C:\Users\JURNAL FKUSAKTI\Docume 187 *Department of Psychiatry, Faculty of Medicine, Atma Jaya Catholic University of Indonesia **Medical Profession Program, Faculty of Medicine, Atma Jaya Catholic University of Indonesia Correspondence: Dr. dr. Surilena Hasan, Sp.KJ(K) Department of Psychiatry, Faculty of Medicine, Atma Jaya Catholic University of Indonesia Jl. Pluit Raya No. 2, North Jakarta Indonesia Phone: +6221-6693168 Fax: +6221-6606123 Email: surilenahasan@yahoo.co.id or surilena@atmajaya.ac.id Date of first submission, June 2, 2017 Date of final revised submission, November 10, 2017 Date of acceptance, November 13, 2 01 7 This open access article is distributed under a Creative Commons Attribution- Non Commercial-Share Alike 4.0 International License ABSTRACT UNIVERSA MEDICINASeptember-December, 2017 Vol.36 - No.3 High perceived discrimination and no family support increase risk of poor quality of life in gender dysphoria Surilena Hasan*, Yovita Alviany**, Cerellia Clarissa**, and Sonia Sudana Kusuma** BACKGROUND Family support and low discrimination perceptions are a factor in protecting against mental disorders and poor quality of life in male to female (MtF) gender dysphoric individuals. The aim of this study was to determine the role of family factors, peer support, self-esteem, perceived discrimination, depression, anxiety, and stress on the quality of life among MtF gender dysphoric individuals. METHODS A cross-sectional study was conducted involving 106 MtF gender dysphoric individuals of Sanggar Swara Jakarta. Respondents filled out questionnaires on demographics, WHOQL-BREF, perceived discrimination, Rosenberg self-esteem, family support, social support (SSQ6), family relations (FACES III), and depression anxiety stress scale (DASS). Simple and multivariate logistic regression tests were used to analyze the data. RESULTS Among the 106 MtF gender dysphoric individuals of Sanggar Swara Jakarta with an age range of 18-45 years, 78.3% had no family support, 64.1% no peer support, 62.3% high perception discrimination, 64.1% low self-esteem, 36% extreme family relations, 44.3% depression, 59.4% anxiety, 35.8% stress and 62.3% poor quality of life. Employment, perception of discrimination, self-esteem, family support, and anxiety were significantly associated with quality of life (p<0.05). Multiple logistic regression analysis showed that perceived discrimination (Odds Ratio=13.89; 95% CI: 5.89-11.99), and family support (Odds Ratio=29.11; 95% CI: 2.45-8.21) were significantly associated with quality of life. CONCLUSION High perceived discrimination and no family support increase the risk of poor quality of life in MtF gender dysphoric individuals. These findings suggest the need for prevention and intervention of stigmatization and discrimination that should have a special focus on families with MtF gender dysphoric individuals. Keywords: Quality of life, family support, perceived discrimination, gender dysphoria DOI: http://dx.doi.org/10.18051/UnivMed.2017.v36.187-196 ORIGINAL ARTICLE Cite this article as: Hasan S, Alviany Y, Clarissa C, et al. High perceived discrimi- nation and no family support increase risk of poor quality of life in gender dysphoria. Univ Med 2017;36: 187-96. doi : 10.18051 /UnivMed.2 017 . v36 .1 87 -19 6 pISSN: 1907-3062 / eISSN: 2407-2230 188 Hasan, Alviany, Clarissa, et al Perceived discrimination in gender dysphoria INTRODUCTION Lesbian, gay, bisexual, and transgender (LGBT) has been the hot topic of conversation in Indonesian society for decades. The LGBT community has long existed in Indonesia but only in recent decades has it become phenomenal. The LGBT community began to present itself in various mass media and some cases of same- sex marriage emerged openly, along with the formation of communities with a clearly visible structure.(1) A transgender or gender dysphoria individual is an individual who expresses his gender identity as being opposed to his biological gender. There are 2 types of gender dysphoria communities, namely male to female (MtF) and female to male (FtM). The MtF gender dysphoria community is considerably more numerous than the FtM gender dysphoria community, with a 1:1 to 6.1:1 ratio. The number of gender dysphoric individuals continues to increase worldwide. It is estimated that by 2030, the number of gender dysphoric individuals will increase by two-fold.(2) Survey in the United States by Bockting, et al.(3) in 1093 gender dysphoria MtF (57.5%) and FTM gender dysphoria (42.5%) showed that there were 464 (56.5%) gender dysphoria MtF with high economic status. Gender dysphoria MtF depression is more likely to be discriminated (verbal 37%, physical 20%, work 39%) compared to non-depressed MtF gender dysphoria. Data from the Kebaya NGO waria Yogyakarta extended family showed that the number of MtF gender dysphoric individuals is 234 people spread over several areas in Yogyakarta.(4) Gender dysphoric individuals experience more psychosocial problems such as stigma, discrimination, social support and low family support compared to lesbian, gay, bisexual (LGB) individuals. The majority of Indonesians (93%) still reject gender dysphoria and only 3% accept it. Discrimination and shame fearing family reactions are two main reasons for gender d ysph o ri c pe o ple n ot t o r e p or t ca s e s o f discrimination they experience to relevant agencies, to be unwilling to document their case, and to be reluctant to seek mental health services. Gender dysphoric individuals may experience dropping out of school because of discrimination and rejection causing gender dysphoric individuals to risk social isolation, problematic academic performance, bullying behavior, feelings of inadequacy to go to school with the biological gender status, experience ostracism, harassment (sexual, physical, verbal, and emotional), persecution, humiliation, difficulty in getting employment, rejection by health care providers, and a disrespectful public attitude both in the workplace and in public places.(5,6) The psychological aspect is strongly correlated to social stigma that ends up to the psychological pressure experienced by the gender dysphoria community. Gender dysphor ia , discriminated, victimized, and stigmatized persons may be at risk of high perceived discrimination, negative self-image (feeling inferior, embarrassed, isolated and rejected by the environment, lonely, helpless, anxious, depressed, attempting suicide), emotional and mental health problems of behavior and deterioration of the quality of life. Depression and suicide attempts are two of the most common transgender mental health problems.(5) The National Center for Transgender Equality and National Gay and Lesbian Task Force survey shows that 41% of gender dysphoric individuals attempts suicide compared with 1.6% of the general population, 32% are depressed, and 29% have somatization disorders.(7) Acceptance as well as family and community support provide a protective effect against many of the “threats” to the well-being of gender dysphoric individuals, including the risk of HIV-AIDS infection, depression and suicide. Inadequate social and family support, especially from biological families, is often reported in the case of the individuals’ sense of security when in a public setting.(6.7) The phenomenon o f various gender dysphoria problems is increasing in Indonesia. gender dysphoric individuals experience stigma and discrimination from various parties such as family, community, religion, culture and country. The role of the family is a protective factor for 189 ge nder dysphoria in the face of stigma, discrimination, sexual identity, and in lowering the risk of mental disorders and poor quality of life.(7) In the present study, the researchers wanted to determine the perceived discrimination in gender dysphoric individuals, which is the perception of gender dysphoric individuals of their sexual identity, unfair treatment, and stigma and discrimination from family, environment, and society. High perceived discrimination has an effect on poor adaptability and low self-esteem in the face of stigma and discrimination that can have further impacts on emotional mental disorders and poor quality of life.(8) Early detection of perceived discrimination, self-esteem and family factors (family relationships, family support, parenting patterns) and social support for ge nder dysphoria in the face of stigma, discrimination and sexual identity, can be made for the prevention and early intervention of the impact inflicted. The aim of this study was to determine the role of family factors, peer support, self-esteem, perceived discrimination, depression, anxiety, and stress on the quality of life of MtF gender dysphoric individuals. METHODS Research design The study design was cross sectional and the study took place in March - November 2016 at the Sanggar Swara Jakarta community. Study subjects Sanggar Swara Jakarta is one of the gender dysphoria community centers in Jakarta with about 300 male to female (MtF) and 50 female to male (FtM) gender dysphoric individuals with an age range of 14-45 years, spread over the five districts of DKI Jakarta (North Jakarta, South Jakarta, West Jakarta, East Jakarta, Central Jakarta). The sample size in this study was 106 MtF gender dysphoric individuals obtained for unpaired categorical analysis and 10% drop-outs. The sample was obtained from all religions using cluster random sampling.(9) The inclusion criteria of this research were MtF gender dysphoric individuals targeted at the five Jakarta Swara areas (South, West, East, Central, North) areas, aged 18-45 years, with no history of drug abuse, able to read and write, and agreeing to fill out questionnaires completely. Excluded from this study were those who were unwilling to sign informed consent, or were suffering from severe mental disorders (psychotic disorder and mental retardation). Measurements The instruments used in this study are the following eight questionnaires. The first is a demographic questionnaire consisting of age, educational level, occupation, and economic status. The second is the Rosenberg Self-Esteem Questionnaire consisting of 10 questions with 4 categories, where self-esteem is high if the total score is 15 and low if the total score is <15.(10) This study also used a perceived discrimination questionnaire consisting of 15 questions, where perceived discrimination is high if total score >13 and low if total score 13 with Cronbach’s alpha of 0.890.(11) The questionnaire on family relations (FACES III) consists of 16 questions with 4 types of family cohesion and 4 types of family adaptability, which are further summarized in 3 types of family relationships, i.e. balanced, extreme, and mid-range family relations.(12) The family support questionnaire consists of 20 questions with supportive results if the total score 60 and non supportive when the total score <60.(13) The social support questionnaire (SSQ6) consists of 6 questions, where the results are peer support if the total score 3 and no peer support when the total score <3.(14) The depression anxiety stress scales (DASS) consists of 42 questions and is divided into 3 sub-scales, namely depression, anxiety and stress, each containing 14 questions. Each sub-scale has a range of values 0-3. The total score is calculated by summing the scores of each sub-scale giving a score range of 0-42 for each sub-scale. Total scores below 10,18,15 on anxiety depression and stress sequentially Univ Med Vol. 36 No.3 190 Hasan, Alviany, Clarissa, et al Perceived discrimination in gender dysphoria A B C indicate normal levels, while total scores above 20, 14 and 25 in depression, anxiety and stress sequentially indicate very severe levels.(15) The WHOQL-BREF questionnaire consists of 24 questions where the results are good quality of life if the total score 60 and poor quality of life when the total score <60.(16) Statistical analysis The data of this study were analyzed using binary simple logistic regression analysis for the relationship of gender dysphoria quality of life with employment, perceived discrimination, self- esteem, family support, and anxiety. Multiple logistic regression analysis was used for the relationship of quality of life with perceived d is c r i mi n at i on a nd f a mi l y s upp or t . T he relationships were considered to be of statistical significance at an error probability of less than 0.05 (p<0.05). Ethical clearance This research has been approved by the Ethical Clearance Committee, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, under number 05/04/KEP-FKUAJ/ 2016- April 18, 2016. RESULTS Characteristics of participants In this study, there were 106 MtF gender dysphoric individuals of Sanggar Swara Jakarta, with the age range of 18-40 years. In this study there were no respondents who dropped out. The maj ority of subj ect s had the following characteristics: 57.5% senior high school education, 69.8% low economic status, 64.2% employed, 35.8% residing in North Jakarta. Most of the respondents had the following pecentages of determinant factors: 62.3% high perceived discrimination, 64.1% low self-esteem, 44.3% depression, 59.4% anxiety and 35.8% stress. A total of 78.3% had no family support, 64.1% no peer support, 36.0% had extreme family relations and 62.3% poor quality of life (Table 1). Variables n (%) Age (years) 18-24 34 (32.1) 25-31 36 (34.0)* 32-38 26 (24.5) 39-45 10 (9.40) Education Senior high school 55 (57.5)* Junior high school 45 (42.5) Occupation Employed 62 (64.2)* Non-employed 38 (35.8) Family Socio-economic Status Middle income (Rp 3.100.000/month or above) 26 (30.2) Low income (below Rp 3.100.000/month) 74 (69.8)* Region North Jakarta 38 (35.8)* Central Jakarta 6 (5.70) West Jakarta 13 (12.2 ) East Jakarta 22 (20.7) South Jakarta 27 (25.6) Perceived discrimination High 66 (62.3)* Low 40 (37.7) Self-esteem High 32 (35.9) Low 68 (64.1)* Family Support Supportive 17 (21.7) Non-supportive 83 (78.3)* Peer Support Supportive 32 (35.9) Non-supportive 68 (64.1)* Family relations type Balanced 18 (16.9) Mid range 50 (47.1)* Extreme 38 (36.0) Depression Negative 53 (55.7)* Positive 47 (44.3) Anxiety Negative 37 (40.6) Positive 63 (59.4)* Stress Negative 62 (64.2)* Positive 38 (35.8) Quality of life Good 40 (37.7) Poor 66 (62.3)* Table 1. Key characteristics of study respondents and other explanatory variables (n=106) Note* = high percentage 191 Table 2 shows that there were 5 variables (employment, perceived discrimination, self- esteem, family support, and anxiety) significantly associated with life quality (p<0.05). But there was no significant relationship of educational level, socioeconomic status, type of family relation, peer support, stress, and depression with quality of life (p>0.05). The study showed that 83.3% of employed respondents had poor quality of life and 16.7% of non employed respondents had poor quality of life. There were 31.8% of respondents with low perceived discrimination who had poor quality of life and 68.2% of respondents with high perceived discrimination who had poor quality of life. There were 40.9% of respondents with high self-esteem who had poor quality of life and 59.1% of respondents with low self-esteem who had poor quality of life. There were 72.7% of respondents without family support who had poor quality of life and 37.3% of respondents with family support who had poor quality of life. This study also showed that 45.5% respondents with anxiety had poor quality of life and 54.5% respondents without anxiety had poor quality of life. Univ Med Vol. 36 No.3 Table 2. Correlation between factors affecting quality of life in MtF gender dysphoric individuals (n=106) OR= Odds Ratio Variable p value Adjusted OR@ 95% CI for EXP(B) Lower Upper Occupation Family support Perceived discrimination Self-esteem Anxiety Socioeconomic status Depression 0.201 0.000* 0.004* 0.069 0.169 0.109 0.089 1.79 29.11 23.89 11.61 6.78 1.89 3.78 1.925 5.899 2.455 5.201 12.221 9.760 10.675 3.422 11.990 8.210 23.901 26.701 14.109 21.670 Table 3. Factors associated with quality of life in MtF gender dysphoric individuals (n=106) Note: CI= 95% confidence interval for the mean; p*= significant association; @Adjusted odds ratio controlled for variables Variables Quality of life p value OR 95% CI Good n (%) Poor n (%) Education Senior high school 23 (57.5) 38 (57.5) 0.301 2.4 11.9-45.9 Junior high school 17 (42.5) 28 (42.5) Occupation Employed 13 (32.5) 55 (83.3) 0.000* 0.46 39.0-78.8 Non-employed 27 (67.5) 11 (16.7) Socioeconomic Status Middle 14 (35.0) 18 (27.3) 0.101 4.9 0.78-98.5 Low 26 (65.0) 48 (72.7) Perceived discrimination High 21 (52.5) 45 (68.2) 0.004* 12.70 29.8-76.55 Low 19 (47.5 ) 21 (31.8) Self-esteem High 11 (27.5) 27 (40.9) 0.001* 2.89 34.1-56.2 Low 29 (72.5) 39 (59.1) Depression Negative 26 (65.0) 33 (50.0) 0.209 6.7 0.21-33.56 Positive 14 (35.0) 33 (50.0) Anxiety Negative 13 (32.5) 30 (45.5) 0.002* 2.15 22.9-42.8 Positive 17 (67.5) 36 (54.5) Stress Negative 21 (52.5) 47 (71.2) 0.602 1.8 0.81-92.7 Positive 19 (47.5) 19 (28.8) Family support Support 14 (35.0) 18 (37.3) 0.000* 23.19 37.1-59.1 No support 26 (65.0) 48 (72.7) Peer support Support 14 (35.0) 14 (21.2) 0.407 3.5 0.42-67.5 No support 26 (65.0) 52 (78.8) Family relations type Balanced 6 (15.0) 13 (19.7) 0.605 0.306 2.9 1 (Reference) 1.9 0.52-23.8 0.34-19.6 Extreme 13 (32.5) 40 (60.6) Mid range 21 (52.5) 13 (19.7) 192 Hasan, Alviany, Clarissa, et al Perceived discrimination in gender dysphoria The binary logistic regression test showed different proportions of quality of life between subjects who were employed and those who were non-employed (OR=0.46, p=0.000), between subj ects with low and high per ceived discrimination (OR=12.70, p=0.004), and between low and high self-esteem (OR=2.89, p=0.001), without family support and with family support (OR=23.19, p=0.000), and with and without anxiety (OR=2.15, p=0.002), respectively (Table 2). There were no significant relationships of educational levels, socio-economic status, type of family relations, peer support, stress, and depression with quality of life (p>0.05). A total of 57.5% of respondents who were senior high school graduates and 42.5% of respondents who were junior high school graduates had poor quality of life. The study also showed that 69.8% of respondents with low economic status and 30.2% respondents with middle economic status had poor quality of life. The study also showed that 60.6% of respondents with extreme family relationships and 19.7% respondents with balanced family relationships had poor quality of life. A total of 78.8% respondents without peer support had poor quality of life and 21.2% respondents with peer support had poor quality of life. The results of this study showed that 28.8% of respondents with stress had poor quality of life and 71.2% without stress had poor quality of life. There were 50% of respondents with depression who had poor quality of life and 50% of respondents without depression who had poor quality of life. The proportion of quality of life was not significantly different between subjects with senior and junior high school level (p=0301); low and middle economic status (p=0.101); extreme and balanced family type (p=0.605); peer support and no peer support (p=0.407); stress and no stress (p=0.602); depression and no depression (p=0.209) (Table 2). Multivariate analysis The results of multivariate logistic regression analysis showed that there were two influencing variables, i.e. perceived discrimination and family support. The variable perceived discrimination had an odds ratio of 13.89 (95%CI: 5.89-11.99), which means that respondents with high perceived discrimination had a 13.89-fold greater risk for poor quality of life. The variable family support had an odds ratio of 29.11 (95%CI: 2.45-8.21), which means that respondents without family support had a 29.11 times greater risk for poor quality of life (Table 3). DISCUSSION The result of this study indicate that among the 106 MtF gender dysphoric individuals in the age range of 18-45 years, the majority of respondents have high school education, most are employed as sex workers, the rest work as salon employees, salon owners, and buskers. They have a low economic status (earning less than Rp 3.100.000 /month) and most live in villages, occupying a narrow boarding-house room. Research by Prabawanti et al.(17) in MtF gender dysphoric individuals in DKI Jakarta showed that 42% had junior high school education, 60% were commercial sex workers (34.9% as sex worker Variable p Adjusted OR@ 95% CI for EXP (B) Lower Upper Occupation Family support Perceived discrimination Self-esteem Anxiety Socioeconomic status Depression 0.201 0.000* 0.004* 0.069 0.169 0.109 0.089 1.79 29.11 23.89 11.61 6.78 1.89 3.78 1.925 5.899 2.455 5.201 12.221 9.760 10.675 3.422 11.990 8.210 23.901 26.701 14.109 21.670 Table 3. Factors associated with quality of life in MtF gender dysphoric individuals (n=106) Note: CI= 95% confidence interval for the mean; p*= significant association; @Adjusted odds ratio controlled for variables 193 for their main income and 24.4% for additional income). Nuttbrock et al.(18) showed that most of the MtF gender dysphoria individuals experiences discrimination and tend to have no choice in running their lives in the community. The large number of constraints from the environment, access to education, access to health and the right to decent work leads to low-income, low-paid work, and sex work. The results of our study showed that 62.3% of respondents had high perceived discrimination, and 64.1% had low self-esteem. Bazargan and Galvan state (19) that discrimination experienced by transgender individuals may be physical or sexual violence, social exclusion, humiliation, being viewed as a sex worker and as HIV positive, discrimination at work and health services. Gender dysphoric individuals suffering from discrimination and stigmatization have a low self- esteem that can have further impacts with emotional mental disorders, suicide and poor quality of life. The results of the present study indicate that 59.4% of respondents had anxiety, 44.3% depression and 35.8% stress. Bockting et al.(3) showed 52% respondents with anxiety, 48.7% depression and 25.1% stress. Depression and s ui c i d e a tt e mp t s a r e t he mos t c o mmo n c o nd i t i ons i n t r a n sge n de r me n ta l h e al t h problems. The survey of the National Center for Transgender Equality and the National Gay a n d L e s bi an Ta s k Fo r c e s t a t ed th a t t he prevalence of depression in transgender was 44.1%, among them 41% suicide attempts, while depression in the general population was 6.6% and suicide attempts 1.6%. There were more suicide attempts by transgender individuals who have lost their jobs due to a negative view of their transgender status, are targets of bullying or bullying at school, or victims of physical or sexual abuse.(20) The results of our study also showed that 78.3% of respondents did not receive family support, 64.1% did not receive social support, and 36% had extreme family relations. This study is in accordance with the study by Simon et al.(21) which showed that 74% of gender dysphoric individuals did not have family support, 59.2% were not socially supported, and 27% had extreme family relations. Gender dysphoric individuals who do not get family or social support have a greater risk of depression and suicidal ideation than those who get family or social support. Two studies in India found that 20.1% of gender dysphoric individuals who did not get fa mi ly supp or t co uld e xp er ie nce gre at er discrimination and violence at home than the 0.4% who received family support. Family rejection of gender dysphoric individuals took the form of judging them to be a “disgrace” to the family. Relationship factors between family members and the environment can affect a f a mi l y’s re f u s a l o f ge nd e r d ys ph o r i a a s individuals “neighbors” that can trigger gender dysphoria behavior by the family and most gender dysphoric individuals leave the house. Low family support is due to the inability of families to adapt and accept their gender dysphoria family members.(20,21) The results of the present study showed that 62.3% of respondents had poor quality of life. George (22) showed that gender dysphoric individuals without family support led them to become homeless, employed as sex worker, and make suicide attempt. The National Transgender Discrimination Survey (NTDS) showed that 19% gender dysphoric individuals were expelled from residence, more than 2.5 times more likely to be jailed, 4 times more likely to work as sex workers, 3 times more likely to be HIV positive and 4 times more likely to make suicide attempts. The National Transgender Discrimination Su rve y als o s howed th at 28% of gender dysphoric individuals delayed seeking health services due to discrimination, 48% did not have sufficient funds, and 19% experienced denial of he alth services. Limited access to health services occurs because rejection or prejudice and lack of knowledge of health care workers on gender dysphoric individuals, making it difficult for these to obtain appropriate and competent health services.(23) Univ Med Vol. 36 No.3 194 Hasan, Alviany, Clarissa, et al Perceived discrimination in gender dysphoria Our study showed that occupation, perceived discrimination, self-esteem, family support, and anxiety were significantly associated with quality of life. Bar et al.(24) showed that most of the MtF gender dysphoric individuals experiences discrimination that tends to leave them no choice in running their lives in society. The many barriers of access to education and the right to decent work cause many of the gender dysphoric individuals to be of low income and low education, and employed in sex work. Prabawanti et al.(17) argues that the frequently stigmatized and discriminated MtF gender dysphoric individuals are forced to become sex workers because it is difficult to compete for decent jobs in Jakarta, with a degree of education that is limited to junior and senior high school. Despite employment opportunities, transgender individuals are often denied work because of their identity as transgender individuals and are judged as a violation of community values and norms. Gender dysphoria people who are employed as sex workers have poorer mental, physical, psychological and social health than gender dysphoria people who are not employed as sex worke rs, experience highe r stigma and discrimination and have a higher risk of drug abuse, physical and sexual abuse, as well as HIV disease or other sexually transmitted diseases that end in emotional and behavioral disorders and poor quality of life.(20.24) The result of our study showed there were two variables, i.e. perceived discrimination and family support that were associated with quality of life. The most dominant variable was family support, which affects the quality of life of transgender MtF individuals. The study by Burgess et al.(25) suggested that unfavorable family support poses a 5.72 times greater risk for anxiety, while the risk of depression is 4.06 times, and suicide risk is 3.09 times compared with proper family support. Family support has the strongest positive effect on mental health and the survival of transgender life. The majority of families will reject family members who take the liberty to express themselves as gender dysphoric individuals, who are judged as a disgrace to the family, as sinners, as exposing the shame of the family to the neighbors, and various other negative stigmata. Family rejection of gender dysphoric individuals always occur, being only different in the type of rejection, from refusal to acknowledge them to refusal that leads to physical violence even to their being expelled from home.(26) Nemoto et al.(27) stated that MtF gender dysphoric individuals who do not have family or social support have a greater suicide risk than those receiving social and family support. Weissman’s (28) study reported that 54.8% of gender dysphoric individuals had high perceived discrimination. Basar et al.(29) stated that high perceived discrimination, poor social support, and poor family support can affect self-esteem and gender dysphoria mental health by degrading the quality of life. Prabawanti et al.(17) stated that MtF gender dysphoric individuals are often stigmatized and discriminated, forcing them to become sex workers because it is difficult to compete for employment in Jakarta, when only having a high school education. Although discriminatory acts are legally prohibited, MtF ge nder dysphoric individuals experience discrimination that causes difficulties in completing education, job search, housing ownership and access to general health services. Wilson et al.(0) stated that 61% of MtF gender dysphoric individuals have difficulties in obtaining jobs due to stigma and discrimination, so they look to sex work for alternatives. The limitation of this study is the cross- sectional design used, that cannot explain any causal relationship of perceived discrimination and family support with male to female (MtF) gender dysphoric individuals’ quality of life. Further research is needed with longitudinal research design to be able to explain causal relationships. The p resent r esear ch was conducted on MtF gender dysphoric individuals in the community of Sanggar Swara Jakarta spread over the five municipal areas of the DKI Jakarta special capital city area with unequal 195 numbers of respondents in the five regions. It is hoped that through the results of this research there may be early detection of psychological problems, stigma and discrimination, emotional mental disorders in transgender individuals and attempts at comprehensive intervention by involving the family or parents so as to achieve good quality of life for gender dysphoric individuals and their families. Further research can be done on gender dysphoria of both male to female (MtF) or female to male (FTM) types on the role of family factors, especially family support for family members with gender dysphoria. Family support and good family communication can help the gender dysphoria individual to face acceptance of their sexual identity, self-esteem, decrease per ceived discrimination, prevent emotional and behavioral mental disorders and obtain a good quality of life CONCLUSION High perceived discrimination and no family support are high risk factors for emotional and behavioral mental disorders and poor quality of life for gender dysphoria people especially male to female (MtF) gender dysphoric individuals. CONFLICT OF INTEREST There are no conflicts of interest ACKNOWLEDGMENT We thank all male to female (MtF) gender dysphoric individuals in Sanggar Swara Jakarta community who have been willing to participate in this research and all the health care staff of Sanggar Swara Jakarta who have helped in this research. CONTRIBUTORS S contributed to drafting and designing the study. S, YA, CCl and SSK contributed to conducting the study. S and YA supervised and/ or performed the data management and data entry. S, YA, CC and SSK contributed to analysis and interpretation of the data. All authors read and approved the final manuscript. REFERENCES 1. Bradford J, Reisner SL, Honnold JA, et al. Experiences of transgender-related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study. Am J Public Health 2013;103:1820–9. 2. Abigail, S. Regional feature: the GWL-INA: the formation of a national network of gay men, transgender and MSM in Indonesia. 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