Changes to trans rights act will worsen access to healthcare for vulnerable individuals

There are likely to be significant health consequences following the legal changes made by the Transgender Persons (Protection of Rights) Amendment Act, 2026, which was notified on Monday.

The act removes the statutory recognition of a self-perceived gender identity. It also makes identity certification contingent on the recommendation of a medical board and subject to approval by the district magistrate. The definition of “transgender person” has now been narrowed, while requiring medical institutions to share details of surgeries with authorities.

The amendments do not repeal healthcare guarantees of the 2019 act, but risk reducing their use.

The earlier legal framework supported self-identification: The Supreme Court in 2014 recognised self-identified gender as part of personal autonomy and dignity. The 2020 Rules for the Transgender Persons (Protection of Rights) Act, 2019, also allowed certification through an affidavit without medical or physical examination.

Section 15 of the 2019 Act had included healthcare obligations for transgender persons.

But the latest amendments shift recognition away from declaration and towards validation. Access to healthcare may now increasingly depend on navigating medical and administrative systems that many transgender persons already experience as exclusionary.

Research continues to describe stigma and discrimination from healthcare providers, facilities designed for binary gender use, poor provider preparedness, reduced care-seeking, high mental health burdens and implementation gaps even under existing law.

Now, the new amendments are likely to have five kinds of health system effects on affecting access and utilisation.

The first is pathologisation. By shifting recognition from self-declaration to medical board recommendation and administrative approval, the amendment revives a medicalised understanding of gender identity. It recasts identity as something to be externally authenticated.

It may advance the idea that gender diversity is a pathology needing diagnosis. In practice, this may increase reliance on non-supportive healthcare systems and reduce engagement with formal healthcare.

The second is bureaucratic access. Under the current Support for Marginalised Individuals for Livelihood and Enterprise-linked welfare architecture for transgender people, a transgender certificate is the gateway to many health benefits. The certificate is mandatory for welfare measures under the SMILE scheme, including insurance, transition-related care, and access to these healthcare-related services through empanelled, or government-endorsed, hospitals and clinics.

If certification becomes more difficult or slower, it may reduce access to insurance, subsidised treatment and welfare support. A model requiring access to medical boards headed by senior doctors will favour those able to travel, navigate procedures and sustain institutional contact. Those in rural areas, lower-income households or already alienated from formal healthcare are likely to face higher barriers. Discrimination, documentation gaps and hostile or unfamiliar facilities reduce health-seeking behaviour and discourage the use of formal services.

The third is administrative deterrence, including delay and harassment. Procedural details are unclear, but the new law adds checkpoints: medical board recommendation, district magistrate scrutiny and the possible involvement of additional experts. Even without explicit requirements for physical examination, more layers of review typically create greater scope for questioning, demands for documents, informal judgment and delays.

Such deterrence has downstream effects. Where institutions are experienced as hostile, people delay or avoid care, as seen in the contexts of caste and gender. Heightened gatekeeping may push some toward informal care, self-medication or unregulated transition pathways.

The fourth is privacy and confidentiality. The new provision requiring medical institutions to share details of surgeries with officials makes the state privy to sensitive information. The uncertainty of confidentiality may deter care-seeking due to fear of disclosure to family members, employers, landlords or officials.

The fifth is exclusion by definition. The amended definition narrows eligibility and excludes persons with “different sexual orientations and self-perceived sexual identities”. This may reduce who can claim legal recognition, protection and certification-linked benefits. In health systems, this affects eligibility for schemes, hospital records, referrals, ward placement and insurance processing. Uncertainty over eligibility can also disrupt continuity of care.

There are also significant mental health implications. Research describes high burdens of mental ill-health among transgender persons, like depression, suicidality and substance use, with stigma and discrimination becoming barriers to care and drivers of poorer wellbeing. A law requiring medical and administrative validation of identity may intensify distress, fear and mistrust of institutions, and worsen mental health.

There are also broader public health implications, including for HIV care. Evidence shows that transgender people have a disproportionately high vulnerability to HIV and other sexual health risks. The National AIDS Control Organisation identifies stigma, discrimination and transphobia as major barriers to accessing care.

More broadly, barriers to documentation, discrimination and institutional exclusion could reduce access to treatment and weaken prevention.

Finally, the 2019 framework was already unevenly implemented. Researchers have documented gaps in service providers’ knowledge of transgender health needs, service delivery and institutional inclusion despite formal guarantees. Ruling in a 2025 case, the Supreme Court had taken note of the challenges in implementing the 2019 act.

Adding further layers of certification and discretion to this system is unlikely to improve access for the most vulnerable.

Much will depend on the subsequent rules, but the direction set by the act is towards greater gatekeeping that will have consequences on HIV prevention and treatment, mental healthcare, sexual and reproductive services, routine outpatient care and continuity of care.

Rishiraj Bhagawati is a public health researcher based in Bengaluru.