An Exploration of Predictors of Psychological Help-Seeking Attitudes in a Transgender Population in a Non-Western Context

Abstract

Barriers to help-seeking behaviors in transgender populations in non-Western contexts are both understudied and poorly understood. Using a quantitative cross-sectional design, this study examined the psychological help-seeking attitudes of 109 transgender persons from Pakistan in relation to their psychological distress and attitudes toward sexuality. This research further identified which components of distress (stress, anxiety, or depression) were stronger predictors and assessed the role of particular demographic/behavioral factors in help-seeking attitudes. Participants completed three validated assessment tools translated into Urdu: Beliefs about Psychological Services Scale, the Depression, Anxiety, and Stress Scale (DASS-21), and the Sexual Attitude Scale. The results indicated that psychological distress predicted expertness and intent but not stigma tolerance. Post hoc analysis using DASS-21 subscales revealed that stress and anxiety were the stronger predictors of attitudes related to expertness and intent. The Sexual Attitude Scale marginally predicted stigma tolerance directly and also moderated the relationship between psychological distress and help-seeking attitudes for stigma tolerance. Finally, a role for demographic/behavioral factors—possibly serving as a proxy for mental health literacy—was identified for stigma tolerance. These findings reiterate the importance of tailored mental health awareness initiatives within the transgender community in non-Western settings and highlight the need for qualitative research to further understand the dynamics of psychological distress along with other linked factors.

1. Introduction

Gender is one of the most widely used categories to identify and differentiate people. Typically assigned at birth, most societies and cultures divide gender/sex into the binary categories of male or female [1,2]. This “binary” view, however, is not merely descriptive, as it takes on both “prescriptive” and “proscriptive” dimensions. That is, it describes what sexes and genders should exist and how these two concepts are related, and individuals who do not fall into these binary categories risk both discrimination and victimization [1,3,4,5].

In the social context, the terms “sex” and “gender” are often used interchangeably. However, sex refers to the biological and physiological characteristics of male and female whereas gender refers to “the socially constructed characteristics of women and men such as norms, roles, and relationships of and between groups of women and men”, characteristics that may vary across societies and cultures [6,7,8]. For most people, gender identity and sex are aligned (cisgender), but individuals whose gender identity does not match the male–female binary system are considered transgender, an inclusive term for persons whose gender identity, gender expression, and/or behavior do not conform to that typically associated with their assigned birth sex [8]. Although the prevalence of non-binary gendered people is unclear, it has been estimated at about 0.6–3.0% worldwide (www.statista.com/statistics/1269778/gender-identity-worldwide-country) (accessed on 25 March 2025).

Cultures and social systems have dealt with transgender people in very different ways, from integration into an existing social structure with specified roles to identification as anomalous and therefore in need of “remediation” (e.g., medical, re-orientation, etc.). In the Asian subcontinent, transgender individuals have deep roots, dating back centuries. In Pakistan, the term “hijra” is most widely used to refer to transgender persons, with this notation serving as an umbrella term for non-binary gender variance, including intersexism, congenital ambiguity, eunuchs, cross-dressers, gay/lesbian/bisexual, transsexual, transvestites, genderqueer youth, drag queens, and other third gender identities [9,10]. Although the transgender population count of Pakistan is uncertain, one recent report suggests that it lies at around 300,000 out of a population of 240 million [11]. But the true count may be much higher, given that many transgender persons may be uncounted, miscategorized, or refuse identification [12].

1.1. Transgender Communities in Pakistan

Research on the psychological and behavioral effects of sexual and/or gender minority status in non-Western nations/cultures has emerged over the past decade as an interdisciplinary topic of interest, though such initiatives have been limited both in number and in scope (e.g., geo-cultural regions). Yet, a person’s response to the distress of stigmatization is greatly influenced by the cultural values and traditions in which the individual is embedded. That is, culture defines the acceptability and marginalization of various socio-sexual roles and therefore plays a critical role in the way men and women describe, interpret, and ascribe meaning to their specific status [13,14,15,16]. Indeed, the interpretation/meaning-making process within a sociocultural tradition is often as important for the individual as the person’s social “location” (gender and/or sexual identity). Yet, most attempts at understanding the psychological experiences of men and women to negative situations/conditions have relied on studies conducted in educated and (sexually) more open Western-oriented samples, even though studies suggest that such samples may be among the least representative in the world [16].

In Pakistan, a Central Asian country with the second-largest Muslim-majority population in the world, marginalization due to gender minority places a heavy psychological burden on the individual. Transgender people in this geo-cultural region face significant human rights issues [17], and despite their relatively limited numbers in Pakistan, they disproportionally account for 17.5% of HIV cases [18]. Pakistan and its neighboring countries (e.g., India, Bangladesh, Nepal) afford a distinctive opportunity for understanding the relationships among gender minority and psychological distress, social support, sexual attitudes, and help-seeking behavior—here, religious and cultural ethics have played an important role in the social contract with transgender individuals, one that dates back to pre-colonial times. Prior to British rule, transgender people (hijra) had an important role and status, where during the Mughal rule, they guarded the ladies of the harem and were considered servants of the nobility, often being promoted to key advisory roles [19]. In the historical tradition of the region, they were attributed significant value due to the belief that they blessed people with fertility, having been granted their power by the goddess Bahuchara Mata herself [20]. Against this tradition, however, in 1870, the British colonized Central Asia and passed morality laws such as the Criminal Tribes Act of 1871 and the Dramatic Performance Act of 1876, which labeled the hijras as “sodomites” and restricted their activities, inheritance, and other rights [17]. Thus, in the post-colonial era of today, members of sexual/gender minority groups in Pakistan continue to experience social stigmatization and marginalization. On the other hand, giving a nod to its pre-colonial past, Pakistan’s Supreme Court has recently (2018) provided official recognition to the “third” gender in the citizen registration category, a recognition that affords both voting rights and access to healthcare [17,21].

Despite the fact that the Pakistan constitution guarantees equal rights to all citizens regardless of their class, creed, ethnicity, and gender, transgender individuals continue to have the lowest degree of rights and honor because of the uninformed and/or prejudiced mindset that exists among the majority of the people in Pakistan with regard to this population [22,23]. Even in their youth, acceptance of a family member’s transgender status is low in Pakistan, with transgender persons typically being disowned or asked to suppress their identity. In extreme cases, transgender children may be killed or abandoned because they are seen as shameful or even as a curse. The effects of stigma, rejection, and isolation by families-of-origin tend to motivate individuals to seek supportive networks that represent the chance for safety, security, and growth-oriented opportunity [24]. Accordingly, transgender people have often formed their own strong social support systems, “transgender communities”, found in many countries worldwide, including Pakistan [22,23,24]. These communities confer benefits on their members, including mitigating the effects of stigmatization and loneliness, providing social support through opportunity for friendships and relationships, and serving as a surrogate family [24]. In Pakistan, such communities, or clans, are sometimes structured as a master–disciple (guru–chela) hierarchy, where older members mentor new members and provide a pathway to earning a living through dancing, begging, or blessing [20]. Although transgender individuals who live with their elders in such communities have reported higher levels of resilience and self-esteem, these communities are typically located in ghettos, where members lack equitable social benefits relative to cisgender peers; as a result, long-term health and longevity typically suffer [20,24,25,26]. Specifically, transgender individuals that leave home, whether willingly or unwillingly, to find shelter in the chelas (as disciples) under the supervision of a an elder (Guru) or teacher, typically live without any social or national identity, which can then result in the deprivation of basic opportunities such as education, healthcare, and participation in cultural, religious, and social events [17,22,24,26,27].

Furthermore, despite support from their dera community (their common place of residence), transgender individuals in Pakistan continue to be treated with discrimination, violence, and in some cases persecution (as an aside, the concept of the dera is portrayed as a particular form of dwelling in Pakistani society, resembling a kinship-based commune system for the transgender community. Within this structure, a guru serves as a surrogate mother or master figure, while the chelas or protégés form the rest of the communal unit. The idea of home and belongingness in this context becomes intertwined with the journey of the transgendered person seeking an identity based on togetherness and a shared culture. It acts not only as a familiar refuge from the hardships of an earlier existence but also as a home beyond the natal home) [21,24,28,29]. The great majority of transgender individuals belong to low-income groups and work as beggars, sex workers, or dancers at marriages, festivals, and births. Those with a low-income status often live hidden lives and cannot afford basic physical or mental health treatment, much less undergo hormonal therapy or sex surgeries. The small proportion in mid- or upper-socioeconomic classes, however, are also often largely invisible but have a better life and opportunities (sometimes being able to find and afford living arrangements and private healthcare abroad). Nevertheless, even for them, prejudice often prevents employment or access to education or health facilities in Pakistan. For example, according to transactivists, a large portion of the transgender community in Pakistan is illiterate [24,26], although this statement must be benchmarked against an overall national literacy rate of about 70%.

1.2. Psychological Distress

As a result of their marginalized status, transgender individuals in Pakistan view themselves as misfits and aliens to society [30]; extreme social exclusion weakens their self-esteem and sense of social responsibility. Not surprisingly, they suffer disproportionately high rates of stress, anxiety, and depression (reportedly as high as 60%) [31], including suicidal ideation, all related to discrimination, victimization, and lack of opportunity [32]. In addition, substance use is common, often entrenching maladaptive coping styles to deal with existing mental health issues and further exacerbating other health challenges [33,34,35,36]. Stigmatization and social exclusion also contribute to financial issues within transgender communities, forcing members to adopt risky behaviors such as selling sex, peddling drugs, and begging [37]. Physical assault and abuse are common toward the transgender population in Pakistan.

1.3. Help-Seeking in Transgender Populations

The distressful conditions and consequences of transgender status in Pakistan lead to an increased need for physical and psychological support and help, whether through formal (e.g., health services) or informal (e.g., friends and family) channels [31,38,39]. Yet, this population is less likely to seek help for their mental health issues due to reported experiences of discrimination as well as fear of mockery and not being taken seriously [9,40,41]. As with any population, the likelihood of seeking help appears to represent a combination of factors related to information, motivators, and barriers; for example, awareness of available treatment (information); perceived severity of the problem (motivator), and likelihood of overcoming barriers (social stigma, cost, or lack of accessibility) [42,43,44,45,46,47,48,49,50]. However, while numerous studies have explored key influencers on psychological help-seeking among the general population, the transgender population has received minimal attention in this regard. Furthermore, for specific populations challenged by sexual issues and identity, attitudes toward sexuality also play an important role in help-seeking behavior. Specifically, sociocultural and individual positive (i.e., less restrictive) attitudes toward sexuality tend to promote more open communication and help-seeking behavior with health professionals than negative (i.e., more restrictive) attitudes [51,52,53].

Finally, while attitudes toward help-seeking behavior in transgender populations have been explored extensively in developed countries (for reviews, see [54,55,56]), only a handful of studies have studied transgender populations in non-Western developing countries such as Pakistan [57,58,59].

The factors associated with the help-seeking behavior of transgender people in Pakistan are largely unknown. It has been loosely associated with awareness campaigns that, in general, target basic human rights and aim to align awareness with constitutional and electoral rights, creating avenues for help-seeking at a factual and fundamental level rather than an emotional one [60]. The layers of stigma faced by transgendered persons and the embedded attitudes toward negative self-perception create a dynamic that posits significant challenges for those seeking psychological help. Societal labels maintain misperceptions regarding the response toward help-seeking even in the healing professions, including clinical psychology. Consequently, few transgender persons in this sociocultural milieu are likely to admit to needing psychological help, and therefore actively seek it unless they are directly approached by NGOs working in the domains of malnutrition, socioeconomic concerns, and/or sexually transmitted diseases/HIV/AIDS, among others.

The situation in Pakistan, however, is undoubtedly replicated in many countries worldwide. Specifically, relative to countries typically espousing Western-based values, salient predictors of psychological help-seeking may vary substantially across cultures; for example, in environments where attitudes toward sexual diversity are fairly restrictive, even among healthcare professionals; where the stigma/shame index associated with seeking mental health services is particularly high; and where mental health literacy among the populace is low [61].

1.4. Rationale and Goals of the Current Study

Although transgender individuals are legally recognized in Pakistan, they face different religio-cultural challenges compared with similar populations in developed, Western countries. Not surprisingly, significant gaps exist in the understanding of attitudes related to help-seeking behavior, not only in restrictive sociocultural milieus, as described above, but also (and more specifically) in transgender populations residing within such environments. Information regarding how such attitudes and beliefs affect inclinations toward psychological treatment within such populations and cultural milieus could assist transgender activists in supporting the rights and health needs of transgender populations in those countries [62]. Accordingly, the purpose of the current cross-sectional study was to identify predictors of attitudes toward psychological help-seeking among transgender individuals in a non-Western, developing nation setting, as characterized by Pakistan. Specifically, we posed four questions:

• To what extent do psychological distress and attitudes toward sexuality predict psychological help-seeking attitudes?
• If psychological distress predicts help-seeking attitudes, which aspects of distress—stress, anxiety, or depression—represent the stronger predictors?
• To what extent does one’s attitude toward sexuality moderate or facilitate the effect of psychological distress on attitudes toward help-seeking behavior?
• Do demographic and behavioral variables that increase exposure to information or interactions beyond the transgender community (e.g., education level, SES, use of social media/communication platforms, etc.) add to the understanding of help-seeking attitudes (e.g., by increasing mental health literacy)?

2. Materials and Methods

2.1. Research Design and Participants

In this quantitative cross-sectional study, we recruited 109 transgender participants (mean age = 34.3, SD = 9.79) from Karachi (Sindh province) using purposive and snowball sampling techniques. This sampling procedure, which relies on word-of-mouth and social media interaction, represented the only viable and cost-effective method for recruiting participants from this population, owing to the general inaccessibility to, suspicion of, and mistrust of outsider contact with the transgender community [63]. This procedure is characterized by developing contacts with a small set of initial participants, known as “seeds”, who then begin a sampling chain of recruitment through community organizations, social media platforms (Instagram, Facebook), personal networks (WhatsApp), health systems, and other sources.

The inclusion criteria were being at least 18 years old, self-affirmed transgender identity, living in Karachi, and competent in understanding Urdu (the native language of Pakistan). Transgender persons seeking or receiving any type of psychological-related help or counseling were excluded.

2.2. Measures

In addition to providing basic demographic data, the participants completed three validated assessment instruments: Beliefs about the Psychological Services Scale (BAPS), Depression, Anxiety, and Stress Scale (DASS-21), and Sexual Attitude Scale (SAS).

2.2.1. Demographic Information Sheet

Demographic information included the transgender pseudonym, age, education, socioeconomic status, source of income, current gender identification, sex assigned at birth, marital status, and questions regarding the use of social media and communication platforms (e.g., the Internet).

2.2.2. Beliefs About Psychological Services Scale (BAPS)

The BAPS, developed to assess attitudes and intentions regarding psychological help [50], is an 18-item scale consisting of 11 positively worded items and 7 negatively worded items (the latter reverse-scored), and it uses a 6-point Likert response scale (1 = strongly disagree; 6 = strongly agree). The BAPS has 3 distinct subscales for analysis: expertness, stigma tolerance, and intent. Scores could range from 18 to 108, with higher scores reflecting a more positive view of psychological services due to psychologists’ expertness (expertness), a greater tolerance for stigma regarding mental health labeling (stigma tolerance), and a greater willingness to seek help if in need (intent). Typical questions for the BAPS subscales can be found in Supplementary S1. Cronbach’s alpha for the overall score is 0.84 and 0.72, 0.78, and 0.82, respectively, for expertness, stigma tolerance, and intent subscales. The scale reportedly has adequate criterion validity [64]. An Urdu version was generated using both backward and forward translation processes to ensure the retention of content validity. In addition, the Urdu version was piloted on 10 Urdu-speaking students and 5 transgender individuals for both clarity and face-validity.

2.2.3. The Depression, Anxiety, and Stress Scale—21 Items (DASS-21)

The DASS-21 was developed to measure negative emotional states, as identified through its three subscales: depression, anxiety, and stress [65]. Each subscale contains seven items, assessed on a 0–3 scale (“does not apply” to “applies very much”), with a possible range of 0–21 for each subscale (0–63 overall). “Depression” assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia. “Anxiety” assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. “Stress” measures levels of chronic nonspecific arousal and evaluates difficulty relaxing, nervous arousal, being easily upset/agitated, irritable/over-reactive, and impatient. Typical questions for the DASS-21 can be found in Supplementary S1. DASS-21 has strong internal consistency, with Cronbach alpha values of 0.81, 0.89, and 0.78 for the respective subscales. It also has good discriminative, concurrent, and convergent validities [66]. A validated Urdu translation of the DASS-21 was available for use in this study (https://dass.psy.unsw.edu.au/Urdu/Aslam.htm, accessed on 25 March 2025) [67].

2.2.4. Sexual Attitude Scale (SAS)

The SAS, developed by Hudson et al. [68] consists of 25 items designed to measure liberal versus conservative attitudes toward human sexual expression. Each item is scored on a relative frequency scale using a 5-point Likert scale (0 to 4). Scores ranged from 0 to 100, with higher scores (above 50) indicating an increasing tendency toward conservative (more restrictive) attitudes, and lower scores (below 50) indicating an increasing tendency toward more liberal (open/less restrictive) attitudes. Typical questions for the SAS can be found in Supplementary S1. Internal reliability, as assessed by Cronbach’s alpha, was 0.94, and the convergent validity coefficient was 0.73 [68]. The scale was translated and validated in Urdu using both backward and forward translation [69].

2.3. Procedure

This project was approved by the Ethics Review Board of the Institute of Professional Psychology, Bahria University Karachi, Pakistan (05/2023). Written consent was obtained from each participant after being informed about the purpose of the research, the maintenance of confidentiality, and the participant’s right to withdraw at any time without penalty. Due to the sensitive nature of the research, the respect, integrity, and welfare of the participants were given the highest priority. Confidentiality was maintained during all phases of the research project, including in the coding and storage of data, which relied on pseudonyms or nicknames for identification.

This study was carried out over an 8-month period. Initially, different NGOs, activist groups working with the transgender community, and transgender activists were approached via social media platforms in order to establish connections with transgender individuals and communities. Following successful contact, the lead researcher took extensive time and effort to establish a working rapport with the transgender communities in order to develop trust and support for the project. As part of this effort, the lead researcher identified six trustworthy transgender (or transgender activist) resource persons for assisting with the recruitment and data collection. To this end, multiple deras (the place where most transgender people live), mostly located on the outskirts of Karachi, as well as government hospitals where transgender persons have separate sections, were then visited with the help of these resource persons. Sample diversity was enhanced by drawing participants from a number of different deras, as each dera is associated with a different familial/tribal origin and as such represents a different lineage, perspective, and religious/cultural value system.

Once identified, the candidates were approached individually or as a member within a transgender community, where each confirmed their transgender identity prior to proceeding with providing their informed consent (as noted above) and their ability to understand spoken Urdu. Of the 127 candidates who were approached, 15 had no understanding of Urdu and were therefore excluded from this study. Another 3 candidates were excluded during the data collection session due to lack of time for completion of all the questionnaires. The final 109 respondents completed the questionnaires/instruments individually in a private setting, with the researcher assuming a position about 12–15 ft away to provide visual privacy for the respondent, yet within hearing distance in case the respondent needed assistance in reading/understanding the item. Due to the limited reading capacity of many respondents (57%), the participants were permitted to ask the investigator for assistance with reading/comprehending items, with the investigator providing assistance while still maintaining visual distance. Afterward, the participants were debriefed, thanked, and queried about other potential participants, thus implementing the snowball/purposive sampling technique.

2.4. Data Analysis

The results were analyzed using SPSS (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY, USA: IBM Corp). In the preliminary analysis, the internal reliability scores for the BAPS and its three subscales were lower than desired (<0.70), so we undertook several steps to assess the reason for this, with the goal of improving the cohesiveness of the overall instrument and the three subscales. Specifically, (1) we determined inter-item correlations for each subscale to identify items that correlated weakly with other items in that subscale; (2) we examined the corrected item–total correlations to assess which items may have been responsible for low alpha scores; (3) and we removed those items so as to improve internal reliability. This exercise resulted in the removal of three BAPS items, two from intent and one from stigma tolerance. Based on the remaining 15 items, the revised version of the instrument resulted in an increase in the overall BAPS alpha from 0.55 to 0.60. Subscale reliability improved in the following ways: intent increased from 0.22 to 0.48; stigma tolerance improved from 0.42 to 0.46; and expertness remained constant at 0.42. Factor analysis failed to identify a clear three-factor structure, as suggested by the instrument; although factors related to intent and stigma tolerance were moderately cohesive, the items related to expertness were poorly correlated and generated separate/individual components. Altogether, these components accounted for 71.1% of the total variance. Despite the suboptimal metrics for the outcome variable, we used this revised version of the BAPS for further regression analyses, noting that it is not unusual to encounter problems with the structural integrity of validated Western-based measures when they are applied to unusual (e.g., transgender) and/or culturally different (e.g., non-Western, uneducated) populations (e.g., [70]), a point addressed later in the Discussion.

In addition to the standard descriptive analyses, regression analyses were carried out, using the overall BAPS and its three subscales (expertness, stigma tolerance, intent) as outcome variables, and SAS (sexual attitudes) and overall DASS-21 (psychological distress) scores as predictor covariates. Post hoc analysis further tested which DASS-21 subscales (depression, stress, anxiety) were significant. In a second round of regressions, the DASS-21 by SAS interaction term (psychological stress by sexual attitudes) was entered to assess whether sexual attitudes moderated the relationship between psychological distress and attitudes toward psychological help-seeking, determined by a significant increase in the R² within the model. For this second set of regressions, SAS was used as a dichotomous variable (positive vs. negative openness) as prescribed elsewhere [68] in order to simplify the interpretation.

In a third round of regression analyses, relevant (as determined by bivariate correlations) demographic and behavioral variables were entered as a second step in the regression analysis to determine whether such variables added significantly to the predictive power of the overall model.

3. Results

3.1. Description of the Sample

Table 1. Demographic information of participants.

Variables	Mean or f	%
Age	34.3
Education Level
Illiterate	62	57%
Primary	11	10%
Middle/Matric	30	28%
FA/Intermediate	3	3%
BA/14 years	3	3%
Socioeconomic Status
Lower Class	105	96%
Middle Class	4	4%
Upper Class	0	0%
Source of Income
Begging	35	32%
Sex Worker	22	20%
Dancing	47	43%
Other or Unemployed	5	5%
Sex at Birth
Male	97	89%
Female	0	0%
Intersex	12	11%
Gender Preference
She/Her/Hers	78	72%
He/His/Him	25	23%
They/Them/Theirs	6	6%
Gender Identity
Male	1	1%
Female	1	1%
Male Transgender	89	82%
Female Transgender	17	16%
None of the Above	1	1%
Marital/Partner Status
No partner	63	58%
Married to Wife	3	3%
Partner	42	39%
Media Use
Use of Mobile Phone (% yes)	92	84%
Use of Internet (% yes)	66	61%
Use of Social Media (% yes)	41	38%
Television (% yes)	70	64%

and

Table 2. Descriptive statistics for major study variables (N = 109).

Variable	Possible Range	Actual Range	M (SD)	Skewness	Alpha
Belief-Psychol Help	18–108	38–103	69.35 (10.8)	0.515	0.60
-Expertness	4–24	4–24	14.98 (3.8)	0.298	0.42
-Stigma tolerance	8–48	13–48	29.00 (6.8)	0.455	0.46
-Intent	6–36	14–36	25.37 (4.4)	0.329	0.48
Psychological Distress	0–63	5–53	23.12 (9.8)	0.832	0.85
-Depression	0–21	0–17	7.22 (4.2)	0.412	0.55
-Anxiety	0–21	2–18	7.37 (4.5)	0.718	0.76
-Stress	0–21	2–18	9.53 (3.6)	0.272	0.70
Sexual Attitudes	0–100	37–89	63.26 (12.4)	0.067	0.77

provide basic demographic data and study variable information on the sample. Briefly, 89% were male at birth; 11% intersex. The education level and socioeconomic status were generally low, typical for transgender persons in Pakistan. A total of 58% were single; 39% reported having a partner. Most (95%) earned a living through begging, dancing, or sex work.

Table 2 provides descriptive measures on all of the major study variables. The central tendency for most measures fell in the midrange of the scale, with the exception being the SAS (Sexual Attitude Scale), which showed a bias toward higher scores, indicating a tendency toward more restrictive attitudes regarding sexual issues and communication. Distributions exhibited minimal skewness. The reliability scores for the various predictor covariate scales were good/acceptable; the scores for the outcome variable subscales, however, as indicated previously, were lower than desired, a point addressed in the Discussion.

3.2. Regression Analysis

3.2.1. Direct Role of Study Variables

Preliminary bivariate correlations were generated to guide covariate inclusions in the regression analyses (Supplementary S1). Regression analyses were carried out to assess non-collinear relationships between the outcome variable and sets of predictor covariates. The outcome variables consisted of the overall BAPS and its three subscales (intent, stigma tolerance, and expertness). An initial regression included the two major predictor covariates: psychological distress (DASS-21) and Sexual Attitudes Scale (SAS), with post hoc analyses aimed at determining which aspect of psychological distress (stress, anxiety, or depression) was most salient.

Table 3. Results of regression analyses on the overall BAPS and its three subscales, with sexual attitudes and psychological distress as predictor covariates, then showing the effects when psychological distress was specified as depression, stress, or anxiety. p-value columns are shaded in gray for easy visualization of significant covariates.

Outcome		Overall BAPS					95% CI
	b	SE	Beta	t	p	VIF	LB	UB
Constant	56.30	5.17		10.88	0.000		46.04	66.56
Sex Attitude	−0.088	0.094	−0.105	−0.94	0.348	1.37	−0.275	0.098
Psych Distress	0.270	0.119	0.252	2.27	0.025	1.37	0.034	0.506
ANOVA F/p	2.62	0.077
R/R2	0.217	0.047
Depression	0.109	0.136	0.087	0.80	0.424	1.25	−0.160	0.379
Stress	0.335	0.146	0.229	2.29	0.024	1.11	0.045	0.624
Anxiety	0.237	0.137	0.200	1.73	0.086	1.46	−0.034	0.507
Outcome		Expertness Subscale					95% CI
	b	SE	Beta	t	p	VIF	LB	UB
Constant	12.41	1.78		6.96	0.000		8.87	15.94
Sex Attitude	−0.010	0.041	0.037	0.37	0.767	1.37	−0.074	0.055
Psych Distress	0.138	0.032	0.359	3.36	0.001	1.37	0.056	0.219
ANOVA F/p	7.10	0.001
R/R2	0.348	0.121
Depression	0.086	0.048	0.192	1.82	0.072	1.25	−0.008	0.181
Stress	0.102	0.052	0.195	1.97	0.052	1.11	−0.001	0.206
Anxiety	0.172	0.046	0.406	3.73	0.000	1.46	0.080	0.263
Outcome		Stigma Tolerance Subscale					95% CI
	b	SE	Beta	t	p	VIF	LB	UB
Constant	32.29	3.13		10.3	0.000		26.08	38.49
Sex Attitude	−0.107	0.057	−0.211	−1.89	0.060	1.37	−0.220	0.005
Psych Distress	−0.001	0.072	−0.002	−0.01	0.989	1.37	−0.144	0.142
ANOVA F/p	3.20	0.089
R/R2	.211	0.045
Depression	−0.049	0.080	−0.064	−0.61	0.546	1.25	−0.208	0.111
Stress	0.092	0.088	−0.103	1.04	0.300	1.10	−0.255	−0.024
Anxiety	−0.072	0.082	−0.101	−0.89	0.377	1.46	−0.234	0.089
Outcome		Intent Subscale					95% CI
	b	SE	Beta	t	p	VIF	LB	UB
Constant	11.61	1.98		5.86	0.000		14.76	22.72
Sex Attitude	0.029	0.036	0.985	0.80	0.427	1.37	−0.043	0.100
Psych Distress	0.133	0.046	0.311	2.93	0.004	1.37	0.043	0.224
ANOVA F/p	7.99	0.001
R/R2	0.362	0.131
Depression	0.071	0.053	0.142	1.36	0.178	1.25	−0.008	0.132
Stress	0.141	0.057	0.239	2.49	0.014	1.11	−0.029	0.253
Anxiety	0.137	0.052	0.289	2.63	0.010	1.46	0.034	0.241

shows the regression analyses for the overall BAPS and each of its three subscales. For the overall BAPS, psychological distress was a significant predictor (p = 0.025), with post hoc analyses indicating that this significance was derived mainly from the stress subscale. Neither depression nor anxiety was a significant predictor of overall psychological help-seeking.

Two of the three BAPS subscales showed overall significance, as indicated by the ANOVA F-statistics. Expertness and intent (but not stigma tolerance) were predicted by psychological distress (p ≤ 0.004), and stigma tolerance was marginally predicted by sexual attitude (p = 0.06). Post hoc analysis, in which psychological distress was replaced by specific DASS-21 subscales (stress, anxiety, or depression), identified stress and anxiety as significant factors in predicting expertness and intent (Table 3). Consistent with the overall analysis, none of the DASS-21 subscale scores predicted stigma tolerance.

3.2.2. Moderating Role of Sexual Attitude

In a second series of regressions, we tested whether the interaction of sexual attitude (SAS) by the relevant (i.e., significant) psychological distress component (DASS-21 subscale) acted as a moderator between “psychological distress” and “attitude toward psychological help-seeking” by including the interaction term as a second step in the regression model (

Table 4. Increased explanatory power of the regression model by considering socioeconomic status (SES) or Outside Exposure (OE) variables. p-value columns are shaded in gray for easy visualization of significant covariates.

Outcome		Expert		Stigma Tolerance			Intent
	R	R2	p	R	R2	p	R	R2	p
Distress only	0.343	0.117	0.000	0.111	0.012	0.249	0.355	0.126	0.000
With SES ΔR/R2	0.412	0.170	0.011	0.387	0.150	0.000	0.374	0.140	0.191
With OE ΔR/R2	0.343	0.118	0.829	0.232	0.054	0.033	0.365	0.133	0.346

Note: OE = Outside Exposure.

). This interaction term resulted in a notable increase in the R² value only for stigma tolerance, with the increase being significant (R² increased from 0.012 to 0.048; beta = −0.616, p = 0.048). The increase in the explained variance was 3.5%, although the overall effect size was still relatively small. This negative interaction term indicated that the tolerance for stigma regarding mental health labeling/treatment (stigma tolerance) was greater for participants with a more open attitude toward sexuality (as indicated by lower SAS scores).

3.2.3. Role of Demographic Factors in the Regression Model

In the third series of regression models, we tested whether knowing anything about the demographic and/or behavioral characteristics of the participants increased the predictive (R²) value of the model. Preliminary bivariate analysis revealed that SES, gender preference (Her vs. Him/Other), and use of social media and communication platforms (a proxy for a variable labeled as “Outside Exposure”) showed significant correlations with the three BAPS subscales (expertness, stigma tolerance, and intent). Then, using a two-step variable entry process, we assessed whether adding any/all of these demographic variables resulted in significant increases in R² (Table 4). Either SES or Outside Exposure (or both together) significantly increased the R² value for stigma tolerance, and SES but not Outside Exposure (OE) significantly increased it for expertness. Neither variable was significantly associated with intent.

4. Discussion

This study revealed significant factors that predict attitudes toward psychological help-seeking in a population (transgender persons) and context (non-Western developing nation) that is rare and understudied. As to the population, our study affirmed the majority (89%) of “self-identified” transgender individuals in Pakistan as male-sexed at birth, with most (72%) assuming a female gender preference. Regarding context, transgender individuals in Pakistan face unique challenges in all sectors of life due to sociocultural and religious reasons, with most living in disguise or separately from society, finding residence within their own dera community.

4.1. Understanding Transgender Populations in a Religio-Cultural Context

Consistent with the theory of minority stress [56], transgender individuals in many regions worldwide suffer rejection, discrimination, and prejudice, resulting in both lack of opportunities and resources; that is, conditions that impart high levels of distress and risk to mental well-being and health. The adverse effects of the multiple levels of stigma are captured in the concept of “gender stress theory”, the idea that stigma-related stressors attached to one’s gender identity may seriously affect both one’s health and their health-related opportunities for treatment [71,72,73,74]. Indeed, germane to the current study, transgender Pakistani people have been found to exhibit unusually high levels of depression and anxiety—56% and 59%, respectively—with 70% of these individuals receiving low-quality or no healthcare [58]. Together, such factors characterize the enormous psychological burden placed on transgender individuals in Pakistan and underscore their heightened and dire need for access to mental health services.

Yet, despite this need, significant barriers prevent transgender individuals from seeking treatment. Such barriers for the population-at-large include lack of awareness of symptoms and/or treatment options; low motivation for change; high stigma/shame; logistical issues (cost, transportation, accessibility); cultural barriers; and preference to self-manage mental health issues [51,52,75,76]. In Pakistan, where cultural issues play an outsized role in creating barriers, additional reasons for not seeking psychological help typically include a lack of confidence in treatment, prohibition by the family, and religio-cultural perspectives involving family shame and fatalistic thinking [34,58,60,77]. In addition, due to their socioeconomic disadvantage, including lack of insurance, low income, and limited transportation [78], many transgender individuals are unable to access necessary mental health care and may instead rely on unqualified community practitioners, which increases the risk of inadequate treatment or even mistreatment [79].

Our study examined psychological health-seeking beliefs in the context of a number of the factors noted above, including stigma tolerance, confidence in treatment, and the role of psychological distress as related to symptomology and need/motivation. We also examined a proxy variable related to mental health literacy and considered a fifth previously unexplored factor, namely attitudes toward sexuality; that is, whether an open sexual attitude renders individuals more amenable to treatment for a sex/gender-related issue. On balance, sexual attitudes in our sample were overall more restrictive (negative) than open (positive), yet they showed considerable variation, thus enabling us to test whether this factor was associated with psychological help-seeking beliefs for sex/transgender-related issues.

4.2. Factors Influencing Beliefs About Attitudes Toward Psychological Help-Seeking

Psychological distress predicted overall psychological help-seeking as well as two aspects of attitudes toward psychological help-seeking, namely a more positive view of psychological services due to psychologists’ expertness (expertness) and a greater willingness to seek help if in need (intent). These models accounted for 12–17% of the variance in those two beliefs. Post hoc analysis specifying the type of distress identified anxiety and stress as stronger predictors related to psychologists’ expertness and intent. In contrast, neither the psychological distress level, nor any of its component aspects, had any direct bearing on stigma tolerance. However, relevant to this point, another unique finding of this study was that sexual attitude marginally predicted stigma tolerance; that is, the more open one’s sexual attitude, the greater the likelihood of overcoming the inhibiting effects of the stigma associated with seeking psychological help. Furthermore, the combined effects of increasing psychological distress and open sexual attitudes were significant, indicating that stigma tolerance was greater for distressed participants with a more open attitude toward sexuality. In this respect, a more positive attitude about sexuality moderated the effects of increasing levels of psychological distress on overcoming the stigma related to psychological help-seeking.

Psychological distress can lead to problems completing daily activities such as work-related tasks; in addition, it negatively impacts one’s social life and imposes a high risk for developing serious health problems. Therefore, its treatment represents a significant public health issue. Nevertheless, the relationship between levels of distress and help-seeking behavior is not as straightforward or simple as it might seem. For example, in our study, psychological distress accounted for under 20% of the variance in attitudes toward psychological services, with some research studies actually reporting a complete lack of relationship between psychological distress levels and help-seeking behavior in select populations [80]. In fact, several studies have even reported an inverse relationship between distress and help-seeking, for example, in populations that identify with minority status [81,82]. Ironically, in those populations, conditions such as anxiety, depression, and post-traumatic stress appear to lower help-seeking tendencies and increase stigma relevance, particularly among individuals with no experience with mental health treatment. Not surprisingly, past mental health treatment can moderate the relationship between depressive/distress symptoms and help-seeking tendencies, particularly insofar as lessening the stigma associated with treatment [82]. That the relationship between psychological distress and help-seeking behavior is complex is borne out by other research that has demonstrated that the relationship between the two often follows a circuitous path. For example, Dagani et al. [83] found that in a student population, psychological distress correlated positively with coping strategies, which in turn was negatively associated with the stigma of seeking help. Their findings suggested that students with significant psychological distress used coping strategies to overcome the stigma of seeking help; andthe lower the stigma attached to seeking help, the higher their chance of developing help-seeking intentions [83]. A similar circuitous route was evident in our study, where psychological distress was related to greater stigma tolerance (and thus greater propensity toward seeking psychological help) only when the variable related to positive sexual attitudes was invoked. Other such relevant mediating/moderating variables for psychological distress likely include social (and/or family) support, predisposition for self-reliance/self-management of psychological issues, and availability of treatment by knowledgeable specialists [58,84,85].

4.3. Issues Regarding Literacy

Transgender individuals in Pakistan not only have low literacy rates but also have low mental health literacy; that is, they possess little or no knowledge and understanding of mental health disorders, including recognizing symptoms and managing their own mental health. An important corollary to mental health literacy is knowing what help might be available and how to access it. Based on our experience, a substantial portion of participants seemed unaware of the role of the “psychologist” and the possibility of “psychological help” as resources for coping with psychological problems. And those that were aware tended to seek information and assistance from their friends and transgender community members. Furthermore, these individuals typically avoided the use of healthcare facilities, where they might face either discrimination and/or ridicule, or in some instances outright denial of services. As a result, transgender people in need of help often rely on self-medication, in many cases (estimated at 38%) using sedatives or various other street drugs to mitigate their symptoms [35,40]. Not surprisingly, the lack of knowledge about psychological illnesses (depression, anxiety) and the corresponding possibility of treatment constitutes a major barrier to seeking help [86,87]. In fact, together with low levels of mental health literacy, the stigma associated with psychological treatment, the likelihood of discrimination, and the lack of transgender-competent providers are among the greatest barriers to treatment in this population [88,89]. As stated succinctly by one participant, “They (mental health specialists) don’t listen to us, that’s why many (transgender people) don’t take help…” (translated from Urdu).

In our study, we did not directly assess mental health literacy, but we did find that two variables—SES and Outside Exposure—increased positive attitudes toward psychological help-seeking. Specifically, both variables were associated with greater tolerance for stigma regarding mental health labeling, and SES was associated with a more positive view of psychological services due to psychologists’ expertness. Although SES was a compromised variable due to its limited variation in our sample, these two variables might serve as proxies for exposure to general knowledge about mental/psychological health. And as such, they suggest that one significant barrier to psychological help-seeking might be overcome quite readily by providing better education about the meaning and manner of psychological well-being, as well as options for the treatment of psychological problems. In other words, barriers to treatment due to low mental health literacy represent an informational challenge rather than an embedded sociocultural challenge (e.g., social stigma/shame), the former being more easily overcome than the latter. This notion is particularly relevant to stigma tolerance, which, in our study, was the most intractable of the barriers to psychological help-seeking, reflecting in part the generally high level of stigma/shame attached to the use of psychological services in Pakistan.

4.4. Implications Beyond Pakistan

The findings from the present study have implications for understanding treatment-seeking behavior among transgender people beyond Pakistan. That is, the situation in Pakistan represents a microcosm for many other—particularly non-Western—parts of the world. For example, unlike most Western countries, much of the world holds more restrictive attitudes toward sexual or gender diversity; has stronger stigmas attached not only to sexual non-conformity but also to psychological help-seeking; and is characterized by lower general literacy and sometimes absent mental health literacy. Thus, many of the same conditions present in Pakistan are replicated elsewhere in the world; in this respect, the current findings broadly apply to issues of healthcare access for transgender populations within those sociocultural systems as well.

4.5. Limitations and Recommendations

As an exploratory study, this well-powered analysis [90] revealed significant challenges in studying transgender populations within a specific religio-cultural context. These challenges included not only the recruitment of participants but also possible issues with the use of “standardized” assessment scales that may lack applicability to a non-Western sociocultural context and/or to specific marginalized populations (e.g., uneducated and/or transgender).

Regarding the recruitment of participants, probabilistic and broad community sampling strategies are simply not viable options for this sort of research. And while snowball sampling increased recruitment potential from this hidden/stigmatized population, it could also increase sampling bias, reduce diversity within the sample, and result in less reliability/confidence in the data. However, two points mitigate the “reliability” concern noted above: (1) most of our findings were supported by highly significant p-values; these p-values—as the best index of reliability within the study—clearly increase overall confidence in the results of the quantitative analyses; (2) drawing participants from a variety of sources, including multiple dera communities and various government hospital wards (as described previously), enhanced the diversity within our sample. Perhaps the strongest evidence for this diversity is seen in the large range of scores on all the various standardized instruments included in this study. At the same time, often absent from the dera communities are transgender individuals from higher socioeconomic classes who, because of their financial independence, are able to overcome some of the obstacles associated with transgender status in Pakistan, including accessing healthcare or even residence in other countries. In this respect, our findings may not be generalizable to this small but select segment.

Regarding the lower internal reliability indices for the BAPS in our sample, readers should exercise caution in interpreting our findings and, as with any social–psychological study, further study and replication in similar samples will be important. We further note that the BAPS, developed in the USA, was based on the responses of college students. As a rule, college students in the USA represent a group with a high level of mental health literacy, as nearly all higher education campuses in the USA place emphasis on the mental health and well-being of their students and provide “free” services through campus counseling centers. The instrument was more recently validated in three other populations: Omani university students, an Icelandic sample, and a South Korean sample of Protestant church attendees [91,92,93]. However, all of these populations represent highly literate, well-educated, and moderately affluent populations which are generally attuned to issues of mental health and help-seeking options. The above populations are contrasted with a supplicant, poorly-educated, marginalized transgender population in our study that, as indicated previously, not only had limited knowledge regarding the psychological constructs surrounding mental health (e.g., anxiety, depression, stress) but was also relatively naïve regarding the role of (and access to) psychologists and psychological services. Furthermore, the BAPS assumes that the three subscales (intent, stigma tolerance, expertness) are at least moderately intercorrelated (as suggested by an overall Cronbach alpha of 0.84), and for well-educated samples, this may well have been the case. However, these three subscales may be unrelated (i.e., independent) in populations functioning within other sociocultural environments. For example, as seen in Supplementary S1, stigma tolerance was only weakly related to intent and expertness (<0.22), indicating 4% or less covariance with those subscales. Nevertheless, this anomalous pattern is consistent with the idea that the large mental health stigma existing in many non-Western cultures constitutes a formidable barrier to psychological treatment-seeking in those populations [49,50,51,52,60].

Although problems with BAPS internal reliability may increase the likelihood of missing real effects (Type 2 errors), we note that we were still able to detect reliable (as determined by p-values) and moderately strong (as determined by beta values) associations between several predictor covariates and attitudes about seeking psychological help. In addition, our preliminary analyses using the unmodified version of the BAPS yielded results (regarding significance and conclusions) that were almost identical to those based on the modified version of the BAPS and its subscales, where internal reliability was moderately improved. Finally, the respectable alpha indices for the DASS-21 and SAS within our sample further implicate issues with the cross-cultural validity and/or applicability of the BAPS to marginalized populations with limited mental health literacy.

Future exploratory research might focus on qualitative analyses to obtain a better handle on issues regarding help-seeking in transgender populations in the context described in the current study. Furthermore, although we carried out due diligence regarding the selection of the BAPS—verifying its reliability in various culturally disparate world populations and pretesting it on samples of both Pakistani students and transgender individuals for face-validity and clarity—future research might benefit from tailored assessment instruments that accommodate less-educated and marginalized populations residing in vastly different sociocultural systems. In addition, separate measures on both literacy and mental health literacy, as well as other help-seeking covariates such as social support and self-reliance/management propensity, should be included as control or predictor/mediating/moderating covariates.

5. Conclusions

Transgender populations in developing, non-Western countries are understudied, and research on help-seeking behaviors in such groups is nearly non-existent. In this study, psychological distress—as manifested in anxiety, stress, and depression—was the most prominent predictor of attitudes about psychological help-seeking, although its association was specific to increasing positive attitudes based on expertness and intent/need for treatment. Other factors such as sexual attitudes and purported mental health awareness were also relevant, particularly insofar as mitigating the inhibiting effects of stigma and shame related to seeking treatment for a psychological issue.