In recent years, India has taken important steps toward acknowledging the rights of transgender and gender-diverse people, from the landmark NALSA judgment in 2014 to the Transgender Persons (Protection of Rights) Act of 2019. Yet behind these legal victories lies a harsher reality. Transgender people in India continue to live with disproportionate levels of social exclusion, unemployment, violence, and poor health. Mental health is perhaps the most neglected area, with depression, anxiety, and suicidality at rates far higher than the general population. This suffering is not inevitable. It is the result of systemic barriers that deny transgender people the chance to live as their authentic selves and access the care they need. The magnitude of crisis is hard to overstate: recent studies find that 31% of India’s trans people have attempted suicide, with nearly half attempting before the age of 20; depression, anxiety, and self-harm are widespread, making trans communities some of the most vulnerable in the country.
Understanding GAC
Gender-affirming care, or GAC, is the umbrella term for a range of interventions that support people in aligning their identity, body, and social recognition. This includes something as basic as using the correct name and pronouns, access to peer support and counselling, as well as medical interventions such as gender-affirming hormone therapy (GAHT) and surgeries when desired. For too long, GAC has been misunderstood as cosmetic or optional. The truth is, it is medically necessary for many transgender people, not only to align their physical characteristics with their gender identity but also to safeguard their mental health. Numerous studies have shown that access to gender-affirming care, including counselling, hormone therapy, and surgeries, significantly reduces gender dysphoria, depression, and suicidal ideation, while improving overall psychological wellbeing. Recent studies in JAMA Network Open and Andrology confirm that those with access to hormones or surgery show markedly improved psychological wellbeing, less reliance on crisis mental health services, and a flourishing in overall quality of life.
Barriers to GAC
Yet in India, even the most basic forms of gender-affirming care remain out of reach for most. There are few endocrinologists trained in transgender health, no national treatment protocols, and prohibitive costs. While Ayushman Bharat TG Plus has pledged to offer support, implementation is incomplete — with most transgender people still forced to pay out of pocket or go without. Average costs for gender-affirming surgery can range from ₹2 to ₹8 lakh in urban hospitals, while annual hormone therapy costs ₹48,000–72,000 — enough to push many families into debt. The danger of neglect is underlined by stories of desperate self-medication with hormones bought without prescription, leading to kidney damage, cardiovascular crises, and lifelong health complications.
Among these interventions, GAHT often plays a critical role. The supervised use of hormones such as estrogen or testosterone can relieve the distress caused by gender dysphoria and help individuals live more comfortably in their bodies. GAHT is one of the most accessible forms of medical transition worldwide, yet in India, it remains largely out of reach. Many individuals are left with no choice but to self-medicate with hormones purchased over the counter or online, without medical supervision, exposing themselves to serious health risks. This dangerous situation is not a product of personal choice, but a result of systemic neglect.
Mental health consequences
The mental health consequences of this neglect are severe. Community-based research in India shows that transgender people face heightened psychological distress not just from stigma and discrimination, but also from being denied access to gender-affirming services. The cycle is vicious: rejection by families, harassment in schools and workplaces, and humiliation in healthcare settings all compound to worsen mental health outcomes. National surveys—including the NFHS and NSSO—largely ignore transgender experiences, erasing their needs from policy and budgeting conversations, and allowing their realities to remain invisible. As a result, critical decisions are made every day in Indian hospitals and government offices without even the most basic data about who is affected. Without access to safe and supportive care, transgender individuals are left vulnerable, often isolated, and forced to navigate life-threatening situations alone.
Necessary solutions
The solutions, however, are within reach. Mainstream health systems must integrate gender-affirming care into routine services, ensuring that doctors, nurses, and mental health professionals are trained and equipped to provide competent, respectful support. Public hospitals need to make GAHT and other services affordable and accessible, ideally covered under insurance or government health schemes. Partnerships with transgender-led organisations are also vital, as community groups have long provided safe spaces, peer counselling, and informal referrals in the absence of State support. These groups must be supported and resourced, not sidelined. Equally important is investment in research. India has very limited data on the impact of GAC and GAHT on mental health, and evidence is essential to design policies and services that respond to the lived realities of transgender people living here.
Consistent evidence
Opponents often argue that the science around gender-affirming care is inconclusive or that it represents a “Western” idea. Yet the evidence is consistent: GAC, including GAHT, improves mental health, reduces suffering, and saves lives. Withholding it does the opposite. More importantly, framing gender-affirming care as an alien concept ignores the Constitutional principles of equality and dignity that India has already committed to. While the right to health is not explicitly recognised as a fundamental right in India, the Supreme Court has interpreted the right to life under Article 21 of the Constitution to include the right to live with dignity and access healthcare. Within this framework, access to gender-affirming care must be understood as integral to the right to life and dignity for transgender and gender-diverse persons.
Political, ethical demand
Feminist scholarship has long challenged the rigid binaries and patriarchal structures that regulate bodies, identities, and expressions of gender and sexuality. The struggle for gender-affirming care is part of this broader feminist pursuit of bodily autonomy and self-determination. By questioning heteronormative and cis-normative assumptions that underpin healthcare and social policy, feminist and queer perspectives remind us that affirming care is not merely a medical issue—it is a political and ethical demand for recognition, equality, and freedom from patriarchal control.
True mental health equity will only be possible when every person—regardless of their gender identity—can access care that is safe, affirming, and rooted in dignity. India cannot wait: the evidence, ethical imperative, and constitutional mandate all demand urgent action on gender-affirming care.
(Manmeet Kaur Bhatia is a research fellow at The George Institute for Global Health India mbhatia@georgeinstitute.org.in; Dr. Y.K. Sandhya is programme lead, mental health syatirajula@georgeinstitute.org.in; Dr. Deepika Saluja is thought leadership advisor & programme manager -Ubuntu initiative at The George Institute for Global Health DSaluja@georgeinstitute.org)
Published – October 09, 2025 10:35 am IST
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