Rubina Bibi  ( Women Medical College, Abbottabad, Pakistan. )
Syeda Farhana Kazmi  ( Department of Psychology, Hazara University, Mansehra, Khyber Pakhtunkhwa, Pakistan. )
Tahir Pervaiz  ( Department of Psychology, Women Institute of Learning, Abbottabad, Pakistan. )
Rabia Bashir  ( Department of Psychology, Hazara University, Mansehra, Khyber Pakhtunkhwa, Pakistan. )

Objective: To study the mental health problems in eunuchs, the neglected segment that has been facing social exclusion and exploitation on behalf of social layers of the society.

Method: The study was conducted from Jan 2017 to April 2017and adopted a qualitative approach by engaging eight eunuchs' group purposefully through focussed group discussion to unearth the issues related to eunuchs in Hazara Division. The participants were informed in detail, about the purpose of the study and their consent was conferred. The discussion was recorded in local language and their views were transcribed and analysed by comparative statements for drawing results through coding of the target groups.

Results: The severe kind of economic and social pressures of poverty and social neglect resulting in depression, anxiety and suicidal tendencies were found among this group, which affected the overall mental health. This showed that, eunuchs have not been provided with basic social rights and can be classed as a neglected gender group. In addition, there is no love and care provided by the kin and relatives which results in the eunuchs facing psychological complications in daily life.

Conclusion: Eunuchs face psychological complications in daily life. The condition necessitates encouragement and social acceptance of eunuch to lead a normal and healthy life in the society. Furthermore socio-psychosocial aid and regular counselling is mandatory for creating hope necessary for leading a normal life.

Keywords: Mental health, Social exclusion, Psychological distress. (JPMA 71: 578; 2021)

DOI: https://doi.org/10.47391/JPMA.887

 

Introduction

 

After the Mughal rule, the category of eunuchs gradually faded. Eunuchs were disapproved because of their figures and numerous sexual characteristics by the British rulers.¹ Eunuchs were unacceptable to carry out any job in public. The underprivileged environments of eunuchs had pushed them into prostitution and begging along with deprivation because their own families were not accepting them.² The effects of retributive policies made by the British rulers were not withdrawn and eunuchs have not been restored their rights even after independence.

Sexual ambiguity generates confusion in the minds of these individuals and thus they do not consider themselves either a man or a woman. This results in negative attributes in the family and the society. In such a situation, sexual abnormality may generate role and status issues for the persons concerned. They are the group with the lowest self-esteem, negative self-assumptions and feeling of disappointment leading to social isolation.³

A report namely, "Understanding and Tackling Social Exclusion", has been developed by Jennie Popay and members of the regional hubs of the Social Exclusion Knowledge Network (SEKN)⁴ and submitted to World Health Organisation, for the cause of social inclusion of individuals with any disability ranging from sex to economy and culture. Research was conducted on such groups, with the objective of social avoidance. It was mainly developed through the sexual orientation of people in the society who are excluded from participating in normal socio-economic aspects of life. These principals of avoidance prevail in the social segments, as the minority groups, people with disabilities or any other taboo unacceptable to families and communities.

The negative perception of the eunuchs has resulted in sheer feelings of social rejection and impact on the psychology and mind set of such people. On many occasions, physical harassment of eunuchs have been observed only because of their feminine behaviour.⁵ Such social attributes have kept eunuchs away from education and social participation and has limited them to selective professions like that of designing and art work.⁶ Different previous studies showed that female appearance of eunuchs compelled them to leave their families because of the negative attitude of the family members.⁷ Ultimately eunuchs choose a way of social separation from the family and clan and adopt a street life which is full of challenges including harassment, sexual abuse and exploitation.⁸

The social negligence and exclusion also creates suicidal and self-destructive behaviour in these individuals. The continuous isolation, low self-esteem and social expulsion leads to mood disorder, depression and anxiety and finally development of mental health issues.⁹ An empirical study¹⁰ showed that the eunuch community had a higher suicidal tendency because of social stress. The prevalence of depression, anxiety, suicide and attempts of suicides and self-harm was higher with a percentage of 50.6%, 26.7%, 31.1%, 17.2%, and 16.6% respectively. Studies have also revealed that nervousness and anxiety among eunuchs as studied by Budge, Adelson and Howard¹¹ was 51.4% and 40.4% respectively. Similar higher trends of psychological disturbances have been reported by Leena, Gwendolyn and Nicole¹² who found that 92.4 % eunuchs had sufferings ranging from posttraumatic and bipolar nature of disorders to stress, anxiety, depression or any other form of psychological problem. The miserable physical, emotional life standard with the negative attitude, specially harassing and bullying by the social segments, with gender identity crises results in severe negative effects on physical and psychological development.¹³

This observation was the basis of this study to understand the reasons for social constraints on eunuchs leading to their exclusion from the society.

 

Subjects and Methods

 

The participants of this study were eunuchs whose gender identity cannot be recognized as a male or a female. The study adopted a qualitative Focus group approach by engaging eight true eunuchs with a profession of begging through purposive sampling technique belonging to different geographical locations of Abbottabad. All the ethical aspects were taken into consideration while dealing with the participants. Participants' names and exact residing locations were kept confidential. No such question was asked which could be psychologically hurting. Only those participants were included who were voluntarily willing. The whole discussion was recorded in an audio device (recorder) and notes taken by the assistant moderator. This was later written in the form of text. First author of this manuscript translated the Urdu text into English text and the second author back translated this English into Urdu. Both translation processes was performed independently. Almost the Back translation text (Urdu) was the same as original text (Urdu). Through Focus group discussion, their views were transcribed and analyzed by comparative statements for drawing results through coding of the target groups. The participants were informed about the purpose of the study and their consent was conferred. The estimated time period of focus group discussion was 40 - 50 minutes. Focus group discussion was held on 2nd Jan 2017 to April 2017 at a segregated hall of a restaurant in Abbottabad. There were some principal questions in the focus group for all the participants. All the participants in the group, actively participated in the group discussion.

While recording the discussion more attention was paid to the actual words used by the participants. Emphasis was paid on the topics and spoken words having a special intensity and depth of feeling in the discussion by the participants. The statements were interpreted in the light of intensity and tone of the oral remarks. The strength of their feeling was closely noted by a change in the tone or excitement in their voice. Discussion based on specific experiences was given more weightage rather than the vague remarks. Importance was given to the conversation in the first person compared to third person answers. The prompting stimulus was noted and the answer interpreted in light of that environment.

 

Results

 

The mean age of the participants was 35.75±3.41 years and their profession was begging. The demographic features of the participants is presented in Table-1.

The findings of the current study have been placed in the form of themes which are given below:

Theme 1:

Poor living style, humiliated by others, non acceptance as a human being by society

Views of Eunuchs:

Most of them were living in rented accommodations, as hotels or rooms in shabby slums, lacking comfortable amenities and bare minimum civic facilities (ventilated rooms, proper sanitation, and potable water). For travelling purposes, they used local public transport but the drivers usually were reluctant to accept them as a passenger although they paid the fare because the other passengers did not like sitting next to them. Some told them to sit in the male section whereas others asked them to find a seat with the females. The reason was the passengers views, (you are in between man and woman). Due to such remarks the eunuchs preferred to travel by foot as they could not afford private transport.

Theme 2:

Perception of ideal family life.

Views of Eunuchs:

They have a strong urge to have a complete female body, live a satisfied family life as a loving wife and bear biological babies to tend and nurture.

Theme 3:

Origin of identity

Views of Eunuchs:

They would grab the colorful dresses in their childhood, wear their mother's dupatta (scarf), help the mother with house hold work, use cosmetics, adopt a female gait, and had an inbuilt tendency for performing art. Joining the "Eunuchs" group and coming to their neighborhood as entertainers made them feel good.

Theme 4:

Money matters

Views of Eunuchs:

Not having sufficient money for their own sustenance although some of them earn between Rs. 400-500 daily by begging, this amount is not enough to fulfill the daily requirements as food which is usually acquired by begging and which is usually in the form of leftovers from others.

Theme 5:

Insecurity because of Social rejection.

Views of Eunuchs:

Homelessness starts with family rejection. Discrimination is initiated by the male family members which leads to hard feelings against them. Everyday humiliation, derogatory behaviour of society in every aspect of life, stigmatizes their existence and further pushes them to social rejection. Sexual harassment while they are at work (livelihood, begging) leaves them very insecure; reaching the refuge (their stay-place) before dusk is reflection of their psychological insecurity. The worst part in sexual abuse is that police becomes a party instead of providing protection.

Theme 6:

Conflicts and desires related to the body.

Views of Eunuchs:

Their discontentment with facial appearance is a major concern in particular facial hair giving them male looks. Heavy voice is a hindrance for social acceptance as a female (because they dress up like a female). They have a strong urge for a feminine body to wear nice female dresses. For breast augmentation they have a handy solution in the form of padded bras.

Theme 7:

Sexual gratification.

Views of Eunuchs:

Bodily deficiencies cannot provide sexual gratification as a normal gender's sexual intercourse and they are aware of this grim reality. Male partner relationship (anal intercourse) cannot satisfy the urge and causes distress.

Theme 8:

Trauma /Tragedies.

Views of Eunuchs:

Being an Eunuch is enough to make the society think that they are available for every use and misuse. Eunuchs suffer as they can be physically mauled by a drunk person on the roadside in front of the passersby without any provocation on her part. Another Eunuch was handed over to a Guru by her helpless mother. Her real brother shot her twice after searching her out, blaming her for harming the family's nobility by her entertainment role. Once she attempted suicide by electrocuting herself when her Guru got angry and scolded her for not helping with house-hold chores; though she was an earning hand in the Eunuch group. The incident triggerred the flash back of how her biological family left her and this thought plunged her into deep depression. Life seemed meaningless to her, and killing herself was the last hope to save herself from more pain.

Theme 9:

Mental health issues

Views of Eunuchs:

They have only a vague idea as to not having a state of mental well-being. When asked if they know 'what is mental health? 'they just expressed that they only know there was mental discomfort (zaihnee parishanee) which affected their life. When probed, they did narrate many symptoms which justifiably were diagnostic features of depression. These were hopelessness, worthlessness, negativism, crying, powerlessness, sad feelings, lack of courage, headache, self-blaming, guilty feelings, emotional instability, disturbed sleep, disturbed eating pattern, flash back, suicidal ideation and suicidal attempts. Many of them suffered from different phobias like Scotto phobia, Faimso phobia, Agora phobia and many of feared ageing.

Theme 10:

Performance in everyday life.

Views of Eunuchs:

Mental disturbance starts affecting physical well-being. Performing arts (the one they use for their livelihood) are based on spontaneous reward, either in the form of applause or money. The performance cannot remain up to the mark when they feel low. This often leads to the lack of spark in the words, voice and body language, to get attraction and earn money.

Theme 11:

Coping strategies.

Views of Eunuchs:

According to one of them, isolation is the best defence to cope the stress. Some of them share their hard feelings with other eunuchs or guru. Gossip makes them feel better. One of them said that she just over entertains the friends whenever she feels gloomy.

Theme 12:

Access to health facilities.

Views of Eunuchs:

Even though physical health care facilities are in their approach but psychosocial factors keep them away from availing them. They avoid going to civil hospital because of general humiliating and discriminating attitude of the medical staff. There are no SOPs (Standard Operating Procedures) in hospital operations how to provide inpatient treatment whenever needed (either in male ward or female ward). They usually prefer to go to female doctors in private clinics as they have less chance of humiliation and rejection. This research also found that eunuchs have difficulty in availing medical treatment as most of them did not want to avail hospital facilities due to the fear of being treated with negligence.

The results showed that eunuchs live a miserable life due to shortage of resources and means of livelihood and jobs. One participant said, "I cry many times when I earn one meal after going through severe difficulties."

In the society eunuchs have almost no source of respectful earning, as all the windows of job opportunities are closed for them and this community has been left for begging.

While the study revealed the readiness for taking up a job among the respondents, but they were not getting any. One respondent said "I want to work and do a job for a respectful life but wherever I go people make fun of me and reject me''.

Eunuchs are isolated from their families and live in poor and unhygienic conditions. They are also socially isolated and live in very poor physical environment: "To withstand harsh weathers, we do not have any facilities. There is no electricity in summer and no heating system in winter."

This research found that eunuchs suffer from disregard, humiliation and disrespect in the society. She narrated, "My surrounding is healthy and caring but I face numerous problems. Once I leave home and reach the streets, people pass negative remarks, and tease and misbehave with me. I feel very hurt as to why people treat me as an alien and not as a human being. The perception of people about us is worse than animals who never accept us as a human being."

Another study participant said, "It is difficult for me to go out of home because of negative remarks that I hear from people"

One of the participants said "We never play or have any recreation. There seems to be no meaning in life as we cannot participate in sports and other recreational activities".

There are issues of making social relationship in the society for such groups "I don't believe in people even in parents"

A respondent said, "People think we are prostitutes having AIDs; sometime I think it would have been better if I had not come to this world."

The negative social perception creates severe self-identity issues by concealing the real personality ultimately resulting into anxiety and distress.

Eunuchs also feel social insecurity, "We have problems of trusting the police when we go back late at night to our homes." "I have undergone sexual harassment and gang rape and was also tortured physically" said one eunuch while breaking into tears.

This research shows that the community of eunuchs is subject to rejection, distress and harassment. To cope with all these situations, they use coping strategies, and the most common one is avoidance. A research participant said, "I have to listen to bad remarks that I have to absorb patiently."

The research found that the eunuchs have disappointment and severe kind of distressful life with suicidal tendencies. As one participant said as "I have a feeling of being worthless, no one needs me, I wish I was not born in this world so that I would not face this life that is full of disgust. I do not want to live further in my life."

There is also male chauvinism that has a tendency of honour killing of the eunuchs. "My brother wanted to kill me but my mother saved me" said one participant.

While this segment of the society wants a respectful life that the family and society denies "I want to have a family and children but I cannot" said one participant.

Eunuchs have a vague idea of not having a state of mental well being. When asked whether they know 'what is mental health? 'they just expressed that they only know there is mental discomfort (zaihnee pehrishanee) which affects their life.

 

Discussion

 

This research has focussed on the social exclusion of eunuchs from the society. The results are based on the experience of the participants of the study as to how they have been excluded and neglected in the society; the results show that such people with issues of sexual identity and disabilities undergo a severe kind of psychological depression, ultimately affecting the mental health. There are many factors that have an impact on mental health of eunuchs as discovered in the focussed group of the study. The situation revealed that eunuchs have economic problems along with social and psychological setbacks in the society.

The current study also revealed that financial problem is one of the serious ones besides other several difficulties faced by eunuchs as also reported by previous researchers¹⁴ that job opportunities for eunuchs are scarce in the society which compels them towards begging. The poor economic condition is one of the strongest triggering factors for developing psychological disorders. A previous study reported that a majority of the eunuchs (62%), tend to beg on the streets, markets and other public places. However, a large number of eunuchs (34.5%), attended wedding ceremonies, entertaining the new couple by singing and dancing.¹⁵

In this study it was also observed that eunuchs are isolated from the families and live in poor and unhygienic conditions. As noted by many researchers, the problems of bad physical environment with compromised hygiene, results into depression, anxiety and mental health issues.¹⁶ Sleep disorder and adverse living conditions develop stress and anxiety which ultimately have grave consequences on mental health.¹⁷

This study indicates that the negative social perception creates severe self-identity issues and mental discomfort similarly preceding investigators¹⁸ noted that the behaviour in society is the key for self-perception which may distort personality. Self-identity has the prime role in defining happiness or depression.¹⁹

This study shows that eunuchs also feel socially insecure which leads to mental distress. Their desire for sports and recreational activities remain unfulfilled and takes away the meaning in life. Willson,2006²⁰ concurred the problem of insecurity leading to psychological stress and mental health issues among eunuchs. A life with no sports activity and negative attitude can lead to mental health issues.^21,22 Research has proved that social isolation and negative perception creates depression and anxiety when a person suffers from social rejection.²³

In this study it was observed that eunuchs have undergone trauma/tragedies, sexual harassment and gang rape and also have been tortured physically. A previous study reported that this harassment was done by the police themselves.²⁴ A review of over 73 articles revealed the exposure of eunuchs to sexual, physical and emotional abuse in the range of 33%, 23.5% and 48.5% respectively.²⁵ This abuse is to the extent that it creates distress, anxiety leading to suicidal thoughts.²⁶ Lombardi and colleagues²⁷ reported that majority of the eunuchs experienced either harassment or violence.²⁸

A meta-analysis of the studies revealed eunuchs to have experienced violent behaviours in many ways, viz. sexual abuse, verbal or physical harassment, rape, theft, physical assault, and death. The violence emanated from people involving family members, partners, peers as well as the policemen. Such violence took place in various places like educational institutions, streets, workplaces, and even in their own residences.²⁹ In a previous study results showed that about 12.5% used to argue with people who misbehaved. A significant number of eunuchs faced different types of violence, with 32% facing physical violence. About 10.5%, stated they faced sexual violence. Some 32.5% of individuals stated that they had fallen victims to sexual abuse or rape or to forceful sex. It is clearly audible in the research that eunuchs are undergoing physical violence in a variety of ways in which about 69.4% were beaten up, 11.7% had to have their heads shaved, and yet others attained brutal and cruel injuries and fractures.¹⁵

The findings of the current study shows that eunuchs have suicidal ideation leading to attempted suicide. Many of them suffer from phobias as Scotto phobia, Faimso phobia, Agora phobia and others had a fear of ageing. A previous study reported³⁰ guilty feelings, emotional instability, disturbed sleep, disturbed eating pattern, Flash back, suicidal ideation and suicidal attempt.³¹

The findings of the current study shows that eunuchs have insecurity because of Social rejection. Fish³² views social exclusion to inversely affect the health of eunuchs; it can create barriers to utilizing health services. Prejudice, discrimination, and stigma pave the way for a social environment very favourable to mental health complications. A strong association is there between physical/sexual violence and suicidal ideation and attempts, and abuse of substance among eunuchs.²⁸

It is apparent that people behave towards eunuchs in discriminating ways. This discrimination often prompts them to face various psychological setbacks. Hence their mental health is inflicted. Such a situation causes negative mental health development due to feeling inferior and oppressed. Some 36% of the eunuchs responded that they felt frustrated because of the people's attitude towards them. However, 34% eunuchs said they felt angry if being taunted or someone commented about their sexuality.¹⁵

A number of studies also found that violating "binary" gender norms resulted in discriminating behaviours of the people towards eunuchs or even exclusion from society in a variety of ways. Other studies suggest that these discriminations undermine these individuals' accessing to education, personal relationships, health care services, workplaces, job markets, governmental institutes as well as public facilities like toilets. It was also reported that activities of transgender individuals found it difficult to participate in different cultures and were likely to face severe forms of discrimination which lead to formation of structural and economic barriers, inequality, and psychological complications. Such pressures would drive them towards risky behaviours, turning to prostitution, and consequently serious health issues.²⁹

 

Conclusion

 

The study showed that the socially neglected people of third gender are leading miserable lives and have no rights, status and honour in the society for no reason than being sexually different from their fellow men and women. This has resulted in depression, anxiety and suicidal tendencies and other mental health problems among eunuchs. They have not been given basic social rights. They face social exploitation, harassment creating insecurity and low self-esteem among them. In this context, many psychological and mental health related complexities emerge in these groups which need social attention and its remedy on moral, legal and humanitarian grounds in the society.

 

Recommendations

 

1. The social group of eunuchs must be provided with basic human rights and specially right of well-being, keeping in view the global preferences under the Sustainable Development Goals 2020.

2. It is recommended that every case of eunuch in the family should be taken to the councilor/psychiatrist for proper teaching of life skills.

3. The government, civil society, academia should develop mechanisms to socially include eunuchs by providing social facilities, skills and space in the society.

4. There should be social awareness campaigns to include them equally in the society.

5. There should be proper legislation against the negligence, exploitation and to provide protection to such groups in the society.

 

Acknowledgement: We are thankful to the Lasani Restaurant Abbottabad for providing us space for conducting the Focus group discussion.

Disclaimer: None to declare.

Conflict of Interest: All authors have no conflict of interest.

Source of Funding: None to declare.

 

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