“We lived by the river, now we survive the city”: Climate displacement and transgender health in Pakistan

Background Research on transgender health has increasingly highlighted the role of social and structural determinants; however, limited attention has been given to how environmental change shapes health outcomes, particularly in Global South contexts. In Pakistan, riverine systems, including the Jhelum, Chenab, and Ravi rivers, have historically supported informal livelihoods of marginalized groups, including transgender (khwaja sira) individuals, whose access to formal labor markets is constrained by systemic exclusion.Aim This study examines how environmental disruption, livelihood loss, and displacement shape the health experiences of transgender individuals who transitioned from river-based economies to urban survival contexts in Punjab, Pakistan.Methods A qualitative study using reflexive thematic analysis, eighteen transgender (khwaja sira) adults who had previously engaged in river-based livelihoods and subsequently relocated to urban areas were recruited through purposive and snowball sampling and community networks. Semi-structured interviews (45-90 min) were conducted in Urdu or Punjabi, audio-recorded, transcribed verbatim, and translated to English by bilingual members of the research team.Results Four constructed themes characterize participants’ transition from riverine to urban contexts: (1) conditional belonging and rhythmic embodiment in the riverine economy; (2) slow erosion and forced choice in environmental displacement; (3) urban precarity and the loss of functional recognition; and (4) relational survival amid accumulated strain. Counter-narratives surfaced from four participants, including accounts of urban anonymity as relief, attribution of river change to industrial and human causes, dysfunctional coping strategies, and ambivalence about community protection, complicating any singular reading of vulnerability.Conclusion The findings support theorizing climate-related environmental disruption as a structural determinant of transgender health, while acknowledging that participants themselves rarely named climate change as the proximate cause of the changes they described. Incorporating environmental dimensions into transgender health scholarship is essential for understanding emerging configurations of inequality in the Global South.