In 2014, the Supreme Court of India delivered a watershed judgment in the National Legal Services Authority (NALSA) v. Union of India case, affirming the rights of transgender persons to self-identify their gender and be recognized as a third gender. This historic decision marked a transformative moment in the struggle for dignity and justice for transgender communities. However, more than a decade later, the promise of inclusion still remains unfulfilled, especially when it comes to public health and healthcare delivery.
Despite legal recognition, transgender persons in India continue to face significant barriers in accessing healthcare. Their health concerns are either narrowly defined or ignored altogether, leading to a fragmented and risk-focused approach. Rather than framing transgender health through the lens of rights and equity, India’s public health narrative has long confined it to the realm of HIV prevention and sexual health, thereby neglecting the broader dimensions of well-being such as mental health, non-communicable diseases, gender-affirming care, and access to general health services.
Understanding Transgender Health Realities
Transgender individuals are those whose gender identity differs from the sex assigned to them at birth. This identity is deeply personal and often evolves despite strong social pressures to conform to binary gender roles. Although the Constitution protects the rights to equality, life, and dignity for all citizens, transgender persons routinely face discrimination, stigma, and invisibility, particularly within the healthcare system.
Health data underscores the disproportionate burden borne by the transgender community. Mental health challenges are especially pronounced, with nearly half of all transgender individuals in India reporting symptoms of depression, and almost one-third having attempted suicide at some point in their lives. These figures reflect the psychological toll of persistent social exclusion, familial rejection, violence, and lack of institutional support. HIV prevalence among transgender persons is estimated at 3.1%—more than fourteen times higher than the general population, which stands at 0.22%—underscoring their vulnerability not just to infection, but to a public health system that sees them primarily through the prism of risk.
The current public health response reinforces this narrow focus. Most government-led interventions for transgender individuals are channeled through the National AIDS Control Programme (NACP), which designates them as a “High-Risk Group.” The services offered under this program are largely limited to HIV testing and counseling, condom distribution, treatment for sexually transmitted infections, and antiretroviral therapy. While these are undeniably critical services, they represent only a sliver of what a comprehensive transgender health agenda should look like.
The Illusion of Inclusion: Fragmented Policy and Service Delivery
In recent years, India has made some positive strides, including extending health insurance coverage to transgender persons under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). This initiative, launched in 2022, offers coverage of up to ₹5 lakh annually for transgender persons. However, even this scheme falls short in key areas. Most notably, it does not include coverage for gender-affirming surgeries or hormone therapies in the majority of states. These medical procedures are not optional but central to many transgender persons’ physical and mental well-being. The lack of access to them reflects a continued failure to recognize transgender health needs as legitimate and urgent.
This exclusion is further compounded by the limited number of public hospitals that offer gender-affirming surgeries. In practice, only a handful—such as AIIMS Delhi and Lok Nayak Hospital—are known to provide such services, leaving the vast majority of transgender persons with few or no options. For those seeking care in private hospitals, the costs are often prohibitively high and not covered by insurance, creating yet another barrier to access.
Complicating matters further is the lack of identity documentation that aligns with a transgender person’s self-identified gender. According to a 2022 report by the Ministry of Social Justice and Empowerment, only 30% of transgender persons possess government-issued identity documents reflecting their chosen gender. Without proper documentation, many individuals are unable to access even those services that technically exist for them, including health schemes and social welfare benefits.
What emerges from this landscape is not simply a story of policy gaps, but of structural inequities that reinforce exclusion. Transgender persons report high levels of discrimination and mistreatment within healthcare settings. The 2022 MSJE report found that as many as 70% of transgender individuals had experienced discrimination while seeking medical care. This often translates into delayed treatment, avoidance of health facilities, and a deep mistrust of public health institutions.
From Risk-Based to Rights-Based Health approach
To truly address these challenges, India must reimagine transgender health not as a subset of HIV prevention but as a fully integrated component of its public health system. A rights-based approach would recognize the agency, dignity, and diverse needs of transgender persons, and would work to dismantle the structural barriers that prevent their full inclusion.
First, policy frameworks need to be reframed to emphasize holistic well-being over risk management. Transgender health must be explicitly included in national health policies, and this inclusion should be reflected in service design, resource allocation, and monitoring. The integration of transgender health into medical and nursing curricula is essential to build a healthcare workforce that is both competent and compassionate in dealing with gender diversity.
Second, service delivery must evolve to reflect the real and varied needs of transgender persons. Gender-affirming care—comprising surgery, hormone therapy, and counseling—must be made available in all major government hospitals and covered under national insurance schemes. Mental health services, reproductive healthcare, and care for non-communicable diseases should be mainstreamed into transgender health programming. Special outreach mechanisms, such as mobile health clinics and community health workers, can help bridge gaps for those in remote or underserved areas.
Third, the health of transgender individuals must be made visible in data systems. Large-scale national surveys such as the National Family Health Survey (NFHS), the National Sample Survey Office (NSSO) rounds, and even the Census must collect disaggregated data on transgender persons. Without data, the needs of the community remain invisible to policymakers and funders alike. In addition, more research must be funded on transgender mental health, aging, disability, and intersectional vulnerabilities—areas that have been almost entirely neglected in India’s health research agenda.
The Way Forward: Inclusion as an Ethical Imperative
At its core, the exclusion of transgender persons from comprehensive healthcare is not simply a policy oversight—it is a failure to uphold the fundamental rights enshrined in the Indian Constitution. The right to health is intimately tied to the right to life, dignity, and non-discrimination. India’s commitment to the Sustainable Development Goals (SDGs), particularly Goal 3 (Good Health and Well-Being) and Goal 10 (Reduced Inequalities), cannot be met without addressing the systemic exclusions faced by transgender communities.
Creating an inclusive public health system is not only a matter of technical reform, but of social transformation. It requires institutions to confront their biases, systems to recalibrate their frameworks, and society to recognize transgender persons not as marginal figures, but as equal citizens deserving of care, respect, and opportunity. The path forward will not be easy, but it is both necessary and long overdue.
Inclusion, in its truest sense, must mean that no one is left behind—not in policy, not in service delivery, and certainly not in health.
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