Barriers to health care access among transgender people in Kerala

Barriers to health care access among transgender people in Kerala | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers to health care access among transgender people in Kerala Bhavya Fernandez, Rakhal Gaitonde This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6826079/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Mar, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background Despite numerous efforts to implement inclusive policies in Kerala, transgender and gender-diverse (TGD) individuals continue to face institutional discrimination, resulting in significant challenges in accessing health care. Existing literature highlights the need for actions to expand the availability and utilisation of health care services for these individuals to prevent institutional erasure. This study aimed to identify the barriers health care faced by transgender people in Kerala. Methods In-depth interviews with 13 transgender people as part of a larger mixed-methods study. Results This study examined barriers to healthcare access among transgender people in Kerala, using Levesque et al.'s framework. Participants (mean age 33 years) included transwomen (73%), transmen (22%), and gender-fluid individuals (5%). Key barriers included the limited functionality of the specialised TGD clinics, a perceived lack of awareness and responsiveness among health care workers, and experiences of discrimination. Financial constraints further restricted access to hormone therapy and gender-affirming surgeries. Structural barriers, such as the absence of gender-neutral facilities and inadequate admission protocols compounded these challenges. Participants emphasised the need for health care worker training and the expansion of public provision for gender-affirming care to address these barriers. Conclusion The identified barriers are deeply rooted in the social position of the TGD community, necessitating an approach that acknowledges the social determinants of their health to achieve meaningful improvements in health care access. transgender health gender-affirming care health care access barriers Figures Figure 1 Introduction The word ‘Transgender’ and the phrase Transgender and Gender-Diverse (TGD) is used as an umbrella term to refer to people whose gender identity and sex assigned at birth are incongruent ( 1 ). Gender is a multidimensional construct that embraces identity (a core element of a person’s individual identity), expression (the way one’s gender is communicated or presented to others through their behaviour and appearance), and social position (or social and cultural expectations about status, characteristics, and behaviour that are associated with sex traits) ( 2 ). Sex, like gender, is a multidimensional construct, but based on a cluster of anatomical and physiological traits. Even though there are an estimated 7–35 million TGD people globally ( 3 ), the concept of cis genderism strengthens the notion that only two valid genders exist, as a result of which minority populations such as TGD people are stigmatised and discriminated against and often consigned to lower socio-economic positions ( 4 ). Gender has in fact been recognised as a cause and predictor for inequity, and thus gender mainstreaming is an unavoidable element in global policy discourse ( 5 ). There is an abundance of data on structural and contextual factors leading to the development of health risks in TGD people- including but not limited to social and economic marginalisation and even brutality faced in various settings including health care centres, thus trapping them in a never-ending cycle of illness and economic burden ( 6 – 8 ). Stigma and discrimination often force transgender people into occupations such as sex work which leads to further marginalisation as well as heightened exposure to illnesses, and these gendered and situated vulnerabilities pushes this vulnerable community down a slippery slope from stigma to sickness ( 9 ). This has been explained using the minority stress theory which states that external stressors like discrimination can lead to internal stressors such as the internalisation of discrimination which can further lead to feelings of self-contempt which can be overcome by exposure to protective factors such as access to health care and education ( 10 ). In recent times, especially since the UN resolution in 2011, and more recently the Lancet Commission on “Race, Xenophobia, Discrimination, and health” in 2022, there has been increasing focus on the direct health impacts of discrimination faced by minoritized groups including TGD people ( 9 , 11 ). In India, the previously punishable offence of same sex behaviour was overturned with the National Legal Services (NALSA) judgment in 2014 by means of which all citizens were given the right to self-identify their gender. Previous studies show that TGD people in India often avoid visiting hospitals in a bid to avoid discrimination and rely on “traditional practitioners” (sic) or directly purchase medicines from pharmacies ( 12 – 14 ). The South Indian state of Kerala was the first in India to execute a state policy for TGD people which included reimbursements for sex reassignment surgeries and establishment of dedicated clinics for TGD people ( 15 ). Despite a slew of attempts at implementing inclusive policies in Kerala, TGD people are still subject to institutional discrimination which result in difficulties in accessing health care ( 16 ), even though primary care settings have the potential to meet their general health care needs, with sensitivity ( 17 ). The attitude of people in positions of power such as policy makers and health care providers with their assumptions of heteronormativity and the resultant choice of language, and design choices can lead to a segregation between cisgender and TGD people and could negatively affect the physical and mental health of TGD people ( 18 ). As per a 2014 survey conducted by Kerala’s Social Justice Department, 51 percent of TGD people in Kerala have experienced discrimination at hospitals ( 15 ). They face a host of hurdles, at the individual, interpersonal and organisational level making the process of accessing health care very complex for a TGD person ( 19 – 21 ). Actions are required to expand the availability and utilisation of health care services by TGD people to prevent institutional erasure ( 22 , 23 ). Research should prioritise enhancing the capability of health systems to address the needs of the marginalised population ( 20 ). In this respect, the focus of this current study was to identify the barriers to health care experienced by transgender people in Kerala. Material and methods This study was part of a larger study which primarily aimed to determine the prevalence of risk factor for non-communicable diseases among TGD people in Kerala, the methodology of which has previously been published.( 24 ) This multiple methods study used a cross-sectional survey among 120 TGD people from three districts of Kerala for the quantitative aspect and in-depth interviews among 13 TGD people for the qualitative aspect. Ethical clearance was obtained from the Institutional Ethics Committee (IEC) of Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCT/IEC/1818/JANUARY/2022) dated on 02-03-2022. In this article, we report the findings of the data related to barriers that transgender and gender diverse people in Kerala face when attempting to access health care. Theory This research adopts multiple theoretical perspectives to examine the barriers faced by transgender and gender-diverse individuals in accessing health care. This section explores how social structures and systems compromise both the health of an already disadvantaged community and their access to health care. The Diderichsen’s model asserts how marginalised social positions, such as those of TGD individuals create differential exposures and vulnerabilities, and consequences of ill health for these groups ( 25 ). This aligns with the minority stress model which posits that sexual minority populations, including the TGD community, endure varying levels of social stress rooted in prejudice and stigma, thereby placing them at greater risk for adverse health outcomes ( 26 ). The Lancet Commission on “racism, xenophobia, discrimination, and health” further reinforces the notion that structural discrimination permeates institutions and systems, including health care ( 11 ). Within health systems, this discrimination manifests in the elements of barriers to accessibility, availability, acceptability, and quality of care – such as provider bias, poor communication, and a failure to accommodate the specific needs of marginalised communities like the TGD population ( 11 ). It is evident from these theories that health-related challenges are an inevitable part of the lived experience of this community, largely due to adverse social conditions and limited access to essential resources. Beyond the repercussions of social marginalisation, access to health care must also be understood in terms of how it is perceived by both providers and users. The Levesque et al . ( 27 ) conceptual framework on access to health care identifies five key dimensions of access: approachability, acceptability, availability, affordability, and appropriateness. These dimensions intersect with the abilities of individuals to perceive, seek, reach, pay for, and engage with health care services (adapted framework according to the results of the study in Fig. 1 ). This framework addresses gaps in explaining why certain barriers disproportionately affect the TGD community’s perception of access. Even when health care services are available, however limited, the systemic barriers outlined in the Levesque et al. framework demonstrate that they may remain inaccessible or unapproachable to TGD individuals due to stigma, bias, and unconsciously exclusionary practices. Thus, this research theorises the barriers that TGD individuals encounter in accessing health care, identifying how these inequities arise from both societal disadvantages and systemic inadequacies within the health care system, as articulated by the Levesque et al . framework. Results The mean age of the study sample was 33 years (SD = 8.8), with an age range of 19 to 58 years. The majority of participants were transwomen (73%), followed by transmen (22%), and the remaining 5% identified as gender fluid. A large majority (78.4%) lived in urban areas with friends, while only about 31% resided with their families. Almost half of the respondents currently had a life partner, and the majority (60%) had an education level of high school or below. Qualitative interviews revealed that discrimination by other students and teachers was a reason for frequent dropouts from schools among the participants. Approximately 67 percent of respondents had only occasional income or were unemployed and the median reported monthly income was INR 10,000 (121 USD). In the following section, the findings on barriers to access to health care are presented using the framework by Levesque et al . ( 27 ). We acknowledge that the challenges faced by the TGD community span across multiple dimensions of this framework. The findings presented under each dimension are only to illustrate that particular dimension and are not meant to confine the meaning or interpretation of these barriers solely to one dimension. Approachability : Although specialised clinics for transgender people had been established in a few government hospitals in Kerala, respondents reported a host of issues at these clinics. These centres operated only on select days, and there was a lack of publicly available information about their schedules, hindering both approachability and health-seeking behaviours. Even hospital staff where these centres were located were sometimes unaware of their existence or their operating hours. “ I had called the Government medical college (where specialised TGD clinic is located) many times before starting hormone therapy. In private [sector], it is very expensive. They said that the clinic is only functioning one or two days in a month. Often, no one answers the phone, or sometimes the staff there itself don’t know about the transgender clinic. Because of all that difficulty, I ultimately chose the private hospital itself ”- (IDI-5, transman, 37 years, Thiruvananthapuram) Participants reported that these clinics often lacked essential equipment and services. The staff assigned to these centres were reportedly uninformed about the specific health care needs of transgender and gender-diverse (TGD) individuals. This was evidenced by an incident where a transman was mistakenly prescribed oestrogen. While both governmental and non-governmental agencies organised health screening events for the transgender community, these were not accessible to all. Respondents noted that camps scheduled to end by early evening posed a challenge for individuals engaged in occupations like commercial sex work, as they typically returned in the early morning hours and found it difficult to attend in time. The corresponding ability of persons that interacts with the dimension of approachability was the ability to perceive a need for health care, and a few respondents displayed an inability to do so due to poor health literacy. While most respondents were aware that tobacco use negatively impacts health, only a few seemed to have a very clear understanding of its relation to Non-Communicable Diseases and the importance of screening for these conditions. “ It will slow down the hair growth … when we take hormones. When I asked, she [doctor] said this. She said there will be side effects (to tobacco use). We might get skin problems like pimples…I got acne in between .” (IDI-13, transman, 24 years, Thiruvananthapuram) Some respondents also had a fear of modern medicine and/or a preference for alternative systems of medicine, which led them to avoid seeking conventional health care. Instead, they relied on herbal concoctions and home remedies, potentially overlooking the need for professional medical evaluation and treatment for their health needs. “I had COVID … I took lots of ayurvedic and homemade treatments…we get lots of messages on WhatsApp, right? As forwards [forwarded messages]…I used to drink these things daily in the evenings.’ (IDI-10, transwoman, 41 years, Ernakulam) Acceptability: Respondents lamented the lack of protocol in health care centres for the treatment of TGD people. There was often a reported lack of clarity regarding which ward a TGD person should be admitted to, as well as a lack of adherence to internationally recommended guidelines such as those prescribed by the World Professional Association for Transgender Health (WPATH), especially for procedures such as Hormone Replacement Therapy (HRT) and Sex Reassignment Surgeries. “We took the ticket itself saying that we are transwomen. In spite of that, they admitted us in the male ward for treatment. When I asked about this they replied saying “We make people like you lie here only”. So, I shouted at them and made a lot of noise and only after that, they unwillingly shifted us to the female ward.’ (IDI-12, 27 years. transwoman, Ernakulam) The health provider’s conventional perceptions of sex and gender influence their approach and care, which in turn impacts the community’s acceptance of seeking care. One transwoman, who had not yet undergone a complete surgical transition, who presented with a genital rash, reported being denied care by a female nurse. Among those surveyed, 55% felt that there was a dearth of HCWs who were friendly to TGD people. “ Government hospitals have transphobic doctors … they speak to us in a bad way … He (the doctor) asked me if we can have sex like normal people and if we get periods every month like women do.” (IDI-6, transwoman, 33 years, Ernakulam) A few respondents opined in the qualitative interviews that they harboured a deep anger or mistrust towards the health system because of previous unfavourable incidents including transphobic ones and the perceived inadequacy of care received for self or family members. “ Personally, I feel anger towards the institutions … they don’t give us our basic rights … some people talk very sympathetically … some people think it is a disorder … like oh this is something that cannot be changed since it is a birth defect … there are even doctors who think like this” ( IDI-12, transwoman, 27 years, Ernakulam district) Internalised stigma and rejection anticipation was also evidently expressed by some respondents with some incidents that could possibly be explained otherwise being attributed to transphobia and this sometimes affected the ability to seek care. “Before the surgery we use binders to cover our breasts. We are stuck in between being male and female. We might desire to go to a male ward, but we cannot. We cannot go to the female ward either.” (IDI-13, transman, 24years, Thiruvananthapuram district) Rejection anticipation impacted gender expression to the degree that some respondents chose to not reveal their gender identities at hospitals. Out of the 70 respondents in the quantitative survey who didn’t not report facing discrimination at health centres in the past year, 27 percent didn’t reveal their gender identities at hospitals. “ I don’t reveal my identity at hospitals any more. Once when I did, the doctor reacted in a bad way. Till then, he was speaking to me well. When I told him I am trans, he didn’t say anything after that …. Just gave me some medicines quickly .”- IDI-13, transman, 24 years, Thiruvananthapuram district) Availability and accommodation: There was a reported insufficiency of initial support at government health centres. For instance, one respondent presenting with gender dysphoria at a government hospital was referred to a mental health institute in another state. Access to counselling services, for both TGD people and their families, was also reported to be a problem for respondents, especially considering that mental health issues were one of their prime concerns due to loneliness, discrimination and abuse suffered at the hands of the general community and in some cases their own partners. TGD people were uncomfortable at government hospitals for counselling purposes due to large crowds and the consequent inability of counsellors to dedicate sufficient amount of time to each patient, whereas the exorbitant prices of private facilities made them an unsustainable option. The currently available government helpline for TGD people was largely deemed to be counterproductive due to restricted timings and difficulty in connecting at crucial times. Geographical barriers were reported as a reason for delayed health care seeking, especially in the case of specialised services such as HRT and SRS, which were available only in a limited number of private hospitals across the state. No single facility provided all essential services routinely, necessitating long-distance travel to access even a portion of the required services. This fragmentation and limited availability of services posed barriers to timely and equitable healthcare access. Social support further influenced the ability of TGD people to navigate and access health care facilities. A larger proportion of those who lived away from their families were likely to have faced discrimination at a health care centre. This was probably because those living with families often visited the same centre with their families over prolonged time periods leading to familiarity with the staff. Such support also highlights the interplay between social position and the accessibility of healthcare services. The quality of lab facilities was also bemoaned due to the unaffordable cost of certain tests and scans and frequent false positive results, especially for Sexually Transmitted Illnesses, leading to unnecessary turmoil. “ There is a need for better testing. I have one friend … she does not go for sex work. Yet one day when she tested at the TG clinic, her VDRL was positive. She was so tensed and upset. So then we went and retested at government hospital thrice and all three time it was negative. Once they are sure of the result only they should inform us .” – IDI-7, transwoman, 22 years, Ernakulam district) Lack of personal mobility due to financial constraints was also reported. Financial issues majorly contributed to delays in health care seeking especially for HRT. Out of the 71 (59.16%) respondents who had started HRT, 12 (16.9%) had discontinued treatment due to reasons such as lack of finances or inability to deal with the physical side effects of the hormones. Since such a specialised service was offered only by private health care, they lacked the option to choose the more affordable and locally available public health care alternative. Some respondents cited other priorities such as the responsibility of caring for aged or unwell relatives as well as constraints due to job timings as factors that delayed their ability to reach and utilise health care. The dimension of “affordability” Among those surveyed, 62.5% preferred government centres for their general health care needs, where services are largely free in Kerala. Almost 43 percent cited affordability as the main factor that affected their choice of centre for health care. There was also a reported lack of specialised services, such as HRT and SRS, in government hospitals. As a result, access to these potentially necessary but expensive services, was limited to those who could afford private care. “ The doctors don’t know how to treat us … about our hormones. If they were knowledgeable, why is it that there is not a single government hospital in Kerala where we can get hormone treatment? They started one…did one surgery I think and then stopped it. If it was there in government, it was convenient for us since we won’t have to pay so much at private hospitals (IDI-8, transwoman, 36 years, Ernakulam). Even though the Government of Kerala issues reimbursements for SRS, this was only disbursed after the completion of the surgery, which was cited as a drawback by respondents since they still had to struggle to make the preliminary payment for surgeries. The majority of the respondents (84.2%) also did not have any form of insurance. “ When the Kerala TG policy came out in 2014, health insurance was included in that. But it has not been implemented...they say it is coming…but we have not gotten it yet…when I got COVID, it turned into pneumonia…It cost close to 1 lakh rupees ” (IDI-13, transman, 24 years, Thiruvananthapuram. The limited capacity of TGD people to generate resources, affected their ability to pay for health care services. Some of those who were well educated and in regular jobs, resorted to sex work temporarily in order to finance their surgeries. Appropriateness A range of infrastructural barriers hampered TGD people’s access to health care services. The unavailability of gender-neutral washrooms was considered to be a problem by 47 (39 percent) of the respondents and many avoided using washroom altogether. “ Whenever we go out, passing urine is very difficult. Sometimes, I hold it till I reach home .” – IDI-4, transwoman, 28 years, Kollam) An issue that cropped up, though albeit with lesser frequency, was the inappropriateness of registration forms at health centres which was reported by 17.5% of the respondents. Many respondents were faced with uncomfortable questions from health care workers (HCWs) while filling out the forms with many of them falsely assuming that surgical transition was mandatory in order to identify as a transgender person. “ Filling forms is sometimes difficult because there will only be two options i.e. male and female. Even if we tick female, questions like “Have you become female?” will be asked. So a transgender option should be there. It is coming in some places but it not that popular yet. ” (IDI-1, transwoman, 38 years, Ernakulam) Nearly 42% of respondents reported experiencing discrimination at a health centre within the past year. This discrimination often took the form of outright refusal of treatment, even in situations the respondents perceived as emergencies. Reports of treatment refusals were especially common for services in high demand by the community, such as HRT and SRS. “ One day at a program, two men asked us our rate. I told him that we were here for a programme and that we are going to the hall. But they didn’t agree and started grabbing and pulling us… he pulled my dress and banged my head against a wall. Other people gathered there and they called the police. The police took them and told us to go to the hospital. We went to the hospital … I was in pain and my forehead was bleeding. My neck was covered in scratch marks and wounds. We waited for a long time and the doctor didn’t even come and look at us. After this, the police bought these accused people to the same hospital. The doctor quickly examined them and wrote (prescriptions). I was there first … lying there and crying out of the pain .” - IDI-2, transwoman, 36 years, Ernakulam) A recurring issue mentioned by respondents was the delay in receiving treatment, often even in emergencies. Some reported being made to wait until all cisgender patients had been attended to. Ubiquitously across all interviews, respondents reported a sense of angst and discomfort due to the demeaning looks and comments that they were subjected to from cisgendered patients at health care centres. “I prefer going to private…it might cost more, but when we go to the general (government) hospital here, there is a lot of discrimination. When we take the ticket, they act like … how do I put it … they treat us like some different creatures. Not everyone … some people...” – IDI-8, transwoman, 36 years, Ernakulam) The majority (80%) of those surveyed felt that health care workers lacked adequate knowledge about transgender and gender diverse (TGD) people. This lack of understanding is a direct consequence of the marginalized social position of the transgender community, which leaves health care personnel ill-prepared to offer appropriate and respectful care. They were often faced with derogatory remarks and queries from even senior HCWs and were often questioned regarding the need for transitioning to the gender they identified with. “ The doctors don’t know how to treat us…about our hormones… ” (IDI-8, transwoman, 36 years, Ernakulam) This lack of knowledgeable doctors probably contributed to the fact that only 31 (25.8 percent) consulted the same doctor regularly, with 25 of them consulting doctors in the private sector. Respondent reported feeling uneasy visiting multiple doctors, since it would require sharing personal details about their transitions and illnesses to multiple people at each visit. “ We prefer to be able to see 1 doctor constantly, so as to avoid repeating and explaining physical issues which might have occurred during sex work – IDI- 12, transwoman, 27 years, Ernakulam district) Participants also reported insufficient information regarding hormone replacement therapy (HRT) and its outcomes. For instance, one transman expressed feeling shocked and disappointed when he began menstruating shortly after starting HRT, having been inadequately informed about what to expect. This lack of information further contributed to the diminished approachability of the health care system for those seeking care. The perceived lack of appropriate care affected the TGD individuals in their ability to engage in the health care seeking process. Rushed consultations left no opportunity for some respondents to ask queries and drastically minimised the patient-provider interaction. “ Earlier (before transition), the doctors used to place the stethoscope on our chest and see if we have any breathing difficulties … they used to understand what our illness is. Now, they will just ask if we have any allergy for any medicine. As soon as we say no, they will write a lot of medicines and give us .” (IDI-9, transwoman, TRV, 35 years) In line with the participatory research approach adopted for this study, respondents were asked for their suggestions to improve health care access for TGD people, so as to engage with their priorities and perspectives. The major suggestion that emerged was the provision of awareness and training sessions for HCW’s, especially for doctors regarding SRS and HRT. The respondents opined that HRT and SRS could be done in government hospitals at a fraction of the cost currently charged in private hospital which would ultimately lead to savings for the government since reimbursement of the large sums for procedures done in private hospitals would not be required. The provision of these specialised services in at least one government hospital per district could also abdicate the struggle of the TGD people to pay huge amounts upfront for their surgeries and travelling long distances for availing these services. In addition to HCW’s, awareness sessions for the cis-gendered society were also deemed to be a necessity, starting at school level and extending up to the level of Local self-government institutions to insure inclusivity and avenues for assistance in case of unsupportive family members. Affordable and accessible counselling services was also an oft repeated demand of the respondents – both for them and their family members. The respondents were almost equally divided regarding the need for separate clinics for TGD people, with 52.5 percent preferring that the existing primary health centres be made TGD friendly. “ What is the need for a separation? We are also ladies. There is no difference. If u slash our hands, it is blood only that flows out .” (IDI-3, transwoman, Ernakulam,20 years) Even though the focus of this study was determining the barriers to health care access, not presenting the other side of the story would result in a partisan view - the side that demonstrates the slowly evolving changes in the health system and the stories of resilience that many community members exhibited. Many shared positive experiences at health care centres, with some opining that HCW’s mirror their attitudes and behaviours. “ When I had corona… it was very crowded and it was very difficult for me. So, I told them my difficulty and asked them for a separate room. They gave me a separate room...they gave me special attention and consoled me a lot” – (IDI-2, transwoman, 36 years, Ernakulam district) “ It also depends on how we act with them (HCW’s)… that is how they will act with us too. I speak with them nicely, so they care for me too. When I go with some other friends, because of the way they act, things can go wrong. ” (IDI-7, transwoman, Ernakulam,23 years) Few respondents also acknowledged that some of the barriers they faced, especially at some government hospitals which are infamous for being overcrowded beyond capacity, are not exclusive to TGD people. “ Not as a trans, even as a common man I have had arguments at the counter. And everyone around me supported me saying that they were also waiting for a long time. It is a common problem in government hospitals. It is not just cis or trans... generally, people are suffering .”- (IDI-5, Transman, 37 years, Trivandrum district.) Respondents also conveyed gratitude for the perceived progressive changes in the recent past, and expressed hope that the future would be even more inclusive. “ We are enjoying the fruits that people before us have planted. So, the generations after us will enjoy the fruits of the trees we plant. All the freedom that we achieve, will be enjoyed by the future generations .” (IDI-3, transwoman, Trivandrum district, 43 years) Discussion This study aimed to explore the barriers to health care access as experienced by the transgender and gender-diverse (TGD) community in Kerala, India. The barriers were framed using the concepts of approachability, acceptability, availability and accommodation, affordability, and appropriateness of the health system and its service providers, as conceptualised by Levesque et al. ( 27 ). Consistent with existing literature, financial constraints, lack of protocols, insufficiently trained health care workers, and discrimination emerged as significant obstacles.( 12 , 14 , 20 ) Although these barriers are common to similarly marginalised communities,( 28 ) it is important to consider why the TGD community, in particular, faces these challenges more acutely, especially in Kerala’s health system where the general population experiences relatively better health outcomes compared to national averages.( 29 ) Despite Kerala being the first state in India to introduce a welfare policy for the transgender community( 30 ) and establish a transgender cell( 31 ) to safeguard their rights – with future initiatives geared towards making the health system more affirmative and responsive to their health needs – barriers to accessing care persist. These policies and initiatives have emerged in a context shaped by decades of deep-seated societal norms and prejudices, which impede and resist their effective implementation. Many participants in this study took the empowering step of disclosing their gender identity to formal health care providers, yet their experiences highlight the limitations of the existing system, which can alienate or exclude them, even when supportive policies are in place. Their experiences with existing social structures provoke distrust, stemming from historical and ongoing harassment by institutions such as law enforcement, which while expected to protect communities indiscriminately, in reality, perpetuate harm among the disadvantaged ones.( 32 ) This divide between policy and practice reflects the inherent design of social systems, which tend to mirror the power imbalances within broader society.( 11 ) Health care institutions are naturally inclined to prioritise utilitarian goals, often at the expense of addressing the urgent concerns of marginalised groups. Their approaches are influenced by harmful stereotypes and personal biases, reinforced by cultural factors and underlying power dynamics. As a result, well-intentioned policies fail to gain traction without naming and addressing the deeper issues of institutional power abuse and denigrating societal attitudes. The collectively compromised social position of TGD individuals in Kerala – marked by educational and financial disparities – further impedes their health care access. As observed in the Kerala Social Justice Department survey,( 33 ) many TGD individuals drop out of school due to discrimination, curtailing their educational attainment and, consequently, their access to stable employment. A majority of the study participants reported having only a high school education or less, alongside infrequent or no income, reflecting the limited employment prospects available to them. These socio-economic disadvantages preclude them from accessing specialised services provided by non-governmental organisations or the private sector. In this context, social support plays an important factor in health care access. TGD individuals who seek health care services with their families reported facing less discrimination than those without familial support. This may be due to the opportunity to foster more stronger relationships between family members and health care providers, thereby reducing the burden on TGD individuals to seek health care independently. Conversely, those lacking social support are more vulnerable to victimisation and neglect within the health system, perpetuating disparities, and, at times leading to harmful coping behaviours, as documented in previous research.( 34 ) The general assumptions held by healthcare providers, shaped by conventional medical education, further compound these barriers. The training that they receive rarely addresses the challenges faced by the TGD community, leaving them ill-equipped to offer sensitive and appropriate care.( 35 – 37 ) Moreover, the current health care infrastructure often fails to accommodate the specific needs of TGD individuals. Consistent with prior research, issues such as the design of toilets and inclusivity in registration forms remain problematic,( 38 ) while our study identified additional challenges related to consultation waiting times and ward admission protocols. These design failures are not merely technical oversights but reflections of the underlying power dynamics that moderate the need for institutional change, reinforcing systemic neglect. The inadequacy of current government healthcare services in meeting the needs of this community is evident in the fact that only 25 percent of TGD individuals have a regular doctor. While government healthcare utilisation has increased overall,( 39 ) the TGD community remains underserved, primarily due to the lack of facilities tailored to their specific requirements. Addressing the health care needs of the TGD community and identifying the barriers they face to access require systemic changes that go beyond the health sector. However, the health system can take a leading role in initiating these changes by adopting a person-centred approach that acknowledges the unique social disadvantages faced by this community. Expanding access to specialised services, such as hormone replacement therapy and sex reassignment surgeries, in at least one government hospital per district, would alleviate some of the current barriers. Diversity in medical education and health care practice is essential for cultivating an inclusive environment that can begin to deconstruct systemic biases and misconceptions. While these reforms will take time, they are critical to ensuring that healthcare services become truly accessible to all vulnerable groups. Conclusion The main barriers to health care access by the transgender and gender-diverse community, as identified in this study, include financial constraints, discrimination; inadequate registration forms, toilet facilities and admission protocols; the inability to consult the same doctor consistently, a perceived lack of awareness and responsiveness among health care workers, lack of reliable sources of information, internalised stigma and the absence of properly functioning clinics for transgender people. Many of these barriers are rooted in the social position of this community and the unique vulnerabilities that amplify their challenges with the health system and health care access. To achieve meaningful improvements, the social determinants of transpersons’ health must be both acknowledged and addressed with intentionality. Glossary Transgender: or trans are umbrella terms used to describe people whose gender identities and/or gender expressions are not what is typically expected for the sex to which they were assigned at birth.(40) Transgender men or Trans men or Men of trans experience are people who have gender identities as men and who were assigned female at birth. They may or may not have undergone any transition.(40) Transgender women or Trans women or Women of trans experience are people who have gender identities as women and who were assigned male at birth. They may or may not have undergone any transition.(40) Gender fluid: denoting or relating to a person who does not identify as having a single unchanging gender. (Oxford Languages) Hormone Replacement Therapy (HRT): Hormone replacement therapy, also called transgender hormone therapy, or gender-affirming hormone therapy (GAHT), is a form of hormone therapy in which sex hormones and other hormonal medications are administered to transgender or gender. Sex reassignment surgery (gender affirmation surgery): Surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity. Sex reassignment surgery can be an important part of medically necessary treatment to alleviate gender dysphoria.(41) Declarations Ethics approval and consent to participate: The study was undertaken after getting clearance from the Institutional Ethics Committee (IEC) of Sree Chitra Tirunal Institute for Medical sciences and Technology (IEC Regn No. ECR/189/Inst/KL/2013/RR-21) which follows national guidelines as prescribed by Central Drugs Standard Control Organisation (https://cdsco.gov.in/opencms/opencms/en/Home/). The IEC clearance (SCT/IEC/1818/JANUARY/2022) was obtained on 02-03-2022. Permission was also obtained from the state mission director of the NHM, in order to attend and collect data at the camps conducted by them. Participants were informed of benefits and risks and they had the freedom to refuse participation or withdraw from the study at any point. Consent for publication: Not applicable Availability of data and materials: The corresponding author will provide the transcripts, data set and analysis of the current work on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: the study was self-funded and did not receive any financial support from any source. Authors contributions: 1) Dr. Bhavya Benzigar Fernandez proposed the topic, prepared the protocol and tools, collected data, undertook data analysis and prepared the first draft of the manuscript. 2) Dr. Rakhal Gaitonde, supervised the work and contributed to the conceptualisation and design of the study, conducted part of the qualitative analysis and made revisions to the report to finalise the manuscript. Both authors have approved the manuscript in its present form. Acknowledgment: The authors would like to acknowledge the National Health Mission for approving and complementing the study’s execution. In addition, we appreciate all the community members whose co-operation assisted in the conduct of the study. References Green ER, Maurer L. Planned Parenthood of the Southern Finger Lakes I. The teaching transgender toolkit: a facilitator’s guide to increasing knowledge, decreasing prejudice & building skills. 2017. Becker T, Chin M, Bates N, and editors. National Academies of Sciences, Engineering, and Medicine. Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation; Measuring Sex, Gender Identity, and Sexual Orientation. [Internet]. [Internet]. Washington (DC): National Academies Press (US). 2022 Mar 9. Summary; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK581047/ WHO/Europe brief – transgender health in the context of ICD-11 [Internet]. 2021 [cited 2021 Dec 24]. Available from: https://www.euro.who.int/en/health-topics/health-determinants/gender/gender-definitions/whoeurope-brief-transgender-health-in-the-context-of-icd-11 Tan KKH, Schmidt JM, Ellis SJ, Veale JF. Mental Health of Trans and Gender Diverse People in Aotearoa/New Zealand: A Review of the Social Determinants of Inequities. New Z. 2020;9. Hawkes S, Buse K, Kapilashrami A. Gender blind? An analysis of global public-private partnerships for health. Globalization Health. 2017;13:26. Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412–36. Bhattacharya S, Ghosh D. Studying physical and mental health status among hijra, kothi and transgender community in Kolkata, India. Soc Sci Med. 2020;265:113412. Garcia C, de Albuquerque L, Drezett GA, Adami J. Health of sexual minorities in north-eastern Brazil: representations, behaviours and obstacles. J Hum Growth Dev. 2016;26(1):95–100. Winter S, Diamond M, Green J, Karasic D, Reed T, Whittle S, et al. Transgender people: health at the margins of society. Lancet (London England). 2016;388(10042):390–400. Meyer IH, Prejudice. Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull. 2003;129(5):674–97. Devakumar D, Selvarajah S, Abubakar I, Kim SS, McKee M, Sabharwal NS, et al. Racism, xenophobia, discrimination, and the determination of health. Lancet. 2022;400(10368):2097–108. Sangamithra A, Arunkumar P. Challenges and Issues in Health Care Utilization among Transgender Community in Tamil Nadu. Shanlax Int J Econ. 2020;8(2):24–8. Sivakami M. Health and Healthcare Seeking Behaviour Among Transgender in Mumbai: Beyond the Paradigm of HIV/AIDS. Social Sci Spectr. 2016;2. Pandya Akumar, Redcay A. Access to health services: Barriers faced by the transgender population in India. J Gay Lesbian Mental Health. 2021;25(2):132–54. Government of Kerala D of SJ. State Policy for Transgenders in Kerala [Internet]. 2015 [cited 2021 Nov 11]. Available from: https://translaw.clpr.org.in/wp-content/uploads/2019/01/State-Policy-for-Transgenders-in-Kerala-2015.pdf Nayar KR, Vinu S. Equity issues in gender-affirming medical care in Kerala: a reflective commentary. Int J Equity Health. 2023;22(1):193. Collier R. Addressing transgender discrimination in health. CMAJ. 2015;187(17):E493–493. Martinez-Velez JJ, Melin K, Rodriguez-Diaz CE. A Preliminary Assessment of Selected Social Determinants of Health in a Sample of Transgender and Gender Nonconforming Individuals in Puerto Rico. Transgender Health. 2019;4(1):9–17. Collier R. Addressing transgender discrimination in health. CMAJ. 2015;187(17):E493–493. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree W, Radix A et al. Barriers to Health Care for Transgender Individuals. Current opinion in endocrinology, diabetes, and obesity. 2016;23(2):168–71. Stroumsa D. The State of Transgender Health Care: Policy, Law, and Medical Frameworks. Am J Public Health. 2014;104(3):e31–8. Winter S, Settle E, Wylie K, Reisner S, Cabral M, Knudson G, et al. Synergies in health and human rights: a call to action to improve transgender health. Lancet. 2016;388(10042):318–21. Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM, Boyce M. I Don’t Think This Is Theoretical; This Is Our Lives: How Erasure Impacts Health Care for Transgender People. J Assoc Nurses AIDS Care. 2009;20(5):348–61. Fernandez B, Gaitonde R. Non-communicable diseases and its risk factors among the transgender population in Kerala: a cross-sectional study. Int J Equity Health. 2024;23:107. Diderichsen F, Andersen I, Manuel C, The Working Group of the Danish Review on Social Determinants of Health, Andersen AMN, Bach E, et al. Health Inequality - determinants and policies. Scand J Public Health. 2012;40(8suppl):12–105. Frost DM, Meyer IH. Minority stress theory: Application, critique, and continued relevance. Curr Opin Psychol. 2023;51:101579. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):18. Goel A, Goel P. Barriers to Healthcare Access in Low-Income Countries and Marginalized Communities. Int J Res Publication Reviews. 2024;5(7):1049–54. Board SP. Thiruvananthapuram, Kerala, India. Economic Review 2017 | Social Services, Medical and Public Health, Health Indicators of Kerala [Internet]. [cited 2024 Sep 22]. Available from: https://spb.kerala.gov.in/economic-review/ER2017/web_e/ch421.php?id=41&ch=421 Social Justice Department. G of K. Beneficiary, Transgenders. Social Justice Department G of K, Schemes. Transgender cell constituted [Internet]. [cited 2024 Oct 21]. Available from: https://sjd.kerala.gov.in/scheme-info.php?scheme_id=MTQ0# Stenersen MR, Thomas K, McKee S. Police and Transgender and Gender Diverse People in the United States: A Brief Note on Interaction, Harassment, and Violence. J interpers Violence. 2022;37(23–24):NP23527. SANGAMA. The Transgender Survey of Kerala, 2014-15 [Internet]. Submitted to the Director, Department of Social Justice, Government of Kerala. 2020. Available from: https://ruralindiaonline.org/en/library/resource/transgender-survey-kerala-2014-15/ Gamarel KE, Watson RJ, Mouzoon R, Wheldon CW, Fish JN, Fleischer NL. Family Rejection and Cigarette Smoking Among Sexual and Gender Minority Adolescents in the USA. Int J Behav Med. 2020;27(2):179–87. Shrivastava SR, Shrivastava PS. Transgender Health and Medical Education: The Existing Gaps and the Need for Curricular Reforms – A Systematic Review. J Sci Soc. 2023;50(2):163. Menon RD. Transgender Healthcare and Indian Medical Students: Is Curricular Revamping the Need of the Hour? Chettinad Health City Med J. 2022;11:16–20. Hana T, Butler K, Young LT, Zamora G, Lam JSH. Transgender health in medical education. Bull World Health Organ. 2021;99(4):296–303. Costa D. Transgender Health between Barriers: A Scoping Review and Integrated Strategies. Societies. 2023;13(5):125. Division NSS. Department of Economics and Statistics, Government of Kerala. Report on Health In Kerala: NSS 71st Round, January - June 2014 [Internet]. 2016. Available from: https://ecostat.kerala.gov.in/storage/publications/149.pdf Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgender Health. 2022;23(sup1):S1–259. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgenderism. 2012;13(4):165–232. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Mar, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 23 Aug, 2025 Reviews received at journal 17 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers agreed at journal 23 Jun, 2025 Reviewers invited by journal 23 Jun, 2025 Editor assigned by journal 09 Jun, 2025 Submission checks completed at journal 09 Jun, 2025 First submitted to journal 05 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6826079","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475579836,"identity":"2d877935-fe34-4eb6-8bb2-868b473ee1ab","order_by":0,"name":"Bhavya Fernandez","email":"data:image/png;base64,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","orcid":"","institution":"Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology","correspondingAuthor":true,"prefix":"","firstName":"Bhavya","middleName":"","lastName":"Fernandez","suffix":""},{"id":475579837,"identity":"2037425c-82e2-46b6-a953-ba0078b0695f","order_by":1,"name":"Rakhal Gaitonde","email":"","orcid":"","institution":"Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology","correspondingAuthor":false,"prefix":"","firstName":"Rakhal","middleName":"","lastName":"Gaitonde","suffix":""}],"badges":[],"createdAt":"2025-06-05 06:53:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6826079/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6826079/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-026-02803-4","type":"published","date":"2026-03-11T16:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85615865,"identity":"dfad3ef8-47cf-46f4-ad14-477d21ae07dc","added_by":"auto","created_at":"2025-06-29 14:32:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130064,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBarriers to health care access for transgender and gender-diverse people, conceptual framework adapted from Levesque et al.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6826079/v1/92e8b3dd98df5bd1b589e641.jpg"},{"id":104740357,"identity":"be26d078-4787-43b1-aa20-0346bb311777","added_by":"auto","created_at":"2026-03-16 16:16:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":644517,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6826079/v1/1d21d0fa-34c0-4dd2-8874-666680b8ae25.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to health care access among transgender people in Kerala","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe word \u0026lsquo;Transgender\u0026rsquo; and the phrase Transgender and Gender-Diverse (TGD) is used as an umbrella term to refer to people whose gender identity and sex assigned at birth are incongruent (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Gender is a multidimensional construct that embraces identity (a core element of a person\u0026rsquo;s individual identity), expression (the way one\u0026rsquo;s gender is communicated or presented to others through their behaviour and appearance), and social position (or social and cultural expectations about status, characteristics, and behaviour that are associated with sex traits) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Sex, like gender, is a multidimensional construct, but based on a cluster of anatomical and physiological traits. Even though there are an estimated 7\u0026ndash;35\u0026nbsp;million TGD people globally (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), the concept of cis genderism strengthens the notion that only two valid genders exist, as a result of which minority populations such as TGD people are stigmatised and discriminated against and often consigned to lower socio-economic positions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Gender has in fact been recognised as a cause and predictor for inequity, and thus gender mainstreaming is an unavoidable element in global policy discourse (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). There is an abundance of data on structural and contextual factors leading to the development of health risks in TGD people- including but not limited to social and economic marginalisation and even brutality faced in various settings including health care centres, thus trapping them in a never-ending cycle of illness and economic burden (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Stigma and discrimination often force transgender people into occupations such as sex work which leads to further marginalisation as well as heightened exposure to illnesses, and these gendered and situated vulnerabilities pushes this vulnerable community down a slippery slope from stigma to sickness (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This has been explained using the minority stress theory which states that external stressors like discrimination can lead to internal stressors such as the internalisation of discrimination which can further lead to feelings of self-contempt which can be overcome by exposure to protective factors such as access to health care and education (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In recent times, especially since the UN resolution in 2011, and more recently the Lancet Commission on \u0026ldquo;Race, Xenophobia, Discrimination, and health\u0026rdquo; in 2022, there has been increasing focus on the direct health impacts of discrimination faced by minoritized groups including TGD people (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn India, the previously punishable offence of same sex behaviour was overturned with the National Legal Services (NALSA) judgment in 2014 by means of which all citizens were given the right to self-identify their gender. Previous studies show that TGD people in India often avoid visiting hospitals in a bid to avoid discrimination and rely on \u0026ldquo;traditional practitioners\u0026rdquo; (sic) or directly purchase medicines from pharmacies (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The South Indian state of Kerala was the first in India to execute a state policy for TGD people which included reimbursements for sex reassignment surgeries and establishment of dedicated clinics for TGD people (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Despite a slew of attempts at implementing inclusive policies in Kerala, TGD people are still subject to institutional discrimination which result in difficulties in accessing health care (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), even though primary care settings have the potential to meet their general health care needs, with sensitivity (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The attitude of people in positions of power such as policy makers and health care providers with their assumptions of heteronormativity and the resultant choice of language, and design choices can lead to a segregation between cisgender and TGD people and could negatively affect the physical and mental health of TGD people (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). As per a 2014 survey conducted by Kerala\u0026rsquo;s Social Justice Department, 51 percent of TGD people in Kerala have experienced discrimination at hospitals (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). They face a host of hurdles, at the individual, interpersonal and organisational level making the process of accessing health care very complex for a TGD person (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Actions are required to expand the availability and utilisation of health care services by TGD people to prevent institutional erasure (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Research should prioritise enhancing the capability of health systems to address the needs of the marginalised population (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In this respect, the focus of this current study was to identify the barriers to health care experienced by transgender people in Kerala.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis study was part of a larger study which primarily aimed to determine the prevalence of risk factor for non-communicable diseases among TGD people in Kerala, the methodology of which has previously been published.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) This multiple methods study used a cross-sectional survey among 120 TGD people from three districts of Kerala for the quantitative aspect and in-depth interviews among 13 TGD people for the qualitative aspect. Ethical clearance was obtained from the Institutional Ethics Committee (IEC) of Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCT/IEC/1818/JANUARY/2022) dated on 02-03-2022. In this article, we report the findings of the data related to barriers that transgender and gender diverse people in Kerala face when attempting to access health care.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTheory\u003c/h2\u003e \u003cp\u003eThis research adopts multiple theoretical perspectives to examine the barriers faced by transgender and gender-diverse individuals in accessing health care. This section explores how social structures and systems compromise both the health of an already disadvantaged community and their access to health care.\u003c/p\u003e \u003cp\u003eThe Diderichsen\u0026rsquo;s model asserts how marginalised social positions, such as those of TGD individuals create differential exposures and vulnerabilities, and consequences of ill health for these groups (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This aligns with the minority stress model which posits that sexual minority populations, including the TGD community, endure varying levels of social stress rooted in prejudice and stigma, thereby placing them at greater risk for adverse health outcomes (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Lancet Commission on \u0026ldquo;racism, xenophobia, discrimination, and health\u0026rdquo; further reinforces the notion that structural discrimination permeates institutions and systems, including health care (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Within health systems, this discrimination manifests in the elements of barriers to accessibility, availability, acceptability, and quality of care \u0026ndash; such as provider bias, poor communication, and a failure to accommodate the specific needs of marginalised communities like the TGD population (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is evident from these theories that health-related challenges are an inevitable part of the lived experience of this community, largely due to adverse social conditions and limited access to essential resources.\u003c/p\u003e \u003cp\u003eBeyond the repercussions of social marginalisation, access to health care must also be understood in terms of how it is perceived by both providers and users. The Levesque \u003cem\u003eet al\u003c/em\u003e. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) conceptual framework on access to health care identifies five key dimensions of access: approachability, acceptability, availability, affordability, and appropriateness. These dimensions intersect with the abilities of individuals to perceive, seek, reach, pay for, and engage with health care services (adapted framework according to the results of the study in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This framework addresses gaps in explaining why certain barriers disproportionately affect the TGD community\u0026rsquo;s perception of access.\u003c/p\u003e \u003cp\u003eEven when health care services are available, however limited, the systemic barriers outlined in the Levesque \u003cem\u003eet al.\u003c/em\u003e framework demonstrate that they may remain inaccessible or unapproachable to TGD individuals due to stigma, bias, and unconsciously exclusionary practices. Thus, this research theorises the barriers that TGD individuals encounter in accessing health care, identifying how these inequities arise from both societal disadvantages and systemic inadequacies within the health care system, as articulated by the Levesque \u003cem\u003eet al\u003c/em\u003e. framework.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of the study sample was 33 years (SD\u0026thinsp;=\u0026thinsp;8.8), with an age range of 19 to 58 years. The majority of participants were transwomen (73%), followed by transmen (22%), and the remaining 5% identified as gender fluid. A large majority (78.4%) lived in urban areas with friends, while only about 31% resided with their families. Almost half of the respondents currently had a life partner, and the majority (60%) had an education level of high school or below. Qualitative interviews revealed that discrimination by other students and teachers was a reason for frequent dropouts from schools among the participants. Approximately 67 percent of respondents had only occasional income or were unemployed and the median reported monthly income was INR 10,000 (121 USD).\u003c/p\u003e \u003cp\u003eIn the following section, the findings on barriers to access to health care are presented using the framework by Levesque \u003cem\u003eet al\u003c/em\u003e. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe acknowledge that the challenges faced by the TGD community span across multiple dimensions of this framework. The findings presented under each dimension are only to illustrate that particular dimension and are not meant to confine the meaning or interpretation of these barriers solely to one dimension.\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eApproachability\u003c/b\u003e:\u003c/div\u003e \u003cp\u003eAlthough specialised clinics for transgender people had been established in a few government hospitals in Kerala, respondents reported a host of issues at these clinics. These centres operated only on select days, and there was a lack of publicly available information about their schedules, hindering both approachability and health-seeking behaviours. Even hospital staff where these centres were located were sometimes unaware of their existence or their operating hours.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI had called the Government medical college (where specialised TGD clinic is located) many times before starting hormone therapy. In private [sector], it is very expensive. They said that the clinic is only functioning one or two days in a month. Often, no one answers the phone, or sometimes the staff there itself don\u0026rsquo;t know about the transgender clinic. Because of all that difficulty, I ultimately chose the private hospital itself\u003c/em\u003e\u0026rdquo;- (IDI-5, transman, 37 years, Thiruvananthapuram)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants reported that these clinics often lacked essential equipment and services. The staff assigned to these centres were reportedly uninformed about the specific health care needs of transgender and gender-diverse (TGD) individuals. This was evidenced by an incident where a transman was mistakenly prescribed oestrogen.\u003c/p\u003e \u003cp\u003eWhile both governmental and non-governmental agencies organised health screening events for the transgender community, these were not accessible to all. Respondents noted that camps scheduled to end by early evening posed a challenge for individuals engaged in occupations like commercial sex work, as they typically returned in the early morning hours and found it difficult to attend in time.\u003c/p\u003e \u003cp\u003eThe corresponding ability of persons that interacts with the dimension of approachability was the ability to perceive a need for health care, and a few respondents displayed an inability to do so due to poor health literacy. While most respondents were aware that tobacco use negatively impacts health, only a few seemed to have a very clear understanding of its relation to Non-Communicable Diseases and the importance of screening for these conditions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIt will slow down the hair growth \u0026hellip; when we take hormones. When I asked, she [doctor] said this. She said there will be side effects (to tobacco use). We might get skin problems like pimples\u0026hellip;I got acne in between\u003c/em\u003e.\u0026rdquo; (IDI-13, transman, 24 years, Thiruvananthapuram)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome respondents also had a fear of modern medicine and/or a preference for alternative systems of medicine, which led them to avoid seeking conventional health care. Instead, they relied on herbal concoctions and home remedies, potentially overlooking the need for professional medical evaluation and treatment for their health needs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I had COVID \u0026hellip; I took lots of ayurvedic and homemade treatments\u0026hellip;we get lots of messages on WhatsApp, right? As forwards [forwarded messages]\u0026hellip;I used to drink these things daily in the evenings.\u0026rsquo;\u003c/em\u003e (IDI-10, transwoman, 41 years, Ernakulam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eAcceptability:\u003c/h3\u003e\n\u003cp\u003eRespondents lamented the lack of protocol in health care centres for the treatment of TGD people. There was often a reported lack of clarity regarding which ward a TGD person should be admitted to, as well as a lack of adherence to internationally recommended guidelines such as those prescribed by the World Professional Association for Transgender Health (WPATH), especially for procedures such as Hormone Replacement Therapy (HRT) and Sex Reassignment Surgeries.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We took the ticket itself saying that we are transwomen. In spite of that, they admitted us in the male ward for treatment. When I asked about this they replied saying \u0026ldquo;We make people like you lie here only\u0026rdquo;. So, I shouted at them and made a lot of noise and only after that, they unwillingly shifted us to the female ward.\u0026rsquo;\u003c/em\u003e (IDI-12, 27 years. transwoman, Ernakulam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe health provider\u0026rsquo;s conventional perceptions of sex and gender influence their approach and care, which in turn impacts the community\u0026rsquo;s acceptance of seeking care. One transwoman, who had not yet undergone a complete surgical transition, who presented with a genital rash, reported being denied care by a female nurse.\u003c/p\u003e \u003cp\u003eAmong those surveyed, 55% felt that there was a dearth of HCWs who were friendly to TGD people.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eGovernment hospitals have transphobic doctors \u0026hellip; they speak to us in a bad way \u0026hellip; He (the doctor) asked me if we can have sex like normal people and if we get periods every month like women do.\u0026rdquo;\u003c/em\u003e (IDI-6, transwoman, 33 years, Ernakulam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA few respondents opined in the qualitative interviews that they harboured a deep anger or mistrust towards the health system because of previous unfavourable incidents including transphobic ones and the perceived inadequacy of care received for self or family members.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003ePersonally, I feel anger towards the institutions \u0026hellip; they don\u0026rsquo;t give us our basic rights \u0026hellip; some people talk very sympathetically \u0026hellip; some people think it is a disorder \u0026hellip; like oh this is something that cannot be changed since it is a birth defect \u0026hellip; there are even doctors who think like this\u0026rdquo; (\u003c/em\u003eIDI-12, transwoman, 27 years, Ernakulam district)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInternalised stigma and rejection anticipation was also evidently expressed by some respondents with some incidents that could possibly be explained otherwise being attributed to transphobia and this sometimes affected the ability to seek care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Before the surgery we use binders to cover our breasts. We are stuck in between being male and female. We might desire to go to a male ward, but we cannot. We cannot go to the female ward either.\u0026rdquo;\u003c/em\u003e (IDI-13, transman, 24years, Thiruvananthapuram district)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRejection anticipation impacted gender expression to the degree that some respondents chose to not reveal their gender identities at hospitals. Out of the 70 respondents in the quantitative survey who didn\u0026rsquo;t not report facing discrimination at health centres in the past year, 27 percent didn\u0026rsquo;t reveal their gender identities at hospitals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI don\u0026rsquo;t reveal my identity at hospitals any more. Once when I did, the doctor reacted in a bad way. Till then, he was speaking to me well. When I told him I am trans, he didn\u0026rsquo;t say anything after that \u0026hellip;. Just gave me some medicines quickly\u003c/em\u003e.\u0026rdquo;- IDI-13, transman, 24 years, Thiruvananthapuram district)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eAvailability and accommodation:\u003c/h3\u003e\n\u003cp\u003eThere was a reported insufficiency of initial support at government health centres. For instance, one respondent presenting with gender dysphoria at a government hospital was referred to a mental health institute in another state.\u003c/p\u003e \u003cp\u003eAccess to counselling services, for both TGD people and their families, was also reported to be a problem for respondents, especially considering that mental health issues were one of their prime concerns due to loneliness, discrimination and abuse suffered at the hands of the general community and in some cases their own partners. TGD people were uncomfortable at government hospitals for counselling purposes due to large crowds and the consequent inability of counsellors to dedicate sufficient amount of time to each patient, whereas the exorbitant prices of private facilities made them an unsustainable option. The currently available government helpline for TGD people was largely deemed to be counterproductive due to restricted timings and difficulty in connecting at crucial times.\u003c/p\u003e \u003cp\u003eGeographical barriers were reported as a reason for delayed health care seeking, especially in the case of specialised services such as HRT and SRS, which were available only in a limited number of private hospitals across the state. No single facility provided all essential services routinely, necessitating long-distance travel to access even a portion of the required services. This fragmentation and limited availability of services posed barriers to timely and equitable healthcare access.\u003c/p\u003e \u003cp\u003eSocial support further influenced the ability of TGD people to navigate and access health care facilities. A larger proportion of those who lived away from their families were likely to have faced discrimination at a health care centre. This was probably because those living with families often visited the same centre with their families over prolonged time periods leading to familiarity with the staff. Such support also highlights the interplay between social position and the accessibility of healthcare services.\u003c/p\u003e \u003cp\u003eThe quality of lab facilities was also bemoaned due to the unaffordable cost of certain tests and scans and frequent false positive results, especially for Sexually Transmitted Illnesses, leading to unnecessary turmoil.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThere is a need for better testing. I have one friend \u0026hellip; she does not go for sex work. Yet one day when she tested at the TG clinic, her VDRL was positive. She was so tensed and upset. So then we went and retested at government hospital thrice and all three time it was negative. Once they are sure of the result only they should inform us\u003c/em\u003e.\u0026rdquo; \u0026ndash; IDI-7, transwoman, 22 years, Ernakulam district)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLack of personal mobility due to financial constraints was also reported. Financial issues majorly contributed to delays in health care seeking especially for HRT. Out of the 71 (59.16%) respondents who had started HRT, 12 (16.9%) had discontinued treatment due to reasons such as lack of finances or inability to deal with the physical side effects of the hormones. Since such a specialised service was offered only by private health care, they lacked the option to choose the more affordable and locally available public health care alternative. Some respondents cited other priorities such as the responsibility of caring for aged or unwell relatives as well as constraints due to job timings as factors that delayed their ability to reach and utilise health care.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThe dimension of \u0026ldquo;affordability\u0026rdquo;\u003c/h2\u003e \u003cp\u003eAmong those surveyed, 62.5% preferred government centres for their general health care needs, where services are largely free in Kerala. Almost 43 percent cited affordability as the main factor that affected their choice of centre for health care.\u003c/p\u003e \u003cp\u003eThere was also a reported lack of specialised services, such as HRT and SRS, in government hospitals. As a result, access to these potentially necessary but expensive services, was limited to those who could afford private care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe doctors don\u0026rsquo;t know how to treat us \u0026hellip; about our hormones. If they were knowledgeable, why is it that there is not a single government hospital in Kerala where we can get hormone treatment? They started one\u0026hellip;did one surgery I think and then stopped it. If it was there in government, it was convenient for us since we won\u0026rsquo;t have to pay so much at private hospitals\u003c/em\u003e (IDI-8, transwoman, 36 years, Ernakulam).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEven though the Government of Kerala issues reimbursements for SRS, this was only disbursed after the completion of the surgery, which was cited as a drawback by respondents since they still had to struggle to make the preliminary payment for surgeries.\u003c/p\u003e \u003cp\u003eThe majority of the respondents (84.2%) also did not have any form of insurance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWhen the Kerala TG policy came out in 2014, health insurance was included in that. But it has not been implemented...they say it is coming\u0026hellip;but we have not gotten it yet\u0026hellip;when I got COVID, it turned into pneumonia\u0026hellip;It cost close to 1 lakh rupees\u003c/em\u003e\u0026rdquo; (IDI-13, transman, 24 years, Thiruvananthapuram.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe limited capacity of TGD people to generate resources, affected their ability to pay for health care services. Some of those who were well educated and in regular jobs, resorted to sex work temporarily in order to finance their surgeries.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAppropriateness\u003c/h3\u003e\n\u003cp\u003eA range of infrastructural barriers hampered TGD people\u0026rsquo;s access to health care services. The unavailability of gender-neutral washrooms was considered to be a problem by 47 (39 percent) of the respondents and many avoided using washroom altogether.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWhenever we go out, passing urine is very difficult. Sometimes, I hold it till I reach home\u003c/em\u003e.\u0026rdquo; \u0026ndash; IDI-4, transwoman, 28 years, Kollam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAn issue that cropped up, though albeit with lesser frequency, was the inappropriateness of registration forms at health centres which was reported by 17.5% of the respondents. Many respondents were faced with uncomfortable questions from health care workers (HCWs) while filling out the forms with many of them falsely assuming that surgical transition was mandatory in order to identify as a transgender person.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eFilling forms is sometimes difficult because there will only be two options i.e. male and female. Even if we tick female, questions like \u0026ldquo;Have you become female?\u0026rdquo; will be asked. So a transgender option should be there. It is coming in some places but it not that popular yet.\u003c/em\u003e\u0026rdquo; (IDI-1, transwoman, 38 years, Ernakulam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNearly 42% of respondents reported experiencing discrimination at a health centre within the past year. This discrimination often took the form of outright refusal of treatment, even in situations the respondents perceived as emergencies. Reports of treatment refusals were especially common for services in high demand by the community, such as HRT and SRS.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eOne day at a program, two men asked us our rate. I told him that we were here for a programme and that we are going to the hall. But they didn\u0026rsquo;t agree and started grabbing and pulling us\u0026hellip; he pulled my dress and banged my head against a wall. Other people gathered there and they called the police. The police took them and told us to go to the hospital. We went to the hospital \u0026hellip; I was in pain and my forehead was bleeding. My neck was covered in scratch marks and wounds. We waited for a long time and the doctor didn\u0026rsquo;t even come and look at us. After this, the police bought these accused people to the same hospital. The doctor quickly examined them and wrote (prescriptions). I was there first \u0026hellip; lying there and crying out of the pain\u003c/em\u003e.\u0026rdquo; - IDI-2, transwoman, 36 years, Ernakulam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA recurring issue mentioned by respondents was the delay in receiving treatment, often even in emergencies. Some reported being made to wait until all cisgender patients had been attended to.\u003c/p\u003e \u003cp\u003eUbiquitously across all interviews, respondents reported a sense of angst and discomfort due to the demeaning looks and comments that they were subjected to from cisgendered patients at health care centres.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I prefer going to private\u0026hellip;it might cost more, but when we go to the general (government) hospital here, there is a lot of discrimination. When we take the ticket, they act like \u0026hellip; how do I put it \u0026hellip; they treat us like some different creatures. Not everyone \u0026hellip; some people...\u0026rdquo;\u003c/em\u003e \u0026ndash; IDI-8, transwoman, 36 years, Ernakulam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe majority (80%) of those surveyed felt that health care workers lacked adequate knowledge about transgender and gender diverse (TGD) people. This lack of understanding is a direct consequence of the marginalized social position of the transgender community, which leaves health care personnel ill-prepared to offer appropriate and respectful care. They were often faced with derogatory remarks and queries from even senior HCWs and were often questioned regarding the need for transitioning to the gender they identified with.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe doctors don\u0026rsquo;t know how to treat us\u0026hellip;about our hormones\u0026hellip;\u003c/em\u003e\u0026rdquo; (IDI-8, transwoman, 36 years, Ernakulam)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis lack of knowledgeable doctors probably contributed to the fact that only 31 (25.8 percent) consulted the same doctor regularly, with 25 of them consulting doctors in the private sector. Respondent reported feeling uneasy visiting multiple doctors, since it would require sharing personal details about their transitions and illnesses to multiple people at each visit.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWe prefer to be able to see 1 doctor constantly, so as to avoid repeating and explaining physical issues which might have occurred during sex work\u003c/em\u003e \u0026ndash; IDI- 12, transwoman, 27 years, Ernakulam district)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also reported insufficient information regarding hormone replacement therapy (HRT) and its outcomes. For instance, one transman expressed feeling shocked and disappointed when he began menstruating shortly after starting HRT, having been inadequately informed about what to expect. This lack of information further contributed to the diminished approachability of the health care system for those seeking care.\u003c/p\u003e \u003cp\u003eThe perceived lack of appropriate care affected the TGD individuals in their ability to engage in the health care seeking process. Rushed consultations left no opportunity for some respondents to ask queries and drastically minimised the patient-provider interaction.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eEarlier (before transition), the doctors used to place the stethoscope on our chest and see if we have any breathing difficulties \u0026hellip; they used to understand what our illness is. Now, they will just ask if we have any allergy for any medicine. As soon as we say no, they will write a lot of medicines and give us\u003c/em\u003e.\u0026rdquo; (IDI-9, transwoman, TRV, 35 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn line with the participatory research approach adopted for this study, respondents were asked for their suggestions to improve health care access for TGD people, so as to engage with their priorities and perspectives. The major suggestion that emerged was the provision of awareness and training sessions for HCW\u0026rsquo;s, especially for doctors regarding SRS and HRT. The respondents opined that HRT and SRS could be done in government hospitals at a fraction of the cost currently charged in private hospital which would ultimately lead to savings for the government since reimbursement of the large sums for procedures done in private hospitals would not be required. The provision of these specialised services in at least one government hospital per district could also abdicate the struggle of the TGD people to pay huge amounts upfront for their surgeries and travelling long distances for availing these services. In addition to HCW\u0026rsquo;s, awareness sessions for the cis-gendered society were also deemed to be a necessity, starting at school level and extending up to the level of Local self-government institutions to insure inclusivity and avenues for assistance in case of unsupportive family members. Affordable and accessible counselling services was also an oft repeated demand of the respondents \u0026ndash; both for them and their family members.\u003c/p\u003e \u003cp\u003eThe respondents were almost equally divided regarding the need for separate clinics for TGD people, with 52.5 percent preferring that the existing primary health centres be made TGD friendly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWhat is the need for a separation? We are also ladies. There is no difference. If u slash our hands, it is blood only that flows out\u003c/em\u003e.\u0026rdquo; (IDI-3, transwoman, Ernakulam,20 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEven though the focus of this study was determining the barriers to health care access, not presenting the other side of the story would result in a partisan view - the side that demonstrates the slowly evolving changes in the health system and the stories of resilience that many community members exhibited. Many shared positive experiences at health care centres, with some opining that HCW\u0026rsquo;s mirror their attitudes and behaviours.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhen I had corona\u0026hellip; it was very crowded and it was very difficult for me. So, I told them my difficulty and asked them for a separate room. They gave me a separate room...they gave me special attention and consoled me a lot\u0026rdquo; \u0026ndash;\u003c/em\u003e (IDI-2, transwoman, 36 years, Ernakulam district)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIt also depends on how we act with them (HCW\u0026rsquo;s)\u0026hellip; that is how they will act with us too. I speak with them nicely, so they care for me too. When I go with some other friends, because of the way they act, things can go wrong.\u003c/em\u003e\u0026rdquo; (IDI-7, transwoman, Ernakulam,23 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFew respondents also acknowledged that some of the barriers they faced, especially at some government hospitals which are infamous for being overcrowded beyond capacity, are not exclusive to TGD people.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eNot as a trans, even as a common man I have had arguments at the counter. And everyone around me supported me saying that they were also waiting for a long time. It is a common problem in government hospitals. It is not just cis or trans... generally, people are suffering\u003c/em\u003e.\u0026rdquo;- (IDI-5, Transman, 37 years, Trivandrum district.)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents also conveyed gratitude for the perceived progressive changes in the recent past, and expressed hope that the future would be even more inclusive.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWe are enjoying the fruits that people before us have planted. So, the generations after us will enjoy the fruits of the trees we plant. All the freedom that we achieve, will be enjoyed by the future generations\u003c/em\u003e.\u0026rdquo; (IDI-3, transwoman, Trivandrum district, 43 years)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study aimed to explore the barriers to health care access as experienced by the transgender and gender-diverse (TGD) community in Kerala, India. The barriers were framed using the concepts of approachability, acceptability, availability and accommodation, affordability, and appropriateness of the health system and its service providers, as conceptualised by Levesque et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsistent with existing literature, financial constraints, lack of protocols, insufficiently trained health care workers, and discrimination emerged as significant obstacles.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Although these barriers are common to similarly marginalised communities,(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) it is important to consider why the TGD community, in particular, faces these challenges more acutely, especially in Kerala\u0026rsquo;s health system where the general population experiences relatively better health outcomes compared to national averages.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDespite Kerala being the first state in India to introduce a welfare policy for the transgender community(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and establish a transgender cell(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) to safeguard their rights \u0026ndash; with future initiatives geared towards making the health system more affirmative and responsive to their health needs \u0026ndash; barriers to accessing care persist. These policies and initiatives have emerged in a context shaped by decades of deep-seated societal norms and prejudices, which impede and resist their effective implementation. Many participants in this study took the empowering step of disclosing their gender identity to formal health care providers, yet their experiences highlight the limitations of the existing system, which can alienate or exclude them, even when supportive policies are in place.\u003c/p\u003e \u003cp\u003eTheir experiences with existing social structures provoke distrust, stemming from historical and ongoing harassment by institutions such as law enforcement, which while expected to protect communities indiscriminately, in reality, perpetuate harm among the disadvantaged ones.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis divide between policy and practice reflects the inherent design of social systems, which tend to mirror the power imbalances within broader society.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Health care institutions are naturally inclined to prioritise utilitarian goals, often at the expense of addressing the urgent concerns of marginalised groups. Their approaches are influenced by harmful stereotypes and personal biases, reinforced by cultural factors and underlying power dynamics. As a result, well-intentioned policies fail to gain traction without naming and addressing the deeper issues of institutional power abuse and denigrating societal attitudes.\u003c/p\u003e \u003cp\u003eThe collectively compromised social position of TGD individuals in Kerala \u0026ndash; marked by educational and financial disparities \u0026ndash; further impedes their health care access. As observed in the Kerala Social Justice Department survey,(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) many TGD individuals drop out of school due to discrimination, curtailing their educational attainment and, consequently, their access to stable employment. A majority of the study participants reported having only a high school education or less, alongside infrequent or no income, reflecting the limited employment prospects available to them. These socio-economic disadvantages preclude them from accessing specialised services provided by non-governmental organisations or the private sector.\u003c/p\u003e \u003cp\u003eIn this context, social support plays an important factor in health care access. TGD individuals who seek health care services with their families reported facing less discrimination than those without familial support. This may be due to the opportunity to foster more stronger relationships between family members and health care providers, thereby reducing the burden on TGD individuals to seek health care independently. Conversely, those lacking social support are more vulnerable to victimisation and neglect within the health system, perpetuating disparities, and, at times leading to harmful coping behaviours, as documented in previous research.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe general assumptions held by healthcare providers, shaped by conventional medical education, further compound these barriers. The training that they receive rarely addresses the challenges faced by the TGD community, leaving them ill-equipped to offer sensitive and appropriate care.(\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Moreover, the current health care infrastructure often fails to accommodate the specific needs of TGD individuals. Consistent with prior research, issues such as the design of toilets and inclusivity in registration forms remain problematic,(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) while our study identified additional challenges related to consultation waiting times and ward admission protocols. These design failures are not merely technical oversights but reflections of the underlying power dynamics that moderate the need for institutional change, reinforcing systemic neglect.\u003c/p\u003e \u003cp\u003eThe inadequacy of current government healthcare services in meeting the needs of this community is evident in the fact that only 25 percent of TGD individuals have a regular doctor. While government healthcare utilisation has increased overall,(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) the TGD community remains underserved, primarily due to the lack of facilities tailored to their specific requirements.\u003c/p\u003e \u003cp\u003eAddressing the health care needs of the TGD community and identifying the barriers they face to access require systemic changes that go beyond the health sector. However, the health system can take a leading role in initiating these changes by adopting a person-centred approach that acknowledges the unique social disadvantages faced by this community. Expanding access to specialised services, such as hormone replacement therapy and sex reassignment surgeries, in at least one government hospital per district, would alleviate some of the current barriers.\u003c/p\u003e \u003cp\u003eDiversity in medical education and health care practice is essential for cultivating an inclusive environment that can begin to deconstruct systemic biases and misconceptions. While these reforms will take time, they are critical to ensuring that healthcare services become truly accessible to all vulnerable groups.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe main barriers to health care access by the transgender and gender-diverse community, as identified in this study, include financial constraints, discrimination; inadequate registration forms, toilet facilities and admission protocols; the inability to consult the same doctor consistently, a perceived lack of awareness and responsiveness among health care workers, lack of reliable sources of information, internalised stigma and the absence of properly functioning clinics for transgender people. Many of these barriers are rooted in the social position of this community and the unique vulnerabilities that amplify their challenges with the health system and health care access. To achieve meaningful improvements, the social determinants of transpersons\u0026rsquo; health must be both acknowledged and addressed with intentionality.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eGlossary\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTransgender: or trans are umbrella terms used to describe people whose gender identities and/or gender expressions are not what is typically expected for the sex to which they were assigned at birth.(40)\u003c/p\u003e\n\u003cp\u003eTransgender men or Trans men or Men of trans experience are people who have gender identities as men and who were assigned female at birth. They may or may not have undergone any transition.(40)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTransgender women or Trans women or Women of trans experience are people who have gender identities as women and who were assigned male at birth. They may or may not have undergone any transition.(40)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGender fluid: denoting or relating to a person who does not identify as having a single unchanging gender. (Oxford Languages)\u003c/p\u003e\n\u003cp\u003eHormone Replacement Therapy (HRT): Hormone replacement therapy, also called transgender hormone therapy, or gender-affirming hormone therapy (GAHT), is a form of hormone therapy in which sex hormones and other hormonal medications are administered to transgender or gender.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSex reassignment surgery (gender affirmation surgery): Surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity. Sex reassignment surgery can be an important part of medically necessary treatment to alleviate gender dysphoria.(41)\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study was undertaken after getting clearance from the Institutional Ethics Committee (IEC) of Sree Chitra Tirunal Institute for Medical sciences and Technology (IEC Regn No. ECR/189/Inst/KL/2013/RR-21) which follows national guidelines as prescribed by Central Drugs Standard Control Organisation (https://cdsco.gov.in/opencms/opencms/en/Home/). \u0026nbsp;The IEC clearance (SCT/IEC/1818/JANUARY/2022) was obtained on 02-03-2022.\u003c/p\u003e\n\u003cp\u003ePermission was also obtained from the state mission director of the NHM, in order to attend and collect data at the camps conducted by them. Participants were informed of benefits and risks and they had the freedom to refuse participation or withdraw from the study\u0026nbsp;at\u0026nbsp;any\u0026nbsp;point.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The corresponding author will provide the transcripts, data set and analysis of the current work on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e the study was self-funded and did not receive any financial support from any source.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Dr. Bhavya Benzigar Fernandez proposed the topic, prepared the protocol and tools, collected data, undertook data analysis and prepared the first draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e2) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Dr. Rakhal Gaitonde, supervised the work and contributed to the conceptualisation and design of the study, conducted part of the qualitative analysis and made revisions to the report to finalise the manuscript.\u003c/p\u003e\n\u003cp\u003eBoth authors have approved the manuscript in its present form.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the National Health Mission for approving and complementing the study\u0026rsquo;s execution. In addition, we appreciate all the community members whose co-operation assisted in the conduct of the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGreen ER, Maurer L. Planned Parenthood of the Southern Finger Lakes I. The teaching transgender toolkit: a facilitator\u0026rsquo;s guide to increasing knowledge, decreasing prejudice \u0026amp; building skills. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBecker T, Chin M, Bates N, and editors. National Academies of Sciences, Engineering, and Medicine. Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation; Measuring Sex, Gender Identity, and Sexual Orientation. [Internet]. [Internet]. Washington (DC): National Academies Press (US). 2022 Mar 9. Summary; 2022. 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Int J Transgenderism. 2012;13(4):165\u0026ndash;232.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"transgender health, gender-affirming care, health care access barriers","lastPublishedDoi":"10.21203/rs.3.rs-6826079/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6826079/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite numerous efforts to implement inclusive policies in Kerala, transgender and gender-diverse (TGD) individuals continue to face institutional discrimination, resulting in significant challenges in accessing health care. Existing literature highlights the need for actions to expand the availability and utilisation of health care services for these individuals to prevent institutional erasure. This study aimed to identify the barriers health care faced by transgender people in Kerala.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn-depth interviews with 13 transgender people as part of a larger mixed-methods study.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis study examined barriers to healthcare access among transgender people in Kerala, using Levesque et al.'s framework. Participants (mean age 33 years) included transwomen (73%), transmen (22%), and gender-fluid individuals (5%). Key barriers included the limited functionality of the specialised TGD clinics, a perceived lack of awareness and responsiveness among health care workers, and experiences of discrimination. Financial constraints further restricted access to hormone therapy and gender-affirming surgeries. Structural barriers, such as the absence of gender-neutral facilities and inadequate admission protocols compounded these challenges. Participants emphasised the need for health care worker training and the expansion of public provision for gender-affirming care to address these barriers.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe identified barriers are deeply rooted in the social position of the TGD community, necessitating an approach that acknowledges the social determinants of their health to achieve meaningful improvements in health care access.\u003c/p\u003e","manuscriptTitle":"Barriers to health care access among transgender people in Kerala","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-29 14:32:52","doi":"10.21203/rs.3.rs-6826079/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-23T08:45:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-17T22:07:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T10:01:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T04:06:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30175905155794399903204864963459556450","date":"2025-06-26T04:33:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306400006405542494760368235959313497097","date":"2025-06-24T07:14:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29182104928680927390846875598772721349","date":"2025-06-23T20:44:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-23T12:27:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-09T15:07:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-09T13:02:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2025-06-05T06:49:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0aa1dc3-d14d-4667-8325-9278e5793a64","owner":[],"postedDate":"June 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:12:45+00:00","versionOfRecord":{"articleIdentity":"rs-6826079","link":"https://doi.org/10.1186/s12939-026-02803-4","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2026-03-11 16:00:00","publishedOnDateReadable":"March 11th, 2026"},"versionCreatedAt":"2025-06-29 14:32:52","video":"","vorDoi":"10.1186/s12939-026-02803-4","vorDoiUrl":"https://doi.org/10.1186/s12939-026-02803-4","workflowStages":[]},"version":"v1","identity":"rs-6826079","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6826079","identity":"rs-6826079","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}