GENDER INDISTINCTIVENESS: PSYCHOLOGICAL PROBLEMS AND THEIR ASSOCIATED CAUSAL FACTORS AMONG TRANSGENDER OF PAKISTAN

In the last few years, transgender people had become more visible in our society, which had sparked a marked increase in awareness, interest, and attention among researcher. Questions had emerged about the psychological problems and its related causal factors of transgender. The aim of the current research is to explore the psychological problems experienced by transgender in Pakistan, moreover thee researcher was intended to explore the causal factors which may cause the psychological problems. A sample of approximately 7 transgender was collected from Punjab, through snowball sampling technique. The phenomenological tradition was used in order to explore the lived experiences of transgender. The In-Depth Interviews was conducted to get rich information regarding their problems. Ideographic Phenomenological Data Analysis was run in order to emerge themes. Specific verification methods were applied to assess the credibility of the research findings. The finding of the study presented many themes such as rejection from society, disrespect and depression, lack of social support and anxiety, family negligence, social withdrawal, and distress, lack of confidence, suicidal ideation, low self-esteem and insomnia. This study will give a better opportunity to transgender in order to make other people understand transgender problems and difficulties. It will also help to improve psychological health related issues of transgender in order to provide relevant services to them in the more effective way. Counseling, encouragement, and future research implications were discussed.


INTRODUCTION
The aim of the current investigation was to explore the psychological problems and its associated causal factors faced by Transgender in Pakistan. A few types of research conducted on Transgender in Pakistan. Mallon stated that if the studies about the gay and lesbian person were limited than researches on Transgender approximately don't exist 1 .

Transgender
A term Transgender is used to depict persons who do not know about gender identity and behaviors. In other words, people who go beyond kind of gender 2 .

Biological Perspective of Transgender
Whitlock depicted the fact and defined the transgender as their sexual presentation were publicly constructed, it was a clean reality described that a few humans were born with a little apart of organs and they normally took into consideration to be the "standard girl" and "fashionable male" type. Some people were born with "ambiguous" genitalia and some had phalluses which seemed between clitorises and penis and like neith 3 .

Psychological Problems:
Psychology experts define a psychological disorder generally as "psychological dysfunction in a human being that is linked with distress or impairment and a response that is not ethnically predictable. When taking into consideration if something is a symptom of a disorder, consider the three Dysfunctions 4 .

Rationale of the Study
The purpose of this study was to assess the psychological difficulties and its related causal factors PAKISTAN POSTGRADUATE MEDICAL JOURNAL faced by Transgender in detail. Other People do not consider them as a normal human being and people make their fun. People do not like to meet them, or want to spend time with them but Transgender are also full citizens of Pakistan like others. The life of the Transgender can be friendless and unsafe in a conventional society of Pakistan. Misbehavior of people cause different psychological problems in Transgender. Psychotherapists even don't give them attention for their problems and issues. A lot of them are turning to prostitution, which goes against the Hijra ideal of starkness. The present study raised the voice to give rights to Transgender.
The current study is of qualitative nature so the basic inquiry question was to investigate the causal factors and the associated psychological problems of the transgender.

Inquiry Question
The basic inquiry question of the present research which was asked from participants was, • What are the psychological problems you faced as a Transgender? • What are the related causal factors of psychological problems among transgender?

Assumptions
Researcher started this research with many assumptions about this particular study and those were of researcher's personal view. The following is the list of some of the assumptions that influenced the design of this research exploration.

Significance of the Study
In Pakistan researches on Transgender problems and issues are very few and it's an emerging topic in the social life sciences. Transgender people experience the depression, anxiety, suicidal ideation, social withdrawal, stigma, prejudice, discrimination, and extreme hostility known as Tran's phobia on a daily basis 2 .
In Pakistan, people were not aware of the difficulties of Transgender. They even not consider them as normal human being. Most of the people thought Transgender are feeling less. So this research provided awareness to people about the issues of Transgender. The current study was also helpful for Transgender to resolve their problems and to know their associated causal factors. It helped the society to understand Transgender problems and it also played a vital role to change people's views and behavior towards them. It is an attempt to provide evidence to a psychologist about the problems of the Transgender and give awareness to a psychologist to treat their mental issues.

METHODOLOGY
The qualitative approach was used in the current research which explores the experiences of transgender. The present study was conducted to explore the psychological issues of the Transgender. It also focused on the causal factors of such problems in transgender. Constructivism paradigm was used. In current investigation, the researcher explored the reality of the Transgender with the collaboration of researcher and participants. The phenomenological tradition was used in order to explore the lived experiences of Transgender. Snowball sampling technique was used. The In-depth interview was used in order to collect data. The researcher used the In-depth interview for data collection and took deeper information regarding study variables.

Data Collection
Data were collected through Semi-structured interview which contains open-ended questions and some probing questions. An audio recorder was used for recording the interviews and all interviews were fully transcribed. The interview schedule was structured into the following three sections; • Participant's demographics • Their psychological problems • Causes of psychological problems

Procedure
The data was collected from different communities of Transgender from Lahore. The permission was taken from respective Gurru of those communities. The researcher ensured informed consent from all participants. All participants signed a consent form in which stated that they were willing to participate in the interview. In consent form the researcher ensuring participants about the confidentiality throughout the process. The in-depth interview was conducted directly with the participants. A total of 13 participants were interviewed but six interviews were excluded due to incomplete information. The detailed demographic information was collected in order to understand the demographic characteristics of the participants. The interviews were recorded via audio tape recorder by the permission of participants. Non-verbal responses were noted on the demographic sheet and semi-structured interview sheet. The transcription of interview was done after conduction of the interview. Then the data was analyzed through Ideographic Phenomenological Data Analysis.
Specific verification methods were used to assess the credibility of the research findings. Peer review was done by four clinical experts from Punjab Institute of Mental Health Lahore. All the reviewers agreed with the most of the generated themes and gave some suggestions to change some themes. In this research, the researcher provides rich information regarding research aim, variables, and experiences. It allowed the reader to make a decision regarding transferability. In this research, the researcher clarified about the past experiences, biases, and orientations that have likely shaped the interpretation of the study. In this research, the researcher reviewed the analysis by study participant and got their opinion about the conformity of data. All willing participants read transcripts specific pages and confirm the statements and their meanings. Ethically considerations were also followed.

Demographic Characteristics and Participant Information
Demographic information was taken from Transgender by filling the demographic questionnaire. The following table shows demographic characteristics of the participant. In order to provide answer about the psychological problems many transgender reported that, they experienced depression in their life due to unhealthy behavior of people they don't respect us. As they reported, when they go outside people tease them and PAKISTAN POSTGRADUATE MEDICAL JOURNAL make fun of them and this behavior lead them to have depressive thoughts.
Participants 1 reported that, ''We feel sadness and become depressive. Sometimes the tears come in our eyes due to unhealthy behavior of the society" Participant 2 stated that, ''There is no place in this world for us (hijrun k liay). They do not even consider us as human beings. Seeing all these things make us depressive''. Similarly Participant 7 stated, ''I'm so tired of life. I do not even want to live, people are so rude to us. They don't even consider us as good people. Society hates us''.

Theme 2: Lack of Social Support and Anxiety.
Anxiety was defined as an emotional feeling of tension, worry and physical changes like increase in blood pressure. In anxiety disorders people experienced recurring intrusive thoughts or concerns and they tried to avoid that situations of worry 6 .
In this research many transgender reported that they feel tension and anxiety because of lack of support and care. In Pakistan, no one help them and no one give them protection. They used to worry about their future and are quite scared regarding their elderly age. Because they think that they will not have any social support in their old age. Due to these worries they suffer headache and muscle aches. Participant 3 described that, ''I feel heart pounding and scared very soon due to thoughts regarding my future''. Participant 4 stated that, ''When I sit alone and I used to think about my future, it make me sad. I am able to move but no one give me support if I will paralyze in future. These thoughts make me restless and make me cry and irritable" Theme 3: Family Negligence and Low Self Esteem Self-esteem is how we perceive our value to the world and how valuable we think we are to others. Self-esteem affects our trust in others, our relationships, our work nearly every part of our lives. Positive self-esteem gives us the strength and flexibility to take charge of our lives and grow from our mistakes without the fear of rejection. Negative self-esteem makes us weaken and grow our fear of rejection 7 .
In this research, many participants reported that they feel as worthless. They feel this world not make for them. They stay here as an unimportant person. They have fear of rejection from others. They were feeling weak emotionally and physically than other normal human being. They are emotionally weak due to the neglect of their families. They couldn't handle their emotions due to their life stressors. Participant 2 narrated that, ''There is no place in this world. They do not even consider us as human beings, our families rejected us even and that makes me worthless" Theme 4: Insomnia. Insomnia is defined as prolonged and usual abnormal lack of ability to obtained appropriate sleep 8 . Many participants described that they suffer sleep problem. They feel difficulty to get asleep. Their sleep disturbed due to worry about future, no social support, and poor pragmatics. They thought their lives were in danger. They spent whole night with painful thoughts. Participant 2 reported that, ''I often cry due to lack of social support which make me frustrated. No one asks us about our difficulties. These thoughts make me restless and upset, which lead to sleepless nights"

Theme 5: Suicidal Ideation.
Suicidal ideation also known as suicidal thoughts defined as thoughts about kill one and arranged a detailed plan of killing one. The most of people who practice suicidal ideation did not take it through 9 .
The current study participants reported that they used to have suicidal thoughts due to cruel behavior of people. They thought about suicide in order to get relief from poor life. They faced a lot of problems during their life and consider death is one solution of their problems. Participant 2 stated that, "When I go out, people harassed me due to my identity which teased me too much and lead me towards suicidal ideations". Participant 5 reported that, ''I face many troubles in society, no social support, no care, no humanity exists for us, no rules and opportunities are available for us, these things trigger me to have suicide"

Theme 6: Social Withdrawal.
Social Withdrawal defined as avoiding other people and actions that usually gives you joy. Some people feel social isolation and start avoiding their families and friends and spent most of time with oneself 8 .
The current study investigation showed that many participants reported that they start avoiding social gathering, meetings with others and started to live alone due to bad and unhealthy behavior of others. People make fun of transgender and showed dirty gestures to them and hurt them badly. One of the Participant described that, ''I feel fear due to behavior of people and I avoid social gathering. I scared of people. I don't want to move in this society due to their bad gestures''.

Theme 7: Distress.
Distress refers to great sorrow, trouble and pain. Here term distress used to describe the trouble and pain of transgender 8 .
Participants reported that mostly transgender spent a very miserable life. They had lack of money to buy food. They don't even have money to buy medicine for the management of their illness. They experienced too much distress in their lives. They spent whole life in troubles from childhood till the current age. From the above exploration it is viewed that most of the transgender have psychological problems like depression, anxiety, insomnia due to their stressful childhood, neglect from family, poor social acceptance and support, lack of freedom to express their emotions and lack of opportunities.

DISCUSSION
The aim of the current research was to explore the psychological problems experienced by Transgender in Pakistan. Moreover the researcher was interested to explore the causal factors behind such psychological issues. Findings were consistent with previous researches that revealed the huge number of psychological difficulties. During exploring this qualitative research, the researcher tried to get intimate knowledge with regard to the psychological difficulties experienced by Transgender in Pakistan and researcher investigated the causes of such problems. Moreover researcher discussed current study results with the support of literature, theories of psychosocial and cultural perspectives.
Findings of this research depicted that Transgender faced many psychological problem. The current study results showed that Transgender experienced depression in different phases of their life due to stigmatization, ignorance, rejection, neglect etc. These findings were consistent with findings of Lewis, Derlega, Griffin and Krowinski (2003), they perceived stigma is positively associated with symptoms of depression among Transgender.
Experiences of prejudice and discrimination may reinforce expectations for rejection that the young person may develop as a result of gender ambiguity 10 .
Another study also supported this point. Brain research results revealed that Transgender youth experienced depression due to ill-treatment of the society. Current research results also indicated that Transgender faced depression due to people unhealthy behaviors 3 . Koken, Bimbi, and Parsons (2009) study results indicated that the greater the young person's expectation for rejection based on their gender identity the more likely they are to report symptoms of depression 11 . Nuttbrock (2010) stated in his research findings lifetime major depression in this study of Transgender 54.3 % was almost three times higher than the corresponding estimate in the general population 19.6 % 12 .
Another psychological problem indicated in the present study was psychological distress. Participants reported that they experienced distress due to their identity. People used to harass Transgender and make fun of them. A study by Johnson, Faulkner, Jones and Welsh, (2007) lesbian, gay, bisexual and Transgender young people are especially vulnerable, with many experiencing harassment and victimization in school, home, work and community settings. High rates of psychological distress are frequently observed among lesbian, gay, bisexual and Transgender youth. As current study findings participant reported as minority they faced ignorance and misbehavior of people due to these deeds of people with Transgender they experience distress. Findings were consistent with previous research that revealed an association between minority stress and psychological distress 13 . Actual experiences of Transgenderism were the strongest individual predictor of distress among the young people. Another study by Moody and Smith (2013) also revealed that such experiences have been linked to a range of negative outcomes including psychological distress 14 .
Anxiety was another psychological problem that reported by current study participants. Transgender experience people rejection in result of rejection and neglect they experienced anxiety. Koken study results also indicated that the greater the young person's expectation for rejection based on their gender identity the more likely they are to report symptoms of anxiety 11 .
The current study themes also indicated that most Transgender had suicidal ideation and some of them even attempted suicide. Many participants reported that they attempted suicide due to worst circumstances of LGBT populations in the United Kingdom (McNamee, 2006) and has linked Suicidality to negative experiences resulting from stigmatization 14 .
Social isolation among Transgender was also found in the current study. Transgender used to isolate them and avoid social gathering because of wrong attitude and poor behaviors of the society. Herbst et al.
(2008) thesis on risk behaviors of Transgender persons in the United States results supported the findings of the current research as Herbst findings revealed that Transgender population more commonly isolate themselves from the society 16 .
Erikeson theory of life cycle stages supported our results as Erikson (1950Erikson ( , 1959 viewed ego development as a result of the mastery of stage specific developmental tasks and crises. He argued that the successful resolution of each crisis from birth to death leads to a sense of ego identity and may be said to constitute the core of one's sense of self. A person faced crises during his identity stage, he will face self identity issues throughout the life. The current study emerged themes showed that they faced identity crises during their childhood and whole life 17 . According to Freud (1923) during anal stage if a person faced any kind of conflict then whole life he did not achieve satisfactory self image. Similarly the participants of present study reported that they faced lack of attention during their childhood as result of their fixation they experienced unsatisfied self-image and lack of awareness regarding self 18 .

CONCLUSION
The current study explored the psychological difficulties of transgender and their associated causal factors. According to the results of present study, Transgender faced depression, anxiety, low self-esteem as psychological issue, insomnia, suicidal ideation, social withdrawal and distress. They also faced rejection and neglect from people on many occasions. People did not support them and showed hatred towards them. Their most of the problems linked with the behavior of people with them. People did not consider them as normal human being and hurt them badly on many occasions. Doctors and hospital staffs did not pay attention to them. They treat them as unimportant.
Participants reported that they faced all above mentioned problems because they are different beings. They did not have equal civil rights. People showed inhumanity towards them. The legal restriction also disturbed them to earn money for survival.

Strengths of the study •
The topic of this research was unique and was not explored by the researchers previously via using qualitative approach so far in Pakistan. So this research will hopefully contribute in the field of psychology and health sciences.

•
The current research explored the deeper information about the different psychological issues of Transgender and their related casual factors, so it provides a guideline to professional and society to reduce and treat the problems of Transgender.

Limitation
• Many Transgender refused to give detailed information about their problems. Some of them gave incomplete information so researcher discards six interviews due to incomplete information.

•
This study was collected from adults only; further study should be done on both adolescents and adults in order to have a comparative study.

Suggestions
• Transgender suffer many psychological problems due to society, so the society should show positive behavior with them and support them.

•
Transgender also face many psychological health related problems so government should provide them health facilities and other occupational opportunities in order to have healthy survival.

Future Implications •
The current research explored the deeper information about the different issues of Transgender so it raises voice to give rights to Transgender.

•
People treat Transgender badly and hurt them badly so this research gave awareness to people about the issues of Transgender. It helped society to understand Transgender problems and it also paid a vital role to change people's views and behavior towards Transgender.

•
Health professional can create better remedial options for such people after considering their mental health issues.