Kamal Gautam, Kiran Paudel, Bandana Bhandari, Kevin Le, Sandesh Bhusal, Md Safaet Hossain Sujan, Manisha Dhakal, Meghnath Dhimal, Laura Dean, Keshab Deuba, Jeffrey A Wickersham, Roman Shrestha, Sally Theobald
Lesbian, gay, bisexual, transgender, and intersex (LGBTI) individuals face persistent barriers to healthcare in many settings. However, little is known about how health-system factors shape inequities in Nepal. This study aimed to examine the experiences of care, barriers to inclusive services, and opportunities to strengthen the health system for LGBTI individuals in Nepal. We conducted in-depth qualitative interviews using an interview guide with 28 participants-LGBTI community members, healthcare providers, leaders of LGBTI-led organizations, and policy stakeholders-in Nepal. Data were analyzed using inductive thematic analysis. Three themes emerged: where the health system breaks down, how LGBTI individuals adapt, and what health system strengthening could look like. Participants described limited availability, affordability, and accessibility of LGBTI-relevant services; exclusion at registration and admission; and clinical encounters shaped by limited provider knowledge and binary assumptions. In response, LGBTI individuals reported concealing their identities, relying on non-governmental organization (NGO)-run services, self-managing health needs and often placing trust in individual providers rather than the healthcare system. Participants emphasized that strengthening care requires moving from legal recognition to implementation through affordable services, trained clinical and non-clinical staff, privacy protections, respectful facility practices, curriculum reform, and institutionalization of LGBTI-inclusive care beyond NGO-run services. The findings show that access to healthcare for LGBTI populations in Nepal is shaped by routine health-system practices, even when services are not explicitly denied. Improving equity will require embedding LGBTI-inclusive care within routine public health services, with clear policy implementation, provider education, facility-level accountability, and sustainable government-community partnerships.