Migration, healthcare access, and the role of government schemes: Insights from South Indian trans women

Abstract

Background

Research on the challenges, marginalization, and identity of trans women in India has sparked important discussions, contributing to progressive changes in society. While the visibility and recognition of trans women is steadily growing, beneficial schemes tailored to their unique challenges are often overlooked, underscoring the need for greater attention and action.

Aim

The article aims to identify the unique healthcare and migration challenges faced by South Indian trans women and the reach and utilization of government-provided facilities by their community.

Method

A survey of 53 and interviews with 4 South Indian trans women focused on the utilization of state and central government schemes. Data from public and private healthcare facilities in Madurai were collected and visualized using Airtable, with results disseminated in Tamil and English to ensure accessibility for the trans community.

Results

A relationship was identified between the effectiveness of state government welfare schemes and the well-being of the trans women’s community. However, central government schemes often fail to reach their entire population. Furthermore, state government transportation schemes do not sufficiently support their healthcare access and economic development.

Discussion

To enhance the socio-economic development of trans women, policymakers can ensure that beneficial schemes comprehensively reach all segments of society. Increased promotion, awareness, and advancements in these schemes are necessary to meet the needs of the trans women community. Additionally, extending free bus fare facilities specifically to trans women is recommended to improve their healthcare access, mobility, economic opportunities, and integration into mainstream society.

Introduction

The pervasive social and institutional stigma against transgender communities promotes violence, social isolation, legal challenges, stereotypes, social prejudices, and lack of opportunities. These forms of discrimination are particularly pronounced in key areas, such as employment, healthcare, education, and migration (Acharya et al., 2023; Bhattacharya & Ghosh, 2020; Cerezo et al., 2014; Nataraj, 2022; Raza & Karthikeyan, 2019; Rosati et al., 2021; White Hughto et al., 2015). Within healthcare and migration, trans women face specific challenges and limitations due to systemic barriers, which include a lack of facilities, understanding, and physicians for treating trans patients (Bhattacharya & Ghosh, 2020; Gupta et al., 2016; Poteat et al., 2013).

Studies such as those undertaken by Cerezo et al. (2014), Fontenot et al. (2020), and Padilla et al. (2016, see also McCauley et al., 2018; Rosati et al., 2021; Safer et al., 2016; Skuban-Eiseler et al., 2023) highlight the migration experiences and challenges of transgender individuals, the need for adequate access of gender-affirming resources and services, the importance of developing policy, education, mental health, and social acceptance to transform the lives of trans communities across different parts of the world. In the Indian context, while trans women have a long cultural history, their community remains marginalized, facing profound challenges in migration and healthcare access. They experience a multifaceted phenomenon influenced by many factors, including social, economic, and cultural dynamics.

Their decision to migrate is frequently driven by the desire to access gender-affirming medical treatments and escape social ostracization and stigma (Cerezo et al., 2014; Padilla et al., 2016). However, some trans women do not desire to undergo feminizing surgeries and treatments; although most undergo gender-affirming surgeries (GAS) such as vaginoplasty, hormone therapy, breast augmentation, facial feminization, voice change surgeries, and body contouring (T’Sjoen et al., 2019). They are compelled and choose to relocate to other states, such as urban centers, to continue their essential healthcare services to align their physical appearance with gender identity and alleviate gender dysphoria (Raza & Karthikeyan, 2019). Carpenter et al. (2022), Padilla et al. (2016) and Safer et al. (2016) emphasize that trans women migrate to locations abroad for advanced and specialized healthcare due to social, economic, and inadequate healthcare in their local areas. By addressing the gaps, research scholars (Bhattacharya & Ghosh, 2020; Cerezo et al., 2014) highlight physical and mental care in local healthcare systems. They emphasize the pressing need for more inclusive and comprehensive medical services in India to ensure that trans women have access to medical care without needing to leave the country. Better education, development, and training of healthcare professionals and legal reforms can create a supportive environment for trans women. In the same way, Clancy et al. (2012) have highlighted the importance and impact of such research where they pointed out that researchers “can identify critical problems, research the benefits and harms of policy solutions, estimate the costs and consequences of policy proposals, and actively participate in the policy process to aid real-time decision making” (p.338). As they mention, this research can serve as a model to improve policies for the trans women community.

Over the past fifteen years, India’s multifaceted diversity, traditions, deep-rooted values, social customs, and regional practices have shaped the development of trans women’s healthcare, leading to improved facilities with greater understanding. Healthcare and migration benefit schemes are available for trans women through both central and state governments. In urban cities like Madurai, Chennai, Delhi, Mumbai, and Kolkata, government and private hospitals are also beginning to expand their services. We define healthcare and migration as individuals moving from one geographical location to another region or country, primarily to seek specialized or more accessible healthcare services. The migration motive can be the non-availability of healthcare, cost difference, quality of care, or legal, social, or cultural barriers to prevent individuals from accessing appropriate care in their place of origin.

Our research explores the current landscape of healthcare and migration for South Indian trans women, identifying the benefits and barriers in central and state government schemes. However, individuals’ challenges may vary from one location to another upon migration. It is crucial to examine the current status of trans individuals, as significant recent healthcare and migration advancements have been granted. The choice to focus on healthcare and migration destinations underscores the necessity of comprehensively understanding the experience of transgender women.

Many scholars and researchers have significantly inquired into issues pertaining to trans women’s identity, marginalization, harassment, and culture. However, to the authors’ knowledge, no literature review has been available that explores the migration, healthcare, and benefit schemes of trans women in the Indian context. Moreover, little attention has been paid to the challenges of accessing medical facilities. In our study, we ask the following key questions:

1. What challenges do trans women face when migrating to access medical facilities?

2. Do the beneficial medical facilities provided by state and central government schemes reach the trans women community, and how are these facilities utilized?

3. How can a digital platform enhance healthcare access, overcome geographical barriers, and contribute to the welfare of trans women?

Aim

This study aims to identify and analyze the specific challenges faced by trans women while exploring the intersection of migration and healthcare, highlighting medical, economic, and logistical barriers. Additionally, it will evaluate the accessibility, reach, and utilization of government-provided medical facilities, particularly state and central government schemes, to determine whether these services effectively benefit the trans women community and how they are being utilized. Furthermore, the research explores the potential of public digital humanities in enhancing the social, and healthcare-related welfare of trans women.

Methods

Study setting

This article employs a mixed-method approach, combining qualitative and quantitative methods to study the experiences of Indian trans women’s migration and medical facilities. The research focuses on a purposive sample of 53 trans women who participated in a survey and 4 interviews regarding the utilization and challenges of government initiatives, specifically “Ayushman Bharat Scheme” (2022) from the central government, “Transgender Welfare Board (2008)” and the “Vidiyal Payanam Scheme (2021)” from the Tamil Nadu state government. Participants were recruited through convenience and snowball sampling techniques from the Transgender Resource Center, to examine the challenges trans women face in migration and access to healthcare schemes in Madurai Metropolitan City, Tamil Nadu.

The method helped us to reach individuals who are involved in the community, but it may cause selection bias. To mitigate this, we focused on clearly defined inclusion and exclusion criteria. Inclusion criteria included (1) individuals identifying as trans women, (2) those aged 20–54 years older, (3) residents of Madurai, and (4) willingness to participate in the study. Exclusion criteria were (1) individuals unable to communicate in Tamil, as this necessary for participants to feel comfortable discussing their experiences with the investigators, (2) refusal to participate, and (3) residents of Chennai or other states to consistently focus on the Madurai region.

Transgender welfare initiatives and regional focus

For our research, we chose two metropolitan cities, such as Madurai and Chennai. However, our focus is solely on the migration and medical experiences of trans women in the Madurai region. Considering the lack of healthcare centers in Madurai, we also examine medical facilities in Chennai to highlight the advanced services available there.

Tamil Nadu was the first state to introduce a “Transgender Welfare Board” in 2008 to provide free GAS in government hospitals, free housing, various citizenship documents, admission in government colleges with a full scholarship for higher studies, and initiating income-generation programs (Social Welfare and Women Empowerment Department (Transgender Welfare Board), 2021). In addition to this scheme, the central government scheme “Ayushman Bharat Scheme” of the Ministry of Health and Family Welfare was introduced in August 2022, under which more than 50 health facilities are being provided. As part of this scheme, the “Ayushman Bharat TG Plus” card is offered to transgender people. It is significant to note that India is the first country in the world to provide free healthcare facilities like cosmetic surgery to the trans community under a government scheme. Concurrently, a person who belongs to a trans community from any state or part of India can take advantage of this scheme using the trans card in any affiliated hospital (Staff, 2022). Such healthcare facilities are broadly categorized into general and gender-related healthcare. Both types of health care are crucial for trans women and can ensure better health outcomes and quality of life. However, our research focuses on gender-related healthcare, such as vaginoplasty, breast augmentation surgery, laser hair removal treatment, mental health counseling and support services, etc. The choice of surgery varies depending on the trans woman’s goals and medical advice. Additionally, the metropolitan cities of Madurai and Chennai are well-known for their advanced medical facilities, research, and innovations. It has a strong presence of transgender non-government organizations (NGOs), community groups, and activists who work tirelessly to advocate for LGBTIQ+ rights initiatives, legal and social support, and employment opportunities in a supportive environment. These factors give the authors unique advantages for concentrating on this particular state and district.

Moreover, for the study, we choose the “Vidiyal Payanam Scheme” (free fare scheme) (2021) to understand trans women’s migration experiences. Through the Department of Social Welfare and Women Empowerment, the government of Tamil Nadu has announced a scheme allowing women travelers to use government-run normal-fare buses for short distances (up to 30 km) within cities and towns free of charge. Women receive zero-fare tickets when traveling on these buses. The Tamil Nadu government extended the fare-free scheme to trans women for a better life.

Participant management

Data was collected by five trans men familiar with the Transgender Resource Center (TRC) and the trans women community. They conducted 49 face-to-face surveys, and researchers carried out 4 semi-structured interviews and surveys over phone calls, all administered in Tamil—the preferred language of both participants and investigators—to ensure clear communication and accurate responses. The investigators documented the surveys, while the researchers audiotaped the interviews with permission and carefully transcribed them into English. In-depth surveys and interviews occurred over five months, from February to June 2024, and each session lasted 1 hour to engage with participants and gather comprehensive information about their migration and medical care, facilitated through the TRC in Madurai. The participants, and the five trans men who collected the data, supported this research voluntarily and did not receive any remuneration, as the authors did not receive funding from any organizations.

Ethical consideration

The research adhered to ethical guidelines, ensuring informed consent from all participants. Before the data collection process, the questionnaire included questions, such as (1) Have you undergone or considered gender-affirming surgery? If so, what services are you interested in or have accessed, and where did you access them? (2) Are you aware of state and central government healthcare schemes? and how did you learn about them? (3) What sources (e.g. friends, community groups, social media) do you rely on for information? (4) Have you accessed the state government’s migration scheme? How helpful was it? it was shared with the TRC to meet ethical standards and was reviewed by the ethical review board before the study commenced. Additionally, the approval letter was signed by the committee member, the data collection team, and the 53 trans women participants. We communicated that participants’ access to the state and central schemes would not be affected. The participants could withdraw from the study at any time. Moreover, the analysis report will be sent to the TRC and our participating trans women community members to ensure transparency and ethical consideration after this research article is published. A Google questionnaire form was used for data collection, and participants documented their information with permission while their names were kept confidential to ensure that trans individuals’ responses could not be traced back to identify or pinpoint any participant. A comprehensive set of standards was established to protect the identities and well-being of the trans women participants throughout the study.

Approach to data interpretation

The interview and survey data were analyzed using thematic analysis to identify recurring patterns and key insights. The process involved carefully reading and rereading the transcripts to gain familiarity with the data, followed by systematically grouping similar responses and concepts. Later, it developed into central themes that capture the core experiences, and challenges faced by trans women in accessing healthcare and migration schemes. The themes were refined to ensure they accurately reflected the participants’ narratives. This thematic approach focused on uncovering both structural barriers and community-driven strategies, providing a deeper understanding of how trans women navigate government schemes and medical services.

Main outcomes

The primary outcomes of this study include (1) the experiences of trans women in accessing healthcare services, (2) the perceived effectiveness of government schemes in facilitating medical care, and (3) the impact of the free fare scheme on the mobility of trans women for healthcare access. Additionally, the study seeks to highlight both the challenges and positive outcomes experienced by participants in navigating these systems.

Data collection procedures

We collected data on gender-related healthcare details in Madurai, including one public and four private centers, and in Chennai, one public and 56 private centers (refer to the CSV file). We used specific key terms in Google search engine, such as “trans women/transgender healthcare clinics, LGBTQ+ healthcare hospitals, gender-affirming healthcare facilities, and medical centers for transgender patients in Madurai and Chennai”, to obtain various public and private hospital name, addresses with phone numbers, URLs (Uniform Resource Locators), information about ties to state and/or central schemes, and details on available medical services for various public and private hospitals.

Social support systems

The collected data has been transformed into a CSV (comma-separated values) file. The primary objective of this data gathering is to convert it into a sustainable format while ensuring its accessibility to all stakeholders. To achieve this, we employed the digital humanities method to visualize and disseminate the collected data. An advantage of digital humanities is the ability to communicate research findings to the scholarly community and the general public. Hence, our approach aligns with public digital humanities principles, which aim to use digital tools and methods to benefit the public, requiring sustainable design, minimal computing, open access, and affordable infrastructure (Ope-Davies, 2022).

Consequently, we selected the free version of the Airtable tool for data visualization and dissemination, and the GitHub¹ repository for long-term data storage. The CSV file is uploaded into the Airtable tool, which converts the data into a table format. The data is available in English² and Tamil³ to facilitate easy access for the trans community, gender non-conforming individuals, and other stakeholders. The reason why we selected this repository and digital tools, such as Airtable and GitHub, is because they are sustainable, maintenance-free, universally accessible, and cost-effective. Furthermore, we are sharing the database in both Tamil and English to ensure it is accessible to the South Indian trans women community, as the data originates from Tamil Nadu. The data has also been shared with local NGOs in Tamil Nadu for broader distribution, and use. Although the digital tools did not significantly contribute to the analysis, we used them as a model for the development of the trans women community by raising awareness about hospitals, their medical facilities, and partnerships with state and central governments to utilize. In the future, we plan to raise funds to upgrade the platform into a website that will provide valuable information and resources for the trans women community.

Results

A total number of 53 individuals are self-identified as trans women and members of the TRC, Madurai. Dai Nirvana, a traditional but risky method of removing male genitalia practiced within trans women communities, is not recommended by doctors. As a result of medical advancements, safety concerns, and risks associated with the traditional method, all of them have opted for GAS in private and public health centers. In the following section, we briefly explain the findings of their interviews and surveys, focusing on themes related to healthcare, migration, economic hardship, and the mental health of South Indian transwomen.

South Indian trans women in gender-affirming healthcare

In India, there has been an increasing recognition of the unique healthcare needs of the trans women community. Table 1 indicates that for trans women participants, there is a close match between interest and utilization of GAS aligns with their strong desire for physical characteristics that match their gender identity. However, they experience significant challenges as a result of the lack of gender diversity awareness in society and social institutions, such as medical and institutional systems, which has profound effects on accessing medical facilities and migration. In the collected survey and interview data, we identified trans women participants who expressed strong direct and indirect barriers to accessing state and central government schemes in healthcare and migration. Firstly, direct barriers, such as in the South Indian trans women community, face discrimination in healthcare settings, limited availability of services in healthcare and migration, financial constraints, social exclusion, and feelings of isolation. Secondly, indirect barriers, such as limited awareness and development of healthcare and migration schemes. These barriers are intertwined with one another and are reflected in their lived experiences.

Table 1.

Address the data on gender-affirming healthcare, economic conditions, and support scheme awareness among trans women (n = 53) in Madurai, Tamil Nadu.

Variable		Total (n = 53)
		n	(%)
Interest surgeries/treatments	Vaginoplasty	53	(100%)
	Breast augmentation surgery	46	(86.80%)
	Laser hair removal treatment	19	(35.80%)
	Mental health	52	(96.2%)
Access statistics	Vaginoplasty	46	(86.90%)
	Breast augmentation surgery	44	(83%)
	Laser hair removal treatment	18	(33.20%)
	Mental health	52	(96.2%)
Hospital accessed	Government hospital	12	(21.70%)
	Private hospital	31	(58.50%)
Not interested in revealing their healthcare choices		10	(19.80%)
Benefits from scheme	State scheme	10	(19.80%)
	Central scheme	2	(3.80%)
Awareness of scheme	State scheme	48	(90.40%)
	Central scheme	6	(11.8%)
Unawareness of scheme	State scheme	5	(9.60%)
	Central scheme	47	(88.2%)
Sources of awareness	Friends and NGOs	44	(83.02%)
	Social media	7	(13.21%)
	Family and relatives	2	(3.77%)
Monthly income of trans women 6000 and 15,000	6000 and 15,000	19	(35.7%)
	15,000–18,000	31	(58.3%)
	18,000–25,000	3	(6%)
Job	Sex works	19	(36.5%)
	Beggers	18	(34.6%)
	Sex workers and beggers	16	(30.8%)
	Acting and modeling, floor cleaning, business, shopkeeping, and working in NGOs	13	(24%)
Savings from the free fare scheme	500–1000	30	(57.1%)
	1000–2500	23	(42.9%)
Free fare scheme	Increased visibility and safety	47	(88.2%)
	Avoid due to bus restrictions	6	(11.8%)

The data in Table 1 proves that many trans women use private hospitals more than government hospitals for their GAS, which leads to community networks. It indicates that trans women are concerned about the quality, expertise, and reliability of the healthcare access. Moreover, a few trans women were not interested in revealing their healthcare choices, citing concerns about personal choice. It highlights privacy, stigma, and potential fear of discrimination in healthcare settings. A trans woman points out,

I chose a private hospital instead of a government hospital. I have heard from friends that some government hospitals are not effectively performing gender-reaffirming treatments. Moreover, the providers do not have enough experience with these surgeries. Since procedures like gender-affirming surgeries involve a one-time payment, I do not want to risk suffering lifelong complications with my body.

Another participant shared,

I had my gender-reaffirming surgery at a private hospital and my breast augmentation surgery at a government hospital. Based on my knowledge, I prefer to have the surgery at either a government or private hospital, depending on which one performs best.

The survey and the trans women’s responses reveal that the choice of healthcare is closely connected with community networks. These networks offer numerous benefits, including access to better quality care, reducing the likelihood of medical complications, providing emotional support and guidance, mitigating risks, increasing confidence, and fostering cultural and identity alignment. However, there are potential disadvantages, including limited healthcare choices, misinformation or biased opinions within the community, and the high demand for certain trusted providers or institutions, which may result in longer wait times, reduced availability, or increased procedure costs. Additionally, when community networks favor private over government hospitals due to perceived quality differences, it can further marginalize public healthcare systems, reducing their utilization, investment, and opportunities for improvement. The balance between reliance on community trust and trans women’s independent research based on evidence-based healthcare information can facilitate well-informed and empowering decision-making while mitigating potential challenges and drawbacks.

Awareness and outreach challenges

The state and central governments offer free gender healthcare schemes that are tied up with a few government and private medical centers, such as those in Madurai, Tamil Nadu, to provide a range of feminine treatments for trans women. It aims to promote inclusive healthcare, foster equity, reduce healthcare disparities, and support the well-being and integration of trans women into the community. Only a low proportion of the trans women participants benefit from state schemes and from central schemes (see Table 1), indicating a lack of awareness and interest in these beneficial programs. A trans woman offered her reply as,

I underwent gender-affirming surgery at a camp organized by Pondicherry Medical College. They provided free gender-affirming surgery, along with 15 days of free bed rest and food. I accessed the central government scheme through my trans women community network. My friend has a friend who works at the medical college, and I trust my community members. Through her, I was able to access and feel comfortable with my gender-affirming surgery.

Another trans woman shared,

I do not know anything about the schemes.

The lack of awareness and interest can stem from distrust of government systems and dependence on informal networks. The first participant’s statement highlights a lack of initial awareness about healthcare centers in Tamil Nadu. However, by accessing beneficial schemes, she set an example that encouraged other trans women within her community network to seek treatment from the same medical institution, and prompting migration to a different state. Additionally, the second participant’s limited knowledge and unwillingness to learn about available schemes perpetuate challenges for their community, as they rely solely on community networks for information and support.

However, while a low proportion of the trans women participants accessed state and central government schemes, a high proportion are aware of the state-level Transgender Welfare Board, likely due to Tamil Nadu being their home state. A moderate proportion are aware of the central Ayushman Bharat scheme, reflecting the broader challenge of reaching people in a large nation like India (see Table 1). A trans woman responded,

I know about the information of Tamil Nadu state scheme, but I do not know about central government schemes. I know both of them will take time and give me more tension, so I did not try both.

The statement highlights that while trans women participants are aware of government schemes, they lack trust in the processes associated with these treatments and programs. This mistrust contributes to the dissemination of skepticism within marginalized trans women communities, discouraging others from availing themselves of these beneficial schemes. Furthermore, when information about the schemes is presented in complex formats, it becomes even more challenging for trans women, particularly those with limited education, to comprehend and access. The negative experiences, including stigma or discrimination faced at government healthcare facilities, further undermine their interest in government programs.

Moreover, a significant portion of the trans women community in Tamil Nadu remains unaware of both state and central government schemes aimed at supporting them (see Table 1). Such proportions of non-awareness can adversely affect the well-being of the trans women community. The lack of awareness significantly limits their access to healthcare, social support, and financial assistance. Furthermore, this gap in awareness hinders the effectiveness of state and central government schemes, rendering them underutilized and ineffective in achieving their intended goals. Addressing the awareness is crucial for the holistic development and integration of the trans women community into society.

Key sources of information for trans women

Trans women are aware of schemes through various sources, such as friends, NGOs, social media, and family and relatives. Trans women point out that they are aware of schemes through friends and NGOs as the primary source of information (see Table 1), which underscores the strong reliance on interpersonal trust; approachable and readily available as always, they are surrounded by friend’s and NGOs circle. However, the completeness and accuracy of the information shared within these networks can vary significantly, leading to inconsistent levels of awareness within the community. Moreover, while the high proportion of key sources from friends and NGOs offers significant potential for accessing government schemes, mistrust and experiences of discrimination in healthcare settings often discourage trans women from engaging with these schemes. It can contribute to the spread of misinformation, further hindering their access to essential resources.

Additionally, social media networking sites can offer several benefits as a source of information. They are easily accessible, allowing users to approach any time without restrictions. It has a quick dissemination of updates, fostering real-time awareness of the schemes and opportunities. Furthermore, these platforms allow users to connect with broader communities, access diverse perspectives, and engage with resources that may not be available locally. However, a trans woman noted the reason for avoiding social media websites as,

I cannot trust social media websites. They only use English, and translating the language takes time, and the translation is not always accurate. There is also a possibility that most of the information is fake or vague. Many trans individuals are around me, so as a first step, I talk with my trans women’s community network and friends. Gender-affirming surgery is important to us. Like me, most trans individuals are interested in and aware of these surgeries. They know at least some information through our community network, and that is how I learned all the details. I trust those who have experience with specific surgeries and healthcare centers. The problem is that some of them are not updated with details about the schemes and advanced technologies.

Another trans woman marked,

There is only limited information on social media platforms related to gender-affirming healthcare.

The low proportion of participants (see Table 1) and their statements highlight that refusing to access social media can pose several drawbacks for trans women, particularly in terms of awareness, connection, isolation from support networks, visibility, advocacy, networking opportunities, and empowerment. Furthermore, maintaining authentic and reliable information on social media platforms related to gender-affirming healthcare is crucial.

The low involvement of family and relatives (see Table 1) highlights a lack of awareness among their biological families and relatives. This reflects a broader societal stigma that limits equality, understanding, and familial support for trans women, pointing to a significant area for improvement in outreach strategies. Increasing awareness of schemes among trans women’s families and relatives offers several benefits. It not only enhances access to information for trans women but also improves emotional support and resource accessibility, reduces financial burdens, strengthens advocacy efforts, fosters inclusion, provides better guidance, and promotes independence within families and society.

South Indian trans women’s migration and barriers

The Tamil Nadu state government announced a free fare scheme for trans women to enhance their lifestyle, following Delhi and Punjab. This increased mobility can lead to greater independence and improved quality of life. In India, they make multiple short or long trips in a day for employment, healthcare appointments, legal and administrative tasks, social support, shopping and personal needs, safety concerns, education, networking and advocacy, recreation and leisure, etc. The implementation of free bus facilities for trans women can have progressive impacts, such as economic empowerment, social inclusion, safety and security, and recognition and validation.

Some trans women participants (see Table 1) note that stepping out helps increase their visibility and confidence in public spaces, making it safer and encouraging more trans women to do the same. This visibility helps other genders to think differently about the perception of sex workers and beggars. Additionally, a trans woman answered,

I am really happy to benefit from the zero-fare bus scheme, just like other women. While society and the government recognize our gender as the ‘third gender,’ I see myself simply as a woman. However, it does not provide much economic support. To my knowledge, this is the first scheme where trans women receive equal treatment. I hope that all schemes and legal rights will be offered equally in the future. Starting with this free fare initiative, I am optimistic the government will continue to ensure our rights in other areas too.

However, A few trans women (see Table 1) highlight that they are not utilizing this beneficial scheme, even though they are well aware of it, as the scheme is not applicable to deluxe and express buses. Additionally, 53 trans individuals point out barriers, such as overcrowded buses and infrequent services. The scheme does not help them get economically strong or access gender health services because they often need to travel long distances to different cities or states for quality treatment. The migration connects not only with physical aspects but also with economic risks and uncertainties. It indicates the need for healthcare and migration support, including social acceptance. A trans woman explains,

I do not often use the Tamil Nadu state government’s free fare facilities in my daily life. As we know, this free fare facility was initially intended for women, not trans women. It was only after we submitted a formal request to the government that trans women were included. However, we are still faced with challenges, as conductors and drivers often do not stop at the correct or crowded points, and some buses are not well-maintained. Additionally, some conductors refuse to let sit free fare passengers on the bus seat. While I do save a little money by using it, these issues make it difficult, so I often prefer to take private buses instead.

Responds from trans women emphasize the profound challenges, particularly in accessing migration. To enhance the socio-economic development of trans women, policymakers must ensure that beneficial schemes comprehensively reach all segments of society. Increased promotion, awareness, and advancements in these schemes are necessary to meet the needs of the trans women community. Additionally, extending free bus fare facilities specifically to trans women is recommended to improve their economic opportunities and integration into mainstream society.

Economic status and hardships

In many parts of South India, trans women continue to face ostracism, violence, and marginalization due to entrenched societal norms and cultural taboos surrounding transgender identity and expression. This discrimination and systemic inequality often lead to significant economic and employment challenges for members of the trans women community. Consequently, many trans women are compelled to engage in precarious and often illegal occupations to survive the economic hardships they face, including sex work and begging, and they are engaged in both activities simultaneously due to their financial difficulties. However, progress is gradually being made through the efforts of NGOs and the resilience of the trans community. As a result, some trans women participants have found alternative occupations, such as acting and modeling, floor cleaning, running their own businesses, shopkeeping, and working with NGOs to sustain their lives (see Table 1).

Participants allocate their entire income (see Table 1) for basic needs, such as food, housing, transportation, healthcare, clothing and personal care, community and support networks, education and training, entertainment, family support, etc. Despite these challenges, GAS remains a top priority, adding to their financial strain and exposing them to unsafe environments and health risks. A trans woman shared her experiences,

However, I went to a government hospital for my breast augmentation surgery, and I spent 35,000 on silicone implants. The higher the price, the better the quality of silicone a trans woman can get, which means it can stay in the body safely for more years. Each type of silicone has different rates and weights. I am really careful about this—since it will be in my body for years, I want it to be better quality and safe for my health. I have used all my long-term savings to cover the costs of my gender-affirming surgeries and treatments.

This statement underscores that while surgeries may be free at government hospitals, silicone implants are not covered, exacerbating financial hardships. This suggests that government schemes promoting free surgeries are often more about public attention than substantive support, further burdening trans women economically. However, government schemes have played a role in facilitating trans women’s migration by offering certain benefits. Participants reported that they could save a minimal amount through free government transportation (see Table 1). A trans woman expressed,

The free fare scheme savings are not changing our community members’ lives or helping improve our economic situation.

The statement demonstrates that state-sponsored free transportation schemes, introduced to improve the economic conditions of trans women, are not significantly impacting their lives or transforming their circumstances. This underscores the need for greater societal sensitivity and inclusivity, as well as the importance of enhancing the free fare scheme to make it more effective. The lack of research, developments, and awareness in the social institutions perpetuates economic hardship, leading to further limited access to basic needs, restricted healthcare access, high migration, educational barriers, social isolations, insecurity and vulnerability, lack of political and social influence, mental health issues, and marginalization in society.

The mental health of trans women in gender-affirming surgery

In Tamil Nadu, mental health counseling is mandatory before GAS to help prevent post-surgery depression and dilemmas. Also, our report shows that many participants (see Table 1) expressed interest in and accessed counseling before their GAS at the state and central-run health centers. This finding highlights a progressive step toward supporting trans women within the healthcare system. Despite this progress, they continue to face discrimination in healthcare settings, as one trans woman shared,

Providers expect me to come in female attire to receive hormone therapy and mental health treatment. I am undergoing hormonal treatment without my parents’ knowledge. Before my gender-affirming surgeries and treatments, I felt they would not be comfortable or accepting of me.

From the narrative, we identified that many counselors lack the experience and understanding necessary to offer meaningful support. This leads to misdiagnosis, misguidance, and the invalidation of trans women’s experiences, eroding their trust in the mental healthcare system. Inappropriate advice can exacerbate the mental health challenges faced by trans clients, causing them to avoid or withdraw from counseling altogether. Such ignorance hinders acceptance and inclusion, with a high likelihood of discouraging others in the community from seeking help, further restricting access to mental healthcare. As a result, individuals may feel hopeless and isolated, significantly increasing the risk of self-harm and suicide. Furthermore, unconscious biases among counselors perpetuate societal stigma, undermining the creation of a safe and supportive environment essential for effective mental health care. Another participant noted,

There are no well-functioning mental health centers or gender-affirming surgery facilities in Trichy or Coimbatore. I learned that Madurai’s healthcare centers are running more smoothly regarding mental health and surgery services. I have heard that mental health counselling in private hospitals is functioning well, but they charge high fees ranging from 27,000 to 1,00,000. In some cases, the services are inadequate, yet they still proceed with gender-affirming surgeries. Moreover, accessing private or public health centers requires multiple visits, especially for mental health care, which often involves a minimum of three to six sessions with providers. The combined costs of time, travel, and expenses make it economically challenging for me.

Moreover, from the data collection, we realized that since the data was gathered in Madurai, trans women actively participated and benefited from mental healthcare services, supported by the TRC. It serves as a vital link between trans women and healthcare providers, facilitating communication and support. This role is crucial because, when doctors lack awareness of trans women’s specific needs, NGOs need to act as intermediaries to support trans individuals until healthcare providers gain the necessary awareness. Nonetheless, their narrative captures the support of the community network throughout her journey of seeking medical facilities, which indicates strong emotional and psychological support. Additionally, the statement indicates that their continued session with mental health services also leads the financial strain, resulting in the importance of establishing mental health centers in their local healthcare facilities and extending free fare services. It underscores the relationships between healthcare, migrations, and economic exchanges that are interconnected in the lives of trans women and underscores the systemic barriers to accessing healthcare.

Discussion

The study provides a comprehensive understanding of gender-affirming facilities, migration, and the direct and indirect barriers faced by South Indian trans women in government schemes. We developed four main themes. First, South Indian trans women face significant healthcare barriers, such as discrimination, limited services, and preference for private hospitals over government facilities, driven by trust and quality concerns. Community networks play a dual role by offering support yet perpetuating biases. Second, Government schemes like free bus fares foster visibility and independence. However, limited services and poor quality lead to increased migration and neglect of the facility. Third, the persistence of social stigma, lack of awareness about available schemes, and preference for private healthcare, with limited access to government schemes, lead to economic hardships. Finally, mandatory counseling for GAS in Tamil Nadu shows progress, but ignorance and discrimination in the healthcare setting hinder effective care. Strong community networks, supported by resources like the Transgender Resource Center, provide vital psychological and logistical assistance.

Overall, our findings highlight that the promotion, awareness, and advancements in the schemes are necessary to meet the needs of the trans women community. Additionally, extending free bus fare facilities specifically to trans women is recommended to improve their healthcare access, mobility, economic opportunities, and integration into mainstream society. However, the awareness does not equate to the utilization, satisfaction, or actual benefits of trans women. The lack of awareness about healthcare services and schemes in their native state and country significantly impacts the GAS and migration experiences of trans women, often preventing them from accessing essential medical treatments. Moving to new regions without this knowledge can lead to fear, stress, anxiety, social isolation, and missed opportunities for support. These challenges can severely limit their access to necessary resources and exacerbate mental health issues, ultimately affecting their quality of life. Moreover, reliable information on where to seek help, available services, and how to apply for them is crucial. While trans women often rely on their community members and friends to choose health centers, this supportive network, though beneficial, may not always provide comprehensive knowledge about all medical facilities and healthcare options in their native state and country, requiring them to spend considerable time verifying information for accuracy with multiple people. Without promotion and awareness from the state and central government, the current trans women community struggles are similar, and there is a possibility to persist in the future trans women community. Using social media platforms and promoting targeted videos and hashtags with credible information about support programs can be crucial. Expanding the use of these platforms could further raise awareness and improve access to beneficial programs, ultimately empowering and improving the well-being of trans women (Selepak, 2017).

Additionally, to enhance healthcare and economic opportunities for trans women, the government can increase the number of public hospitals and medical facilities in their local cities and districts. This will allow trans women to access timely healthcare services and reliable information, helping them avoid economic challenges. Through these facilities, education about specific care and gender diversity in society can reach everyone. Reducing or eliminating bus fares in Tamil Nadu, India, can help trans women save money, promote social inclusion, enhance healthcare services and mental well-being, and improve economic support, which they can use for further self-improvement. Furthermore, to promote the well-being of the trans women community, it is significant to ensure knowledge providers and treatments are available in all GAS-specialized centers. Researchers (Divya & Menon, 2022; Hana et al., 2021; Shrivastava & Shrivastava, 2023) emphasize that gender-related and mental healthcare topics should be incorporated into medical education better to address the needs of the trans women community. Moreover, it is significant that all NGOs, like the Transgender Resource Center, establish connections with GAS-specialized centers. Furthermore, state and central schemes across all private hospitals must provide these facilities exclusively and comprehensively. The study highlights the crucial role of awareness in reaching the broader trans women community. It demonstrates that a lack of awareness results in challenges not only in physical well-being but also in mental and economic stability. The analysis emphasizes that increased awareness can significantly improve access to medical and migration access.

However, community networks play a vital role; it is significant in enabling trans women to access all necessary resources independently and comprehensively. Creating Airtable provides valuable information to the trans women community and gender-nonconforming children (refer to the CSV file). Establishing supportive networks not only benefits the trans women community but also aids research scholars. This was one of the key motivations for creating the Airtable initiatives.

Public digital humanities can be leveraged to disseminate resources to the trans community when it comes to healthcare access and advocacy. As outlined in the methodology, we utilized the Airtable online application to distribute in Madurai, including 1 public and 4 private centers, and in Chennai, one public and 56 private centers details electronically (refer to the CSV file). Sharing gender-related healthcare access information, and advocating within the trans women community and non-governmental organizations are crucial for trans women who migrate or move between locations, especially when considering their personal choices. This information helps them obtain treatment near their new locations and ensures quality care, allowing them to access necessary medical services more easily without geographical barriers (refer to the CSV file). Additionally, NGOs and trans women can use this information as a guide for their healthcare needs in different hospitals and places to access healthcare policies. This practice also raises awareness about inclusive healthcare practices.

In the Airtable, we compiled a corpus of information about healthcare details on the website platform (refer to the CSV file). Additionally, engaging in discussions and collaborations with NGOs can help transform this corpus into trustworthy and reliable information, empowering better decision-making within the community. Moreover, sharing the data with scholars can enhance transparency, facilitate interdisciplinary usage, and provide easy access to structured information. It also enables collaboration input and expansion of the dataset, fostering an open-data culture that encourages innovation within the field.

However, based on the data collection, Chennai, has a higher number of health centers compared to Madurai. Despite this, Madurai shows significant activity, there is a possibility of migration to Chennai, a metropolitan city, or other districts or states to access GAS. Furthermore, the limited free fare facility and high migration rates can contribute to economic hardships and highlight the need to enhance GAS and free fare facilities (refer to the CSV file).

Future research

Our future investigations focus on a broad spectrum of topics, including the impacts, challenges, and developments of educational, financial, and healthcare schemes offered by the state, and central, addressing critical gaps of trans women in India. These inquiries will encompass their migrations and experiences of barriers and successes. Moreover, it is crucial to examine the family’s and society’s acceptance, stigma, and violence impacting their migrations both within and outside India. As an initial step, our study explores the state and central schemes of trans women in Madurai, Tamil Nadu, with a significant focus on key aspects of healthcare and migration. Additionally, our future research aims to document educational, healthcare, and financial scheme tie-up institutions on the website. We are enhancing our research to ensure accessibility and maximize benefits for trans women, gender non-conforming children, and stakeholders.

Limitations of the study

Examining various aspects of medical and free fare facilities from central and state government schemes in all districts and states in India is essential for understanding the benefits, challenges, and developments experienced by trans women; however, encompassing all states and districts of India is beyond the scope of this article. So, for this research, considering limitations, we chose Tamil Nadu, particularly with the trans women community in Madurai. Collecting data directly from trans women proved challenging due to several concerns they raised. Many participants questioned the benefits of the research, particularly regarding financial compensation, and expressed frustration, stating that despite having participated in interviews with other researchers in the past, they had not experienced any tangible benefits, whether legal, financial, or social. Some participants were reluctant to discuss the medical facilities they accessed with heterogender or individuals outside their community. Although we intended to offer remuneration for their valuable time, it became evident that their frustration stemmed from societal challenges and a perceived lack of benefits from participating in research. Despite our efforts to passionately and thoroughly explain the significance and potential advantages of the study, it was clear that the participants were frustrated by societal challenges, lack of financial support, and the frequency of interviews and surveys. Consequently, as previously described, we decided to refocus our efforts and engage a team of trans men for data collection.

Conclusion

The study provides a nuanced exploration of healthcare and migration challenges faced by South Indian trans women, particularly in the context of government schemes. The findings reveal that central government schemes have not reached a significant portion of the trans community compared to state initiatives. This highlights the critical need for inclusive policies that address the specific needs of trans women, particularly in gender-affirming and migration services, to enhance socio-economic conditions. Increased promotion, awareness, and advancements in the schemes, along with community-centric digital initiatives, are essential to ensure broader accessibility. Overall, the research underscores the importance of creating supportive environments where trans women feel safe, included, and understood.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

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