Barriers to health and social inclusion among transgender and MSM populations in India: a mixed-methods multicentric study

BACKGROUND: Despite legal reforms advancing the rights of transgender (TG) individuals and men who have sex with men (MSM) in India, social exclusion, stigma and systemic barriers continue to undermine their access to healthcare and social services. Evidence on identity recognition, service utilisation and healthcare gaps remains limited. METHODS: We conducted a sequential explanatory mixed-methods study. The qualitative phase involved 26 in-depth interviews, 14 focus group discussions and 3 key informant interviews with TG and MSM participants in Delhi and West Bengal. Insights informed a quantitative survey across 14 states (n=2208), exploring socio-demographic profiles, identity documentation, employment and healthcare utilisation. Data were analysed thematically using NVivo V.14 and statistically using SPSS V.27. RESULTS: TG and MSM participants reported pervasive educational exclusion, precarious livelihoods and limited family support. Only 52.4% of TG respondents possessed a TG identity card, while fewer than 20% had updated other legal documents. Employment remained insecure, with 35% of TG individuals reliant on sex work, begging or ritualistic practices. Health service uptake was low: only 12% of TG respondents accessed Ayushman TG Plus insurance, and 3.9% received human papillomavirus (HPV) vaccination. While most HIV-positive respondents reported being linked to antiretroviral therapy centres, many participants diagnosed with other sexually transmitted infections (STIs) or hepatitis B/C were not receiving treatment. Qualitative findings highlighted stigma in healthcare interactions, administrative delays in accessing welfare schemes and restrictions within community-based support structures such as Deras. Despite these barriers, peer networks provided critical emotional and financial support. DISCUSSION: Findings reveal persistent gaps between legal recognition and lived realities for TG and MSM individuals. Structural stigma, economic marginalisation and administrative inefficiencies undermine access to identity documentation, healthcare and social protection schemes. Addressing these inequities requires stigma-sensitive healthcare, streamlined administrative processes and inclusive welfare programmes. Embedding psychosocial support and trans-inclusive care beyond HIV services into India's public health system is essential for ensuring health equity and advancing Sustainable Development Goals 3 and 10.