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International Journal of Transgender Health logoLink to International Journal of Transgender Health
. 2021 Jul 15;24(1):49–58. doi: 10.1080/26895269.2021.1939220

Sex work, gender transition, family rejection and depressive symptoms among transgender women in India

Ankur Srivastava a,✉, Jordan P Davis b, Prachi Patel c, Elkan E Daniel d, Shama Karkal d, Eric Rice e
PMCID: PMC9879189  PMID: 36713140

Abstract

Background: Transgender women in India face unique stressors associated with minority experiences, such as experiences of gender transition and participation in sex work. However, the relationship between sex work, transition and mental health outcomes is understudied in this population.

Aims: This article aims to examine the association between gender transition status, sex work, family rejection and depressive symptoms among transgender women in India.

Methods: Data comes from a cross-sectional epidemiological study with transgender women from three states of India; Karnataka, Maharashtra and Tamil Nadu (N = 1366). Multivariate regressions were used to examine the association between sex work status and gender transition and how gender transition, and sex work are associated with depressive symptoms.

Results: 70% of the sample reported being in sex work and over 82% endorsed taking some form of gender transition service. Those who reported being in sex work were significantly more likely to have undergone breast augmentation, hormonal therapy and gender affirming surgery. Those who reported ever being married were less likely to report gender affirming surgery and were more likely to report hormonal therapy. Additionally, being in sex work, undergoing transition, leaving home because of sexual orientation, and being married were significantly associated with depressive symptoms.

Discussion: Community-led organizations and other service agencies must incorporate intersectional experiences and identities, including sex work and gender transition, in their programs to further social and health justice for transgender women in India. Policy and programmatic implications are discussed.

Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1939220

Keywords: Gender transition, India, mental health, sex work, transgender women

India has a strong historical presence of transgender women, who present a diverse group based on subcultures, identities, practices, norms and geographic locations (Kalra, 2012; Singh et al., 2014). Hijras are sometimes considered a pan-Indian identity, however there are many other sub-groups of transgender women that are rooted in cultural and linguistic specificities (Chakrapani, 2010; Reddy, 2006). Regardless of specific identities, the socio-economic marginalization due to transgressive gender identities and expressions is one of the most prominent experiences binding all transgender women subgroups in India. Across the spectrum, many transgender women have reported experiences of discrimination and harassment, health inequalities, limited economic opportunities, stigmatized livelihood options, and rejection from families (Chakrapani et al., 2018; Chakrapani & Dhall, 2011; Singh et al., 2014). Unfortunately, one of the major correlates of experiencing discrimination or harassment is depression. In fact, among transgender women in India, over 40% report lifetime prevalence of depression compared to 4%−15% lifetime prevalence in the general population (Chakrapani et al., 2017; Rao et al., 2014; Runwal et al., 2018; Shidhaye et al., 2016). Prior work has reported long term social, physical, and psychological consequences stemming from depression such as HIV related sexual-risk, substance use and victimization, many of which are amplified among transgender women (Chakrapani, Newman, et al., 2017; Chakrapani, Vijin, et al., 2017).

Given the socio-economic marginalization, transgender women in India are often limited to working without any formal training such as, begging, dancing and performing, and sex work (badhai, mangti and pan)1 (Chakrapani, 2010; Kalra, 2012). Studies have suggested a large proportion of transgender women are engaged in sex work across the country (Chakrapani, Vijin, et al., 2017; Subramanian et al., 2015). For example, Subramanian et al. (2015) reported that there are approximately 62,000 transgender women in 17 states of India, and that nearly 62% of them engaged in full-time or part-time sex work. Researchers have discussed multiple pathways of entry into sex work for transgender women in India; these include, (a) societal negative attitude and lack of family support leading them to joining hijra community (gharanas),2 with sex work as tradition in certain gharanas; (b) discrimination in school and colleges, low formal education and lack of economic opportunities; and, (c) decreasing income from community-specific livelihood options (e.g., begging or dancing), employment discrimination and underpayment in formal and informal sectors, leading them to practicing sex work (Chakrapani et al., 2018). Moreover, many transgender women have reported leaving their parental homes because of stigma and violence faced from their family members in efforts to coerce them to conform to expected gender norms (Chakrapani & Dhall, 2011). Leaving or getting evicted from parental homes may create additional barriers toward economic sustenance, leading many to enter sex work (Chakrapani et al., 2018).

Additionally, sex work and gender transition have a complex relationship. Gender transition services are considered essential health services for many transgender women to help achieve a physical body that is congruent with their gender identity (Coleman et al., 2012). These services include both surgical and non-surgical practices, such as, breast augmentation (including, silicone implants and injections), hormonal therapy, laser hair treatment, and gender affirming surgery (Reddy, 2003; Singh et al., 2014; Srivastava et al., 2020). Traditionally, transgender women in India, due to lack of economic and health care support, have practiced dai nirvana which refers to removal of male external genitalia in a ritual ceremony by an older hijra (dai amma) (Singh et al., 2014; Srivastava et al., 2020). In more contemporary times many transgender women have reported engaging in sex work to save money to pay for gender transition services (Chakrapani et al., 2018). However, some transgender women who practice sex work have also reported undergoing breast augmentation to look more feminine and increase their chances of soliciting clients (Srivastava et al., 2020).

Minority stress theory and negative outcomes

Negative health outcomes among transgender women have been attributed to unique stress experiences related to sexual orientation and gender identity known as minority stress (Meyer, 2003; Testa et al., 2015). In particular, studies with transgender persons have reported on how gender minority-specific experiences, including gender-related discrimination and rejection, are linked to negative mental health outcomes (Chodzen et al., 2019; Hoy‐Ellis & Fredriksen‐Goldsen, 2017; Testa et al., 2017). Additionally, gender minority stress is further heightened by the presence of multiple minority experiences such as practicing sex work, experiences around gender transition, and rejection from families. For example, stressors associated with sex work stemming from stigma, violence, or harassment contribute to negative health outcomes (Chettiar, 2015; Ganju & Saggurti, 2017; Nemoto et al., 2011). Similarly, studies have suggested additional stressors associated with restricting or delaying gender transition, and lack of access to health care (including post-operative care, and mental health counseling) are associated with psychological distress (Budge et al., 2013; Riggs et al., 2015; Srivastava et al., 2020). Moreover, stressors associated with family rejection, causing one to leave parental home may contribute to negative mental health outcomes, such as depression and suicide (Chakrapani et al., 2018; Klein & Golub, 2016; Yadegarfard et al., 2014). Hence, it is imperative to examine these intersectional experiences (for example, sex work, transition, and family rejection) and their association with mental health outcomes among transgender women.

The current study

There is limited knowledge on prevalence of gender transition among transgender women in India; and our current knowledge of experiences of transition are limited to results from either qualitative investigations or smaller samples from urban centers. It is also critical to report on association between sex work and gender transition, or how these may be associated with mental health outcomes. The current study uses data from a cross sectional epidemiological study with transgender women from three states in India: Karnataka, Maharashtra and Tamil Nadu. The aim of this paper is to examine the association between gender transition and sex work; and the impact of stressful experiences and circumstances (such as, sex work, transition and family rejection) on depressive symptomology of transgender women.

Methods

Overview

Swasti, a nonprofit in Bengaluru, India, along with its sister organizations, Vrutti and Catalyst Management Services were funded by the Bill and Melinda Gates Foundation to lead the Phase III of Avahan India AIDS Initiative. The current paper uses data from a cross-sectional structured survey with transgender women conducted during the period July–September 2017 under Avahan III. The data was collected through community organizations in three states of India, Karnataka, Maharashtra, and Tamil Nadu. Sampling procedure was based on a multi-stage, stratified, probability proportionate to size, systematic random sampling procedure. The state wise estimated sample size was then distributed among the community organizations in the respective states using the probability proportionate to size method. At community organizations level, study participants were selected from two different sample frames. Fifty percent of participants were drawn using systematic random sampling method from the list of transgender women covered during first outcome monitoring survey. The remaining fifty percent participants from the lists of transgender women covered during the subsequent census as well as the newly registered members enrolled by the community organization.

Data collection procedures

Swasti provided the necessary training program for community organizations leaders, staff and the researchers as well as the supervisors, on ethics so that the optimum ethical standards were maintained at all levels throughout the different stages of the study. The survey instruments were provided in English and other regional languages (Hindi, Marathi, Kannada, Telugu and Tamil). Data was collected on tablets using an Open Data Kit platform; and to ensure data integrity, and confidentiality, the tool and the data were hosted on Open Data Kit servers; encrypted and not accessible to any other party without prior consent. Other safety protocols included, deactivating and disabling any audio (voice) recording application and video recording camera on the tablets during the study period. The study protocols were approved by the Sigma Institutional Review Board, New Delhi, India. Informed consent was sought with the participants at the beginning of the survey, and they were informed that their participation was voluntary, and they could terminate the survey at any time. Additionally, a counselor was available on call in every location to support the participants if needed during or after the survey. There were no incentives given for participating in the study, however their cost of travel to study site was reimbursed. A total of 1,414 transgender women participated in the survey, and 48 participants were excluded from the analyses because of incomplete survey information, and duplicate participant ID. The final sample for this paper is 1,366.

Measures

Demographic control variables

Age and education variables were assessed as number of completed years. Participants were asked “What is your marital status?”, and the options included: married, never married, deserted/separated/divorced, widowed, don’t know and no response. For analytical reasons, marital status was recoded, as (1) ever married (including, married and deserted/separated/divorced) (2) never married. Family rejection was assessed by asking; “Did you have to leave your family because of your sexual orientation?” and the options included: Yes, No, No response (see Supplement 1).

Engagement in sex work

To assess one’s engagement in sex work, participants were asked “Do you solicit clients for money?” and the options included: Yes, No, No response.

Gender transition

Participants were asked to respond to a variety of transition questions. To assess gender affirming surgery, they were asked, “Have you undergone any surgery for sex change?”; and options included: Yes, No, No response. Additionally, those who endorsed gender affirming surgery, were further asked for the method of gender affirming surgery, “Which method are you using? Through guru non-professional surgery; emasculation; “sex reassignment surgery”3; no response”. To assess breast augmentation, participants were also asked, “Have you undergone Silicone Surgery?” and to assess hormonal therapy, “Have you had Hormone treatment through injection or drugs?”; the options included: Yes, No, No response.

Depressive symptoms

Symptoms of depression were measured using the Center for Epidemiologic Studies Depression Scale Short Form (CES-D-10), which contains four items assessing the frequency of depression symptoms during the past week. Items include “I felt lonely” and “I had crying spells.” Participants responded on a Likert scale with response options ranging from 0 (rarely or none of the time [less than 1 day]) to 3 (most or all of the time [5–7 days]). Scores were summed (0–30), with a clinical cutoff point of 10 or higher indicating probable depression (Andresen et al., 1994)

Data analysis

Bivariate analyses were conducted to detect differences in outcome variables by sex work status. Multivariate regressions were used to examine the association between sex work status and endorsement on gender transition (gender affirming surgery, breast augmentation and hormonal therapy) after controlling for age, education, marital status and leaving family because of sexual orientation. The final model examined how gender transition, sex work, and other demographic characteristics (age, education, marital status and leaving family because of transgender identity) are associated with depressive symptoms. Data were analyzed using Stata 14.2 (Long & Freese, 2006).

Results

Sociodemographic characteristics

The average age of the sample was 33.7 years (SD = 8.6; range = 18–73 years), with the majority of participants reported being in sex work (70.2%, n = 952). On average participants reported 7.3 years of education (SD = 3.9). Most participants also reported never being married (92.2%, n = 1259), followed by married (6.5%, n = 89) and deserted/separated/divorced (1.0%, n = 13). More than half of the participants reported leaving family because of their sexual orientation (58.3%, n = 793). Additionally, the majority of the participants endorsed having undergone or in the process of gender transition; with 74% of the sample reported undergoing gender affirming surgery (n = 1013), followed by hormonal therapy (34.9%; n = 476) and breast augmentation (30%; n = 410). Among those participants who endorsed gender affirming surgery, most reported undergoing “sex reassignment surgery” (83.9%; n = 847), followed by unprofessional surgery assisted by guru (11%; n = 111) and emasculation (5.2%; n = 52) (see Table 1 for more information).

Table 1.

Descriptive statistics of transgender participants (N = 1366).

  N (%) In sex work Not in sex work Chi-sq (df)
Age (years) 33.7 (8.6)      
Education (years) 7.3 (3.9)      
Marital status        
Married 89 (6.5)      
Never married 1259 (92.2)      
Deserted/Separated/Divorced 13 (1.0)      
No response 5 (0.4)      
Leave family 793 (58.3)      
Sex work 952 (70.2)      
Gender transition        
Breast augmentation 410 (30.1) 345 (36.3) 62 (15.3) 59.63 (1)
Hormonal therapy 476 (34.9) 356 (37.5) 117 (28.9) 9.21 (1)
Gender affirming surgery 1013 (74.2) 735 (77.2) 271 (66.9) 15.70 (1)
Gender affirming surgery method        
Through guru-unprofessional surgery 111 (11.0) 65 (8.9) 45 (16.6)  
Emasculation 52 (5.2) 36 (4.9) 16 (5.9)  
Sex reassignment surgery 847 (83.9) 631 (86.2) 210 (77.5) 12.93 (2)
Depressive symptoms 526 (38.5) 401 (42.1) 117 (28.9) 21.08 (1)
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Notes. Mean (standard deviation) is provided for age and education; Leave family: leaving family because of their sexual orientation; gender affirming surgery method was asked to only those who endorsed gender affirming surgery; for depressive symptoms, scores were summed (0–30), with a clinical cutoff point of 10 or higher indicating probable depression diagnosis. Bold indicates significance, p < 0.05.

Differences in characteristic by sex work

In the bivariate analysis (see Table 1), participants who reported being in sex work were significantly more likely to endorse uptake of any form of transition: gender affirming surgery (77% vs 67%); hormonal therapy (37.5% vs 28.9%); and breast augmentation (36.3% vs 15.3%) compared to those who did not report being in sex work. Use of gender affirming surgery methods also differed significantly by sex work status (χ2 = 12.9(2), p < 0.05); with those in sex work endorsing more for sex reassignment surgery compared to other methods, nonprofessional surgery assisted by guru and emasculation. Additionally, participants who reported being in sex work were also significantly more likely to report probable depression diagnosis (clinical cutoff point of 10 or higher) compared to their counterparts (42.1% vs 28.9%).

Gender transition and sex work

Table 2 presents multivariate logistic regression models examining the association between sex work status and gender transition. In the first model, participants who reported being in sex work (Odds Ratio (OR) = 3.07), and those with more years of education (OR = 1.09) had higher odds of endorsing breast augmentation. In the second model, those who reported being in sex work (OR = 1.37), who were ever married (OR = 2.13) and those who reported leaving family because of their sexual orientation (OR = 1.72) had higher odds of endorsing hormonal therapy. In the third model, being in sex work (OR = 1.89), older in age (OR = 1.03), and more years of education (OR = 1.05) were associated with had higher odds of endorsing gender affirming surgery; while those who reported ever being married (OR = 0.56) had significantly lower odds of endorsing gender affirming surgery.

Table 2.

Association between gender transition and sex work.

  Breast augmentation
OR (95% CI) 		Hormonal therapy
OR (95% CI) 		Gender affirming surgery
OR (95% CI)
Sex work 3.07 (2.24–4.21) 1.37 (1.05–1.78) 1.89 (1.44–2.49)
Age 1.00 (0.99–1.02) 0.99 (0.97–1.01) 1.03 (1.02–1.05)
Education 1.09 (1.06–1.14) 0.97 (0.95–1.01) 1.05 (1.02–1.09)
Marital status (ever married) 0.87 (0.55–1.39) 2.13 (1.34–3.25) 0.56 (0.36–0.87)
Leave family 1.07 (0.84–1.38) 1.72 (1.35–2.19) 0.80 (0.62–1.04)
Final N 1344 1344 1346
–Loglikelihood –774.53 –847.24 –748.93
Pseudo R2 0.0583 0.0254 0.0291
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Note. Reference categories were not in sex work; never married; not leaving family because of sexual orientation; OR = Odds Ratio, CI = 95% Confidence Interval; Bold indicates confidence interval does not contain 1.

Gender transition, sex work and depressive symptomology

The final multivariate logistic regression model (Table 3) examined the association between sex work, gender transition and depressive symptomology. Being in sex work (OR = 1.40), undergoing transition: gender affirming surgery (OR = 1.41), hormonal therapy (OR = 1.47), and breast augmentation (OR = 2.03) were associated with higher odds of reporting depressive symptoms. Participants who reported more years of education (OR = 1.07) and those who reported ever being married (OR = 2.05), had higher odds of reporting depressive symptoms. Additionally, the participants who reported leaving family (OR = 0.66) because of their sexual orientation were found to have lower odds of reporting depressive symptoms.

Table 3.

Association between gender transition, sex work and depressive symptoms.

  Depression
  OR (95% CI)
Breast augmentation 2.03 (1.56–2.63)
Hormonal therapy 1.47 (1.15–1.89)
Gender affirming surgery 1.41 (1.06–1.87)
Sex work 1.40 (1.05–1.84)
Age 1.01 (0.99–1.02)
Education 1.07 (1.04–1.11)
Marital status (ever married) 2.05 (1.95–4.78)
Leave family 0.77 (0.60–0.98)
Final N 1343
–Log likelihood –830.53
Pseudo R2 0.0706
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Note. Reference categories were not in sex work; never married; not leaving family because of sexual orientation; OR = Odds Ratio, CI = 95% Confidence Interval; Bold indicates confidence interval does not contain 1.

Discussion

This paper reported on prevalence of transition services, sex work, family rejection and depressive symptoms among transgender women in India. In addition, the paper also examined how minority experiences (for example, sex work status, and endorsement on transition services) impact mental depressive symptoms among transgender women. Results are consistent with the literature on gender minority stress, emphasizing how minority-identity based experiences and gender-based discrimination affect mental health and well-being (Bockting et al., 2013; Hendricks & Testa, 2012). In our sample, the majority of participants reported having undergone or are in the process of gender transition including gender affirming surgery. The literature from India reporting on transition is limited to qualitative samples (Singh et al., 2014; Srivastava et al., 2020), or small clinical samples (Kalra & Shah, 2013). Kalra and Shah (2013), in a clinical sample of transgender women from Mumbai, reported 32% of their participants had already undergone castration or emasculation (nirvana) and few more awaiting the procedure. We believe there are multiple reasons why there are higher rates of endorsement for transition and gender affirming surgery in our sample. Firstly, our sample included participants from Tamil Nadu, which was one of the first states in the country to provide transition services through their public health system through their long-standing Tamil Nadu Transgender Welfare Board (Chakrapani, 2012). Secondly, there are more community-led efforts since the 2014 NALSA judgment (National Legal Services Authority v. Union of India, 2014)4 to streamline gender transition services in the country (Bhattacharya, 2019; Jain & Rhoten, 2020). Thirdly, the sample comes from transgender women who are registered with community organizations, and may have more access to health care services and community support.

In our sample, the majority of participants reported being in sex work. This finding is consistent with the national estimation study of transgender women, where they reported 62% of transgender women from 17 states of India engaged in full-time or part-time sex work (Subramanian et al., 2015). Chakrapani et al. (2018) have reported on multiple pathways and reasons for high prevalence of sex work among transgender women in India, including, family rejection and school environment, limited livelihood options, sex work as part of traditional source of income for certain transgender communities, and paying toward gender transition services. Our paper also showed an association between sex work and transition services. In our study those who reported being in sex work were also more likely to endorse for gender transition. This finding is in line with the literature that argues that some transgender women in sex work undergo transition to look more feminine, to solicit more clients (Chakrapani et al., 2018; Winter & Doussantousse, 2009), and also, some transgender women enter or retain sex work to pay for their transition services (Srivastava et al., 2020). We also found that those transgender women who were ever married to women, were more likely to endorse using hormonal therapy and less likely to endorse gender affirming surgery. Transgender women in India operate under complex systems where even after joining a transgender community (gharana) the societal and family pressure on social gender roles may continue, such as marital expectation for sexual engagement with a spouse. Similarly, for transgender women integrated within the family system through marriage, some may consider gender affirming surgery as a permanent exclusion from family (Srivastava et al., 2020). Hence, those who are still or ever married and are in sex work would be less likely to undergo an irreversible transition procedure, such as gender affirming surgery; although they may use hormonal therapy to meet the demand to look feminine for sex work.

Another, important result of the study was the relationship between minority experiences (sex work and gender transition) and depression. Although there are limited explorative studies that have discussed the association between gender transition experiences and mental health among transgender women in India (Singh et al., 2014; Srivastava et al., 2020), studies from other countries have reported on gender transition and positive outcomes (Aldridge et al., 2020; Glynn et al., 2016; Murad et al., 2010; White Hughto & Reisner, 2016). For example, Glynn et al. (2016) in a community sample of transgender women with a history of sex work reported that social and medical gender affirmation were significant predictors of lower depression and higher self-esteem. Similarly, a meta-analysis reported that transgender persons who underwent gender affirming surgeries (including hormonal therapies) reported significant improvement in psychological symptoms, quality of life, and sexual function (Murad et al., 2010). However, we believe in India the absence of national guidelines and resources on gender affirming surgeries, lack of access to comprehensive healthcare and discrimination at healthcare settings makes transition stressful (Gupta & Murarka, 2009; Srivastava et al., 2020). In addition, lack of post-operative care, and at times loss of family ties because of transition may lead to increased depressive symptoms among transgender women (Srivastava et al., 2020). Results support the need for accessible and affordable transition resources and services for transgender women to promote better quality of life among an already vulnerable population. In our sample, those who reported being in sex work were also more likely to report depressive symptoms. This finding is consistent with literature on sex work, where stigma and violence associated with sex work, and legal issues around soliciting and harassment from police may contribute negatively to mental health among transgender women (Chakrapani et al., 2018; Chettiar, 2015; Ganju & Saggurti, 2017; Gupta & Murarka, 2009). Even though our research has presented an association between depression and minority experiences (sex work and transition), more research is needed to examine the underlying mechanisms (such as, gender minority stress), and how they are associated with the poor mental health outcomes among transgender women. Moreover, there is also a need for longitudinal investigations to understand and examine the directionality of these associations, and also changes in outcomes over time. Similarly, those who were ever married were twice more likely to have depressive symptoms compared to those who were not married. Given the social sexual and gender expectations from families and marriage, pressures to hide their sexual orientation and transgender identities, may amplify stress resulting in poor mental health (Chakrapani et al., 2018). However, those who reported leaving their families because of sexual orientation were less likely to report depressive symptoms. We believe, though there may be temporary stressors associated with leaving home for many transgender women, leaving home may also indicate an end to abuse and violence at homes. In addition, leaving parental home may also correspond with induction into the transgender community (gharana) and may act as a protective factor in mitigating the negative mental health outcomes (Srivastava et al., 2020).

Policy and program implications

The NALSA judgment paved way for a multitude of community-led efforts toward seeking social, economic and health justice for transgender persons in India. Transgender specific services, such as mental health counseling and comprehensive gender transition care are still absent from the national program (Jain & Rhoten, 2020). Given the programmatic reach of the national HIV program in the country (National AIDS Control Organization, 2017), the program may help reduce mental health disparities by training community workers on screening for mental health symptoms, providing mental health counseling, and services specific to gender transition. Additionally, there is much that can be learnt from the successful implementation of a range of programs and services for transgender women by the Tamil Nadu Transgender Welfare Board (https://www.tnsocialwelfare.org/pages/view/third-genders-welfare-board). Some of these services include free gender affirming genital surgeries at public hospitals, assisted living during crisis, and loans toward small businesses (Chakrapani, 2012). We believe these community-led processes and advocacy initiatives at local, state and national levels are needed to change attitudes and laws to increase family acceptance, educational outcomes, and employment opportunities for transgender women in India. In addition, our findings also suggest that many transgender women engage in sex work. Hence, the national program and targeted interventions with transgender women, must be sensitive and responsive to the needs of transgender women in sex work, and must include necessary legal reforms, risk and vulnerability reduction strategies, condom negotiation and crisis redressal along with community sensitization as part of their program.

Limitations

This study had several limitations. The sample featured transgender women from three states registered at community-led organizations and were part of Avahan III intervention. Hence, these findings cannot be generalized to transgender women living in other states or to those who are not registered at or are availing services from community-led organizations. Additionally, transgender men were not one of the targeted groups under Avahan III, and therefore were not included in the study sample. Engagement in sex work was measured as those who reported soliciting clients for money, which limits the implication of our results. The results are not extended to transgender women in sex work who exchange sex for food, shelter, drugs, gifts, and any other needs and wants. Because the study was cross-sectional, the results only indicate associations and not causality. All data were self-reported; anonymity was ensured by not collecting any identifying information, which minimized response bias. Despite the aforementioned limitations, our results remain the most comprehensive examination of gender transition, sex work and depressive symptoms among transgender women in India to date.

Supplementary Material

Supplemental Material
Click here for additional data file. (19.9KB, docx)

Acknowledgment

We would like to thank the implementing team members from Swasti, Vrutti and Catalyst Management Services for their contribution and support in designing of the programme, research, and data collection.

Footnotes

1

Badhai: blessing newborn babies and newlywed couples. Mangti: begging in trains and public places; Pan: sex work. These livelihood occupations became more common after the transgender community was suppressed by the colonial British authorities

2

Gharana: clan/community headed by a nayak (supreme leader) under which gurus (masters) and chelas (disciples) are organized.

3

Sex reassignment surgery is an obsolete term and is generally replaced by gender affirming surgery.

4

National Legal Services Authority v. Union of India (2014) is a landmark decision by the Supreme Court of India which declared transgender people the “third gender,” and upheld the right to self-determination of gender identity as male, female or third gender.

Disclosure statement

The authors have no conflict of interest to declare.

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