Paruresis, Toilet Anxiety, and Gender Minority Victimization Among Transgender Individuals in Urban South India: A...

Background Toilet anxiety and shy bladder syndrome (paruresis) are significant, yet underreported public health concerns among transgender and gender-diverse individuals, who frequently face barriers related to restroom access and safety. Restroom-related anxiety in this population is compounded by social stigma, discrimination, and a lack of safe, inclusive facilities, with downstream effects on urinary behavior, bladder health, and overall well-being. Objectives This study aimed to assess toilet anxiety, maladaptive urinary behaviors, bladder health, and victimization experiences among transgender individuals in urban Tamil Nadu, India. Methods A cross-sectional observational study was conducted among 50 transgender individuals in the Trichy district of Tamil Nadu, recruited via snowball sampling through community-based networks and non-governmental organizations. Data were collected using structured, self-administered, Tamil-translated and back-translated questionnaires comprising an adapted Urinary Behavior Questionnaire (UBQ), a Bladder Health Questionnaire, an adapted Gender Minority Stress and Resilience (GMSR) victimization module, and an adapted Toilet Anxiety Scale. Results The mean participant age was 45.77 ± 7.23 years. Most participants identified as transwomen (n = 38, 76%). More than half belonged to a lower socioeconomic class (n = 26, 52%), and the majority (n = 35, 70%) had undergone some form of medical transition. Maladaptive urinary behavior of moderate-to-severe degree was observed in 27 participants (54%), and moderate-to-severe bladder dysfunction was observed in 26 participants (52%). Gender minority victimization was the most prevalent domain affected, with 36 participants (72%) reporting moderate-to-severe victimization. Moderate-to-severe toilet anxiety was reported by 28 participants (56%), and 28 participants (56%) met criteria for shy bladder syndrome - markedly higher than general-population estimates of 7%-13%. Conclusions Transgender individuals in urban South India experience a substantial, multidimensional burden of restroom-related morbidity spanning psychosocial victimization, toilet anxiety, and physiological urinary and bladder dysfunction. These findings underscore the need for inclusive restroom infrastructure, supportive policy enforcement, and transgender-competent clinical training.