Does Gujarat's 'Mental School Health Programme' misunderstand transgender people?

“It takes a great deal of courage and independence to design your own image instead of the one that society rewards, but it gets easier as you go along,” says Germaine Greer in The Female Eunuch. Yet journeys of transformation never seem to get easy if you are a transgender person living in India. For many, a question of identity becomes painfully tangled when it is defined and imagined by institutional policies as a mental health problem.

It was recently reported that the Gujarat government has factored mental health into its School Health Programme, a thoughtful initiative, given the scant attention such problems get. However, the government, in its wisdom, has decided that the strangely named “Mental School Health Programme” should treat “mental diseases” such as autism, dyslexia, “mental retardation” and depression in a continuum with gender nonconformity. The module includes a seven page questionnaire for parents and teachers. It asks them whether “a boy behaves like a girl” or a “girl like a boy”, whether “a girl expresses her wish to be a boy” or vice versa, whether a child is “consumed in thoughts of his/her gender”.

Psychiatrists linked with the project explained that children who feel trapped in the wrong body often have sex change operations later in life. The module was meant to identify such children, give them the medical and psychiatric support necessary. The module is perhaps well-intentioned, and it does address a vital concern. Children battling with the mismatch between their bodies and the gender they identify with in their minds often suffer from anxiety and depression. According to a survey conducted in the United States in 2010, 41% of transgender people had attempted suicide at some point. It is important for such individuals to get the psychiatric care they need, apart from access to medical procedures such as hormone therapy or sex reassignment surgery.

But questions of identity, “the fact of being who or what a person is”, cannot be elided with the distress they often cause. Is it right to pathologise basic questions about one’s self as a mental disorder? A little more than four decades ago, homosexuality was called a mental illness even in progressive countries like the US and the United Kingdom. India, of course, is still home to enlightened thinkers like Baba Ramdev, who believes homosexuality can be cured with yoga.

Countries in the West are moving away from definitions of gender nonconformity as disorder, trying to deepen their understanding of what it means. What is heartening is that this change has taken place at the level of policy.

The United Kingdom’s “Government Policy concerning Transsexual People”, published in 2002, observes “Transsexual people feel the deep conviction to present themselves in the appearance of the opposite sex”. The document sounds rather like a sporting great aunt trying to get with the changing times. But for all its limitations, the policy does try to evolve a more sensitive approach towards transsexualism.

The document does not take into account the various shades of gender that lie between the binaries of “male” and “female”. It focuses only on transsexual people, who wish to identify with the opposite sex. It does take pains to note what transsexualism is not. It is not a sexual preference for people of the same sex and “it has nothing to do with drag queens”. But it is also “not a mental illness. It is a condition considered in itself to be free of other pathology (though transsexual people can suffer depression or illnesses like anyone else).”

In 2009, the French government declared transsexualism would no longer be classified as a psychiatric problem. A couple of years later, the American Psychiatric Association expunged the words “Gender Identity Disorder” from the Diagnostic and Statistical Manual of Mental Illnesses and replaced them with “gender dysphoria”. Literally, this translates into a profound unease arising from gender. In psychiatric contexts, dysphoria may refer to depression or anxiety, thus shifting the focus of medical attention from identity to the attendant symptoms. The DSM clarifies that “gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.”

In these countries, changes in definition have begun to create a space for transgender identities outside the narratives of delusion and disorder.

In India, the recognition of transgender identities has come indirectly, through legal safeguards and by drawing them into the discourse of citizenship. Finally, this April, the Rajya Sabha passed the Rights of Transgender Persons Bill, 2014, addressing the need to protect such individuals from discrimination and violence, acknowledging their right to livelihood. The bill defines a transgender person as someone whose “gender does not match the gender assigned to that person at birth”. It accommodates “gender queers and a number of socio-cultural identities such as  — kinnars, hijras, aravanis, jogtas etc.”

There seems to be a dissonance between this bill and the Gujarat government’s mental health policy. For how can an identity marked out for the rights of citizenship also be a form of mental illness? It doesn’t help that mainstream Indian attitudes to both transgenderism and mental health leave much to be desired.

This is still a culture where words for transgender are often terms of abuse and the transgender body is attributed supernatural powers. Even apparently sympathetic medical literature starts by mentioning transgender characters in Indian mythology, such as Shikhandi and Ardhanariswara, as if ancient culture must be summoned to ease such people into social acceptance.

Social stigmas to mental health problems are equally virulent, loaded with their own set of superstitions. And the law does not help here. It was only in the 1980s that the medieval Indian Lunacy Act, 1912, was discarded. The Mental Health Act, 1987, is also a limited, archaic law, largely concerned with procedures for confinement. One of its objectives is to “protect” society from potentially dangerous mentally ill persons. A new bill, which takes a rights-based view of mental health problems, is yet to be passed.

Does listing gender nonconformity as a mental disease place the affected children at the intersection of prejudices? Does it make it make it harder for young people trying to design their own image in the face of tremendous odds? Can the medical and psychiatric care they need be reached to them without making a disease out of identity? These are questions that the Gujarat government needs to answer before it goes ahead with its Mental School Health Programme.