Deliberate Absence: Mapping the Presence of Indian Transgender and Gender Diverse (TGD) Youth in Social and Medical Rights-Based Work Initiatives for the Community

Abstract

Background:

Adolescence, the transitional phase between childhood and adulthood, involves significant biological, social, cognitive and emotional changes. In India, adolescents (10–18 years) form 21% of the population, increasing to 33% when including those aged 10–24 years, making India home to the world’s largest adolescent population. The concept of adolescence, unlike the biological process of puberty, is culturally determined and influenced by globalisation and changing societal values.

Objectives:

This article aims to (a) elucidate the barriers hindering transgender and gender diverse (TGD) youth in India from accessing gender affirmation, including familial rejection, constraining legal provisions and inadequate public health infrastructure; (b) underscore the impact of socio-cultural and political attitudes on health disparities faced by TGD youth, emphasising the need for comprehensive and individualised healthcare and socio-cultural support; (c) advocate for a socio-medical approach to address the unique challenges of Indian TGD youth, focusing on collaborative efforts among healthcare professionals, social institutions and policymakers; (d) propose strategies for improving access to early gender-affirmative care, including training healthcare providers, promoting comprehensive medical support and advocating for the rights of TGD youth.

Methods:

A blind review of literature was conducted using PUBMED/MEDLINE, Google Scholar, Web of Science, PsycINFO and SCOPUS with keywords such as ‘transgender youth’, ‘nonbinary and gender diverse youth’, ‘gender-affirming medical care in India’ and ‘youth mental health’. The search eventually included peer-reviewed publications, books, reviews, editorials, opinion pieces, feature stories and individual case reports. Articles were screened and thematically analysed to synthesise findings.

Results:

The review highlights significant barriers to gender-affirming care for TGD youth in India, including familial rejection, restrictive legal frameworks and inadequate public health infrastructure. Socio-cultural and political attitudes contribute to health disparities, necessitating comprehensive healthcare and socio-cultural support.

Conclusions:

Addressing the challenges faced by TGD youth in India requires a socio-medical approach, emphasising collaborative efforts among healthcare providers, social institutions and policymakers. Strategies for improvement include training healthcare providers, promoting comprehensive medical support and advocating for the rights of TGD youth to ensure early and effective gender-affirmative care.

Introduction

Adolescence, the transitional phase between childhood and adulthood, is an important developmental period marked by relatively rapid biological (puberty), social (new roles), cognitive (advanced cognitive abilities emerge) and emotional changes (self-image, intimacy, relationship with adults and peer group).^1–3 In India, it is estimated that adolescents aged 10–18 years make up 21% of the total population, and this percentage increases to 33% when young people aged 10–24 years are included. ⁴ Thus, it is not surprising that India has the world’s largest adolescent population. ⁵ The developmental stage referred to as ‘youth’ or ‘adolescence’ (these terms are used interchangeably in this article to denote young persons aged 10–18 years), unlike puberty, is culturally determined and not universal. While puberty is considered to be a biological process, adolescence is rather a transitional period. Consciousness about adolescence as a phase is a fairly recent phenomenon in the Indian context. This growth in awareness is attributed to increased globalisation, individualism, materialism and cyber connectivity, as well as shifts in value systems and developmental trajectories. ⁶ Traditionally, the transition from childhood to adulthood in Indian society was smooth, organic and marked by continuity; free from the rebellion, disruption and conflicts ⁷ that dominate the Western construction of the concept. This is still the case in various economic classes, genders and geographies. ⁸

As per the ancient Indian stages of life, or what is termed the ‘Ashram Dharma’, youth forms part of the stage of Brahmacharya, which is marked by self-discipline, preparation to achieve braham (i.e., the individual’s ultimate potential, or what the humanistic school of thought would term ‘self-actualising tendencies’), focus, celibacy, and freedom from distraction. Due to diversity in psychosocial backgrounds and cultural variation, perceptions of adolescence differ. However, resistance to the concept of adolescence persists across all social groups. ⁹ That said, India as a society remains uncomfortable with the sexual agency, risky behaviour and questioning of authority that this individualised version of youth entails because these potentials challenge the value of interdependence that is emphasised by India’s strong kinship networks and collectivist culture. ¹⁰ The same can be seen in many societies in which youth are subjected to various forms of ageism, which often result in a tendency to doubt young people, their identities, their agency and to dismiss their voices and needs. ¹¹ As a result of this mentality, insufficient attention and resources have been devoted to people of this age group. Thus, Indian adolescents remain an unserved population group, ¹² with their social, physiological, psychological and physical needs left unmet in national policies and strategies.

This is especially the case for the population of adolescents that is gender diverse. Transgender and gender-diverse (TGD) youth face significant challenges due to their non-normative gender identities. Their age exacerbates these difficulties, subjecting them to ageism, transphobia and cisnormativity. This intersection of ageism and cisnormativity results in heightened developmental oppression, characterised by experiences of non-recognition and invisibility, making it hard for them to receive adequate attention and support in India. ¹³

Yet, India as a country is not estranged from gender diversity. It has the largest population of TGD people ^1* in the world, that is, approximately half a million transgender persons. ¹ This number is likely underestimated, according to members of the transgender community and organisations that work with them. ¹⁴ Gender diversity has been recorded in Indian society for over 4,000 years. Evidence of this can be found in the form of images depicting gender transgression in temples and cave carvings throughout the country, as well as in various manuscripts. ¹⁵ The hijras ^2* of India held important positions in the court and the administration during the Mughal era. Thus, Indian society once respected and celebrated gender diversity, ¹⁶ but in post-colonial times, there was a shift towards a rigid and legitimised enforcement of the gender binary. Colonisation, therefore, has had many consequences for the Indian TGD population, fundamentally altering how they are perceived and treated in society. ¹⁷ As such, the TGD community has experienced a century of compromised human rights and ostracisation. They have been shunned and ridiculed; subjected to constant surveillance and threats of criminal action, prejudice, social intolerance, public violence and police brutality; and faced a lack of education and employment opportunities. These factors have combined to trap this group in a vicious cycle of isolation, poverty, degradation, exploitation and violence. ¹⁸

Today, India has implemented progressive administrative and legislative initiatives and has demonstrated the political will to ensure the protection of TGD people. The landmark Supreme Court judgement of 2014, known as the NALSA judgement, ¹⁹ granted TGD individuals full citizenship and the right of self-recognition of their gender as third gender or binary gender. Path-breaking Transgender Persons (Protection of Rights) Rules of 2020 ²⁰ seek recognition of the identity of TGD persons and prohibited discrimination in all walks of life. A national portal has been set up by Ministry of Social Justice and Empowerment (2022) ²¹ for comprehensive rehabilitation and welfare of TGD persons. Recent advisory by The Ministry of Home Affairs is a step to ensure recognition of TGD persons in prisons. ²² Ongoing setting up of a Centre of Excellence to ensure comprehensive training and treatment of needs and concerns of transgender health at the All-India Institutes of Medical Sciences ²³ are testimonial of these initiatives. That said, these protections apply only to the adult population. Indeed, despite the National Education Policy (2020) that requires equity and inclusion of TGD children in education, ²⁴ societal measures and protection have generally been limited to adults. Consequently, TGD youths’ social and medical needs and rights are rarely discussed by policymakers and care providers. Initiatives directed towards the needs and welfare of TGD youth are therefore progressing slowly and majority of these initiatives have not carried over to TGD youth.

This article examines the factors that facilitate and impede social support for TGD youth in India and their access to gender-affirming healthcare. Supported by the World Professional Association of Transgender Health, gender-affirming medical care (GAMC) for adolescents includes interventions such as puberty blockers or hormone therapy to alleviate gender dysphoria. ²⁵ Puberty is a critical developmental period for TGD youth as their autonomy increases, allowing them to affirm their gender more strongly. However, puberty also leads to significant body changes and potential distress due to increased incongruence between sex assigned at birth and gender identity, prompting some to seek GAMC.^26,27

The article was conceptualised during the recruitment process for an internation, longitudinal qualitative study titled ‘Growing Up Trans’ spanning across Australia, India, the UK, the USA, Canada and Switzerland, TGD youth aged 8–15 and their families were to be interviewed by local researchers about their trajectories of medical and social gender affirmation. Only four families with TGD youth could be contacted despite a year-long effort to find possible participants through non-government organisations and community-based organizations (NGOs and CBOs) dealing with trans community, activists, schools and education-based NGOs, trans-health-based organisations (when the aim was 10 families). There was general unease about dealing with the minor TGD group. The absence of database, intelligibility or standardised system in place to serve the transgender youth in the country with the biggest number of transgender people worldwide was bothersome and led to the idea behind this article.

This article presents a review of literature about the social context, medical care model and key legislation in India that have contributed to stereotypical and deeply ingrained attitudes towards gender non-normativity and the absence of young TGD population from human and medical rights discourses and policy initiatives. A blind review using the keywords ‘transgender youth’, ‘nonbinary and gender diverse youth’, ‘gender affirming medical care in India’ and ‘youth mental health’ was carried out on PUBMED/MEDLINE, Google Scholar, Web of Science, PsycINFO and SCOPUS. The search results were restricted to human users, peer-reviewed publications and English-language sources. Due to a lack of academic publications based in Indian context, the scope was expanded to include books, reviews, editorials, opinion pieces, feature stories and individual case reports. The information was obtained between October 2023 and the subject’s founding. October 1, 2023 was the date of the most recent search. Articles were first screened according to their title and abstract, and then the entire title for those that were judged to satisfy the preliminary screening standards. Data were extracted from the articles and thematically analysed to synthesise findings.

The aims of this article are (a) to elucidate the multifaceted barriers hindering TGD youth in India from accessing gender-affirmation, including familial rejection, constraining legal provisions and inadequate public health infrastructure; (b) to underscore the impact of socio-cultural and political attitudes on health disparities faced by TGD youth, emphasising the need for comprehensive and individualised healthcare and socio-cultural support; (c) to advocate for a socio-medical approach in addressing the unique challenges of Indian TGD youth, focusing on collaborative efforts among healthcare professionals, social institutions, and policymakers; and (d) finally, to propose strategies for improving access to early gender-affirmative care, including training healthcare providers, promoting comprehensive medical support and advocating for the rights of TGD youth.

Unique Social and Medical Care Needs of Transgender and Gender-diverse Youth in India

Despite observable ‘modernist’ trends and secularising trajectories, India remains deeply orthodox, with entrenched attitudes regarding traditional family structures, gender roles, permissible gender performance and other alterations in gender-based social orderings. Therefore, intimate spaces such as the family can be extremely non-supportive of and violent towards gender transgression. ²⁸ TGD youth are the targets of various form of maltreatment, fuelled in part by the prevalence of hypermasculine mindsets ²⁹ that punish stereotypically feminine traits in men. ³⁰ TGD youth assigned male at birth are often shunned by their families, particularly by male relatives, and subjected to familial physical abuse ³¹ and are pushed out from their homes ³² for unconventional gender performance. Little is known about India’s trans feminine adolescents, which may be a reflection of the low status of their birth sex, ³¹ as Indian culture privileges men over women ³³ and values sons more than daughters. ³⁴ Chakrapani et al highlight that gender norms, enforcement of gender roles and experiences of rejection and discrimination within family and social environments present significant obstacles for trans female TGD youth in affirming their gender identity and sustaining mental well-being in Indian context. They demonstrate that pressure to conform to assigned gender roles and gender policing typically begins in adolescence and increase over time, within familial context. ³⁵

Many gender-nonconforming or exploring youth are pushed out of the formal education system early.^36,32 Any diversion from the prescribed norm results in shaming, discrimination and harassment. Sahodaran—a male sexual health project in collaboration with UNESCO—conducted a study among sexual and gender minority groups and found that 60% and 50% of those identifying outside of mainstream sexual identities were physically harassed in middle/high school and higher secondary school respectively. ³⁷ Sexual harassment was high among the primary-school-level participants, at 43%. However, only 18% of these respondents had reported the bullying to school authorities. A doctoral research project at the University of Delhi found that educational institutions enforce a cis-hetero binary model, privileging cisgender identities and heterosexual orientations. ³⁸ This normativity is perpetuated through key practices and ideologies, including student-teacher interactions, curriculum content, teaching methods and teacher interventions, ranging from silence and omission to occasional support. The study highlights the lack of inclusive curricula and accurate information, strict gender policing by elders and peers, on-campus harassment and limited freedom of visibility and decision-making in Indian education. ³⁸ In the ubiquitous and hegemonic version of socio-cultural reality, TGD youth take longer to understand, associate and validate their non-normative gender preferences. Sex education curricula have, until recently, emphasised the reproductive system, avoidance of adolescent pregnancy, HIV/AIDS and other sexually transmitted infections. ³⁹ Thus, participation in the available forms of formal education leaves gender-exploring or gender-incongruent learners in confusion and guilt, with body image issues and reliant on uncensored online content to help clarify their deeply felt emotions.

Thirty-one percent of TGD persons in India die by suicide, and 50% of them attempt suicide at least once before their 20^th birthday. ⁴⁰ While exact figures on completed suicides among TGD persons in the country remain unavailable, high levels of depression (43%), problematic alcohol use (37%), anxiety (39%), depression (21%), suicide risk (75.8%) and violence (52%) based on stigma and discrimination are reported in trans womens.^40–43. Four out of 10 TGD persons face sexual abuse before reaching adulthood, states a survey administered by the Swasti Health Resource Centre—a non-profit organisation—to 2,169 TGD respondents. Survey data indicate that the abuse starts as early as age five, but most vulnerable are those aged 11–15. ⁴⁴ A report from a qualitative study in West Bengal documented the prevalence of conversion or curative treatments for young transgender individuals. These treatments were administered by formal healthcare and mental health providers, as well as quacks and religious or spiritual leaders. ⁴⁵ Ranade et al. in Trans Affirmative Mental Health Care Guidelines highlight pathologising, medicalised approach to a trans-affirmative model of mental healthcare in India and urge for a shift in health practice, curriculum, teaching and training of mental health practitioners. ⁴⁶ A study conducted by the National Institute of Epidemiology with 60,000 transgender people across 17 Indian states found that a lack of familial support leaves young TGD persons vulnerable to abuse and violence. The findings showed that a large percentage of the survey sample received no support from their biological family. ⁴⁷ In addition, only 2% of Indian TGD persons live with their families. ⁴⁸ Many parents disown or evict their children due to societal shame, concern regarding marital prospects and so forth. ⁴⁹ Moving out may be done under the pretext of better educational or employment opportunities ⁵⁰ and physical and emotional distance from family may be maintained to cope and survive. ⁵¹ The rights of children and youth in India are viewed through the myopic lens of the gender binary, and there is an urgent need to think of children’s rights beyond this dichotomy. ⁵²

A considerable body of research reflects similar lived realities of youth across the world. Global research has established that TGD youth face significant stigma^53,54 and are at increased risk of self-harm, depression and anxiety with 2 to 3.5 times higher rate of suicidal ideation compared to non-TGDY^55–59 as well as a higher rate of eating disorders^60–62 and neurodevelopmental presentations such as autism, attention deficit hyperactivity disorder (ADHD) and intellectual disabilities.^63–65 They are more likely to experience victimisation and substance use disorders and to engage in risky sexual behaviour. ⁶⁶ Rejection by family, peers, teachers and their intimate circle (e.g., in the form of intentional use of the name and pronoun with which the youth does not identify, failure to acknowledge the affirmed gender identity, bullying, harassment, verbal and physical abuse, poor relationships, and eviction) is strongly linked to these negative outcomes.^67–72 It is important to note that negative symptoms increase with increased levels of rejection and continue into adulthood. ⁷² The combination of greater acuity and fewer healthcare provisions translates into poorer outcomes in adulthood in terms of substance abuse, traumatic experiences and behavioural health decompensation. ⁷³

Gender affirmation (GA), the process by which individuals are affirmed in their gender identity through social interactions as well as medical and legal affirmation and recognition mechanisms,^74,75 is known to be important in advancing the health of TGD populations. Emerging research indicates that youth who are affirmed in their gender identity experience positive mental health outcomes on par with those of their cisgender peers.^76,77 According to the Trevor Project’s 2022 Report, young people who felt strongly supported by their family reported attempting suicide at less than half the rate of those who did not receive support. ⁷⁸

Research shows that GAMC supports TNBY to live in the gender that feels most real and comfortable to them without experiencing restriction or ostracism. ⁷⁹ GAMC is known to positively affect many aspects of TGD youths’ well-being (e.g., social and psychological functioning), while lack thereof can lead to adverse health effects.^75,80–84. Treatment of TGD youth with GAMC decreases suicidality, self-harm, depression, anxiety, substance use and gender dysphoria and increases quality of life.^63,85–87. Furthermore, GAMC reduces the mental distress associated with the development of secondary sexual characteristics by providing time for the adolescent and their family to explore their gender identity, seek out psychosocial support, develop coping skills and define appropriate intervention goals. ⁸⁸ The Standards of Care version 8 points out that health should be promoted through public policies and legal reforms that advance tolerance and equity for TGD people and eliminate prejudice, discrimination and stigma. ²⁵ Hence, depriving TGD youth of the necessary healthcare is an attack on their fundamental rights to life and liberty, two principles clearly stated in The Constitution of India. ⁸⁹ The discussion highlights the significant gap in meeting the socio-medical care needs of TGD youth in the Indian context. This deprivation of necessary healthcare not only violates their fundamental rights but also perpetuates discrimination and invisibility.

International and Indian Standards of Healthcare for Transgender and Gender-diverse Youth

It is important to understand that adolescent health and well-being needs differ from those of children and adults due to several factors. These include puberty-induced physical changes, brain development, the exploration and concretisation of sexual identity, individuation from caregivers or parents and the development of abstract reasoning and decision-making capacity, which occurs alongside a lack of the life experience needed to inform high-stakes decisions. To provide a thorough understanding of the healthcare landscape for TGD youth, it’s imperative to delve into both international standards and their application within the Indian context. This section explores the unique challenges faced by TGD adolescents, examining global guidelines such as the World Professional Association for Transgender Health’s Standards of Care (SOC), alongside India’s evolving healthcare framework, including the recently developed Indian Standards of Care (ISOC-1). Through this examination, aim is to highlight the existing gaps, barriers and opportunities for enhancing healthcare access and support for TGD youth in India.

Discussions of adolescent health in the National Health Commission (an initiative led by the Indian Ministry of Health and Family Welfare) primarily focus on nutrition, education, counselling and guidance to ensure that youths develop into healthy adults. According to the programme, major threats to adolescent health include several preventable and treatable health problems, such as early and unintended pregnancy; HIV/AIDS and other sexually transmitted infections; nutritional disorders such as malnutrition, anaemia, and obesity; alcohol, tobacco and drug abuse; mental health concerns; injuries and violence. ⁹⁰ Gender-based identity development, associated dysphoria, gender affirmation and the required medical care are not mentioned under adolescent health facilitation, while the suggested health promotion approach retains a limited focus on the sexual and reproductive health of youth. There has been an unprecedented increase in the number and visibility of TGD people seeking support and gender-affirming medical treatment globally, as well as significant growth in the scientific literature in this area. ²⁵ Nonetheless, transgender medicine, surgery and endocrinology are absent from the Indian undergraduate medical curriculum. In addition, the lack of focus on transgender health at the postgraduate level means that most current medical practitioners are untrained in transgender medical issues and the treatment of transgender patients for general medical issues. ⁹¹

To increase scientific research on the lived experiences of people with non-normative gender identities and their healthcare needs and access, the World Professional Association for Transgender Health (WPATH) established the Standards of Care (SOC) in 1979. The SOC promotes the highest standards of healthcare for TGD people. It provides clinical guidance to healthcare professionals to assist TGD persons in safely achieving lasting comfort with their gender identities with the aim of optimising their overall physical health, psychological well-being and self-fulfilment. The latest version, the Standards of Care version 8 (SOC-8), is based on evolving scientific evidence and was commissioned in 2022, a decade after the publication of SOC-7.

In Chapter 6, SOC-8 provides clear recommendations for healthcare professionals who provide treatment to TGD adolescents. The recommendations include training these professionals to help diverse children, adolescents and families and to refrain from favouring a particular gender identity. The standards emphasise the importance of collaboration between professionals from various medical backgrounds in assessment and decision-making. Healthcare professionals are also advised to promote the social acceptance of diverse gender expressions by engaging with home, school, and other relevant social settings while respecting the autonomy of individuals. SOC-8 prohibits reparative and conversion therapy to align gender identity with sex assigned at birth among TGD youth and states eligibility conditions that must be met before the professional provides gender-affirming medical or surgical treatment requested by the patient. ²⁵

Indians, with their cultural, regional, linguistic, religious, economic and demographic diversity, have particular healthcare needs. Consequently, it is necessary to contextualise the global healthcare guidelines to the sociocultural context of the country. Given the lack of standardised and scientifically supported guidelines for gender affirmation and professional practice in healthcare settings, care providers and organisations working for health rights differ in their practices and expectations. ⁸⁸ The need for contextualisation led to the development of the Indian Standards of Care for Persons with Gender Incongruence and People with Differences in Sexual Development/Orientation (ISOC-1) in 2021. It adjusts the WHO’s views and WPATH’s globally accepted Standards of Care to the Indian context and formulates best practices for transgender health needs particular to the Indian context. ISOC-1 (2021) supports affirmative care, the early recognition of gender incongruity, early access to healthcare services and the provision of a gender-sensitive environment for psychosocial development, and stresses the need to adopt a multipronged, proactive approach to manage gender incongruence. The standards endorse puberty suppression and psychological support as the only GAMC to be provided to youth until they are old enough to give informed consent to gender-affirming hormonal intervention. ISOC-1 (2021), in addition to providing medical guidelines for work with TGD youth, places strong emphasis on sensitising the key stakeholders who engage with the gender identity of these young people on an everyday basis. It includes guidelines for family members, caretakers, teachers, therapists and allies and attempts to create a society free of intolerance, discrimination and injustice. ⁸⁸

Presently, GAMC is offered to TGD individuals and people experiencing dysphoria only after they reach 18 years of age, with or without parental consent. The Mental Health Care Act (2017) ⁹² enables those aged 16 years and above to receive mental healthcare with parental consent and approval from a mental health practitioner. ISOC-1 (2021) identifies several barriers to care in the gender-incongruent paediatric population, including limited access to gender-affirming care; prejudice or lack of understanding among caregivers; the cost and inaccessibility of transgender healthcare; off-label use of drugs and use of street hormones; lack of medical insurance; lack of government support (with the exception of a few states); the paucity of clinical programmes; lack of structured training and lack of legal support. Qualitative study by Singh et al. reports a near-total absence of gender-affirmative hormone therapy and surgeries in public hospitals and points to systemic barriers TGD individuals face in accessing essential healthcare services related to gender transition. ⁹³ Furthermore, non-binary individuals, as a minority within the already marginalized trans community, face additional pressure to conform to binary gender norms imposed both within the transgender community and through trans healthcare practices. Non-binary identifying people include those for whom the existing, normative understanding limited to only two genders does not fit their personal experience of gender. Because gender is self-determined and can take multiple forms, it does not fall into one, two or three categories under the non-normative column. Rather than being confined by conventional social constructs, gender is determined by lived and felt experiences. ⁹⁴ The cause of this additional pressure is precisely because their gender embodiment is still mainly culturally unintelligible and the present GAMC models that are wholly binaristic do not take into consideration their embodiment desires. ⁹⁵

These barriers make accessibility and affordability a major concern for rural and lower-income TGD youth and adults. Hence, the TGD population often resorts to unscientific and life-threatening means of gender affirmation. Despite the increase in visibility and support for TGD individuals globally, India’s policies and medical curriculum have been slow to adapt, leaving significant gaps in care and support. The development of the Indian Standards of Care (ISOC-1) represents a positive advancement; however, challenges persist, including limited access to care, inadequate understanding of trans health needs, and entrenched systemic prejudices. Addressing these issues requires contextualising global guidelines to the Indian sociocultural landscape and fostering a more inclusive, supportive environment for TGD youth.

Policies and Legal Provisions that Prevent Transgender and Gender-Diverse Youth from Receiving Assistance

To better understand genesis of limited attention and resources dedicated to TGD youth in India, it is important to note that India has a visible, conventional transfeminine, transgender population (hijras, kinnars, jogtis and aravanis), who must often resort to begging, toil-badhai and sex work to earn a living.^96–98 Among lawmakers, policymakers and executioners, the image of a transgender person has been limited to this visible, transfeminine version of gender non-normativity and does not include trans men, trans women, non-binary, gender-queer, gender-fluid and other gender identities that fall under the umbrella term. This holds true not only for India but also policies and research arising from the entire Indian subcontinent.^99,100 Educational reforms have discussed bringing TGD learners into classrooms and sensitising the school system around their needs in advance, as if gender-exploring, gender-dysphoric and TGD learners are not already present in the classroom. ²⁴ It is only recently that perceptions of TGD individuals in Indian policy documents have embraced the larger transgender community beyond the hijra-kinnar community.^19,20 However, for the majority of Indians, their first association with the term ‘transgender’ is still the hijra-kinnar community. While acknowledging this community’s marginalisation at multiple levels, this association often limits legislative initiatives to a particular class and cultural gender non-normative community and does not cater to the needs of other TGD persons. It fails to acknowledge the spectrum of gender that cuts across class and caste backgrounds.

Currently, there are multiple gender-affirming initiatives run by grassroot activists, support groups, non-governmental and community-based organisations and civil society. They aim to end discrimination and achieve identity-based and health-based rights for the TGD community in India. However, legal structures pose various barriers to these collectives. Attempts to assist TGD youth, despite global recognition of the need to disseminate knowledge and support the well-being of youth with non-normative gender identities and sexual orientations^101–103 as well as the willingness to help these youth, are completely absent.

Parents of TGD youth are often ill-equipped to understand their child’s struggle. ¹⁰⁴ There is no exact data on how many youths flee their homes due to a lack of familial understanding regarding non-normative gender expression and sexual inclination, forceful affirmation to the gender assigned at birth and hostility towards gender transgression. ¹⁰⁴ Under the 2012 Protection of Children from Sexual Offences Act (‘POCSO Act’), the legal age of consent for children of all genders is 18 years. Thus, youth cannot consent to healthcare procedures without parental assent and knowledge. ¹⁰⁵

In the legal battle regarding the striking down of Section 377 of India’s penal code—a relic of British colonial rule that punished ‘carnal intercourse against the order of nature’ with 10 years to life in prison—the lawyer defending the law compared homosexuality to ‘perversions’ such as bestiality and incest. This statement reflects a common sentiment about same-sex sexuality in India. Activists and organisations working for LGBTQ rights in India consistently face accusations of paedophilia. These organisations have received threats and have even been charged under the POCSO Act 2012. ¹⁰⁶ Similarly, an adult who tries to help a child by providing resources can be arrested, depending on the complaint of the guardians and how the POCSO Act regarding the sharing of explicit material is applied. Several people working in the child rights space have pointed out that the POCSO Act does not recognise that children have a sexuality too. ¹⁰⁴

One of many documented persecutions of the TGD community occurred in the city of Bengaluru in 2016. A 21-year-old trans woman, studying cosmetology at a state college, found support from another trans woman. However, Kannada channel TV9 conducted a sting operation, airing a six-hour programme where her parents spoke about their ‘son’ without knowing the show’s intent. The show allegedly claimed she was forced into a ‘sex change operation’ by other trans community members. This led to the arrest of six trans women on charges of abduction, wrongful confinement and attempted homicide, with one placed in a men’s lockup. The trans woman later clarified in a press conference that she willingly underwent gender affirmation surgery and was happier as a trans woman. Alongside the Karnataka Transgender Samiti (KTS), she organised a rally against TV9 for its transphobic content and filed a complaint with the Karnataka State Human Rights Commission (KSHRC). ¹⁰⁷

The LGBTQ community was threatened by the misuse of the criminal justice system made possible by Section 377 of the Indian Penal Code until 2018, when the Supreme Court of India struck down this section of the code. To ensure continuity of their work on LGBTQ rights, organisations cannot involve themselves with individuals under the age of 18 and risk police complaints or threats thereof. Even if a case does not hold up in court, the legal proceedings are persecutory, financially devastating, and detrimental to the cause. It is precisely due to the misuse of the law that activists remain wary of supporting TGD minors. Thus, few organisations end up providing support to TGD youth in India, and most of the support that is provided is psychological.

In conclusion, despite some progress, India’s policies and legal structures continue to pose significant systemic barriers to TGD youth seeking assistance. The pervasive stigma and legal risks associated with supporting TGD youth hinder the efforts of organisations dedicated to this cause.

The Way Forward

TGD youth face significant barriers to gender-affirming care, including lack of familial acceptance, limited access to gender affirming care, high out-of-pocket medical costs, weak public health support and reliance on expensive private healthcare. They often use off-label drugs and street hormones due to few clinical programmes and inadequate training for care providers. ⁸¹ The absence of legal and structural support exacerbates their struggles, reinforcing the binaristic identity model.

Health disparities faced by socially disadvantaged populations such as TGD youth are not always a determinant of lack of clinical care or medical infrastructure. They are more often rooted in socio-cultural and political attitudes towards the marginalised group. Therefore, comprehensive, structured, standardised yet individualised healthcare and socio-cultural support for Indian TGD youth are essential to address their unique challenges and promote a just and inclusive society. To address these challenges, India needs to adopt a socio-medical approach that considers lived experiences, provides strategic support for youth and their families and fosters cooperation among social institutions and medical professionals. Training physical and mental healthcare practitioners on gender-specific needs and incorporating these issues into medical curricula are essential steps. Shifting from a model of cure to a model of care and promoting comprehensive GAMC can significantly improve the well-being of TGD youth.

Early gender-affirmative care has been shown to reduce mental health issues and high-risk behaviour. Support from parents, teachers, peers, mental health practitioners and paediatricians, through non-judgemental listening, respectful language, and safe environments, is crucial. Early diagnosis, comprehensive medical support, sensitive care, advocacy for youth rights and dissemination of scientific resources contribute to a social ecology of acceptance. Denying young individuals the right to health by ignoring their gender-based needs is fundamentally flawed, sends a message of intolerance and discrimination and creates a society that is divided, unjust, and unequal.

The Indian TGD community is diverse, with varying struggles based on economic class, religion, caste, sex assigned at birth, and other factors. Actions against stigma must be individualised and inclusive, avoiding tokenism. Progressive affirmative action should be tailored to address these differences and promote understanding of TGD youth’s specific health and well-being needs.

To create a truly inclusive and supportive environment for TGD youth, it is essential to reform legal structures, broaden the understanding of gender diversity beyond visible transfeminine identities and enhance educational and familial support systems. Only then can we hope to provide equitable care and assistance to all TGD individuals, ensuring their well-being and affirming their identities.