DHAIAF: a structured method for digital health access and identity affirmation for the transgender community in India

This paper introduces the Digital Health Access and Identity Affirmation Framework (DHAIAF), a structured five-component method designed to address the systemic exclusion of transgender and gender-diverse (TGD) individuals from India's digital health infrastructure. The sections fig 1 that follow first present the framework and its components, before situating DHAIAF within the Indian socio-legal and digital health context that necessitates its development.India's digital health expansion through national telemedicine services and electronic health records has improved service reach. However, transgender populations experience layered exclusion due to documentation mismatch, stigma, and binary digital infrastructure. Census 2011 identified approximately 4.9 lakh transgender persons in India, though community estimates suggest underreporting. Studies indicate high prevalence of mental health distress (over 40-50%), barriers in accessing public hospitals, and limited coverage of gender-affirming procedures under insurance schemes (Bockting et al., 2013). Digital identity-linked systems intensify these disparities when legal documents do not reflect self-identified gender. Improving access to transgender and gender-diverse (TGD) health care, alongside strengthening the training of healthcare professionals (HCPs), has been identified as a critical strategy for reducing stigma toward TGD populations (Reisner et al., 2016). To address persistent access barriers such as extended waiting periods and long travel distances to specialized clinics digital and internet-based interventions, including online mental health services like counseling and psychotherapy, are increasingly being implemented and empirically evaluated to assess their capacity to complement conventional healthcare delivery by HCPs (European Union Agency for Fundamental Rights, 2020). These digital interventions hold particular promise in engaging TGD individuals within their everyday lived contexts by providing early psychological support and facilitating connections with medical experts offering gender-affirming care. Their relevance is especially pronounced for TGD populations residing in remote, rural, or underserved suburban regions (James et al., 2017;Dhejne et al., 2016). Concurrently, the integration of online training curricula, supervision models, and consultation platforms for HCPs can enhance professional competence in transgender health care, while also mitigating stigma-related barriers within clinical practice.1. India's ethno-cultural transgender communities: India is home to a plurality of socio-culturally distinct transgender identities that have no direct equivalents in Western frameworks of gender diversity. These include the Hijra (widely present across North and Central India), Aravani/Thirunangai (Tamil Nadu), Kinnar (North India), Jogta/Jogappa (Karnataka and Maharashtra), and Shiv-Shakti (Andhra Pradesh and Telangana), among others. These communities have deep historical and religious roots traceable to ancient texts including the Vedas, Puranas, and the Kama Sutra, which reference a 'third nature' or Tritiya Prakriti (Frontiers in Public Health, 2024). The Hijra community, for instance, occupies a ritualised social role in conferring blessings at births and marriages, while Aravanis hold significant presence in South Indian religious ceremonies (PMC, 2020).Jogappas are revered as 'brides of the deity' in temple traditions. These communities experience healthcare exclusion not as a generic marginalisation but through the specific lens of their social organisation including the guru-chela (dera/gharana) kinship system which critically mediates health-seeking behaviour. As research in Uttarakhand demonstrated, transgender women living within the dera system required explicit permission from their guru to access services, and many communicated in an internal language ('Farsi') that further isolated them from mainstream systems (Frontiers in Public Health, 2024).The Transgender Persons (Protection of Rights) Act, 2019, and its disputed 2026 Amendment, create a uniquely Indian bureaucratic framework. While the landmark NALSA v. Union of India (2014) Supreme Court judgment affirmed the right to self-identify gender, the 2019 Act introduced a District Magistrate-based certificate process that in practice has been slow, inconsistent, and burdensome. The proposed 2026 Amendment additionally introduces a medical board verification requirement for gender recognition a significant regression from selfidentification principles (PRS India, 2026). These legislative tensions generate downstream digital exclusion: Aadhaar-linked health systems require consistent documentation, but transgender persons especially those who left home young and lack residence or birth certificates often cannot complete these requirements (The Print, 2024).In Delhi, for instance, only 51% of certificate applicants received approval, compared to a national rate of approximately 80% (The News Minute, 2024). NACO's 2015 mandate linking Aadhaar to HIV treatment access created a specific privacy crisis for transgender persons, with documented cases of individuals discontinuing treatment to avoid being identified across databases (GenderIT.org, 2020). Together, these contextual factors the cultural specificity of Indian transgender identities, the uneven legal landscape, the gaps in digital health infrastructure, and the intersectional socio-economic barriers underscore the need for a structured intervention. Table 1 summarises the key structural barriers that DHAIAF is designed to address. (Fraser, 2009;Shipherd et al., 2016). DHAIAF emphasizes that inclusive digital health services welcoming persons of diverse gender identities and sexual orientations-can contribute to broader gender equality goals (Hughto et al., 2015). By embedding intersectional perspectives within digital governance structures, the framework addresses layered forms of marginalization that arise from the interaction of gender identity, socio-economic status, caste, rurality, and digital literacy. In doing so, DHAIAF positions digital health systems as active agents in stigma reduction and institutional transformation, rather than passive service-delivery mechanisms.