• Access to healthcare was a big issue for the community. Participants cited a variety of issues leading to difficulty receiving the care that they needed, including:

• Lack of information in the community about how to find providers and what kind of care they needed

“We don’t have any awareness regarding the hormones, neither the surgeries, and … the things that you’re supposed to know while taking the HRT [hormone replacement therapy], and what are the side effects and how we’re supposed to take care of our health. So we have zero knowledge about it.” (Bengaluru)

•  Lack of available providers, especially in rural areas

“People migrate to metro cities. Metro cities are a bit supportive because the doctors are able to practice more regarding all these things…But there is nothing for the people in villages.” (Mumbai)

• Dealing with uninformed or misinformed providers, whom participants needed to educate

“He will never say ‘I don’t know’. That is a doctor’s attitude.” (Bengaluru)

• Being treated poorly by healthcare providers or being denied care

“One of my friends who, a trans man…asked the doctor … How are you going to do the surgery? Because he wanted to know what his chest would look like and he needed the information. So the doctor screamed at him, saying ‘Are you the doctor or am I the doctor? I’ll decide how it should be, it is none of your business. Just shut up and go do the surgery.’ That is the attitude” (Bengaluru)

• Low standards of care, such as poor surgery outcomes or improper hormone injection techniques

“In fact, we are like guinea pigs to the doctors. We’re guinea pigs and whatever they want to learn, experiment, they get free bodies.” (Bengaluru)

“He went to his chemist [to receive his hormone injection]. He kept on looking at it, [wondering] ‘is he doing it right, is he not doing it right?’ So the chemist said ‘if you’re so concerned, just learn it and do it yourself. And he said ‘okay, I can do it’. So he got his first injection wrong and he was in pain and he couldn’t get up for four days.” (Delhi)

“They want to experiment doing the surgery. They get a chance to do it, they’re doing it…So they don’t want to miss that opportunity of experiment, so that’s why they do it in that rubbish manner.” (Bengaluru)

• Difficulty navigating the complicated GID certificate process and all the necessary referrals

• High cost of gender affirming procedures and lack of insurance coverage

• Participants talked about significant mental health challenges faced by the community, resulting from discrimination, social and family pressures, and difficulty accessing healthcare.

“It does affect your work, mentally it feels like I don’t want to live, everything ends.” (Mumbai)

“I have to do it [transition] before death, at least for one day. That is how it is with us is that we just want to live for a day and die…Well, they don’t realize that we have not really lived our lives. Because we have not lived lives… on our terms.” (Mumbai)

• Although mental health challenges were common in the community, participants reported limited use of mental health services due to a lack of queer- and trans- competent providers, mistreatment, and stigma associated with seeking mental healthcare. Previous experiences with mental health professionals often involved attempts to change the trans person’s gender identity (to make them cisgender or non-trans) at the urging of parents.

“The psychiatrist and counselors, most of them, like 80% to 90%, will always talk in favor of our parents. They will never talk in our favor. In a very rare case the psychiatrist or the counselor will say, ‘No your son is alright.’ Otherwise, in every other case they will always say, “There is some or the other deficiency in your son and we will cure that. You come for 10 sessions, you come for 4 months, come for 6 months, it will cost so and so—” (Mumbai)

“I know a lot of friends who were taken by their parents to the psychiatrist and the psychiatrist said, “Yes this is a disorder and we will cure it.” This is where the parents start pressurizing the kids and like in our brother’s case, he mentioned that the doctor took it personally to cure him.” (Mumbai)

•  Many cited the community as a great source of support and strength.

• Participants spoke of issues in education, including how lack of access to care, poor mental health and discrimination lead to poor performance and high drop out rates in school, especially for trans youth.

“People are facing violence, but they are not able to understand they are experiencing violence. And they are dropping out of school but not understanding that this is the result of violence.” (Mumbai)

• Similar factors, as well as employment discrimination, make it difficult for transmasculine people to find jobs, stay at jobs, and feel safe living as a trans person in their workplace.

“If you want to get an education, that’s difficult, getting a job is also difficult. The government says, ‘you can work anywhere’. But it is difficult because there is the private sector, the government sector, the government people say, ‘work in this environment if you want to, if not, leave’.” (Mumbai)

• Violence, harassment, and fear of experiencing violence and harassment are issues when navigating public spaces, including transportation and restrooms in public, at work, or at school.

“In Delhi I was riding my bike, so like, a traffic policeman stopped me, and he asked me to show the documents, right? So at that time I hadn’t gotten my documents changed, and he was from Haryana, so he’s trying to say to me, [mockingly] “Come on man, this document is a girl’s! You’re a boy! Where’s the girl gone? Where’d she go? Whose bike have you stolen?” So basically saying that I’m a thief.” (Mumbai)

“What we have to understand is that a lot of people are getting killed because they are trans men. Because they don’t, they can’t access information to prove what they are to their parents or to their friends and family and so on and so forth. So a lot of them are getting killed. A lot of them cannot express themselves, so they suppress it” (Bengaluru)

• Participants spoke of safety issues around being in a separate “transgender” category legally, and feeling like this set them up for discrimination and violence.

“Because if you’re arguing from the point of legal gender recognition, then you can argue that this legal gender recognition is about your social safety. Tomorrow if my passport has TG on it, and I am living as a male person in society, then anyone seeing my passport might discriminate against me. Meaning this which was created for my protection, is being used to control me.” (Mumbai)

• Some participants had difficulty changing legal documentation such as ID cards, to match correct gender identity and name.

“From transition, everything, what documents we legally get changed, like the Aadhar card, PAN card, voter ID, passport, everything. So I think there is a procedure, but it is very lengthy and one loses a lot of time in that.” (Mumbai)

• Participants did not feel protected against discrimination, violence, or harassment by current anti-discrimination laws.

“If something happens with trans people, they don’t take any steps for that. So there should be proper rights and laws for that also. If something happens with us.” (Delhi)

• Participants reported that many in the community are not supported in their identity by their families, with some being forced by family to participate in “treatments” for their gender identity, including psychiatric, medical and alternative procedures.

“When my parents came to know about me…they took me to some psychiatrist right? Also I was hospitalized because of some of my relatives. So at that time, a psychiatrist asked me to wear a saree and marry the boy. I denied her and they trapped me in the hospital which was very difficult for me…She started giving me female hormones.” (Delhi)

• Participants described the familial and social pressure to live as a woman, marry a man, have children, and take on tasks traditionally for women, such as cooking and cleaning.

“They [transmasculine people] are often pressurized to have sex, physical relationship and contact with a male. They are often asked, ”Why aren’t you interested in males? Is it because you have not tried it yet, at least give it a try once.” Sometimes their own brothers ’try’ or get someone else from outside to ‘try’. This is what happens to [pre-transition] men. Sometimes they are married to someone against their will, so there is this physical violence too.” (Mumbai)

• Participants emphasized the importance of family support.

“Family plays an important role in this whole thing. When family accepts us, everybody else will also accept us.” (Delhi)

• Protecting anonymity and safety of trans masculine people participating in research

“We know that we have to maintain each other’s safety and privacy.” (Mumbai)

• Online surveys in multiple languages, as well as private one-to-one interviews

“One-on-one in-person survey because that will make them more comfortable, we can talk to them and maybe they can do it more nicely and efficiently.” (Delhi)

•  Sharing the results widely, including to families, schools, employers, policymakers, and healthcare workers

“If there is data on how people are … managing even being trans men, managing their life. That will be some good data to show to the parents. Like, there are people who are having jobs and managing their life, that might give them confidence that people are doing it.” (Delhi)

“Basically we need awareness from the ground levels and villages and towns. Even in Delhi many people are not aware of, in terms of the transgender so we need that awareness. We need to work on that. When there will be awareness… only then will they be able to accept it and even respect.” (Delhi)

• Many felt information would be most influential if it came from the government, such as appearing on a government website.

“I think parents will only understand once they see or learn about this from a government site. From government advertisements. Because many times I ask my parents ‘Can you please watch this video on YouTube?’, they’re reluctant to. We have to approach government and convince government.” (Delhi)