Barriers to health and social inclusion among transgender and MSM populations in India: a mixed-methods multicentric study

Abstract

Background

Despite legal reforms advancing the rights of transgender (TG) individuals and men who have sex with men (MSM) in India, social exclusion, stigma and systemic barriers continue to undermine their access to healthcare and social services. Evidence on identity recognition, service utilisation and healthcare gaps remains limited.

Methods

We conducted a sequential explanatory mixed-methods study. The qualitative phase involved 26 in-depth interviews, 14 focus group discussions and 3 key informant interviews with TG and MSM participants in Delhi and West Bengal. Insights informed a quantitative survey across 14 states (n=2208), exploring socio-demographic profiles, identity documentation, employment and healthcare utilisation. Data were analysed thematically using NVivo V.14 and statistically using SPSS V.27.

Results

TG and MSM participants reported pervasive educational exclusion, precarious livelihoods and limited family support. Only 52.4% of TG respondents possessed a TG identity card, while fewer than 20% had updated other legal documents. Employment remained insecure, with 35% of TG individuals reliant on sex work, begging or ritualistic practices. Health service uptake was low: only 12% of TG respondents accessed Ayushman TG Plus insurance, and 3.9% received human papillomavirus (HPV) vaccination. While most HIV-positive respondents reported being linked to antiretroviral therapy centres, many participants diagnosed with other sexually transmitted infections (STIs) or hepatitis B/C were not receiving treatment. Qualitative findings highlighted stigma in healthcare interactions, administrative delays in accessing welfare schemes and restrictions within community-based support structures such as Deras. Despite these barriers, peer networks provided critical emotional and financial support.

Discussion

Findings reveal persistent gaps between legal recognition and lived realities for TG and MSM individuals. Structural stigma, economic marginalisation and administrative inefficiencies undermine access to identity documentation, healthcare and social protection schemes. Addressing these inequities requires stigma-sensitive healthcare, streamlined administrative processes and inclusive welfare programmes. Embedding psychosocial support and trans-inclusive care beyond HIV services into India’s public health system is essential for ensuring health equity and advancing Sustainable Development Goals 3 and 10.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Despite legal progress in India, transgender (TG) individuals and men who have sex with men (MSM) continue to face stigma, social exclusion and barriers to accessing healthcare and welfare schemes. Existing studies largely focus on HIV-related services, with limited evidence on broader health and social determinants.

WHAT THIS STUDY ADDS

• This study provides comprehensive national evidence on identity documentation, livelihood insecurity and healthcare utilisation among TG and MSM populations. It reveals critical implementation gaps in social protection and healthcare access, despite formal legal recognition and targeted policies.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Findings underscore the need for stigma-sensitive, trans-inclusive public health services and streamlined administrative systems. Integrating psychosocial and welfare support into national health programmes could bridge the gap between rights recognition and lived realities for TG and MSM individuals.

• Policy context: Findings reflect the legal and administrative environment preceding the Government of India’s March 2026 revisions to TG definitions and identity documentation procedures.

Introduction

Transgender (TG) individuals have long been a part of Indian society, yet they remain among marginalised communities, facing persistent social and economic challenges. However, significant strides have been made toward legal recognition and inclusivity. The recognition of TG individuals as the ‘third gender’ marked a historic step in advancing their rights.1,3 The landmark National Legal Services Authority’s (NALSA) 2014 judgement affirmed their right to self-identify their gender and mandated state protection of their rights.⁴ This was followed by the decriminalisation of Section 377 of the Indian Penal Code in 2018, which removed legal barriers against same-sex relationships, and the enactment of the Transgender Persons (Protection of Rights) Act, 2019 aimed at securing their rights to education, employment, healthcare and social welfare (Government of India, 2019).⁵ Moreover, the issuance of a Transgender Certificate under the 2019 Act has become a critical prerequisite for accessing these government benefits (Ministry of Social Justice and Empowerment, 2020).

However, despite these legal advancements and progressive reforms, the lived realities of TG individuals reveal persistent structural barriers, societal stigma and systemic discrimination, which keep them from taking full advantage of these policies. The 2011 Census recorded a TG population of 487 803⁶ which was calculated on the basis of self-reporting by the individuals. However, Patna-based TG activist challenged Bihar TG population, as 2022 caste survey done in the state, the population of TG in Bihar is 825⁷ in contrast to 40 827 of 2011 census data. Research highlights that 92% of TG individuals remain economically inactive, with less than 50% having access to education (National Human Rights Commission, 2018). Social exclusion remains widespread, with 99% facing ostracisation and 96% unable to find dignified employment, often forced into low-wage or stigmatised jobs.^{8 9}

Healthcare access remains one of the most critical challenges for TG individuals.^{10 11} Many engage in high-risk behaviours such as unprotected sex work and hormone injections, leading to an increased prevalence of HIV and other sexually transmitted infections (STIs).^{12 13} Worldwide, around 1 million individuals are impacted by STIs each day (WHO, 2024). While targeted interventions by the National AIDS Control Organisation provide essential services-including free STI screenings, condom distribution and peer counselling-social stigma,^{14 15} lack of healthcare provider sensitisation and financial constraints continue to create barriers to adequate medical support.¹⁶ Mental health concerns such as depression and substance use are also prevalent, often exacerbated by social exclusion,¹⁷ family rejection¹⁸ and limited access to psychological support services.¹⁹

The scientific rationale for the present investigation arises from the intersection of infectious disease preparedness and entrenched health inequities faced by TG and men who have sex with men (MSM) communities. Evidence consistently shows that structurally marginalised populations carry disproportionate burdens of HIV, STIs and emerging infections such as Mpox, owing to the combined effects of stigma, limited health-seeking opportunities and inadequate access to gender-affirmative healthcare. Although national programmes offer targeted services for high-risk groups, there remains limited empirical understanding of how TG and MSM individuals navigate health systems, their patterns of service utilisation and the identity-related experiences that shape these behaviours. Given this context, the present study aims to explore identity-related experiences and to assess the utilisation of the healthcare services availed by TG individuals in India and to understand various factors influencing healthcare access. Specifically, this research examines their accessibility to these services, and their experiences in availing them. By understanding gaps and barriers in service delivery, this study seeks to contribute to policy development. This study is a part of the major study (Project title: Assessment of stigma related to Human Monkeypox Virus (MPox) among high-risk populations in India) conducted to assess Mpox stigma. A section catering to the barriers to health and social inclusion by the TG and MSM population has been incorporated in the present study.

Methodology

Theoretical framework

Interpretation of qualitative findings was informed by the socio-ecological model,^{20 21} which recognises that health behaviours and inequities are shaped by interacting influences at multiple levels, including individual, interpersonal, community, organisational and policy environments. This framework was used to organise emergent themes related to disclosure, stigma, livelihood vulnerability, healthcare access, documentation barriers, and structural exclusion among TG and MSM participants.

Study design

This study employed a sequential explanatory mixed-methods design (shown in figure 1) in which an initial qualitative phase informed the development of a subsequent multicentric quantitative survey. In mixed-method notation, this corresponds to qual → QUAN, indicating an exploratory qualitative component followed by a quantitatively dominant phase. Findings from both phases were integrated during the interpretation stage to generate meta-inferences regarding barriers to health and social inclusion barriers among TG and MSM in India.

Figure 1. Sequential exploratory mixed-methods design (qual → QUAN) showing qualitative phase, survey development, multicentric quantitative phase across 14 states and integration through triangulation. This figure presents a schematic overview of the study design, showing the sequence of key methodological steps—including site selection, CBO engagement, participant recruitment, data and biospecimen collection and analysis flow. The diagram outlines the mixed-methods approach adopted for both TG and MSM populations across multiple regions of India. CBO, community-based organisation; FGDs, focus group discussions; IDIs, in-depth interviews; KIIs, key informant interviews; MSM, men who have sex with men; TG, transgender; UT, union territory.

The qualitative phase guided the development of a large-scale quantitative survey deployed across 14 Indian states, ensuring a comprehensive understanding of facilitators and challenges in healthcare and social access (shown in figure 1). In the qualitative phase, in-depth interviews (IDIs), key informant interviews (KIIs) and focus group discussions (FGDs) were conducted using purposive sampling to capture diverse experiences. The subsequent quantitative phase used a structured online survey administered by trained counsellors, collecting data on socio-demographic profiles, health service utilisation and access barriers. Statistical analyses were conducted using IBM SPSS V.27. All qualitative and quantitative data for this study were collected between January 2024 and December 2024. This study was conducted prior to the Government of India’s revised transgender policy and definitional changes introduced in March 2026; therefore, findings related to identity documentation and welfare access should be interpreted in the policy context prevailing during the study period.

Participant selection

Qualitative

Eligible participants were TG and MSM individuals aged 18 years or older, self-identifying as transgender (whose gender identity differs from sex assigned at birth²²) or MSM (men engaging in sexual activity with other men regardless of orientation²³). Participants were sexually active within the previous 3 months and provided informed consent.

Quantitative

Inclusion criteria mirrored the qualitative phase-participants aged ≥18 years identifying as TG (TG male or TG female) or MSM. Only individuals who consented voluntarily and were capable of understanding the study objectives were included.

Sample size and sampling

Qualitative

Purposive sampling was adopted to reach marginalised and hard-to-reach populations. IDIs, KIIs and FGDs were conducted across Delhi and Hooghly (West Bengal). FGDs comprised six to eight participants each, representing TG and MSM subgroups. Data collection continued until thematic saturation was reached. KIIs were conducted with community leaders and individuals with extensive exposure to TG and MSM community structures, including those linked to Deras²⁴ and people living with HIV. Support from community-based organisation (CBO) personnel facilitated recruitment, trust and participant retention.

Quantitative

The sample size was determined using OpenEpi software based on an estimated TG–MSM population of 400 000 adults. Assuming a 10% expected prevalence, 1.2% absolute precision and 5% significance, the initial sample was 1946, adjusted to 2335 to account for 20% non-response. Ultimately, 2208 valid responses were retained after excluding incomplete or duplicate entries. Participants were recruited via 13 partnering CBOs, ensuring proportional representation across states. No participants refused to participate or dropped out because of the help we took from the CBO

Study setting

Qualitative

Fieldwork was conducted in Delhi National Capital Region (NCR) (urban) and Hooghly, West Bengal (semi-urban) which were purposively selected to capture contrasting socio-cultural and service delivery contexts. Delhi NCR represents a large metropolitan setting with comparatively greater service availability and migrant diversity, while Hooghly reflects a semi-urban eastern India context with different community dynamics and healthcare access pathways. Both locations had established CBO networks that facilitated trust-building, recruitment and safe engagement with participants from marginalised populations. In collaboration with local CBOs maintaining community registers, CBO support facilitated inclusion of individuals regularly accessing health or welfare services, with trained staff also assisting in translation where required. Approximately 62% of interviews were conducted in person and 38% via telephone.

Quantitative

The survey spanned 14 states—Karnataka, Madhya Pradesh, Punjab, Assam, Tamil Nadu, Delhi NCR, Telangana, West Bengal, Uttar Pradesh, Jharkhand, Maharashtra, Kerala, Andhra Pradesh and Uttarakhand—to ensure diverse regional, socio-cultural and urban–rural representation (shown in figure 2).

Figure 2. Spot map showing the geographical distribution of 33 data collection sites across India. The figure displays the zonal distribution of study sites coordinated through collaborating community-based organisations. North Zone: Mansa Foundation (Amritsar, Punjab); Faridabad (Haryana); Alliance India (Delhi); Pehal Foundation (Gorakhpur and adjoining districts—Basti, Balrampur, Deoria, Dewas and Maharajganj) and Basera Samajik Sanstha (Noida, Gautam Buddh Nagar) in Uttar Pradesh; Prayojan Kalyan Trust (Dehradun, Uttarakhand). Central Zone: Anmol Sewa Sansthan (Bhopal, Indore and Jaunpur, Madhya Pradesh); Raipur (Chhattisgarh). West Zone: Humsafar Trust (Mumbai Suburban, Thane and Pune, Maharashtra). South Zone: Humsafar Trust (Bengaluru, Bengaluru Urban, Chitradurga) and YRG Care (Belagavi, Karnataka); Humsafar Trust (Chennai, Thiruvallur and Visakhapatnam, Tamil Nadu); Alliance India (Hyderabad—East Godavari, Khammam, Medchal-Malkajgiri and Ranga Reddy) and YRG Care (Vijayawada—Krishna) in Andhra Pradesh and Telangana; Alliance India (Thiruvananthapuram, Kerala). North-East Zone: Humsafar Trust (Kamrup Metro, Assam). East Zone: Utthan Sewa Sansthan (East Singhbhum and Ranchi, Jharkhand); Amitie Trust (Hooghly and Howrah, West Bengal). The map was generated using the freely available mapping tool at https://www.mapchart.net/india.html.

Data collection

Qualitative

A semi-structured interview guide, collaboratively developed by three researchers and pilot-tested with community members, explored themes of community challenges, identity and access to healthcare. Interviews (≈45 min) and FGDs (45–90 min) were audio-recorded with participants’ consent, complemented by field notes. No identifying information was collected. Data collection continued until saturation.

Quantitative

A structured questionnaire, administered via Google Forms through trained field staff, took approximately 20 min per participant. It comprised two sections:

✓Socio-demographics: age, gender identity, education, religion, employment, income and living arrangements.

✓Healthcare utilisation: type of identity documentation, insurance coverage, screening and treatment history for STIs/HIV/hepatitis, vaccination and awareness of welfare schemes (eg, Garima Greh). CBO counsellors personally administered the survey to ensure inclusivity and accurate responses.

Research team and reflexivity

The qualitative team comprised one public health scientist (MD, epidemiology, male, with STI expertise), two anthropologists (PhD, females, with expertise) and one research associate (PhD, female), ensuring interdisciplinary expertise. Team members were trained in gender-sensitive communication, confidentiality and non-judgmental engagement. Rapport was built through prestudy interactions with CBOs, and all researchers introduced themselves transparently, emphasising voluntary participation and confidentiality.

Quantitative data collection was conducted by trained CBO counsellors (male, female, TG) familiar with local contexts and terminologies. Pre-data collection training covered ethics, informed consent and standardised interviewing. Researchers maintained reflexivity through ongoing debriefing and critical reflection on their positionality to minimise bias.

Data analysis

Qualitative analysis

Audio-recorded interviews and FGDs were transcribed verbatim, translated into English where required and analysed using NVivo 14 (QSR International). An inductive thematic analysis²⁵ approach was adopted because it enables system identification, comparison and interpretation of recurring patterns across diverse participant narratives and is well suited for exploratory public health research. Two researchers independently conducted open coding after which related codes (coded transcripts) were grouped into categories, then organised into subthemes and overarching themes through iterative discussions and consensus meetings. However, transcripts were not returned to participants for comment and/or correction. Investigators triangulation was used to enhance analytical credibility. Interpretation was informed by a socio-ecological perspective examining individual, interpersonal, community and system-level barriers to healthcare and social inclusion.

Quantitative analysis

Data were analysed using IBM SPSS V.27. Descriptive statistics summarised demographic characteristics and service utilisation patterns. Inferential analysis (independent samples t-tests) examined associations, such as between income and gender-affirming surgery. Data integrity checks ensured reliability and accuracy.

Integration of qualitative and quantitative findings

Integration of findings occurred at the interpretation stage following completion of separate qualitative and quantitative analyses. Convergent and divergent findings were compared through joint display tables to generate meta-inferences regarding documentation barriers, healthcare exclusion, stigma, livelihood insecurity, and systems-level challenges affecting TG and MSM populations.

Data reporting and dissemination

Findings were reported using anonymised participant identifiers to preserve confidentiality. Direct quotations illustrated key themes. While formal member-checking was not feasible due to logistical constraints, reflexive discussions within the research team ensured interpretations were grounded in participants’ perspectives. Thematic consistency across IDIs, FGDs and survey data supported the credibility of findings. Major and subthemes were systematically presented in the results section, emphasising coherence between qualitative insights and quantitative patterns.

Data monitoring and quality assurance

Regular monitoring was implemented to ensure completeness and consistency of data entries. Supervisors reviewed field reports weekly, and periodic cross-checks were conducted by the principal investigators. Any discrepancies such as missing data were addressed immediately. The data was again collected from the participants. Participants were provided contact access to community counsellors for clarifications or psychological support during and after participation and also non-participation.

Results

Participant profile and demographics

A total of 2208 participants were included in the quantitative survey, representing TG and MSM populations from 14 Indian states. The qualitative component consisted of a total of 26 IDIs, 14 FGDs and 3 KIIs conducted across Delhi and Hooghly (West Bengal). Two repeat interviews were carried out for FGD among MSM as the audio recording was clear. FGDs comprised six to eight participants each, representing TG and MSM subgroups including diverse voices such as individuals from rural areas, those living with HIV and members of traditional Dera communities. The mean age of qualitative participants was 31.6 years (SD=10.07), with ages ranging from 20 to 58 years. While 58.6% reported living with family, others resided alone or in community-based housing.

Employment patterns varied: 55.2% of qualitative participants were salaried workers, 20.7% were engaged in sex work and 10.3% worked in informal sectors such as physical labour or traditional cultural roles like badhai/mangti. The demographic diversity ensured a broad and representative understanding of lived realities across different socio-geographical contexts. Full demographic characteristics are presented in table 1.

Table 1. Socio-demographic information of participants.

Total participants (N=2208)	TG (n=1068)	MSM (n=1140)
Age	TG	MSM
Less<30	763 (71.4%)	637 (55.9%)
30–45	272 (25.5%)	422 (37%)
>45	33 (3.1%)	81 (7.1%)
Education	TG	MSM
Learnt to read and write	23 (2.2%)	7 (0.6%)
Primary school	69 (6.5%)	43 (3.8%)
Middle school	100 (9.4%)	95 (8.3%)
High school	265 (24.8%)	282 (24.7%)
Intermediate/diploma	138 (12.9%)	149 (13.1%)
Graduate and above	296 (27.7%)	516 (45.3%)
Illiterate	52 (4.9%)	36 (3.2%)
NDA*	125 (11.7%)	12 (1.1%)
Current religious faith	TG	MSM
Hindu	679 (63.6%)	909 (79.7%)
Islam	175 (16.4%)	177 (15.5%)
Christian	48 (4.5%)	39 (3.4%)
Buddhist	12 (1.1%)	6 (0.5%)
Sikh	12 (1.1%)	2 (0.2%)
No faith	25 (2.3%)	1 (0.1%)
NDA*	117 (11%)	6 (0.5%)
Employment status	TG	MSM
Unemployed	80 (7.5%)	44 (3.9%)
Government employee	10 (0.9%)	28 (2.5%)
Private employee	321 (30.1%)	557 (48.9%)
Business	70 (6.6%)	96 (8.4%)
Skilled labour	57 (5.3%)	132 (11.6%)
Unskilled labour	139 (13%)	224 (19.6%)
Student	16 (1.5%)	7 (0.6%)
Others†	375 (35.1%)	52 (4.6%)
Income	TG	MSM
Mean	17 868.3	18 475.6
Median	15 000	15 000

^*NDA, not disclosed answer.

^†Including badhai/mangti/begging/sex worker.

MSM, men who have sex with men; TG, transgender.

The thematic categories that have emerged broadly include livelihood, care and belonging (Need); disclosure and psychosocial challenges (Barriers); and access to identity and health services (Challenges) (shown in figure 3) (see table 6 in online supplemental file 1).

Figure 3. Generated codes, subthemes and related final themes as an example of code generation for the data collected from TG and MSM surveyed in 2024 across India. Process of code generation, subtheme development and theme consolidation for qualitative data from TG persons and MSM surveyed in 2024 across India. The figure illustrates how initial codes derived from participants’ narratives were grouped into subthemes, which were further synthesised into broader analytical themes reflecting key patterns in livelihood, care, belonging and social vulnerability among TG and MSM communities. MSM, men who have sex with men; TG, transgender.

Theme 1: livelihood, care and belonging (need)

This theme captures the role of family, education, livelihood opportunities and community networks in shaping the lives of TG and MSM individuals.

Subtheme 1.1: conditional family support

Family support was a critical determinant of safety, belonging and resilience for TG and MSM individuals, though it was rarely unconditional. Quantitative analysis showed that while a majority of MSM (76.4%) and fewer TG individuals (28.8%) continued to live with their families, co-residence did not always translate into acceptance. Many relied instead on alternative arrangements (see table 1 in online supplemental file 1) such as community living (22.9%) or Deras (2.2%). Qualitative accounts illustrated the fragility of such support: “Outside, people know me as who I am. Inside this house, I’m invisible.” (TGF_9). Others described being pushed away after conflicts: “I ran away after another altercation with my family and never returned.” (TGF_7, 40). In some cases, education or class did not predict acceptance, as one MSM participant shared, “I was born to a lower-class family staying in a slum… but still they supported me and accepted my identity.” (MSM_7, 33).

Subtheme 1.2: limited education access

Educational exclusion emerged as a key barrier shaping future opportunities. School dropout due to bullying, discrimination and family rejection was widely reported and contributed to limited access to higher education. The absence of health literacy further compounded challenges, as seen in one TG participant’s reliance on peers for treatment instructions: “I’m not very educated. My friend used to give me slips… she told me that I have to take the injections every month and avoid drinking alcohol.” (TGF_4, 31). This educational gap directly restricted formal employment opportunities and reduced independence.

Subtheme 1.3: economic vulnerability

Employment data revealed significant exclusion from the formal labour market. Among TG participants, only 30.1% worked in the private sector, 13% in unskilled labour, 5.3% in skilled labour and 6.6% in self-employment. A much larger share (35.1%) engaged in occupations such as sex work, begging or ritualistic toli badhayi, with an additional 7.5% unemployed. Narratives reflected this precarity: “We have a certain ritual… Many don’t like to do so, but have to do it for survival.” (TGF_8, 28). Discrimination in workplaces was also common: “I used to work in a private company. When they found out [I was TG], they didn’t renew my contract.” (TGM_3). Economic insecurity was closely tied to access to health services. Quantitative analysis found a significant association between income and gender-affirming procedures (p=0.002, Cohen’s d=0.108), highlighting how financial resources determined access to transition-related care.

Subtheme 1.4: emotional and financial security through community

In the absence of consistent family or institutional support, many TG and MSM individuals turned to peers and community networks for belonging and survival. Quantitative data indicated that 22.9% resided with friends or community members, while others joined structured community systems such as Deras. These provided refuge but also enforced restrictive norms. One TG participant explained, “A group of nine individuals resides together… One serves as the Guru, another as the Gurubhai, and the remaining six are our Chelas.” (TGF_7, 40). Another described limitations imposed by such systems: “Those staying in the Dera are not allowed to do sex work. Even having a boyfriend is not allowed.” (TGF_8, 28). These narratives underscore the dual role of chosen families-as sources of emotional solidarity but also as sites of economic dependency.

Theme 2: disclosure and psychosocial challenges (barriers)

This theme reflects the internal struggles of identity disclosure, reactions from others and the psychosocial consequences of stigma.

Subtheme 2.1: fear and selective disclosure

Most participants reported becoming aware of their gender nonconformity in childhood or adolescence, often accompanied by confusion and secrecy. Quantitative findings showed that although disclosure to someone was common (81.8% of TG and 95.1% of MSM), disclosure to family remained very limited, with only 16.9% of TG and 9.9% of MSM sharing with male relatives and slightly higher proportions with female relatives (23.8% TG, 14.5% MSM) (see table 1 in online supplemental file 1). Participants highlighted their fear of rejection and violence, often disclosing only to trusted peers or NGOs: “From childhood, I used to feel different… I preferred to wear girls’ clothes even though I was born male.” (TGF_1, 25).

Subtheme 2.2: psychosocial and healthcare barriers

Experiences of stigma and discrimination created deep mistrust of healthcare systems. Many delayed care or sought private services despite higher costs. Narratives described humiliating encounters: “Our surgery [was] just an experiment for them… They have no idea what mental trauma we went through.” (TGM_1, 33). Another participant explained avoidance of public hospitals: “We exclusively seek medical care in private hospitals due to the discomforting experiences at government hospitals.” (TGF_7, 40). Such psychosocial barriers translated into reduced uptake of preventive and therapeutic health services, reinforcing cycles of vulnerability.

Subtheme 2.3: societal exclusion and stigma

Beyond families and healthcare, participants faced persistent stigma in housing, employment and everyday social interactions. Housing discrimination was particularly striking, as one participant shared: “Even though I am a woman inside, when I try to rent an apartment, they refuse, saying they can’t rent to transgender people.” (TGM_33). Such experiences reinforced alienation and invisibility, with lasting impacts on social participation and economic mobility.

Theme 3: gaps in systems and services (challenges)

This theme highlights systemic failures in welfare schemes, health services and bureaucratic processes.

Subtheme 3.1: lack of awareness and gaps in identity documents

Many participants were unaware of welfare schemes such as Ayushman TG Plus or struggled with complex application procedures. Quantitative data confirmed low awareness levels, with fewer than one in five TG individuals successfully updating gender across official documents (see table 2a and 2b in online supplemental file 1). Narratives reflected this uncertainty: “A transgender was saying that a transgender card is being issued… but I don't have it, and I don’t know where to get it.” (TGF_4). A considerable proportion of TG participants had updated their identity documents (see table 7 in online supplemental file 1) to reflect their gender such as voter ID (19%), Aadhaar (14%) and PAN (Permanent Account Number) card (14%). In contrast, very few MSM participants reported making such changes, with less than 1% updating standard ID cards and only 7.5% holding a TG-specific card.

Subtheme 3.2: health insurance uptake and gender-affirming care

Insurance coverage remained limited (see Table 3 in online supplemental file 1): only 12% of TG respondents reported availing services through Ayushman, while 74.5% either lacked insurance or were still applying. Among MSM, 73.8% had no insurance coverage. Preventive services also remained underused: only 0.4% of the entire study population had received HPV vaccination, while 23.8% reported hepatitis B and 8% hepatitis C vaccination (see Table 5 in online supplemental file 1). In terms of gender-affirming procedures, TG individuals reported much higher rates of hormonal therapy (93.1%), top surgery (90.9%) and bottom surgery (83.7%) compared with MSM, where the majority (39.2%) had no surgical interventions. A χ² analysis confirmed a significant association between gender identity and type of surgical care (χ²(14) = 1082.177, p<0.001) (see Table 4a and 4b in online supplemental file 1). Qualitative accounts highlighted stigma during medical care: “Doctors will say, ‘You look like a man but have a vagina.’ They ask personal questions, then discuss it in groups. That’s mentally disturbing.” (H_TGM_1, 34).

Subtheme 3.3: public health and shelter experiences

Awareness and utilisation of Garima Greh shelter homes was low-only 44.7% of TG and 22.8% of MSM had even heard of them. Even when accessed, experiences were mixed, with reports of family interference and limited autonomy: “I know one case in Delhi where one TG ran away from family and lived in Garima Greh, but that night their family created a ruckus and police were also called… finally that person had to go home with their family.” (TGF_8, 25).

Subtheme 3.4: administrative delays and bureaucratic barriers

Administrative inefficiencies further limited access to identity and welfare services. Only 75.6% of TG respondents reported having a TG identity card, and even fewer had consistent gender updates across all documents (14–19%). Several participants described waiting months or even years for documents: “I applied for my TG card two years ago, but I am still waiting for it. The process is so slow.” (TGF_9, 22). Such delays reinforced distrust in state systems and contributed to reliance on informal community networks.

Integration of qualitative and quantitative findings

To enhance integration between qualitative and quantitative components, a joint display was developed linking final qualitative themes with relevant survey findings and resulting meta-inferences (table 2).

Table 2. Joint display integrating qualitative themes with quantitative findings and meta-inferences.

Qualitative theme	Supporting quantitative findings	Meta-inference
Livelihood, care and belonging (Need)	35% of TG participants depended on sex work, begging, ritual-based income or informal occupations; low educational attainment reported across participants	Social exclusion from education and formal employment produces economic precarity, increasing reliance on informal/community-based survival systems
	Low rates of family disclosure and support; many participants reported dependence on peers/community housing	Peer and chosen-family systems compensate for inadequate family acceptance and limited state support
Disclosure and psychosocial challenges (barriers)	Disclosure to male family members remained low (around 10–17%); female relatives slightly higher	Fear of rejection and stigma drives selective disclosure, concealment and psychosocial distress
	Low uptake of preventive services (HPV vaccine 3.9%); untreated STI/HBV/HCV cases remained substantial	Anticipated stigma and mistrust in healthcare settings suppress preventive care and treatment continuity
	Continued reports of unstable housing/employment and exclusion	Structural discrimination extends beyond health systems into housing, labour markets and daily life
Gaps in systems and services (challenges)	Only 52.4% TG participants had TG identity cards; fewer than 20% updated other legal documents	Legal recognition has not translated into accessible, efficient administrative implementation
	Only 12% TG participants used Ayushman TG Plus; insurance coverage remained suboptimal	Welfare schemes exist but suffer from low awareness, bureaucratic barriers and weak implementation
	Most HIV-positive participants linked to ART, but treatment gaps persisted for other STIs/hepatitis	Public health services remain HIV-centric, while broader routine and preventive healthcare needs remain neglected

ART, antiretroviral therapy; HBV, hepatitis B virus; HCV, hepatitis C virus; HPV, human papillomavirus; STI, sexually transmitted infection; TG, transgender.

Discussion

The findings of this study provide critical insights into the lived experiences of MSM and TG individuals, highlighting the intricate interplay of socio-demographic factors, identity recognition challenges, legal barriers and economic hardships that shape their realities. The diversity within gender and sexual minorities, with 50.9% identifying as MSM, 41.3% as TG and 7.8% still exploring their identity,²⁶ underscores the fluidity and complexity of identity formation.²⁷ Gender self-recognition often begins in adolescence, yet many individuals encounter significant familial and societal resistance.²⁸ The qualitative findings reveal that internal conflicts and struggles with self-acceptance are common, emphasising the necessity of supportive environments that facilitate self-realisation.^{29 30} Overall, while access to general identification documents is relatively high, gender-affirming documentation remains a challenge for many MSM and TG individuals. Many MSM do not seek gender-affirming documentation per se, unless they identify as transgender or non-binary. The process is hindered by bureaucratic inefficiencies, lack of awareness and prolonged waiting periods, ultimately affecting their ability to access essential services. Addressing these systemic barriers is critical to ensuring that formal recognition translates into tangible benefits for these communities.

Despite policy advancements, the study reveals substantial disparities in legal recognition and documentation. Although nearly all MSM and TG individuals possessed an Aadhar card (99.8% and 98.1%, respectively), only 52.4% of TG individuals had a TG Card, highlighting gaps in access and awareness. Additionally, legal recognition through gender marker changes remains limited across key identification documents, with only 18.53% having updated voter ID cards, 11.7% ration cards and 4.38% passports. These systemic barriers persist due to bureaucratic inefficiencies, lack of awareness and lengthy processing times, creating significant hurdles for individuals seeking official recognition. As socio-economic advantages are not available to them in general or to physically disabled,¹⁹ they cannot participate in any political or socio-economic process requiring an officially endorsed identity. The low uptake of government initiatives such as Garima Greh further exacerbates these challenges, underscoring the need for targeted awareness campaigns and streamlined administrative processes to bridge the gap between policy and practice. As also noted in one study³¹ that such structural exclusions from legal and social recognition significantly hinder access to services, entitlements and participation in formal socio-economic or political processes, ultimately reinforcing marginalisation.

Economic vulnerability emerged as a key concern, with a significant proportion of respondents engaged in precarious employment. Only 1.7% of participants held government jobs, while 39.8% worked in the private sector, and many relied on unskilled labour (16.4%) or self-employment (7.5%). Traditional community-based earnings, including begging and toli badhayi practices, remain a significant source of income for some TG individuals and they rely on such practices due to educational disruptions and job market discrimination.³² Discrimination in mainstream employment often forces individuals into informal economic strategies, exacerbating financial instability. School dropout rates remain high due to bullying and gender-based harassment, severely limiting future opportunities. These experiences are often compounded by poor mental health outcomes and high substance use among transgender individuals, as emphasised in one systematic review.³³ Furthermore, communal regulations within Deras provide a sense of belonging but impose additional financial constraints. The study highlights the pressing need for expanded government support, including access to social welfare programmes such as pension schemes, skill development and housing assistance.

The study also identifies significant gaps in healthcare access, medical support and insurance coverage among MSM and TG individuals. Despite the existence of schemes like Ayushman TG Plus, which provides financial assistance for gender-affirming surgeries, uptake remains low, with only 107 out of 912 TG respondents using these services. The low insurance coverage among TG individuals (43.7%) compared with MSM (53.3%) further highlights the barriers to affordable healthcare. A strong association was observed between gender identity and the likelihood of undergoing gender-affirming medical procedures, with 93.1% of TG individuals having undergone hormonal therapy and 90.9% top surgery, compared with 55.5% of MSM who had not pursued any surgeries. However, financial constraints and bureaucratic challenges continue to hinder access to these essential medical interventions, reinforcing the urgent need for improved healthcare accessibility and financial support mechanisms. This finding is supported by the research stating the poor availability of gender-affirming surgeries in the country, especially in government hospitals and lack of expertise in this field of existing surgeons.¹³ Poor health literacy, discriminatory attitudes among healthcare providers and the absence of standardised treatment protocols have been identified as major barriers to healthcare access.³⁴ In rural areas, additional factors such as lack of awareness, fear of breaches in confidentiality and inadequate outreach efforts further discourage MSM from seeking HIV-related and general health services.³⁵

Findings on STI testing and treatment rates reveal concerning trends in healthcare access and adherence. While 51.3% of respondents underwent HIV testing, 16% tested positive, yet 15% of those diagnosed did not seek treatment. Similarly, despite a high syphilis positivity rate, nearly 45% of those diagnosed remained untreated. The treatment gap for hepatitis B and C was even more pronounced, with more than half of those diagnosed not receiving care. These statistics indicate persistent structural barriers such as stigma, fear and inadequate healthcare infrastructure, preventing individuals from seeking necessary medical support. Moreover, vaccination rates were notably low, with only 3.9% of respondents having received the HPV vaccine and 23.8% covered for hepatitis B, reflecting a critical gap in preventive healthcare awareness and accessibility.

Social support systems, including family, friends and community networks, play an essential role in the well-being of MSM and TG individuals. Even though the situation is slowly changing, transgender people in India are misunderstood by their own family members and risk facing violence from them. They continue to face stigma and discrimination across different domains including healthcare settings and the workplace.⁵ However, family acceptance remains limited, with only 15.9% of participants disclosing their gender identity to female relatives and an even lower 11.2% to male family members. As a result, peer networks, friendships and romantic partners often serve as primary sources of emotional and psychological support. While the Dera system offers structured communal support, it also imposes restrictions that may limit personal autonomy and economic opportunities. Community structures such as deras or gharanas serve as socio-cultural anchors for many TG individuals, offering belonging but also imposing rigid hierarchies. The dera system involves strong social regulation, where individuals require permission from gurus to seek healthcare or move outside.^{36 37} Stigma and discrimination remain pervasive, affecting access to housing, employment and social inclusion. Many participants reported experiences of derogatory language, social exclusion and difficulties securing rental accommodations, reinforcing the urgent need for anti-discrimination policies and inclusive social programmes. The urgent need was emphasised³⁷ to broaden the discourse on trans-inclusive healthcare beyond HIV to encompass comprehensive, routine care that addresses the broader health burden in the community.

Policy and practice implications

The findings highlight the need for coordinated structural responses that move beyond symbolic legal recognition. Mandatory gender-sensitivity and anti-stigma training for healthcare providers should be institutionalised across public and private facilities. Standardised non-discriminatory clinical documentation systems, inclusive intake forms and confidentiality safeguards are necessary to improve trust and service uptake. Administrative pathways for identity-document correction and TG certification should be simplified through time-bound digital systems with grievance redressal mechanisms. Community-led peer navigator models may improve enrolment in insurance schemes, vaccination uptake, STI treatment adherence and linkage to welfare services. In addition, livelihood interventions such as reservations, anti-discrimination employment protections, skill-development programmes and housing support are required to reduce long-term socioeconomic vulnerability among TG populations.

However, interpretation of documentation-related findings should consider subsequent policy changes introduced in March 2026, which may influence current administrative pathways for transgender identity recognition and service access.

Strengths and limitations

This study has notable strengths, including its multicentric design across 14 states, large sample of over 2200 participants and the integration of both quantitative and qualitative methods to capture the lived realities of TG and MSM populations. However, several limitations must be acknowledged. First, the cross-sectional design limits causal inference. Second, recruitment relied partly on community networks and snowballing, which may have excluded those less connected to community organisations. Third, sensitive issues such as sexual behaviour, HIV status and stigma were self-reported, raising the possibility of social desirability or recall bias. The focus on TG and MSM populations means findings may not generalise to other high-risk groups such as female sex workers or injecting drug users. Finally, while the survey covered diverse regions, qualitative insights were drawn from only two states, which may not capture the full range of experiences across India.

Conclusion

This multi-centric mixed-methods study highlights a persistent gap between progressive legal reforms and the lived realities of TG and MSM populations in India. Despite advances in formal recognition, substantial barriers continue in identity documentation, equitable healthcare access, uptake of welfare entitlements, dignified employment and protection from stigma and discrimination.

Addressing these inequities requires an integrated response that combines stigma-sensitive and inclusive health systems, simplified and accountable administrative processes, enforceable anti-discrimination safeguards and community-led investments in education, livelihood, housing and psychosocial support. Future efforts should also evaluate the impact of trans-inclusive interventions, expand access to gender-affirming care and strengthen scalable social protection mechanisms. Advancing these priorities will contribute directly to Sustainable Development Goals 3 (good health and well-being) and Sustainable Development Goals 10 (reduced inequalities), while ensuring dignity, opportunity and social justice for TG and MSM populations in India.

Data availability statement

Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available.