Mental Health of Transgender and Gender Diverse Persons in India: A Scoping Review of Literature Since Legal Recognition of Self-Affirmed Gender Identity, 2014-2024

Abstract

Purpose

India’s 2014 Supreme Court ruling in National Legal Services Authority v Union of India affirmed transgender and gender diverse (TGD) persons as equal citizens with a right to self-identified gender. This scoping review (2014–2024) sought to map TGD mental health research in India, characterized study details and themes, and identified gaps to guide future research and interventions.

Methods

Following Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we conducted a systematic search of peer-reviewed literature (PubMed, PsycINFO, Web of Science, Google Scholar, specific journal search, hand search) and grey literature (Google Scholar, websites of LGBTQ organizations, and digital thesis repositories Shodh Ganga and Shodh Gangotri). All publications between April 2014 and December 2024 focused on mental health of the Indian transgender population were included.

Results

From 246 initial sources, 124 were included in the review. The reviewed studies described prevalence rates of common mental disorders, transgender-specific psychosocial stressors, positive psychology variables, role of mental health professionals, mental health interventions and guidelines, forced gender “correction” practices, mental health impact of gender-affirming surgeries, links between sexual health and mental health, and experiences during the COVID-19 pandemic.

Conclusions

This review demonstrates substantial mental health needs among TGD communities in India but a narrow, uneven evidence base. Several articles revealed researcher misconceptions indicating ethical and epistemic harm. Priority next steps are adequately powered, intersectional longitudinal studies and rigorously evaluated, community-partnered interventions (including family support and mental health professional training) to advance gender-affirming, evidence-based care.

Introduction

The rights of transgender and gender diverse (TGD) persons – individuals whose gender identity and/or expression differs from the sex assigned to them at birth – have been receiving increasing attention in India over the last decade. The Supreme Court of India passed a landmark judgement, popularly known as the National Legal Services Authority (NALSA) judgement,¹ on April 15, 2014, asserting that TGD persons are equal citizens of the country, affirming their right to self-identification, and directing central and state governments to ensure discrimination-free access to healthcare, education, and employment. Since this decision, India has introduced several legal and policy developments to empower the TGD communities.

Reviews of research enable the identification of health disparities among TGD persons and help synthesize policy recommendations.² In the past decade, a few review articles have examined lesbian, gay, bisexual, transgender, and queer (LGBTQ) health,^3,4 and two have focused exclusively on transgender persons.^5,6 However, none has addressed mental health as its primary focus. Two reviews that examined mental health included the entire spectrum of LGBTQ populations, not focusing primarily on TGD persons.^7,8

In those reviews, a broad range of mental health issues was not described in depth. These include clinical variables such as prevalence of different mental and substance use disorders, suicide, trans-specific psychosocial stressors, the relationship between gender dysphoria and mental health, coping, resilience, well-being, the role of gender-affirming interventions in enhancing mental health, counselling and mental health interventions with TGD persons, and TGD persons’ experiences with mental healthcare systems. The current scoping review aims to fill this gap.

The objectives of this review were to systematically map the characteristics of research studies on TGD persons’ mental health in India (e.g., topics covered, methodological approaches) and identify mental health outcomes and psychosocial factors documented after the NALSA judgment.¹ We aimed to inform evidence-based mental health interventions and policy development by identifying research gaps and opportunities.

Methods

We followed the scoping review methodology of the Joanna Briggs Institute (JBI)⁹ and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.¹⁰ The protocol for the scoping review was published on the Open Science Framework prior to commencing the review.¹¹ Deviations from the published protocol included the addition of a co-author, language edits to the title and research questions, and a change in the starting date for inclusion of articles (April 2014 instead of January 2014). Ethics committee approval was not required, as we analyzed previously published data and did not involve human participants.

Research questions

This scoping review addressed the following questions:

• (1)What are the characteristics of research studies on TGD persons’ mental health in India from 2014 to 2024?
• (2)What key research topics have been covered in this literature?
• (3)What are the gaps in the available evidence on TGD persons’ mental health in India?

We defined mental health broadly as ‘variables/concepts related to the continuum of mental wellbeing, psychosocial stressors and mental illness.’ We adapted the broad definition of TGD persons as used in the World Professional Association for Transgender Health (WPATH) guidelines,¹² which includes anyone who identifies as transgender, including but not limited to trans men, trans women, gender non-conforming, non-binary, genderqueer identities, as well as indigenous identities such as hijra, kinnar, thirunangai, shiv-shaktis, and jogappa/jogta.

Eligibility criteria

Criteria for inclusion and exclusion of records in the review are summarized in Table 1. Duplicate records were eliminated before screening. Two reviewers independently screened titles and abstracts, decided on inclusion/exclusion, and resolved any conflicts through discussion.

Table 1. Criteria for inclusion and exclusion of articles in the review.

Category	Inclusion criteria	Exclusion criteria
Population	Records specifically about transgender persons in India	Articles that did not report data on, or discuss concerns separately and specifically for transgender participants
Content	Records discussing mental health	Records that do not report mental health related data/ do not specifically include description of mental health variables
Context/ setting	Records about the Indian transgender population	Records that do not include India specific data, or enumerate on India specific challenges
Publication timeframe	Records published between April 2014 and December 2024	Records published before 1st April 2014 and after 31st December, 2024
Publication types	Interdisciplinary studies from psychology, psychiatry, public health, policy, social work and social sciences, if they focused on mental health of transgender persons Peer-reviewed journal articles (including quantitative, qualitative and mixed methods original research studies, case reports, theoretical/conceptual articles, reviews, commentaries, and viewpoints) Academic books and book chapters Grey literature, specifically research reports from non-governmental or governmental organizations working with TGD individuals Doctoral research theses Articles published in English	Conference proceedings Non-academic records such as news articles and organizational annual reports Records published in languages other than English Records not available in full text

Search strategy

For peer-reviewed literature sources, we searched the academic databases PubMed, PsycINFO, and Web of Science, and the academic search engine Google Scholar, using combinations of search terms (see Table 2). From Google Scholar, we included peer-reviewed journal articles, books or book chapters from reputed publishers, and reports from academic and LGBTQ+ organizations. We also scanned the online contents of six prominent Indian and international journals focused on either mental health or LGBTQ populations to cross-check if any studies on TGD persons’ mental health had been missed. These included: Indian Journal of Psychiatry, Indian Journal of Clinical Psychology, Indian Journal of Social Work, Indian Journal of Social Psychiatry, Journal of Homosexuality, and International Journal of Transgender Health. Reference lists in these articles were used to identify other relevant articles.

Table 2. Search terms for literature review.

Concept	Transgender	Mental health
Search words India AND	Transgender, gender minorities, gender non-conforming, gender diverse, TGNC, TGD, transwomen, transmen, trans women, trans men, non-binary, genderqueer, genderfluid, agender, hijra, kinnar, transmasculine, transfeminine, gender dysphoria, GID, gender incongruence, SRS, gender affirmative therapy, gender affirmative surgery AND	Mental health, mental illness, wellbeing, mental distress, psychopathology, psychiatry, psychology, psychosocial, mental healthcare, therapy, counselling, resilience, coping, depression, anxiety, suicidality, self-harm, self-injury, substance abuse, neurodivergence, schizophrenia, psychosis, quality of life, OCD, body image, body dysmorphia, psychological tests, DSM

We used the same search terms when accessing grey literature via Google Scholar and two digital thesis repositories in India for doctoral research named Shodh Ganga and Shodh Gangotri. We also manually scanned websites of prominent LGBTQ organizations in India. These included: Government of India’s National Portal for Transgender Persons, Association for Transgender Health in India, Humsafar Trust, Orinam, Tweet India, Naz Foundation, Nazariya Foundation, Creating Resources for Empowerment in Action, Talking About Reproductive and Sexual Health Issues, Mariwala Health Initiative, Sappho For Equality, Our Health Matters, Solidarity and Action Against the Human Immunodeficiency Viruses (HIV) Infection in India, and Asia Pacific Transgender Network. The search was undertaken from January 1, 2025, to January 31, 2025.

Data charting, collating and summarizing

Google Dropbox was used for article storage and management, Google Sheets were used for data extraction, and Google Docs were used for collaborative manuscript preparation. A standardized data extraction form was used, in line with the JBI Population, Concept and Context Framework.⁹ One reviewer abstracted data from all the selected articles onto the sheet. A second reviewer checked the extracted data for accuracy. Narrative synthesis was used to summarize qualitative and quantitative findings.¹³

Results

Study characteristics

Figure 1 presents the outcomes of the stagewise article selection process. A total of 246 records were identified, of which 124 were selected.^14–137 On average, there were 11 articles published per year. There were 73 primary research sources (including peer-reviewed articles, theses, reports, and one book chapter).^{14–33, 40–45, 49,50, 52–63, 65–72, 74–82, 100–102, 108, 110, 122,123, 125, 127–129, 131–133, 136,137}

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta Analysis Flowchart for record identification and selection ¹⁰.

Methods used

Out of 73 research studies, 44 (60.27%) used quantitative methods,^{14,15, 17–19, 21–29, 31–33, 41–45, 49–50, 53, 58–60, 65–67, 69–71, 74, 77–80, 100–102, 122, 127} 21 (28.77%) used qualitative methods,^{16, 52, 54–57, 61, 63, 72, 75, 82, 110, 123, 125, 128,129, 131–133, 136–137} and 8 (10.96%) used mixed methods.^{20,30,40,62,68,76,81,108} Primary research consisted of thirty-eight cross-sectional surveys or observational studies, five descriptive studies on hospital-based casework, eight case-control or comparative studies, one intervention study, and twenty-nine studies using qualitative methodologies (focus group discussions, interviews, and discourse analyses).

Study sites

Figure 2 describes the geographical location/state where the primary research studies (n=73) were conducted. Most studies have been conducted in five states (Maharashtra, Karnataka, Tamil Nadu, West Bengal, and Delhi) of India, with several states having no representation in research on TGD mental health. Of the 40 studies that specified participants’ urban/rural location, 29 studies had urban representation,^{14,16,17, 27,28,30,31,33,40,42,45,49,52,55,56,58, 67,68, 70,72,75,78, 82,100–102,127,128,132} one had only rural representation,¹⁸ and 10 had both urban and rural representation.^{15,20,25,29,32,44,61,71,77,81}

Figure 2. State-wise distribution of primary research studies.

Funding

We also analyzed funding details for all journal articles and reports (N=104), and found that 27 (25.96%) received financial support,^{16, 21, 25, 26, 31, 38,39, 49, 55, 58, 63, 66,67, 72, 82, 102, 108, 110,111, 125–128, 130, 133, 136,137} 43 (41.35%) reported that they did not receive financial support, ^{7, 19, 22–24, 27–29, 32, 35,36, 44, 50–52, 62, 65, 80, 84–88, 90, 92, 94–96 100,101, 104, 107, 114–117, 119–122, 124, 131, 134} and 34 (32.69%) did not specify funding details.^{18, 33,34, 40,41, 43, 45, 47, 53,54, 56, 59, 64, 70,71, 73,74, 78, 83, 89, 91, 93, 97–99, 103, 105,106, 109, 113, 123, 129, 132, 135} Most studies had funding from overseas, and the Indian Council for Medical Research, a key government funder for health research, was reported as a funder in only three of the studies included in this review.^49,66,127

Participant characteristics

There were 69 studies that included TGD participants,^{14–33, 40–45, 49,50, 52–63, 65–72, 74–82, 100–102, 108, 122,123, 127–129, 131–133} and five included other key informants^{110, 123, 125, 136,137} (one had both).¹²³ Key informants included medical practitioners, mental health professionals, feminist researchers, LGBTQ activists, lawyers, journalists, and transgender welfare board members. Of the primary research studies reporting data on TGD participants (n=69), 7 had participants from hospitals^{23, 24, 33, 65, 100–102} and 62 had participants recruited from TGD communities or agencies.^{14–22, 25–32, 40–45, 49, 50, 52–63, 66–72, 74–82, 108, 122, 123, 127–129, 131–133} 6 studies compared TGD and cisgender participants on varied variables,^{15, 43, 45, 70, 79, 100} and 4 included TGD participants along with LGBQ persons.^{58, 66, 82, 122}

Among all transgender identities, indigenous transgender identities (hijra, kinnar, jogta) were the most represented group (53 studies), 13 studies included trans women or trans feminine participants who did not subscribe to indigenous identities, 19 studies included trans men, including Thirunambi (a local term in Tamil Nadu for trans men), and only five included non-binary trans persons.

Listing the exact number of participants across age groups is difficult because of different age ranges and the varied ways age data are presented (percentages, means, ranges). Most research focused on young adults and middle-aged adults, and covering the 18 to 45-year-old demographic. Concerns about children and adolescents and older transgender participants were mentioned in some commentaries, but these groups had less representation in the primary data.

Focus areas and findings

Topics covered in the 124 articles under review were grouped into nine major thematic areas. We have described the thematic areas below, and have summarized some of the key observations reported within each of these thematic areas.

Prevalence of mental health concerns

Table 3 describes prevalence rates of mental health concerns reported in 20 original research articles.^14–33 Overall focus of these studies was on mental illnesses such as anxiety, depression, and other common mental disorders, substance use/abuse, and suicidality. In addition, commentaries³⁴ and case studies^35,36 reported that TGD individuals may be at higher risk for varied mental illnesses, and a book chapter³⁷ highlighted psychiatric comorbidities in children and adolescents with gender dysphoria. A scoping review of gender differences in suicides in India underscored the paucity of Indian research on suicides among TGD persons.³⁸ This is a significant observation given the high worldwide suicide rates (32% to 50%) among TGD individuals.³⁹

Table 3. Prevalence of mental health concerns among transgender participants in research studies.

Authors, publication year	Research method and assessment tool	Sample size, participant identity	Location	Findings
Elancheliyan, 201614	Thesis, community-based descriptive survey using Depression Anxiety Stress Scale 21	240 N, Aravani	Coimbatore	52.1% sometimes felt negative feelings 27% feeling disturbed always
Garg, 2021 15	Thesis, case comparison quantitative study, Depression Anxiety Stress Scale	50 N, transgender	Ambala and Panchkula-Haryana, Chandigarh, Mohali, Patiala-Punjab	42% moderate depression, 38.0% severe depression, 8.0% extremely severe depression. 46.0% moderate anxiety, 32.0% severe anxiety, 14.0% extremely severe anxiety
Gomes de Jesus et al, 202016	Journal article, exploratory community-based mixed methods study, World Health Organization World Mental Health-Composite International Diagnostic Interview+ Suicidality subscale	23 N, transgender women	Hyderabad, Telangana	61% lifetime suicidal thoughts 9% suicidal thoughts in last year 61% suicidal plan lifetime 13% suicidal plan in last year 52% lifetime suicidal attempt 9% suicidal attempt in last year
Halli et al, 202117	Journal article, community-based study, World Health Organization Quality Of Life-Human Immunodeficiency Virus, Hamilton Anxiety Rating Scale, Beck Depression Inventory 2	282 N, transgender	Bengaluru, Karnataka	32.5% high depression 42.3% had suicidal ideation/attempt 45.4% high anxiety
Hani and Pandiyan, 202218	Journal article, hospital-based observational survey, Mini International Neuro-psychiatric Interview plus scale+ history+ Mental Status Examination	60 N, met gender dysphoria criteria	Bengaluru, Karnataka	18.3% adjustment disorder 5% anxiety disorder 3.3% insomnia 76.6% had psychiatric morbidity 26.7% substance-use disorder 16.7% depressive disorder 6.7% dysthymia
Hebbar and Singh, 201719	Journal article, cross-sectional hospital-based observational survey, Mini International Neuro-psychiatric Interview plus scale+ history+ Mental Status Examination	32N, met gender dysphoria criteria	Imphal, Manipur	62.5% alcohol abuse/dependence 46.8% drug abuse/dependence 37.5% generalized anxiety disorder 31.2% depressive disorder 18.7% dysthymia 6.2% panic disorder 25% social phobia 9.4% agoraphobia 9.4% post-traumatic stress disorder 31.2% past suicidal attempts 41.2% current suicidal risk
Joseph, 202120	Thesis, mixed methods, survey questions	129 N, transgender	Dindigul, Tamil Nadu	63.6% Alcohol consumption 20.9% smoking habit 60.5 lifetime suicidal ideation 34.6 % constant suicidal thoughts 89.9 % lifetime suicidal attempt
Joshi et al, 2022 21	Journal article, descriptive community-based intervention study, Generalized Anxiety Disorder 7 +Patient Health Questionnaire 9+ Suicide Behaviours Questionnaire Revised	33 N, transgender women	Mysuru, Karnataka	45.4% and 39.4% moderate and severe anxiety 30.3%, 30.3% and 24.2% moderate, moderately severe and severe depression 75.8 at risk for suicide
Madhavan et al22	Journal article, cross-sectional community-based descriptive survey, Fagerstorm Addiction scale+ Alcohol Use Disorders Identification Test scale	200 N, transgender	Puducherry	43.5% tobacco users, 11.7% out of smokers and 29.1% out of smokeless tobacco users- high nicotine dependence 64.5% Current alcohol users, 45% had hazardous use, 21% showed harmful use, 19.3% possible dependence
Majumder et al, 202023	Journal article, hospital-based observational study, evaluation by psychiatrist	120 N, met gender dysphoria criteria	Kolkata, West Bengal	3.75% had depression/anxiety 55.4% substance addiction
Majumder et al, 202124	Journal article, hospital-based observational study, Transgender Health Questionnaire	120 N, met gender dysphoria criteria	Kolkata, West Bengal	55.4% substance addiction 17.5% had suicidal thoughts 25.8% had thoughts and attempts 18.3% had single attempts, 2.5, 1.7, 2.5 had 2, 3, 4 attempts, .83% lethal attempt, 20% non-lethal. 0.8% died suicide.
Mitra and Ghoshal, 202025	Report, community-based survey	197 N, transgender persons assigned female at birth	Pan India	30.9% reported affected mental health sometimes, 23.6% expressed that it happens very often while 13.6% said that their mental health gets affected all the time. 51.3% depression 57.2% feeling anxious 21.9% have or have had suicidal thoughts and tendencies 17.6% drug and alcohol abuse and 14.4% others
Our Health Matters Team, 202326	Report, cross sectional community-based survey	377 N, Transmen	Across 22 states and union territories	34% moderate or severe depression 45% had moderate or severe anxiety 44% lifetime suicidal ideation 36% lifetime suicidal attempt
Sartaj et al, 202027	Journal article, cross sectional community-based survey, Primary Care Evaluation of Mental Disorders-Patient Health Questionnaire, World Health Organization-Alcohol, Smoking and Substance Involvement Screening Test	50 N, Hijra	New Delhi	38% at least one mental illness 26% alcohol abuse 8% anxiety disorders 8% depressive disorders 6% somatoform disorders Less than 1% bulimic disorder 64% lifetime use of alcohol, while 54% tobacco use, 16% cannabis use. For tobacco, 26% in moderate-risk, 20% high-risk category. For alcohol, 16% and 14% moderate and high-risk
Sinha et al, 201728	Journal article, community-based cross-sectional epidemiological study	90 N, transgender	Kolkata, West Bengal	22.2% drug abuse in the past 1 year
Sucharitha et al, 202229	Journal article, community-based cross sectional analytical study	734 N, transgender	Chennai, Tamil Nadu	64.4% current use of tobacco 7.2% using more than two tobacco products in a day 28% in the habit of using tobacco products within 5min of waking up 39.5% had a health issue because of tobacco use.
Sudha, 201530	Thesis, cross-sectional descriptive community-based survey, General Health Questionnaire 12	299 N, Aravani	Chennai, Tamil Nadu	39% severe psychopathology
Thompson et al, 201931	Journal article, cross-sectional community-based survey, Hamilton Anxiety Scale+ Beck Depression Inventory 2	282 N, hijra and kothi	Karnataka	42.4% constantly worrying 33.5% always saddened 18.5% always feeling life is not worth living Mean depression and anxiety score-8.5
Virupaksha and Muralidhar, 201832	Journal article, community-based survey	60 N, transgender	Karnataka	13.3% alcohol abuse/use 10.0% tobacco use/abuse 50% both alcohol and tobacco use/abuse
Yadav et al, 202133	Journal article, hospital-based descriptive study, evaluation by psychiatrist	20 N, met Gender Dysphoria criteria	New Delhi	20% psychiatric illness 10% depression 5% dysthymic disorder 5 % anxiety symptoms subclinical

Beyond mental illnesses, sources also reported variables of psychological distress, or perceived stress, and found in most cases that about 50% or more of TGD participants showed significant distress on relevant scales such as the Robertson Emotional Distress scale, Perceived Stress Scale, Kessler’s Psychological Distress Scale, or on survey questions^{15, 40–42} with scores higher than those of cisgender participants.^{15, 43} One study found low self-concept and higher alexithymia (e.g., difficulties processing or describing one’s emotions) among hijra-identified persons.⁴⁴ Two laboratory studies found higher scores on biomarkers of allostatic load, such as higher salivary cortisol and oxidating stress, for TGD persons compared to cisgender participants;^{43, 45} these biomarkers explain the relationship between stress and its impact on the immune and cardiovascular systems.

TGD-specific psychosocial stressors

Commentaries, reviews and book chapters described varied psychosocial factors relevant to lives of TGD persons across the life span,^{34, 39, 46–48} which can be divided into the categories-systemic and interpersonal stressors, family and social support, and risk and protective factors for mental illness.

Systemic and interpersonal stressors

Quantitative studies reported high levels of stigma and discrimination, including physical and sexual violence,^{27, 28, 31, 42, 49} with one study finding that 30% of participants had experienced at least one victimization event in the past 6 months, and that poly-victimization was associated with higher odds of reporting depressive symptoms.⁵⁰ Perceived and enacted transgender stigma were correlated with or predictive of depression, anxiety and substance abuse in some studies,^{15, 49, 51} but not in one study. ³¹ Qualitative and mixed methods studies further elaborated limited educational and occupational opportunities, discrimination in healthcare, and transgender participants’ felt and enacted stigma, describing structural stigma and interpersonal stigma – rejection, exploitation and violence perpetrated by family members, peers, intimate partners, and conflicts within hijra communities.^{16, 40, 52–54} Some researchers used minority stress theory to describe links between transprejudice and lack of gender affirmation, experiences of discrimination, and mental health consequences.^49,55,56 One study described how shaming of trans men in collectivistic cultures contributes to seeing transness as ‘abjection’ (repulsion) and helplessness.⁵⁷ Some studies highlighted the role of other macro-level factors that influence mental health outcomes, such as water insecurity,⁵⁸ financial exclusion,⁵⁹ and permanent versus migrant residency status.⁶⁰ One thesis used intersectional frameworks to illustrate that gender, caste, color, socio-economic class, and religion, together form heightened vulnerability that affects mental health.⁶¹

A study conducted in Gujarat⁶² reported that, after the NALSA judgement,¹ TGD participants perceived increased awareness about their community, greater support by non-governmental organizations, and improved educational and job opportunities. However, they also perceived higher rates of family rejection and abandonment, societal discrimination, abuse from law enforcement, and a worsened social image.⁶²

Family and social support

Qualitative studies described experiencing varied familial reactions upon disclosure of identities,^{55, 63} and commentaries have highlighted the role of peer support, especially among indigenous TGD communities.⁶⁴ Studies described mixed findings about whether social support and resilient coping can protect against the impact of stigma on mental health.^{49, 65,66}

Risk and protective factors for mental illness

Several quantitative studies reported findings about the relation between varied demographic variables and depression, anxiety, substance abuse, and suicidality.^{24, 26, 29, 51, 53, 67,68} However, findings about demographic variables and their association with mental health outcomes, or the direction of such associations, were inconsistent.

Positive psychology variables

The most researched positive psychology variables were resilience, coping and social support, ^{20, 30, 32, 55, 68–76} as well as quality of life and life satisfaction.^{14, 23, 27, 30, 67,68, 77–80} Researchers also studied self-esteem and empowerment,^{27, 44, 74, 79} emotional well-being, cognitive emotion regulation and self-consciousness,⁸¹ emotional intelligence,⁷⁷ spiritual beliefs,⁷⁷ positive sociogenic needs satisfaction,⁷⁶ empathy,¹⁵ body image and appearance satisfaction^{15, 79} and intimacy.⁸²

Role of mental health professionals (MHPs)

Literature on the role of MHPs can be broadly classified into three areas: diagnosis and assessment of gender dysphoria, management of gender dysphoria, and experiences of TGD persons with mental health services.

Diagnosis and assessment of gender dysphoria (GD)/”gender identity disorder (GID)” Several reviews, chapters, viewpoints, commentaries, editorials, and case studies, discussed challenges related to the diagnosis of gender dysphoria,^{37, 83–93} such as differential diagnosis, diagnosis in children and adolescents, ethical issues, and the impact of socio-cultural factors. Several case studies described challenges in differential diagnosis by reporting clients who showed gender dysphoria secondary to delusions,⁹⁴ manic episodes,^95,96 and obsessive-compulsive disorder that included ruminations with gender dysphoric themes.⁹⁷

Articles explored procedures used to assess gender dysphoria and challenges related to the same, such as the absence of transgender-specific norms for assessments and the need for stratified norms.⁹⁸ Some articles used specific assessment tools, such as the Rorschach test for assessing the phenomenological experience of gender dysphoria,⁹⁹ and the Minnesota Multiphasic Personality Inventory (MMPI) and MMPI-2 tests to profile individuals with gender dysphoria.^100,101

A multi-country study that included participants from India suggested that data supported the International Classification of Diseases-11 position that gender dysphoria is not a mental disorder, and argued that the additional diagnostic requirements of distress and/or dysfunction in Diagnostic and Statistical Manual-5, reduced its predictive power.¹⁰²

Management of gender dysphoria (GD)

Case studies described clients with GD and management approaches. These approaches focused primarily on alleviating symptoms of depression accompanying GD,¹⁰³ and in one instance, dealing with morbid jealousy in a transgender client.¹⁰⁴ In addition, case studies with adolescents,^105–107 and reviews, commentaries, and editorials^{84, 86, 88} highlighted clinical and ethical issues in the management of clients with GD, particularly minors, and described the need for, and importance of, gender-affirming treatment options.

Experiences of transgender persons with mental health services

A few studies reported knowledge about mental health services,³⁰ attitudes (e.g., reluctance) towards visiting MHPs,¹⁶ and help-seeking behaviours^{25, 30, 108} within TGD communities. The proportion of study participants who accessed mental health services ranged from 53.6% to 67.3% in these studies, with a majority of participants reporting positive experiences with MHPs and a much smaller percentage reporting negative experiences.^{25, 108}

Mental health interventions and guidelines

Six guidelines and/or manuals highlighted good practice principles for gender-affirming mental health care for TGD individuals.^109–114 In addition, some researchers have explored trans-affirming concepts and practices within therapeutic approaches for TGD persons. These included: hijra-inclusive history taking,¹¹⁵ reflective models and experiential learning in clinical practice,¹¹⁶ “queering” of therapeutic concepts (i.e., questioning cis-heteronormative therapeutic ideas),¹¹⁷ and intersectoral collaboration across law, social work, health services, and public policies as necessary for community mental health care.⁶⁴

Some researchers proposed specific therapeutic models for use with TGD individuals, such as the SPACE model (Sensitize, Positive parenting, Acceptance, Child-centric approach, Empower the child) as a framework for facilitating healthy parenting of gender-diverse individuals,¹¹⁸ an attachment-based family intervention as an adjunct to individual therapy approaches,¹¹⁹ and narrative therapy techniques for gender-diverse children and adolescents.^120,121 Only one pre-post intervention study described positive feedback from TGD participants for “Meditation on Twin Hearts,” a module based on Pranic healing (energy-based therapy) and yoga.²¹

Forced gender identity correction and conversion practices

We found five articles that explored gender or sexual orientation correction efforts and identified a range of practices used for gender identity correction by religious leaders, homeopathic and ayurvedic practitioners, medical and mental health professionals, and sex therapists. ^122–126 These articles highlighted the negative mental health impact of these practices on TGD persons and suggested that the motivation for gender identity correction was rooted in familial discomfort with gender non-conformity and protection of familial honor, ^122–125 as well as “pathologizing of transgenderedness”¹²⁵ by some medical professionals, and highlighted the lack of punitive protocols against conversion practices in the Indian mental health systems.¹²⁶ Only recently, in 2022, the National Medical Commission issued an advisory categorizing “conversion therapy” as “professional misconduct.”¹³⁸

Mental health impact of gender-affirming treatments

Researchers have described the mental health impact of varied forms of gender-affirming treatments, including the Nirvan procedure (the traditional method of removing male external genitalia by an experienced hijra-identified person called Dai maa) (see Table 4). ¹³⁹

Table 4. Impact of gender affirming treatments on mental health.

Author, year of publication	Publication details	Findings
Elancheliyan, 2016 14	Thesis, quantitative study with Aravanis (N=240, Tamil Nadu)	Significantly different scores on all four domains of quality of life, and differences in depression, anxiety and stress scores, among those who had and hadn’t undergone gender affirming surgery
Joesph, 202120	Thesis, mixed methods study with transgender individuals (n=129, Tamil Nadu)	68% of respondents suggested that “society has a good opinion about the transgender after their operation;” there was no difference found in the quality of community life or perceived social support of transgenders who have and who haven’t undergone gender affirming surgery
Sudha, 201530	Thesis, mixed methods study with Aravanis (n=299, Chennai)	No significant differences in transgender identity stigma for Ackwa and Nirvan Aravanis (those who had not undergone the traditional castration procedure and those who had) and but there was significant better quality of life post Nirvan.
Srivastava et al, 202153	Journal article, community based cross sectional survey (N=1366, 3 states)	74.2% had undergone gender affirming surgery and undergoing transitioning was reported with higher odds of depressive symptoms.
Srivastava et al, 202056	Journal article, qualitative exploratory study	Experiences of transitioning among hijra community members described using the paradigm of the minority stress theory. Individuals wanted gender affirming surgery as a way of gender affirmation, but other factors, such as engagement in sex work and distribution of financial resources within the gharana, also influenced the decision. Some participants reported fear of harassment during the transitioning process, along with anxieties regarding the process itself and access to resources, and communal support during and after transitioning was seen as crucial.
Chandran, 202169	Thesis, quantitative study with transgender individuals (N=113, Kerala)	No significant difference in interpersonal support and coping for participants who had undergone gender affirming hormonal treatment and those who hadn’t, and between those who had undergone gender affirming surgery and who hadn’t.
Patki et al, 202474	Journal article, comparative study with 2 groups of transmen (those who hadn’t undergone gender affirming surgery and those who had, N=30)	Transmen who had undergone gender affirming surgery demonstrated significantly higher self-esteem and lower levels of depression, along with higher perceived support from friends.
Agarwal, 202383	Journal article, review of global studies	Quality of life, body image, and mental health of transgender people globally have all significantly improved following gender affirming surgery, although it may have minimal risks and problems

Sexual risk and mental health

Four original research articles highlighted the relationship between sexual and mental health.^{66, 72, 127, 128} Cross-sectional surveys found associations between victimization, sexual risk, frequent alcohol use, and depression, and explained results using Syndemics theory. ^66,127 A qualitative study with transgender women living with HIV found multiple intersecting stigmas (related to transgender identity, HIV, and sex work), and highlighted how lack of gender affirmation affects HIV care engagement. ¹²⁸ Another study described the relationship between stigma, violence and HIV vulnerability through micro-level mechanisms (intrapersonal factors – distress and low self-efficacy to challenge abuse, inter-personal factors – interpersonal violence), meso-level mechanisms (community norms), and macro-level mechanisms (police, health providers, context of sex work).⁷²

Transgender lives and COVID-9

We found seven articles (four qualitative studies, two case reports, and one viewpoint) that mentioned mental health concerns of TGD persons during the COVID-19 pandemic. ^{95, 129–134} They illustrated how financial difficulties, disrupted livelihoods, domestic violence, poor offline social support, and heightened challenges in mental health care access, amplified mental health concerns.^129–134 One case study described a TGD individual with COVID-19 infection experiencing a manic episode and gender dysphoria.⁹⁵

Discussion

The NALSA judgment¹ by the Supreme Court of India in 2014 is significant as it provided, for the first time, legal recognition to TGD-related gender identities in India (as a man, woman or “transgender” person). Prior to NALSA, the only state policy recognition of TGD persons occurred in the context of targeted HIV prevention by the National AIDS Control Program, which used the term “hijras/transgender people” (or the abbreviation “H/TG”) in its policy documents.¹⁴⁰ NALSA provided guidelines for gender identity recognition and reservations in education and employment, and suggested welfare and empowerment measures.¹ Although implementation barriers persist, and subsequent legislation (Transgender Persons [Protection of Rights] Act, 2019)¹⁴¹ has not upheld the spirit of the NALSA judgement, the judgment transformed discourse around transgender rights in India.¹⁴² Research on TGD health, including mental health, has risen steadily since the NALSA judgement.^3,5,6 Prior to this period, there was a paucity of research on transgender mental health and general health, and the available research was mostly centered on studies of HIV among Men having Sex with Men and transgender women.¹⁴⁰ The increase in research likely reflects multiple factors: greater visibility leading more queer and trans persons to access mental health services, expanded funding for mental health programs and research that might have been driven by legislative and policy discourse, and growing public attention to queer and TGD persons’ welfare.¹⁴⁰ Alongside the increase in volume, mental health discourse has shifted from pathologization to affirmation¹⁴⁰ – a trend this review confirms through the broader range of topics now covered beyond HIV risk.

As Table 3 indicates, a high burden of mental illness likely exists among TGD persons in India. This aligns with reviews from other Asian countries (e.g., China),¹⁴³ and global research.¹⁴⁴ However, small sample sizes, scattered research sites, and varied measurement scales, limit interpretations of population prevalence rates.

In addition, most prevalence studies focused only on depression, anxiety, suicidality, and substance abuse, leaving other mental health conditions – especially severe mental disorders (SMDs) – under-researched. This gap is notable because existing case studies emphasize differentiating primary GD from GD secondary to SMDs. ^94–97 One review claimed that co-morbidity of schizophrenia with GD/GID is high and both stem from abnormal brain development.¹³⁵ Some researchers suggest the need to differentiate between a “true GID” [sic]- correct GD diagnosis and “pseudo-GID” diagnosis which they claim to result from child sexual abuse or other mental illness.⁹³ Thus, despite the absence of primary research on SMD prevalence or co-occurring GD-SMD presentations, clinical/opinion-based mental health literature continues to draw erroneous connections between GD and SMD.

Trans-specific psychosocial stressors and risk/protective factors synthesized in this review are consistent with vulnerabilities reported in global systematic reviews.¹⁴⁵ Persistent stigma, violence and discrimination against TGD persons contribute to poor mental health. This underscores the need for gender sensitization programs across institutions (families, schools and universities, workplace, healthcare and public services), and tailored social and economic welfare schemes. Although the Transgender Persons (Protection of Rights) Act of 2019¹⁴¹ and its Rules (2020) include provisions against discrimination of TGD persons, proper implementation and access to substantive justice remain elusive for many.^140,146

Primary research on gender transition’s mental health impact for TGD persons remains insufficient (see Table 4). Inconsistent findings about mental health outcomes of gender-affirming procedures suggest the need for more in-depth, especially mixed methods, research. Few studies have examined the full range of gender-affirming procedures (including gender-affirming hormone therapy and surgeries) or the increased vulnerabilities TGD persons face during gender transition, barring one exception.⁵⁶

Studies in this review, particularly hospital-based research and case studies, used pathologizing language and misgendered TGD participants, recommending invasive genital examinations and laboratory investigations as part of GD assessment to determine suitability and fitness for gender-affirming treatments^{105, 107} and employing psychological measures for assessing GD such as intelligence, personality, and projective tests. Two articles included in our review documented this “gatekeeping” role,^136,137 with subsequent publications detailing these pathologizing practices.¹⁴⁶ They highlight that despite WPATH Standards of Care-8¹² stating a formal diagnosis of GD or Gender Incongruence is unnecessary to access gender-affirming treatments, local guidelines and practice in India still require assessment by an MHP for the same.¹⁴⁷

A commentary describing challenges in conducting systematic reviews on the TGD populations in India has noted a “perceptional error” wherein the heterogeneity of gender identities and expressions under the umbrella of ‘transgender’ are not adequately understood.² This heterogeneity was evident in our review: researchers frequently used indigenous gender identity labels (e.g., hijra, thirunangai) and Western umbrella terms (transgender, transgender woman, outdated terms like “male-to-female transgender”) interchangeably to describe study participants. This fluidity in the use of identity terminology raises concerns about whether categories reported across studies represent equivalent or distinct identity groups, complicating synthesis of findings and comparisons of health inequalities among subgroups. A particularly illustrative example is the identity category kothi. The term ‘kothi’ continues to function in several states in India (e.g., Tamil Nadu and Karnataka) as both an identity for same-sex-attracted feminine males and an identity for transfeminine persons, with some kothi-identified individuals being incorporated into the guru-chela hierarchies of hijra communities (gharanas). As a result, in research literature participants with kothi identity are categorized as men who have sex with men or transfeminine person, depending primarily on how individual authors conceptualized and framed their participants.³ This means, whether studies on kothi-identified persons appear in reviews of TGD health or men who have sex with men research depends entirely on how individual study authors categorized and framed their participants – a classification choice that introduces further ambiguity into systematic synthesis.

This terminological heterogeneity reflects the linguistic and social realities of contemporary India and is consistent with global recognition that transgender and gender diverse communities encompass diverse identities that exceed Western frameworks for understanding and naming experienced gender. In India, sex and gender are not conceptually or terminologically distinguished in most Indian languages, and the Western term “transgender” coexists alongside longstanding indigenous gender identities – identities such as hijra, thirunangai, and kothi that have no direct English translation and represent culturally specific gender experiences. Individuals may identify as hijra and transgender woman, or as thirunangai and transgender person, depending on context, community, and access to global transgender networks.

This diversity in use of identity terms arises from several factors: India’s 2014 NALSA ruling,¹ which used the terms “transgender” and “third gender” to recognize gender identity in English legal terminology; the Ministry of Social Justice and Empowerment’s 2014 Expert Committee report,¹⁴⁸ which introduced glossaries of both Western and indigenous gender terminology in policy documentation; the institutionalization of the term “H/TG” (hijras/transgender) by the National AIDS Control Organization for nearly two decades in HIV prevention programming; and increasing exposure to global transgender communities through digital media.

A significant gap within this landscape is the near-invisibility of trans masculine persons in both policy and research – whereas trans feminine persons and hijras receive specific attention in HIV interventions and research, transmasculine persons (who may identify as man, transgender man or trans man, or using indigenous terms like Thirunambi in Tamil Nadu) remain understudied and largely absent from national health and policy frameworks. Similarly, a binary notion of gender was pervasive in the language used in research, with only a very small percentage of research studies including non-binary TGD persons.

Gaps on current and culturally-competent TGD-related knowledge among researchers were evident, with some conflating gender identity and sexual identity⁹⁶ or confusing intersex variations with TGD identities.^52,85 Some made erroneous assumptions about the “causality” and “etiology” of being a TGD person.⁸⁵ Others used outdated, incorrect or pejorative words such as “eunuch,”³⁵ “transsexual,”^{35, 119} “transvestite,”⁷⁸ or “hermaphroditism,”⁵² or incorrect definitions for hijra-identified persons such as “individuals who have been born with incomplete sex organs of both sexes thereby making the individual incapable of sexual reproduction.”⁵²

Strengths and limitations

A key strength of our review is the inclusion of diverse sources, particularly the inclusion of grey literature, which provides contextual information often unavailable in peer-reviewed literature, and was recommended in a previous scoping review on LGBTQ health.³ This review has some limitations as well. First, because researchers’ inclusion criteria varied across studies and most reported aggregated findings, this review cannot identify mental health differences across specific transgender and gender diverse subgroups, nor can it examine how intersectional factors (sex work status, caste, HIV status) shape outcomes within subgroups.

In addition, TGD persons who may be assigned male at birth or female at birth, may show differences in mental health concerns, that are not adequately represented in this review. Similarly, most records included did not stratify participants based on their sexual orientation, which may be an additional variable that affects their relationships and marginalization therein. Future research would do well to explore the complex interplay of gender and sexual orientation to identify specific challenges faced by TGD persons.

Second, as is typical for scoping reviews, quality assessments are not mandatory;¹⁴⁹ however, we attempted to mitigate this issue by critically evaluating the claims made in light of the evidence presented, while acknowledging that articles and reports of varying methodological rigor were included. Our search was limited to English-language publications due to resource constraints, and English remains the primary language for academic and policy discourse in India.

Third, although this review captures research following the 2014 NALSA judgment, causal links between the judgment and research changes cannot be established. In addition, the limited volume of pre-2014 research precludes meaningful pre-post comparisons. Barring one thesis,⁶² no other studies have explicitly examined the legal-mental health interface. Some of these studies may have been conducted before 2014, and specific details about the exact date of execution of the research have not been provided in a majority of the studies.

Implications and future directions

TGD persons do not constitute a homogenous community. Given the diverse and complex nature of Indian society, multiple intersecting social identities or positions – including socioeconomic class, caste, religion, sexual orientation, and disability – profoundly shape access to resources, vulnerability and marginalization. Barring two studies in the present review,^61,128 an explicit intersectional analytic framework to examine mental health concerns of TGD persons with intersectional marginalized identities or positions (e.g., HIV-positive status, engagement in sex work, caste, class, religion, and disability) was not presented. Future research must move beyond documenting broad mental health inequalities toward identifying specific mechanisms through which intersecting oppressions operate, using theoretical frameworks such as intersectionality and gender minority stress models adapted to the Indian context. Longitudinal studies tracking mental health outcomes using a life-course approach across gender transition stages, stratified by intersectional marginalized positions, would enable identification of critical intervention points. More research is needed on diverse identities under the TGD umbrella from non-metropolitan and rural parts, underrepresented age groups (children and adolescents, older adults), and those with disabilities or from marginalized caste backgrounds and other minority statuses to generate locally relevant, contextual information for tailored mental health interventions.³

Given the central role of families in Indian society, future studies must systematically examine family members’ perspectives, attitudes, and needs. Critically, intervention research is needed to design and evaluate psychoeducational interventions for families, and culturally-adapted family therapy models. TGD persons do not lead solitary lives; research on intimate partner relationships, couple-specific stressors, parenting experiences and chosen families (e.g., hijra gharanas) would generate evidence to inform couple and family therapy adaptations. Further, although positive psychology constructs were explored in the articles included in this review, more research is needed on strengths-based research, with measurement of resilience, body satisfaction, gender euphoria, post-transition flourishing, and queer joy.

The review also highlighted researchers’ misconceptions and lack of clarity about diversity within TGD umbrella that have led to misrepresentation, thereby actually causing ethical harm to participants who should be protected under the “do no harm” principle. This raises ethical and epistemic challenges in TGD mental health research, with a ‘top-down, expert’ stance being perpetuated. More community-driven, participatory research models – in which TGD persons are involved across all stages of research – would be useful to enhance relevance and accountability.¹⁵⁰

The review also brought to the forefront knowledge gaps among MHPs, that lead to perpetuation of harm to their TGD clients. Systematic curriculum reform is urgently needed across medical, psychiatric, psychology, social work, and counseling training programs. Reforms must align with emerging Indian guidelines and international best practices (WPATH Standards of Care).¹² Implementation science research is needed to identify facilitators and barriers to integrating TGD-affirming mental health care into existing health systems, including feasible training models for MHPs and strategies to reduce structural stigma in healthcare settings. Research evaluating the effectiveness of MHP training interventions – using pre-post designs measuring knowledge, attitudes, clinical behaviors, and client-reported outcomes – is essential.

Conclusions

This scoping review systematically mapped the landscape of TGD mental health research in India post-NALSA (2014-2024), revealing areas of progress alongside critical substantive and methodological gaps. It documented high mental health burden, trans-specific psychosocial stressors, and systemic barriers to care, but most studies were concentrated in five metropolitan hubs, overrepresented specific indigenous transfeminine identities (e.g., hijras), and included very limited data on transmasculine and gender non-binary persons. Notably, researchers’ misrepresentation of TGD identities – conflating sexual orientation with gender identity and employing outdated terminology – perpetuated epistemic harm. Two urgent priorities emerge: first, adequately powered, longitudinal studies employing intersectional frameworks to identify mechanisms linking caste, class, and gender marginalization to mental health outcomes; second, rigorously evaluated intervention research – including family support programs, MHP training curricula, and community-based mental health models – developed through participatory approaches with TGD communities. Addressing these gaps requires sustained investment in community-engaged research infrastructure and in building researchers’ technical and cultural competence to conduct rigorous, ethically sensitive mental health research with TGD communities.

Data availability

The authors’ data extraction sheets are not publicly available but can be made available on request.