproar of the ill-informed .

Conclusions
There is an increasing trend in help seeking by TXL individuals in SL . Majority present when they are independent from their families due to sociocultural barriers imposed . Many were unable to have SRS and legal recognition of their gender transition .
There is a major gap in service provision, services mainly concentrated to Central and Western provinces . The study creates awareness on the distribution of the TXLs in SL, their epidemiological characteristics and deficiencies in management and would help medical fraternity and authorities to plan culturally appropriate management protocols .