The structural violence of cisgender norms: A participatory qualitative study of access to health and social welfare for older transgender women in Indonesia

Abstract

Background

Transgender women commonly experience poor health outcomes. However, little is known about older transgender women’s experiences of government healthcare and social welfare programs in low and middle-income countries, in the context of discrimination and neglect.

Aims

This article discusses older transgender women’s barriers to accessing government health and social welfare programs in Indonesia, and how intersecting factors like gender, age, and poverty contribute to poor health outcomes.

Method

A transgender community-led participatory study utilized rapid ethnographic assessment (REA), comprising surveys with 48 older transgender women, interviews with a subset of 15 transgender women, and interviews with five government officials.

Results

Applying an intersectional lens, the following themes were identified from the data: 1) document ownership and program enrollment; 2) healthcare needs and challenges; 3) employment and poverty; 4) housing, family, and social network; 5) barriers to accessing government health and social security programs; 6) consequences of exclusion from programs; and 7) enablers of accessing government health and social security programs. Across these themes, cisgender norms embedded in Indonesia’s bureaucratic practices exacerbated participants’ vulnerability to poor health.

Discussion

A transgender-led research project helped to identify barriers and advocate for the government to adopt a transgender health equity lens. Exclusion from government health and social welfare programs was due to both gender expression and criteria centered on nuclear family structures, which were misaligned with all participants, who were unmarried. These cisgender norms are a form of structural violence that results in poor health, exacerbated by poverty, old age, and housing insecurity.

Introduction

Transgender individuals globally face significant challenges in accessing healthcare and social welfare services (Joint United Nations Programme on HIV/AIDS, 2022; Safer et al., 2016; Tangpricha, 2021; Veale, 2023). A key area of concern is that many governments, including those supporting health and social welfare services, are grounded in cisgender norms, which naturalize the assumption that gender identity normatively aligns with assigned sex, particularly in medical and bureaucratic frameworks. Structural violence refers to deeply entrenched social, economic, and political systems that systematically disadvantage marginalized groups, leading to health and social disparities. For Paul Farmer, structural violence constitutes a “social machinery of oppression,” best understood by focusing on “the experience of people who live in poverty or are marginalized by racism, gender inequality, or a noxious mix of all of the above” (Farmer, 2004, p.308). Cisgender norms can become a form of structural violence when they hinder transgender individuals’ access to healthcare and social welfare services, contributing to the perpetuation of health and social inequities (Ansara, 2012; Bretherton et al., 2021; Scheim et al., 2022; Veale et al., 2022; Wesp et al., 2019; Winter et al., 2016).

The impact of cisgender norms on transgender people’s health is even more pronounced during old age, a time of life that requires increased interactions with state-run social welfare and health services. Research has examined older transgender people’s experiences of mental health issues (Hoy-Ellis et al., 2017), intimate partner violence (Hillman, 2022), social support during the COVID-19 pandemic lockdowns (Toze et al., 2023), access to health insurance (Bakko & Kattari, 2021), and preparation for old age (Henry et al., 2020). However, these studies have largely neglected the role of cisgender norms in healthcare and social welfare services in shaping health inequities for older transgender adults, often with limited participation by transgender researchers and community members.

Research on the impact of cisgender norms on transgender health predominantly originates from high-income countries with greater access to resources and robust healthcare systems, such as the United States of America, Australia, and the United Kingdom. This body of work is centered around research that addresses HIV (Reisner et al., 2016; Wirtz & Restar, 2023) and the role of gender affirmation as a strategy to improve the health outcomes of transgender people (Gamarel et al., 2023; Restar et al., 2020; Wesson et al., 2021). While most research related to transgender health has been conducted in high-income settings, the majority of the world’s transgender population also lives in low- and middle-income countries. This context requires a focus not only on individual gender identity but also on the impact of cisgender norms. This research contributes to a growing emphasis on addressing systemic barriers faced by transgender people, including challenges related to gender identity and social exclusion from public services (Janamnuaysook et al., 2024; Restar et al., 2023; Scheim et al., 2022).

Indonesia, the largest country in Southeast Asia with a population of approximately 281 million people, is a key example where healthcare coverage and social welfare programs have expanded rapidly over the past decade (Mboi et al., 2022; Pisani et al., 2017; Rahayu et al., 2018; World Health Organization, 2024). The Indonesian government has implemented one of the world’s largest single-payer health insurance systems, aimed at providing affordable healthcare to citizens in low- and middle-income brackets. Currently, the universal healthcare scheme boasts 95% coverage and is theoretically accessible to all citizens (Badan Penyelenggara Jaminan Sosial Kesehatan, 2024; Rahmi et al., 2020). In parallel, Indonesia has expanded its social protection system to reduce poverty and promote economic resilience through initiatives such as conditional cash transfers and food assistance, with a long-term goal of achieving near-zero poverty by 2045 (Holmemo et al., 2020). However, despite these advancements, critical gaps remain in program coverage for vulnerable groups, including transgender women, known in Indonesia as waria (Praptoraharjo et al., 2015). These gaps are largely attributable to the lens of moral deviance; a stigmatizing view that continues to shape medical practices and societal attitudes toward transgender individuals (Rodríguez & Murtagh, 2022; Thajib, 2022).

For transgender women in Indonesia, one significant barrier to enrolling in and utilizing the country’s universal healthcare scheme and social welfare programs lies with the cisgender norms of civil registration documents, such as birth certificates and national identity cards. These documents are required to access most healthcare and social welfare programs, yet many Indonesian transgender women face barriers in obtaining these documents due to estrangement from their families of birth and high levels of mobility (Hegarty, 2023; Rahmi et al., 2020). In the aftermath of the COVID-19 pandemic, efforts by transgender communities, including initiatives led by members of this research team, have successfully expanded access to identity documents in recent years (Mallay et al., 2021; Susetyo, 2022). However, increased access to identity documents has not resulted in equitable access to universal health and social welfare schemes, resulting in forms of structural violence related to cisgender norms.

This paper is based on a qualitative study developed and led by transgender activists and researchers, designed specifically to guide community advocacy efforts aimed at enhancing the inclusivity of health and social welfare schemes. To best capture the lived experiences of older transgender women, this study utilized a participatory rapid ethnographic assessment method to collect in-depth qualitative data. Drawing on intersectional transgender health equity (Poteat & Simmons, 2022; Wesp et al., 2019) and structural violence (Farmer, 2004) frameworks as analytical tools, this study seeks to uncover how cisgender norms, which influence most aspects of social welfare schemes, contribute to health disparities faced by older transgender women. These frameworks allow for a comprehensive analysis of both the visible and subtle forms of exclusion and marginalization that impact health outcomes, emphasizing the importance of addressing systemic barriers and advocating for inclusive policies on social welfare.

The research aimed to answer two questions: 1) What barriers do older transgender women encounter in accessing government-sponsored health and social security programs? 2) How do intersecting factors like gender, age, and poverty exacerbate poor health outcomes? We argue that these changes are best guided by research methods that facilitate ways for vulnerable transgender communities to share expertise about their own lives in ways that can lead to localized forms of advocacy that are directed at relevant government bodies.

Materials and methods

Study design and collaboration

This study drew on rapid ethnographic assessment (REA), a qualitative method that facilitates rapid collection and analysis of locally relevant data through brief surveys, focus group discussions (FGDs), semi-structured interviews, field notes, and observations. REA enabled researchers to quickly assess complex structural challenges faced by older transgender women, particularly on the structural violence they face in accessing social welfare and healthcare services (Hanssmann, 2020; Sangaramoorthy & Kroeger, 2020). The research design was a collaborative effort that integrated professional researchers, activists, and transgender community members, emphasizing advocacy and community-led initiatives that are grounded in the needs and lived experiences of the transgender community at every stage (Guta et al., 2013; Restar et al., 2023). The study was conducted in collaboration with three organizations: two in the Greater Jakarta area (covering Jakarta, Bekasi, Bogor, and Serang) and one in Yogyakarta. A team of professional researchers, including one Indonesian transgender woman, engaged with 12 transgender community researchers through dialogue with national and local activists and organizations from the outset. Community researchers received training and compensation for their contributions; US$400 per region and US$6 for each of the monthly meetings.

Study locations

Five Indonesian cities—Jakarta, Bekasi, Bogor, Serang, and Yogyakarta—were purposively selected to leverage existing networks while complementing ongoing community initiatives that support older transgender women, particularly in accessing national identity documents and public services (Susetyo, 2022). The selection aimed to represent a diversity of urban profiles, ranging from densely populated metropolitan areas like Jakarta and Bekasi to mixed urban-rural settings in Bogor and Yogyakarta, as well as Serang, a smaller city on the periphery of larger urban centers. Although the study is limited to Java, Indonesia’s most populous island, the focus on urban and semi-urban settings reflects the current landscape of development and community organizing in the country.

The focus on Java may limit the generalizability of the findings to the entire nation, yet it is aligned with the available participatory research networks to capture the needs and lived experiences of the community. The insights gained, therefore, provide a valuable understanding of the sociocultural dynamics that shape the lives of transgender communities in Indonesia.

Research process and data collection

The research began in July 2022, involving nine members from a donor organization and three transgender-led implementing organizations to select target locations and refine research questions and objectives. This was followed by an initial FGD in September 2022 with 12 transgender community researchers (two per location, and four in Yogyakarta) to gather input on the data collection process, survey design, and interview questions. Monthly FGDs were conducted, transcribed, and coded, enabling full participation of transgender community researchers who were trained in research methodology, ethics, and informed consent. Community researchers recruited participants using three age bands defined by Indonesian government policy to define “elderly” people: pre-elderly (40-59 years), elderly (60-69 years), and high-risk elderly (70 years and above or those with chronic health conditions). Due to the project’s alignment with Indonesian government policy, not all participants were aged 60 and above, which is the United Nations’ definition of elderly. In line with qualitative methodology, the sample size was selected based on the number needed to reach saturation, defined as when no new insights could be found in the data.

A survey was conducted from September to October 2022, using a community-based, purposive sampling guided by recommendations from community researchers. The survey provided broad insights, including participant demographics such as age, gender identity, education, socioeconomic conditions, employment, health status, housing, family relationships, and access to health and social security programs. Although the possible range of responses was limited to aid analysis, the brief survey method and use of community researchers allowed for open-ended responses to guide later stages of data collection.

Both surveys and interviews with transgender participants were conducted in person, employing door-to-door methods. Community researchers visited participants at their homes or gathered together in a safe location to explain the research; obtained informed consent and conducted surveys and interviews.

In November-December 2022, semi-structured interviews were also conducted with five government officials from the local Social Services Agency in each location. These interviews aimed to gain insights into the limitations of social welfare provision and to facilitate dialogue between government officials and community members. The interviews were conducted after providing the officials with an overview of the transgender community interviews; all for context. Open-ended questions were designed to focus on: 1) key challenges faced by older transgender women, based on perspectives of government officials; 2) available social services programs for older transgender women, including access to government assistance, social benefits, and rehabilitations; 3) challenges faced by Social Services Agencies in providing assistance and protection, including data collection issues; and 4) steps undertaken to improve access and reduce barriers for the transgender community, including internal evaluation and assessment done by the government.

The research concluded with two advocacy dialogues in June 2023, serving as final dissemination events. Held in Jakarta and Yogyakarta, these in-person meetings brought together 47 participants in Jakarta and 23 in Yogyakarta, including community researchers, activists, and representatives from non-government organizations, government agencies, and other development partners. Led by transgender researchers, the dialogues focused on sharing key findings and identifying practical solutions to the identified gaps. Information from these meetings were documented in a report format and integrated into the research material.

Data analysis

Throughout and after data collection, monthly meetings were held to update and discuss data collection, analysis, and interpretation. Data, including focus group discussions, interviews, observations, meetings, and reflections, were transcribed and analyzed collaboratively, using thematic analysis techniques in collaboration with community researchers (Braun & Clarke, 2012). Survey responses were recorded and analyzed, regardless of whether all questions were completed. A preliminary coding scheme was created using deductive methods (Saldaña, 2021), with a list of preliminary codes refined and resolved inductively through meetings with community researchers. Transcripts were analyzed using Dedoose software (2021, Los Angeles, CA, USA: SocioCultural Research Consultants, LLC), with all identifying information removed and pseudonyms assigned to protect the identity of participants.

Results

Study results were based on data collected from 48 participants who completed the survey, including ten from Jakarta, Bekasi, Serang, Yogyakarta, and eight from Bogor. Semi-structured interviews were conducted with three transgender participants from each city (n = 15), lasting between 15 min and one hour, along with one government representative per city (n = 5). Participants, aged between 42-76 years old, were residents in one of the five cities selected for the study. Despite variations in interview durations, due to the varying skills and experience of community researchers, data saturation was achieved, defined in qualitative research as when no new information emerged from final interviews (see Table 1).

Table 1.

Sociodemographic profile of participants.

Sociodemographic profiles	n	%*
Age
Pre-elderly (40-59)	31	64.6
Elderly (60 and above)	11	22.9
High-risk elderly (70 and above or with chronic health conditions)	6	12.5
Gender identity
Waria	42	87.5
Transpuan	3	6.3
Not stated	3	6.3
Place of residence
Jakarta	10	20.8
Bekasi	10	20.8
Bogor	8	16.7
Serang	10	20.8
Yogyakarta	10	20.8
Monthly income
Very low (beneath Global Poverty Line, $US2.15 per day)	24	50
Low (beneath lowest Indonesian minimum wage, $US4.50 per day)	14	29.2
Moderate (beneath highest minimum wage, $US11.45 per day)	8	16.7
Employment status
Self-employed (informal work)	33	68.8
Unemployed	15	31.3
Ever worked as a sex worker
Yes	43	89.6
No	4	8.3
Not stated	1	2.1
Education
Elementary school	18	37.5
Junior high school	15	31.3
High school	13	27.1
Bachelor’s degree and above	1	2.1
Housing status
Rented room	23	47.9
Own a home	11	22.9
Rented home	10	20.8
Friends or family member’s home	3	6.3
Nursing home	1	2.1
Household makeup
Lives alone	34	70.8
Lives with family	7	14.6
Lives with partner	5	10.4
Lives with friends	2	4.2

*Percentages were rounded to one decimal place.

Throughout the study, several national and regional programs designed to provide social welfare services to vulnerable populations were identified. Notable among these were the Social Assistance Program for the Elderly and Family Hope Program, which provide financial and psychosocial support for elderly individuals, as well as conditional cash transfer to low-income families (Adioetomo et al., 2014; Huda et al., 2020). However, despite the existence of these programs, older transgender women continue to face barriers in accessing government services, including the lack of proper documentation, discrimination from service providers, and lack of program awareness (Susetyo, 2022).

This results section presents findings across several key areas, including participants’ sociodemographic profiles, document ownership, healthcare needs, employment, housing, barriers to accessing government programs, and factors enabling access to government services. Each section is discussed in relation to the study objectives. Survey results are presented as percentages, using the total sample size of 48 as the denominator.

Sociodemographic profile

Participants were recruited across age groups ranging from “pre-elderly” (between 40 and 59) to “at-risk elderly” (70 and above or with chronic health conditions). The largest group of participants (64.6%), fell into the “pre-elderly” category, reflecting the purposive sampling methods used and the lower-than-average life expectancy of transgender women. Despite the focus on younger participants, the insights gained from this demographic are crucial for understanding emerging concerns as transgender women age. Seventeen participants were in the elderly category, aged 60 and above (35.4%). Participants were all either employed informally (68.8%) or unemployed (31.3%), reflected in the very low incomes reported, with the majority reporting an income less than the lowest Indonesian minimum wage (79.2%). Around 89.6% participants reported having worked as a sex worker at some point in their lives.

During survey data collection, participants were invited to use terms that best described their gender identity, either waria, transpuan, or a free text field where participants could write what they wished. Forty-two participants identified as waria (87.5%) and three as transpuan (6.3%). Waria is a term that combines the Indonesian words “wanita” (woman) and “pria” (man), with a history in the local context dating back to the 1970s. Waria is often used to describe transgender women within Indonesian society but is sometimes viewed as government-imposed and carries certain stigmas. On the other hand, transpuan is a more recent term that combines “transgender” and “perempuan” (a respectful term for woman). It emerged in the 2010s as part of transgender activism and offered a form of self-identification that some participants prefer as it resonates with global understandings of transgender identity (Hegarty, 2022, 2023).

Within this study, we have opted to translate the Indonesian terms that our participants referred to themselves as waria and transpuan, into English, as “transgender women.” Our use of the phrase “transgender women” in this paper is not intended to erase the possibility of other terms of identification in light of long histories of gender pluralism in Indonesia (Hegarty, 2022; Peletz, 2009) but rather helps to draw analytical insights that link the historical and contemporary forms of inequality and discrimination faced by transgender women to those in other parts of the world.

Although there are differences in cultural and historical context, both have similarities and were used interchangeably by participants in this study to refer in some way to a person assigned male at birth who identifies as a woman and/or wears women’s clothing and/or makeup. Self-identification as waria among older transgender participants was found to be closely intertwined with particular informal work associated with the urban poor, most prominently busking and sex work.

Document ownership and program enrollment

All participants surveyed possessed state-issued identity cards (see Table 2). The high rate of document possession is likely a result of the purposive sampling method and the collaboration between community organizations and this project, which had previously assisted transgender women in obtaining these documents (Susetyo, 2022). In general, those with access to social security programs described a greater sense of “safety.” Mila, a 57-year-old from Yogyakarta, expressed this sentiment: “I know that I am guaranteed social security support when I need it.”

Table 2.

Civil registration, document ownership, and program enrollment.

Civil registration, document ownership, and program enrollment	n	%*
Civil registration documents
National Identity Card (Kartu Tanda Penduduk; KTP)	48	100
Family Card (Kartu Keluarga; KK)	45	93.8
Insurance scheme enrollment
National Health Insurance (BPJS Kesehatan)	26	54.2
Employment-based Social Security System (BPJS Ketenagakerjaan)	27	56.3
Other government insurance schemes (Jaminan Kesehatan Sosial; Jamkesos)	1	2.1
Private insurance	0	0
Assistance received
Government poverty assistance programs (cash)	6	12.5
Government poverty assistance programs (non-cash, food aid)	23	47.9
Social assistance from transgender community organizations	42	87.5
Social assistance from religious groups	18	37.5
Social assistance from private companies	1	2.1

*Percentages were rounded to one decimal place.

All participants surveyed possessed state-issued identity cards, but only approximately half were registered for the National Health Insurance (54.2%) and Employment-based Social Security schemes (56.3%). In contrast, 87.5% of participants reported receiving support from community organizations. Older transgender women reported bureaucratic barriers and lack of suitable programs as reasons they were not able to access programs in addition to discrimination. Government officials also reported bureaucratic limitations, specifically the design of programs and reporting requirements, as barriers to facilitating access for older transgender women, with some officials suggesting that older transgender women did not actively seek out or wish to access available programs.

Healthcare needs and challenges

Although 62.5% of surveyed participants reported being in overall “good health,” several had experienced physical (35.4%) and mental health issues (4.2%) over the past year. During interviews, some participants reported dealing with chronic conditions that progressed with age.

Yes, [the government-funded health program] is very beneficial, especially as I have diabetes. I have to visit the health center every month to check my blood sugar and [sometimes] uric acid levels… It’s free, and I have also had my eyes checked—Mila, 57-year-old, Yogyakarta.

In terms of support during periods of ill health, 83.3% of participants relied on community support, with 45.8% accessing family support. Only three surveyed participants depended on healthcare professionals (6.3%) and two on government services (4.2%). Generally, 64.6% participants encountered no specific barriers to accessing healthcare, though some cited not owning government health insurance (16.7%), fear of discrimination (6.3%), and cost (4.2%) as obstacles. Reported access to HIV testing was high, with 95.8% participants being aware of their HIV status and 16.7% being HIV positive.

Only one out of 48 participants had accessed a medical form of gender affirmation (i.e. breast augmentation surgery). The most common gender affirmation practices, all of which took place outside of the medical system, were taking birth control pills, silicone injections, and alterations to appearances (“dandan” in Indonesian). Dandan, involving makeup application, hairstyling, and clothing, emerged as the most frequent practice of gender affirmation, practiced by 77% of surveyed participants. Half of the participants had injected silicone at some point in their lives, a practice that is not medically regulated and is associated with significant health risks (Van Schuylenbergh et al., 2019). Most participants placed importance in maintaining a feminine appearance into old age (mostly through practices of dandan). For those who did not, reasons offered included fear of discrimination and that it was unnecessary.

Employment and poverty

A majority of participants reported that they had been informally employed in the past 12 months (68.8%). Around 85.4% participants indicated that their main source of income was their own earnings. Only a few participants received economic support from their families (12.5%) and government financial assistance (10.4%), while a greater number received community support (31.3%). Reported sources of income were varied. Around 89.6% of participants had engaged in sex work at some point in their lives, with the youngest started at 15 years old. At the time of the survey, some participants worked as buskers (16.7%), in non-governmental organizations (10.4%), beauty salons (8.3%), other casual work (8.3%), small business ventures (6.3%), sex work (4.2%), and tailoring (2.1%).

Most participants lived below the poverty line, earning below the minimum wage (83.3%). In particular, six out of 10 participants from Jakarta earned around IDR 500,000-1,500,000, despite it having the highest living cost and minimum wage (IDR 4,600,000). Around 66.7% of participants deemed their income as “not enough,” apart from Yogyakarta, where most found it sufficient (seven out of 10), likely due to the lower cost of living in that city.

Only 75% of participants attained up to high school education. If working, 68.8% of participants typically engaged in informal sectors, which were characterized by limited job security. This economic vulnerability made it more difficult for them to access health and social security programs, which required financial contributions or co-payments. Additionally, pension schemes in Indonesia are almost exclusively attached to formal, wage-based work (Rahayu et al., 2018). Although participants’ economic status rendered them eligible for state schemes for the poor, the majority did not access them; instead, they worked to support themselves into older age.

Housing, family, and social network

At the time of the survey, none of the participants reported being homeless or having ever stayed in government-designated shelters for socially disadvantaged individuals. However, five participants (10.4%) had experienced homelessness at some point in their lives, with some reported accessing shelters provided by non-governmental organizations. Half of participants had stayed in shelters operated by community organizations specifically serving transgender people, while 16.7% had resided in shelters that were not explicitly targeted toward transgender population.

Around 70.8% participants reported living alone, with fewer residing with family (14.6%), partners (10.4%), and friends (4.2%). None lived as a married couple or in community housing. Housing status revealed a diverse range of living arrangements: 47.9% resided in rented rooms, 22.9% inhabited their own homes, and 18.8% leased their homes. A smaller subset reported temporarily residing in the homes of friends or family members (6.3%), with one participant being accommodated in a nursing home (2.1%). Some government officials perceived the housing instability of transgender women as a result of their “high mobility,” attributing it to the frequency with which they moved from one city to another.

We do not allow a person with a [different] National Identity Card to be registered here. [Sometimes] that [trans] person lives in [a different area], but [came here while they were already] registered in another place. If they keep moving places, social workers can be confused—Social Services Agency Official, Jakarta.

While some participants did not reside with their families, 72.9% of participants reported having frequent contact with family members. Only 6.3% and 18.8% participants had a little or infrequent contact with their families, respectively. Around 47.9% and 20.8% of participants described their families as supportive or very supportive, respectively, while fewer found them to be less supportive (25%) or not supportive at all (4.2%). Most participants did not provide financial support to their families (68.8%). In this vein, while the overall survey indicated how family of origin might play an important role in the lives of older transgender women, the interviews revealed some preference to live alone.

By the time I reached a certain age… My siblings asked me to return to our village, but I didn’t want to be a burden to them. I prefer to be independent in Jakarta. Besides, I have many friends here, and many brothers and sisters in faith. I just pray with my friends. In Java, it would indeed be nice to be with my older sibling… But I can’t stand living in Java. I want to venture out on my own—Linda, 74-year-old, Bekasi.

Barriers to accessing government health and social security programs

Barriers to accessing government health and social security programs emerged in the context of social stigma and discrimination. These barriers manifested in requests for participants to remove makeup or prohibitions against maintaining a feminine appearance when accessing government services. Participants reported discrimination by government employees, including the use of offensive language and requests to align their gender presentation with their sex assigned at birth. Alam, 46, from Jakarta, said, “I was called ‘bencong’ (an Indonesian transphobic/homophobic term) while arranging my BPJS,” and Kristina, 49, from Jakarta, recounted, “At the district office, while getting my KTP, I was told to go home and return without makeup.”

The challenges faced by older transgender women were exacerbated by their non-conformity to traditional nuclear family structures, which are deeply ingrained in Indonesian society. In Indonesia, the nuclear family—consisting of a married heterosexual couple and their children—is the normative framework around which social and economic support systems are structured (Platt et al., 2018). The government’s sole recognition of traditional nuclear family structures systematically excludes older transgender women, who often live alone, are unmarried, and have no children. As one Social Services official explained, the design of social welfare programs inherently favors those who conform to family norms recognized by the state (Huda et al., 2020), leaving older transgender women without adequate support.

Once listed in the state database for disadvantaged people, [trans women] can be registered and receive social assistance. So, for example, there is a social welfare program for families, but those who register must be part of a family—Social Services Agency Official, Yogyakarta.

Those unable to access programs cite the disparity between national policies that appear inclusive for the marginalized, poor, and elderly, such as those for obtaining national identity cards, and their inconsistent implementation across provinces and districts. Barriers often arose when negotiating with local officials, with whom participants sometimes had strained relationships. Discrimination based on gender identity and socioeconomic status often compounded these issues, with some participants emphasizing the importance of being “socially acceptable” to local neighborhoods. Participants emphasized that although these were not formal “rules,” they needed to “fit in” and adjust their behavior to be accepted in order to access social welfare and health programs.

I’m quite close to my neighbors… There are no problems, and in our neighborhood, waria are truly accepted as long as they follow the rules of the village. I believe it depends on us. Being friendly with the neighborhood, with family and friends… we have to approach them, be polite, and understand our place in the community—Mila, 57-year-old, Yogyakarta.

Consequences of exclusion from programs

Survey findings indicate that government’s social assistance was underutilized by participants. As detailed in Table 2, while a subset of participants were the beneficiaries of relevant government programs, including cash transfers (12.5%) and non-cash food aid (47.9%), more support also came from non-government entities, such as community (87.5%) and religious organizations (37.5%). These findings were consistent with experiences shared by some participants during the interview process.

We often got funding from transgender community organizations. It might be enough for groceries, rice, eggs… but that’s it. We also got some support from other non-government organizations during the COVID-19 pandemic. However, we haven’t actually received any assistance from the government yet—Melisa, 45-year-old, Bogor.

Thank God, I received some assistance from the government. I got a [direct cash transfer] from the Social Services Agency, and a local organization also provided support. Additionally, I also receive some support from residents—Sariasih, 62-year-old, Yogyakarta.

I received support once from the local government, four times from transgender community organizations, and three to four times from religious organizations. We were the ones who received and distributed the support—Efan, 54-year-old, Bekasi.

In describing challenges faced by older transgender women in accessing services, officials contrasted structural barriers with their perception that transgender women were hesitant to seek out government support. One official emphasized the difficulty in encouraging older transgender women to accept assistance, noting that many did not seek help. Nonetheless, there were instances where individuals overcame this reluctance, successfully sought out support, and were guided to suitable programs designed to meet their needs.

The biggest problem for older transgender women is that they tend to be closed off. They don’t want to open up [about their needs] and sometimes feel no urge to seek help from others. However, there were instances when they were in dire situations. For example, just yesterday, we attempted to arrange transfers to pay for national health insurance… I advised them to join the rehabilitation program and even requested assistance to cover their insurance costs, free of charge—Social Services Agency Official, Bogor.

Enablers of accessing government health and social security programs

Our research indicates that community support initiatives, particularly those provided by other transgender women affiliated with non-governmental organizations, have been instrumental in facilitating access to services. This involvement underscores the role of community networks in bridging gaps between individuals and services.

I just found out yesterday when I joined a meeting with friends who worked at the [local transgender] community organization. We really need access to the National Health Insurance scheme. In the past, it was difficult to access… I felt inferior and embarrassed when I went from the ward office to the sub-district office. But thank God, there are friends from other organizations who helped transgender people access the National Health Insurance scheme, so I felt comfortable—Melisa, 45-year-old, Bogor.

At first, I didn’t understand the registration process. I was helped because I didn’t understand how to enter the data digitally. It was very difficult, so I asked a transgender NGO worker for help—Sari, 49-year-old, Jakarta.

Despite structural barriers, participants expressed a desire to access government healthcare programs. Those who had accessed programs reported positive experiences. Generally, officials were confident in their ability to assist older transgender women in accessing existing programs, provided they had the necessary identification documents and proof of residency, as well as being registered in the state database for disadvantaged people used to distribute social support payments. In addressing discrimination, government officials acknowledged existing challenges and highlighted opportunities for improvement. This approach demonstrates a recognition among state officials of the need for comprehensive strategies to address the systemic barriers faced by transgender women who were also experiencing poverty.

We don’t have a Regional Regulation [specific to support the trans population] yet, and I’m unsure if community members were involved. Indeed, policies in Yogyakarta need further action, as each city’s condition is different. Programs and activities should align with the specific needs of the waria community in each area. The Yogyakarta Social Services Agency always involves affected communities in its activities… If there is no accommodation for waria in the future, it is man-made and it can be revised… Waria should be present at all hearings and involved in the policy drafting process. We need detailed policies—Social Services Agency Official, Yogyakarta.

Discussion

Our findings support the hypothesis that health inequities experienced by older transgender women are not solely attributable to gender identity but are deeply influenced by the intersection of gender norms, aging, and poverty, which collectively exacerbate disparities in accessing health and social services (Benbow & Kingston, 2022; Fredriksen-Goldsen et al., 2014; Oswald et al., 2023; Poteat & Simmons, 2022; Wesp et al., 2019). This aligns with Farmer’s (2004) concept of structural violence, which highlights how institutional and social structures create and perpetuate inequalities by embedding discrimination and exclusion into systems intended to provide support; a struggle also acknowledged by some government officials regarding program accessibility for this group.

To illustrate, even though our study found that all participants possessed state-issued identity documents, many still faced challenges due to structural barriers of cisgender norms within bureaucratic practices, such as being required to modify their appearance to conform to gender expectations when seeking government services. This occurred despite dandan—a practice of feminization involving makeup and women’s clothing—being an essential part of gender identity and expression for 77% of participants. Moreover, some social welfare programs for socioeconomically disadvantaged individuals, including aid for living expenses, are targeted at the family and household to which it belongs (Huda et al., 2020). This exemplifies structural violence, as described by Farmer (2004), highlighting how institutional practices systematically disadvantage marginalized groups. By prioritizing nuclear family structures, policymakers overlooked the lived realities of older transgender women, many of whom were single (85.4%) and lived alone (70.8%). This disconnect underscores the gap between government policies and the needs of those who do not conform to these family models, reinforcing exclusion and inequality (Platt et al., 2018).

Government programs were infrequently accessed by participants in our study. For instance, enrollment in social assistance was low, with only 12.5% of participants receiving cash benefits and 47.9% accessing non-cash benefits. More participants relied on support from non-government sources: 87.5% participants received assistance from community organizations, and 37.5% from religious organizations. Such exclusion reemphasized that possessing formal identification alone did not guarantee access to government welfare and services, a challenge that has been previously documented by researchers (Ansara & Hegarty, 2014; Arayasirikul et al., 2022; Susetyo, 2022).

As echoed by other studies that applied an intersectional lens on transgender health equity, older transgender women live at the intersection of multiple marginalizations (Oswald et al., 2023; Poteat & Simmons, 2022; Wesp et al., 2019). For these women, the process of aging is compounded by structural challenges, including poverty, lack of employment, minimal support, and exclusion. Poverty and limited access to social welfare forced participants to continue working in low-paying informal work, highlighting the economic distress experienced by most. Employment opportunities are often restricted to informal sectors such as sex work and busking, which have become increasingly difficult due to the growing enforcement of public order regulations by municipal police, particularly in urban centers where this research was conducted (Katjasungkana et al., 2016; Thajib, 2022). Furthermore, many participants lived independently, often without social support from their families of origin. As they age and deal with chronic health conditions, this situation becomes increasingly challenging; complicating their ability to receive needed assistance (Adan et al., 2021; Fredriksen-Goldsen et al., 2014). Only a small subset who lived close to family in their city of birth or had strong connections within their local neighborhoods were able to do so. This was not an option for most participants, who had moved from the city where they were born or were socially excluded by their families and neighbors.

Reflecting on structural violence faced by older transgender women, collective efforts must focus on advocacy to combat discrimination and drive inclusive policy reforms that address the health and social needs of marginalized groups (Asia Pacific Transgender Network Asia Pacific, 2021; Janamnuaysook et al., 2024; Lestari et al., 2022; Restar et al., 2023). Over the past decade, Indonesia has seen a rapid expansion of social welfare programs, in the form of healthcare insurance, income support, food aid, and other social benefits (Holmemo et al., 2020; Rahayu et al., 2018). However, these programs often fail to meet the specific needs of marginalized groups, as highlighted in previous studies (Adioetomo et al., 2014; Arayasirikul et al., 2022; Huda et al., 2020; Maulana et al., 2022; Rahayu et al., 2018).

In this light, the government has the opportunity to address structural violence against older transgender women by recognizing diversity and aligning with family structures as they are practiced in the community. This approach includes extending support to those without complete identity documentation or who live independently, while fostering accessible, inclusive, and secure government programs and services that address their unique needs (Joint United Nations Programme on HIV/AIDS, 2022; Susetyo, 2022; Toze et al., 2023). Recognition of transgender identities within Indonesia’s civil registration and data systems is also critical, as the invisibility of older transgender women perpetuates structural violence through systematic erasure and exclusion, ultimately limiting access to services (Divan et al., 2016; Farmer, 2004; Thomson & Katikireddi, 2019; Winter et al., 2016).

The current approach from the government, which remains largely passive, falls short of promoting equity and addressing structural violence experienced by participants. For example, the hesitancy of older transgender women to access government services, as noted by some officials, reflects deeper structural barriers rooted in the legacy of exclusion and mistrust that perhaps could not be mitigated, unless there is an active effort to locate, support, and empower this community to access services (Divan et al., 2016; Wesp et al., 2019). Therefore, potential approaches to addressing structural violence should involve fostering meaningful engagement and genuine partnerships in the development of strategic policies and programs (Ravaghi et al., 2023; Restar et al., 2023).

As echoed by participants, community support, especially from other transgender women experienced in HIV outreach programs, has been instrumental in facilitating access to health and social security for older transgender women. For instance, when ill, 83.3% participants typically seek care and guidance from peers to navigate healthcare insurance and wider services. At the organizational-level, the role of transgender community-based organizations, such as those in Yogyakarta, is also evident in establishing and operating shelters specifically for transgender individuals and other marginalized groups (Mallay et al., 2021). A preference shared by half of the participants in this study, community shelters present a practical solution to mitigate housing insecurity and discrimination faced by participants in government-owned shelters (Fraser et al., 2019; McCann & Brown, 2021).

Reflecting on previous examples, transgender communities play dual roles as peer supporters and leaders in creating safe spaces and supportive programs, underscoring the crucial contribution of community-driven health and social inclusion initiatives (Guta et al., 2013; Restar et al., 2023). Previously, the Indonesian government has collaborated with community-led organizations, particularly in HIV programs. This experience provides a valuable model, as similar partnerships could be extended to address the broader needs of older transgender women (Direktorat Jenderal Pencegahan dan Pengendalian Penyakit Kementerian Kesehatan Republik Indonesia, 2023; Fauk et al., 2019; Joint United Nations Programme on HIV/AIDS, 2022).

The intersecting challenges of gender, age, and socioeconomic status faced by older transgender women underscore the urgent need for policy reform (Divan et al., 2016; Oswald et al., 2023). This aligns with Farmer’s research on HIV/AIDS in Haiti, which demonstrated that a sole focus on biomedical solutions, without addressing structural violence and power imbalances, can perpetuate inequities (Castro & Farmer, 2005; Farmer, 2004). Rather than applicable to transgender people alone, an intersectional transgender health equity lens raised fundamental questions on the inclusivity of universal health coverage and social security system for other older adults too, including other HIV key population groups, women, persons living with disabilities, and persons with Indigenous backgrounds (Joint United Nations Programme on HIV/AIDS, 2022; Moyano et al., 2022; Sakolsatayadorn & Chan, 2017).

Drawing on the strengths of qualitative study using REA (Sangaramoorthy & Kroeger, 2020), our community engagement went beyond mere “enumerators” or “data collectors,” reflecting the vital advocacy role that independent research could play in fostering meaningful engagement between community members and state service providers. The findings, thus, underscore the importance of highlighting perspectives of transgender researchers and communities, at each step of the research process (Restar et al., 2023). The research also led to two advocacy workshops to present and discuss findings with government stakeholders. By empowering community organizations to engage directly with government and service providers, this study not only supplies essential data to enhance program quality (Hanssmann, 2020), but also enables community members to lead their own advocacy—asserting agency and collective power to drive meaningful change (Ravaghi et al., 2023; Restar et al., 2023).

Limitations

The primary limitation of this study was the purposive sampling method used to recruit both community researchers and participants. Despite the focus on older adults, the relatively younger age of participants, most falling into the Indonesian category of “pre-elderly” (ages 40-59), may reflect the lower life expectancy commonly seen in the transgender population in other parts of the world (Jackson et al., 2023). Additionally, the study’s geographical focus on cities within Java inherently limits the generalizability of the findings to transgender populations across the broader Indonesian archipelago, particularly in non-Java regions where cultural and social dynamics may differ. However, the choice of these locations was strategically driven by the need to leverage well-established community networks and ongoing local initiatives, which are crucial for a participatory rapid ethnographic approach (Sangaramoorthy & Kroeger, 2020). Future research endeavors could include more diverse locations across Indonesia and utilize other methods, including quantitative methods.

Furthermore, community researchers, while provided with substantial training and support, possessed limited research experience, which was evident in the brevity of some interviews. However, professional researchers’ detailed oversight, including by a transgender member of the research team, mitigated some effects of these limitations and presented further opportunities for skill enhancement in conducting interviews. Nevertheless, the use of purposive sampling and the leadership role of transgender researchers in this participatory study is instrumental in diversifying analytical perspectives, which is essential for a nuanced understanding of the structural violence experienced by older transgender women.

Conclusions

This study, utilizing a participatory rapid ethnographic approach designed and conducted by and for the transgender community and led by an Indonesian transgender woman researcher, identified intersecting vulnerabilities faced by older transgender women in Indonesia. The research highlighted how structural violence embedded within cisgender norms systematically limit access to essential health and social services. Despite possessing state-issued identity documents, older transgender women encountered bureaucratic hurdles, such as being turned away from government services due to their feminine appearance and being denied support because they were unmarried and lived alone—conditions that effectively exclude them from government welfare programs designed around state-imposed nuclear family structures.

Structural socioeconomic challenges further compound the difficulties of aging for older transgender women, with intersecting factors of gender, age, and socioeconomic status forcing many to continue in informal employment into old age, often living independently and relying heavily on community networks for support. The exclusion of transgender identities from official data and program design also exacerbates their invisibility within the systems meant to support them, reinforcing marginalization and systemic neglect.

Addressing the urgent need for policy reform, this research emphasized the value of engaging with transgender community members in designing solutions. Transgender-led initiatives, such as peer HIV outreach and community-operated shelters, demonstrated the transgender community’s capacity to support its members and reveal a potential partnership model that the government could leverage to promote inclusion. Close collaboration between researchers and community members established throughout this research was instrumental in advocating for relevant government agencies to adopt transgender health equity lens. To effectively dismantle barriers to access, promote inclusion, and ensure no one is excluded from government programs, it is imperative that the state reevaluate its policies and programs to better serve marginalized groups.

Funding Statement

This study was fully funded by the Indonesia AIDS Coalition (IAC).

Ethical approval

The Atma Jaya Catholic University of Indonesia’s Human Ethics Review Board granted the ethics approval for this study (0008 R/III/PPPE.PM.10.05/10/2022).

Disclosure statement

No potential conflict of interest was reported by the author(s).