In the first three months of his re-election, US President Donald Trump enacted several policy changes, one of the most controversial being his executive order redefining gender identity in public policy. The directive mandates that the US will officially recognise only two sexes – male and female – effectively eliminating legal recognition for transgender and non-binary individuals. This move has far-reaching implications, not only for civil rights protections within the US but also for global discussions on gender identity.
In stark contrast, India has taken a more progressive stance. The country legally recognises three genders – male, female, and transgender (the third gender). In a landmark decision in 2014, the Supreme Court of India affirmed the right of transgender individuals to self-identify their gender, reinforcing their legal and constitutional rights. In 2009, India’s Election Commission had allowed transgender persons to register as “other” on ballots and official documents, ensuring greater visibility in the democratic process.
The 2011 Census of India reported that approximately 4,87,803 individuals identified as transgender. However, activists and population experts argue that this figure is an underestimation, with the actual number likely closer to 1.5 million. This under estimation is primarily due to factors like stigma, fear of discrimination and administrative barriers to self-identification.
The Transgender Persons (Protection of Rights) Act, 2019, requires individuals to apply for a “Certificate of Identity” from a District Magistrate to be officially recognised as transgender. However, the implementation of this system has been slow and inefficient – only 9,064 applications have been received nationwide and 23% of them have been pending for over 7-12 months.
This lack of formal recognition further marginalises transgender persons, making it difficult for them to access affirmative action policies, employment opportunities, specialised healthcare and legal protections. These fundamental and systemic challenges were further exposed during the COVID-19 pandemic, when the Indian government announced a financial relief package of Rs 1,500 for transgender persons. A large proportion of the community lacked bank accounts, preventing them from receiving the assistance. This underscored the broader issue of their exclusion from formal financial and social systems.
Despite official and public recognition, transgender individuals often face unique and complex healthcare challenges, compounded by social stigma, systemic discrimination and a lack of inclusive medical services. In India, these barriers have had devastating consequences – 30% of transgender suicides between 2016 and 2021 were attributed to illness and inadequate healthcare, making it the leading cause of suicide within the community (See graph).
They experience higher rates of depression, anxiety, and mental health disorders, yet they continue to encounter personal, social, and institutional barriers when seeking medical care. Recognizing these challenges, India took a bold step in 2021 with the establishment of Mitr Clinic, the country’s first dedicated healthcare facility for transgender individuals. Launched in Hyderabad, and later expanding to Pune and Thane, Mitr Clinic provided comprehensive, specialised medical services tailored to the needs of the transgender community.
The clinic offered HIV treatment, hormone therapy guidance and medication, counselling on mental health and sexually transmitted diseases (STDs), legal aid, and general medical care. More than just a medical center, Mitr Clinic became a safe space where over 6,000 transgender individuals could access not only healthcare but also a sense of community and support. The initiative was made possible in 2003 through a collaborative effort involving Johns Hopkins University, the US Agency for International Development (USAID) and the Indian government. The clinics were funded under the US President’s Emergency Plan for AIDS Relief (PEPFAR), receiving approximately Rs 2,50,000 per month to sustain its services.
Reasons for Transgender suicides in India (2016-2021)
In a move with far-reaching consequences, US foreign aid under the USAID was recently frozen for 90 days following an executive order by Trump as part of his “America First” policy.
This decision has had far-reaching consequences, particularly for developing nations of the Global South that rely on US assistance to sustain critical healthcare, education, and infrastructure projects. One of the immediate casualties of this decision was Mitr Clinics.
Previously operational in three cities – Hyderabad, Thane, Pune – Mitr Clinics played a critical role in providing specialised healthcare services to transgender individuals. However, with the withdrawal of USAID funding under PEPFAR, all three clinics have now shut down, leaving a significant healthcare vacuum for transgender individuals in India.
With the closure of Mitr Clinics, transgender individuals seeking healthcare are left with two challenging options – government-run public hospitals or expensive private healthcare facilities. While public hospitals in India are theoretically open to all, social barriers deter transgender individuals from seeking timely medical assistance at these facilities. Many face hostile attitudes from medical professionals, lack of gender-sensitive healthcare and bureaucratic obstacles, making it difficult for them to access essential services. Accessing healthcare, even for common illnesses, can be an overwhelming challenge for transgender individuals, as they do not fit into traditional gender roles, and a lack of gender-sensitive care due to gaps in provider awareness and training.
Without legal recognition as a transgender person, accessing many specialised medical services – including government-subsidised health insurance for transgender persons introduced in 2024 – becomes an arduous task. While private hospitals may offer a safe space and inclusive healthcare services for transgender individuals, they come at a substantially higher cost, imposing a severe financial burden on a community that already faces significant economic marginalisation and social exclusion.
Moreover, these well-equipped private medical centres are heavily concentrated in urban areas, making access even more difficult for transgender individuals in semi-urban and rural regions. The lack of financial support, combined with high out-of-pocket medical expenses, further exacerbates existing inequalities.
According to India’s National AIDS Control Organisation (NACO), the transgender community faces a heightened risk of HIV due to their significant involvement in sex work – often a consequence of limited economic opportunities. This increased vulnerability underscores the urgent need for targeted and accessible healthcare services, with a focus on both prevention and treatment. However, systemic barriers and societal stigma continue to hinder access to essential medical care, making government intervention crucial in ensuring inclusive and sustainable healthcare support for this marginalised group.
With USAID funding now paused, the responsibility of ensuring accessible and equitable healthcare for the transgender community falls entirely on Indian public institutions, which severely suffer from healthcare budget cuts. Addressing this systemic issue requires a multi-pronged policy approach such as:
- Mandating gender-sensitivity training for medical professionals to eliminate discrimination and improve healthcare experiences for transgender individuals.
- Simplifying the bureaucratic process for obtaining legal recognition as a transgender person, ensuring that access to gender-affirming care and government-sponsored health insurance is not restricted by administrative hurdles.
- Expanding state-funded transgender healthcare facilities to ensure equitable access to medical services, particularly in regions where economic and technological barriers exacerbate challenges.
- Investing in tele-health solutions to provide remote consultations, which could enhance privacy and accessibility for those hesitant to seek in-person care due to social stigma.
Even though India has taken steps to recognise transgender rights, the closure of Mitr Clinics highlights the precarious dependence of critical social programs on external funding. For a truly inclusive and resilient healthcare system, India must establish self-sustaining, locally funded models that ensure uninterrupted, accessible, and specialised healthcare for all including transgender individuals.
Tara Awasthi is a student of economics honours at FLAME University, Pune.
Rituparna Kaushik is an assistant professor of economics at FLAME University, Pune. All views expressed are personal.
