From discrimination and denial of health care services to misgendering and lack of gender-affirming care of transgender people in Pakistan

Background Despite recent legal recognition, transgender people in Pakistan remain profoundly marginalized across family, community, and institutional spheres. Mental health, access to healthcare, and survival are formed through structural stigma based on patriarchal standards, moral governance, and the ineffective institutions. Existing research provides limited insight into how these forces interact collectively, particularly within healthcare contexts.Methods A grounded theory approach was used to explore the lived experiences of 19 transgender participants, who resided in Lahore and Mianwali. Semi-structured interviews were used to collect data and these data were analyzed using open, axial, and selective coding, constant comparison, and writing memos.Findings Structural stigma turned out as the key organizing procedure that structures the life of the participants. It was unceasing and prospective and overlapped with exclusion in the economy, ambivalent relations in the family, institutional discrimination in healthcare, and acculturation to violence. Healthcare environments often operated as locations of misidentification, degradation, and denial of service, which resulted in care avoidance and self-medication and self-dose of hormones. The participants used limited coping mechanisms such as faith-based meaning making, transgender community support and substance use but these had minimal protection unless there was a systemic reform.Conclusion Transgender health inequities in Pakistan are predetermined by the stigma inherent in the structure, rather than by personal actions or characteristics. Recognition by the law is not enough to enhance health outcomes. To tackle the underlying causes of inequity and vulnerability, effective interventions necessitate aligned changes in healthcare delivery, economic inclusion and institutional accountability with transgender voices and lived realities at the center of the change.