Abstract

Objective

Transwomen are one of the most marginalised groups globally, with their experiences of prejudice significantly impacting their access to dental care and leading to social isolation. This study aimed to explore the experiences of transwomen in accessing oral health care services in Khyber Pakhtunkhwa, Pakistan.

Methods

A qualitative phenomenological study design was utilised to gain in-depth insights. Eight transwomen were purposively recruited from the districts of Haripur, Abbottabad, and Mansehra in the Hazara division of Khyber Pakhtunkhwa, Pakistan. Semi-structured interviews were conducted in Urdu, transcribed, and translated. A descriptive approach was utilised for thematic analysis.

Results

The analysis revealed several barriers faced by transwomen in accessing oral health care, organised into key themes: (1) Healthcare discrimination and marginalisation, (2) Quality of care and dental professionals鈥� attitudes, (3) Cost and affordability of dental care, (4) Social stigma and absence of community support, and (5) Inclusive dental care facilities.

Conclusion

This research highlights barriers faced by transwomen in Pakistan when accessing dental care, leading to delayed treatment and poor oral health outcomes. Financial constraints and a lack of empathy from dental professionals further exacerbate these challenges. Participants recommended policy reforms such as anti-discrimination laws, separate waiting rooms, and counters to improve access. These findings underline the need for policymakers to create inclusive dental service systems tailored to the needs of transwomen.

Introduction

Individuals who are transgender have a gender identity that does not match the biological sex they were assigned at birth [1]. The wide range of identities covered by this umbrella term may not adhere to the societal norms usually linked to their sex [1]. In South Asian countries such as India, Bangladesh, and Pakistan, the transgender community encompasses various identities related to genetic traits and gender presentation [2]. In Pakistan, gender-diverse individuals may be classified as 鈥�zenana鈥� (effeminate men or transgender women), 鈥�hijra鈥� (a socio-cultural group of transgender and intersex people), or 鈥�khunsa鈥� (intersex individuals in Islamic terminology), but they are more commonly referred to as 鈥�khwaja sira鈥� [3]. In Pakistan, transgender individuals, known as 鈥�hijras,鈥� typically live in close-knit groups with a distinct social identity and support structure (4). Traditionally, 鈥�hijras鈥� have been seen to possess distinct spiritual qualities, notably during blessing ceremonies, reflecting a long-standing cultural framework that differs from Western notions of gender and sexuality [4, 5]. The 鈥�Hijras鈥� community are invited to celebrations like childbirth and weddings, where they bring prosperity and protection through singing, clapping, and dancing [6, 7]. They bless infants and couples in exchange for monetary gifts, food, or tokens of gratitude [7].

The transgender community faces significant marginalisation on a global scale, leading to limited healthcare access due to social rejection and discrimination [8]. In high-income countries such as Australia and New Zealand, transgender people face adverse encounters with healthcare professionals, including feelings of discomfort and hostility, as well as outright denial of care and mockery [9, 10]. The challenges are particularly severe in low- and middle-income countries (LMICs) such as Pakistan, emphasising the widespread prevalence of discrimination [2, 3]. Despite legal recognition as citizens in Bangladesh, India, Pakistan, and Nepal since 2010, the health needs of transgender individuals have received minimal attention [11, 12].

Transgender individuals often face worse oral health results compared to their non-transgender counterparts in LMICs. Evidence from South Asia, particularly India indicates that transgender communities experience notable oral health disparities, with higher rates of untreated dental caries, periodontal disease, and tooth loss than non-transgender individuals [13]. A recent meta-analysis of Indian transgender individuals highlights poor oral health outcomes, such as low toothbrush usage, high tobacco use, and increased rates of cavities, calculus, and bleeding [14]. Similarly, a cross-sectional study in Pakistan found a high prevalence of dental caries among transgender individuals, with a mean DMFT score of 6.86, highlighting their oral health challenges [15].

In Pakistan, transgender individuals face significant social exclusion due to the country鈥檚 entrenched binary gender norms of man and woman, masculinity and femininity [3]. This social unacceptance has led to considerable disparities in access to and utilisation of healthcare services [2, 16, 17]. In December 2019, the Pakistan government introduced the Sehat Sahulat Programme, aiming to offer healthcare services to all citizens, including the transgender community, as part of universal coverage [18]. The implementation of the Sehat Sahulat Card package for the transgender community still faces significant challenges, including issues with accessing and utilising healthcare services [19]. Postponement of medical care among the transgender population is significantly linked to financial constraints, alongside challenges like social stigma, lack of awareness about available services, and difficulties accessing necessary documentation, which hinder full utilisation of programs like the Sehat Sahulat Programme [20, 21]. These gaps continue to deprive transgender individuals of their basic right to equitable healthcare access [21].

Literature has highlighted that oral health, an essential aspect of general health, has been even more overlooked in terms of care for transgender people [22]. Many transgender individuals experience dental fear, which is often linked to prejudice and negative attitudes encountered in dental settings [23]. Accessing oral healthcare through social healthcare packages like Medicaid insurance or universal health coverage is often hindered by disrespectful and belittling attitudes exhibited by certain healthcare providers [24]. A survey conducted in 2023 in the United States found that transgender people face disparities in receiving medical and dental treatment, highlighting a larger problem of discrimination within the healthcare industry [25].

Limited qualitative research has been carried out on access to oral health care for the transgender community in LMICs despite the existing challenges. This study aims to address this gap by exploring the lived experiences of transgender individuals concerning their access to oral health care. Highlighting the experiences of marginalised groups in Pakistan is crucial for improving oral health outcomes and minimising inequities in healthcare for the transgender community. This study may provide policymakers with valuable insights for making inclusive decisions.

Methods

Study design

This study utilised a qualitative phenomenological method to explore how transgender people in Pakistan access oral healthcare. The phenomenological approach was chosen to understand how individuals interpret their experiences, particularly in contexts where personal experiences are vital. The methodology operates under the assumption that individual perspectives shape and define reality, which makes it particularly useful for comprehending the intricate experiences of marginalised communities [26]. It adopts a relativist ontological stance, acknowledging diverse realities formed by individual experiences [27]. The evidence generated is presented from a constructivist perspective, emphasising the subjective interpretation of these experiences [27, 28].

Participant recruitment

A wide range of perspectives within the transgender community was ensured by recruiting participants through maximum variation purposive sampling. Maximum variation sampling was sought by considering factors such as the age when gender identity was declared, education levels, and geographical regions, including urban versus rural living areas, to capture diverse experiences within the transgender community. A local non-profit organisation (NGO) with established connections to the transgender community identified potential participants, which helped build trust between the interviewer and the interviewees and facilitated accessibility during the recruitment process. Initially, potential participants received a participant information leaflet through the NGO, outlining the study鈥檚 purpose, process, and significance. Those interested in the study were requested to contact the interviewer via telephone. Subsequently, the interviewer arranged a time and location convenient for the interviewees and conducted the interviews. Before the interviews, written informed consent was obtained from those who chose to participate. Participants needed to be 18 years or older, have socially accepted their gender identity (publicly affirming their gender through the use of preferred pronouns, social interactions, and recognition by others), and have visited a dental hospital or clinic at least once for dental issues to meet the inclusion criteria. Individuals who were unable to provide informed consent were excluded.

Data collection

The team of researchers at Khyber Medical University in Pakistan developed a semi-structured interview topic guide (Supplementary file 1), based on the aim of the study, and drawing from their expertise in clinical dentistry (SIK, AA), dental public health (SK), and experienced qualitative researcher (MIK), as well as a thorough review of existing literature. The interviewer (AHJ), a cisgender female, was given prior training on how to conduct neutral interviews, ensuring that personal preconceptions were not imposed on the participants. The interviewer鈥檚 goal in conducting the research was to contribute to the understanding of oral health disparities faced by transgender individuals in Pakistan, a community often underrepresented in oral health studies.

The interviews were held in a private room in the NGO office, with the sites chosen for the convenience of the participants. Before each interview, participants were given the chance to ask questions, which the interviewer addressed. All interviews were conducted by the interviewer (AHJ) in the local language (Urdu) and were kept to 30听min to lessen the burden on participants, with only the participant and interviewer present during the interviews. All participants provided informed written consent, in which they were informed about the anonymisation of their data and the assignment of a unique identification code to ensure confidentiality. Participants were also assured that their data would be securely stored with password protection, and they were made aware of their right to withdraw from the study at any time, with their information being removed upon withdrawal. Furthermore, all participants consented to the audio recording of the interviews, fully understanding the procedures involved and their rights.

The interviewer (AHJ) remained neutral and made reflective notes after each interview to ensure authenticity and minimise bias. Data saturation was reached after eight interviews, at which point no new information emerged, leading to the discontinuation of further interviews. The interviews took place with only the interviewee and the interviewers present. To safeguard the identities of the participants, unique study numbers were assigned. To ensure the quality and consensus of the information, the qualitative research team (MIK, AHJ, SIK, SK) held regular meetings.

Data analysis

The interviews were carried out and transcribed in Urdu. Participants were given the opportunity to review their transcripts to ensure their views were accurately reflected and to enable them to add or clarify their perspectives, no participants requested any changes. Subsequently, the transcripts were transcribed into ad verbatim English by two members of the research team (AHJ, AA).

A thematic analysis, based on a descriptive approach was utilised. We followed a similar method to Sundler et al. (2019) where a thematic analysis was applied to phenomenological research with a focus on lived experiences and themes that were data-driven [29]. Methodological principles applied included: emphasising openness, being reflexive and questioning presuppositions [29]. The qualitative software package ATLAS 1.8 was employed to facilitate the organization and execution of thematic analysis.

The analysis involved first researchers (AHJ and MIK) reading and immersing themselves in the interview transcripts to deepen their understanding of the participants鈥� experiences. They identified and extracted significant statements that were closely linked to the participants鈥� lived realities. Following this, the researcher (AHJ) identified meanings that were clustered into themes that were common across all participant accounts. Subsequently, a comprehensive description of the phenomenon was developed, integrating the identified themes into a cohesive narrative that reflected the participants鈥� experiences. The themes were reviewed and discussed within the team before being written up.

Several measures were taken to ensure rigour and credibility, and that findings reflected participants鈥� lived experiences. First, the participants were given the opportunity to review their transcripts. The bracketing of pre-suppositions was carefully considered, discussed and recorded to prevent any potential influence from existing theories. Finally, team members (AA, SIK, SK) engaged in a review and discussion of the themes to ensure a rigorous and accurate interpretation. The study was conducted and reported in alignment with the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Supplementary file 2) [30].

Ethics

The study followed the ethical guidelines for research on human subjects as outlined in Declaration of Helsinki. Ethical approval has been obtained from Khyber Medical University (Reference: DIR/KMU-AS&RB/EP/002379).

Results

A total of 10 participants were initially approached to participate in the study, with 8 provided informed consent to take part. To ensure confidentiality, the identities of the participants are not revealed; all participants were assigned unique identification codes. All participants identified themselves as transwomen. Table听1 illustrates the considerable diversity among the participants regarding age, gender identity at the time of gender declaration, and educational background.

Table 1 Demographic characteristics of the participants

We identified five primary themes and 10 sub-themes, which emerged from the data. The five primary themes are as follows:

• 1. Healthcare discrimination and marginalisation (2 sub-themes).

• 2. Quality of care and dental professionals鈥� attitude (2 sub-themes).

• 3. Cost and affordability of dental care (2 sub-themes).

• 4. Social stigma and the absence of community support (2 sub-themes).

• 5. Inclusive dental care facilities (2 sub-themes).

Healthcare discrimination and marginalisation

Sub-theme 1.1: discriminatory treatment by healthcare professionals and patients

Participants indicated that they frequently encountered discrimination and marginalisation in healthcare environments. Numerous individuals recounted instances of being mocked, belittled, and subjected to inhumane treatment by both healthcare professionals and fellow patients. Such adverse interactions led transgender individuals to feel unwelcome and alienated within healthcare settings, contributing to their discomfort and reluctance to seek care at public dental facilities.

鈥淭hey were mocking, saying things like 鈥渙 look! Your paternal uncle鈥檚 uncle has arrived, he is your uncle, he is your aunt 鈥榶our maternal aunt has come.鈥� (PID 1).

鈥溾�� in government facilities, people don鈥檛 treat us with respect when we go to a doctor or some problem like that. We鈥檙e just humiliated. Even for something like toothache, or tooth extraction if we go to a government doctor it is very hard to reach him.鈥� (PID-3).

鈥�. If we visit a hospital, it鈥檚 like we鈥檙e forbidden. Like we are an incurable disease.鈥� (PID-7).

Sub-theme 1.2: lack of adequate facilities and services for transgender patients

Participants stated postponements in their dental care during hospital appointments, resulting in extended waiting times compared to others. This situation fostered a sense of fear while being marginalised and perceived as less significant. Additionally, participants reported the absence of clear direction and the necessity to navigate between various healthcare departments exacerbate their feelings of alienation. The lack of stringent legislation and regulatory structures designed to safeguard their rights further also exacerbated their feelings of neglect and undervaluation.

鈥淏ecause there is no law for us, there is no government who would implement strict laws, nobody thinks anything of us. They don鈥檛 even think we are humans, why would they implement laws for us.鈥� (PID 1).

鈥溾�� they prioritize other people over us. We鈥檙e often asked to sit and wait longer. 鈥�(PID-2).

鈥溾��. Firstly, they just sometimes tell us to move to the side. They ask normal people, male or female to come forward first. We鈥檒l be dying of pain, and they won鈥檛 focus on us.鈥� (PID-4)

鈥淲e are afraid of government hospitals because we don鈥檛 have any respect over there, we don鈥檛 have any place over there, and nobody values us or looks at us respectfully鈥�.鈥� (PID 1)

Participants also indicated that the lack of distinct registration counters and the absence of specific areas for transgender patients within waiting rooms and other sections of dental hospitals intensified their experiences of exclusion and discrimination. The failure to provide separate registration facilities and waiting spaces for transgender individuals heightened their discomfort in healthcare environments.

鈥溾��. When we stand in the men鈥檚 line, they tell us to go stand in the women鈥檚 line. And when we stand in the women鈥檚 line they say, no! No! Go stand in the men鈥檚 line. This creates a new problem. So, we just knowingly go and stand in the men鈥檚 line.鈥� (PID-3).

鈥溾��. If there鈥檚 only a queue line for men and women, it makes it hard for us. Which line do we have to wait in? We face a lot of problems that way. There should be another line for us as well.鈥� (PID-8).

鈥溾赌�Y别蝉, I mean people don鈥檛 leave us alone in the waiting room. They don鈥檛 allow us in the queue line, we don鈥檛 have a separate doctor to see us, nor do we have anyone to look after us. We鈥檙e just stuck standing in the crowd鈥︹�� (PID-3).

Quality of care and dental professionals鈥� attitude

Sub-theme 2.1: neglect and substandard care

The standard of care delivered by dental professionals and their perceptions of transgender patients emerged as critical issues. Numerous participants indicated experiences of neglect and substandard treatment from dentists and dental auxiliary personnel, which included inadequate examinations and erroneous prescriptions.

鈥淎nd if we finally reach the doctor, he just gives us medicine for temporary relief and tells us off.鈥� (PID-3).

鈥溾��but they don鈥檛 do our (transgenders) work and treatment with as much interest as they鈥檇 of other patients鈥︹�︹��They just quickly go through their formality and protocols when you go, prescribe you medicine, and ask us for follow-up after 10 days or whatever. They just try to get done with us and evade鈥︹�� (PID-4).

Additionally, some participants noted that dental care providers were reluctant to conduct thorough examinations, often offering only temporary solutions that failed to tackle the underlying causes of their health concerns.

鈥淭hey鈥檒l just give us random medicine. I mean for example if I鈥檝e a stomach-ache, the doctor will give me headache medicine. Just to get rid of us quickly. For example, Allah forbids that for me and everyone but if I have a heart problem the doctor would just give me fever pills. This is not something nice.鈥� (PID-6)

鈥淎nd when I went to the doctor, even he wasn鈥檛 willing to check and examine and prescribed us medicine without examining.鈥� (PID-8).

Furthermore, some participants indicated that, as a result of neglect and insufficient care, they frequently turned to self-medication to address their health requirements.

鈥溾��. they don鈥檛 take care of us properly, and when they don鈥檛 take care then we must take tablets for relief.鈥� (PID-5).

鈥溾��Just went and bought medicine from the medical store and left.鈥� (PID-7).

Sub-theme 2.2: positive experiences with compassionate care

Participants indicated that positive experiences were observed when dental care providers exhibited empathy and compassion, which greatly enhanced the overall experience for them.

鈥淥惫别谤补濒濒, I believe all doctors, regardless of identity, care for humanity. I pray for their success. I haven鈥檛 faced significant issues. They care for us, first Allah cares for us and then they care for us.鈥� (PID-2).

Cost and affordability of dental care

Sub-theme 3.1: financial barriers to quality care

Many participants noted that private dental clinics generally offer higher quality and more respectful services. However, the significant costs associated with these services posed a major barrier to accessing the services. While participants acknowledged and experienced superior quality and respect provided by private dental clinics compared to public dental hospitals, the high fees continued to be a considerable challenge.

鈥淚鈥檝e got all my treatments done from a private clinic. I don鈥檛 trust government hospitals鈥︹�︹�� it was good. You do have to spend some money, but you save your time, and they respect you there as well.鈥� (PID-4).

鈥淎nyone can go to government hospitals, but in private ones, only those who can afford it, who can pay the fees, can go, and they are taken care of.鈥� (PID-2).

鈥溾�� well, we don鈥檛 have well enough income to afford private health care. But you鈥檙e respected in a private hospital鈥︹�� Because private clinics are expensive, and we don鈥檛 have that good of an income.鈥� (PID-6).

Sub-theme 3.2: lack of support from public healthcare

Participants stated that public hospitals typically do not offer social health packages that include dental care and medications, further limiting transgender individuals鈥� access to necessary healthcare. The issues described, such as the lack of social health packages and the high cost of medications, are challenges that disproportionately affect transgender individuals due to their specific social and economic vulnerabilities. The participants reflected on broader systemic problems within the public healthcare system in Pakistan, where limited resources and financial barriers affect many marginalized populations, further exacerbating the difficulty in accessing necessary healthcare services.

鈥溾�� they suggested bringing an application for free treatment as they didn鈥檛 have resources for free services.鈥� (PID-2).

鈥淗e was seeing all the patients, writing prescriptions, and telling them to buy medicines from outside the hospital: inside the hospital they are expensive.鈥� (PID-5).

Social stigma and the absence of community support

Sub-theme 4.1: societal rejection and harassment

Social stigma and the lack of community support significantly influence the healthcare experiences of transgender individuals. Numerous participants reported that rejection from society and family members posed obstacles to obtaining dental care, as they frequently encounter invasive inquiries and harassment within medical settings.

鈥淭he problem is people just keep asking us, 鈥榳hy we鈥檙e here? What are we doing here? What鈥檚 the problem?鈥� the women and the men there question us. They eat our brains out by asking us such questions. They ask us different questions. Why are we here? What are we doing here? This happened and that happened. Drives us crazy with all the questions鈥� boring and frustrating for us.鈥� (PID-3)

People harass us here and there. The improper way they look at us. We don鈥檛 even know. (PID-8)

Another participant emphasised that transgender individuals face rejection first from their families and then from society, with even family members often casting them out. They explained that the healthcare system is no exception to this discrimination.

鈥淟isten to me, we are cast out of society. Even our families don鈥檛 accept us. If you go to our families, they cast us out. The remaining whole society casts us out even more.鈥� (PID-7).

Sub-theme 4.2: emotional toll of social rejection

Participants indicated that ongoing experiences of rejection and stigma lead to hesitance in pursuing dental care, as they often feel disheartened and dissuaded from seeking assistance.

鈥溾��After listening to this teasing, we have forgotten to share our dental pain. We became upset with our gender identity. Then I came back.鈥� (PID 1).

One participant articulated the emotional pain caused by social rejection within dental environments, conveying their frustration regarding being perceived as outsiders and not being acknowledged as integral members of society.

鈥溾�� We鈥檙e Allah鈥檚 creation as well. We came from a woman as well, like the rest of humans. We weren鈥檛 just dropped down from the sky. We have feelings too and we get hurt as well. And we can鈥檛 even curse鈥� because even they have kids and a family. We don鈥檛 want bad for anyone; we interact with everyone on good terms. But when our feelings get hurt, then Allah鈥檚 all-seeing and all-knowing.鈥� (PID-6).

Inclusive dental care facilities

Sub-theme 5.1: need for tailored healthcare environments

Participants offered a range of suggestions aimed at enhancing the dental care experience for transgender individuals. Among the key recommendations was the creation of specific treatment and waiting areas tailored for transgender patients, which would promote their comfort and safety during visits. To improve their experience and avoid humiliation, participants underlined the necessity for dedicated counters and waiting rooms that are similar to those used by men and women.

鈥�I only want to say, there should be a separate section for us. A separate doctor, a separate waiting area, and a separate queue line. Things like that will make it accessible and better for us. If not, we鈥檒l just keep getting humiliated just like I said before. We people鈥�We want a separate doctor, a separate hospital, a separate office, I mean a separate waiting area. That鈥檚 all we want鈥�. I鈥檒l say, it鈥檒l be easy for us if we, I mean鈥� if we have our separate doctor, I mean鈥� a separate ward鈥� a hospital everywhere鈥�.鈥� (PID-3)

鈥淲e should also have a separate counter. Because there is one for women and one for men. So why not one for us? Talking about the waiting room, why isn鈥檛 there one for us? There is one for men and one for women, why isn鈥檛 there one for us?鈥� (PID-7)

鈥淚 want it to be a better place for us. There should be separate counters for us. A separate waiting area where we don鈥檛 get to face problems like we do now.鈥� (PID-8)

Sub-theme 5.2: empathy and compassionate care

Participants highlighted the importance of providing compassionate and attentive healthcare, calling on dental care professionals to approach marginalized and underprivileged populations, including transgender individuals, with empathy, respect, and dignity to enhance the quality of care.

鈥淒entists should be nice, should listen to the patient peacefully, should examine the patient nicely. So, the patient will understand that he has listened to what I said and given me good medicines so he will feel peaceful and comfortable. If he does like that then I will tell four more people about that doctor that he is nice and go to him.鈥� (PID-5)

鈥淚 just want to say that doctors know the poor people. Doctors should empathize with the poor because they understand their struggles. If doctors show compassion towards the poor, Allah will reward them. Wealthy individuals can afford treatment anywhere, but the poor don鈥檛 have the option to visit private hospitals. If doctors in hospitals collaborate with people like us, transgender individuals, and the poor, it would be beneficial for the underprivileged 鈥�. (PID-2)

鈥沦辞, we require more attention. If we visit a doctor, the more they cooperate with us with love, the faster we鈥檙e going to get better. The more they ignore us, the more we鈥檒l feel disheartened. We鈥檙e humans as well. For the love of God, we should also be taken care of. Doctors should think of us as humans as well. We should be helped as well. That鈥檚 all I鈥檇 like to say that, please鈥� please鈥� take care of us. These doctors, the people of the world, and society should accept us.鈥� (PID-7).

Discussion

The findings from this study highlight that transgender individuals face wide-ranging discrimination, marginalisation, and institutional barriers in dental care settings in Pakistan. These barriers manifest at various levels of dental care delivery, from individual interactions with the community and dentists to organisational restrictions that generate a sense of hostility among transgender individuals.

Findings regarding the discrimination, marginalisation and humiliation experienced, often characterised by outright mocking and belittling remarks, deterring participants from seeking dental care. This is consistent with prior research studies highlighting the harmful impact of circumstances of stigma, discrimination and marginalisation on transgender individuals and their willingness to seek healthcare services [31, 32]. In contrast, several high-income countries such as the United States of America and the United Kingdom have shown improvements in various settings with anti-discrimination policies that are strictly implemented [33, 34]. These policies aim to protect transgender individuals in healthcare settings and reduce the risk of discrimination, providing a useful benchmark for Pakistan, where there is a notable lack of such policies. This gap indicates a need for robust policy enforcement to protect transgender individuals鈥� rights in healthcare settings in Pakistan.

The inadequate care in dental settings that transgender individuals experienced reported by participants in this study mirror the conclusions drawn from a review of the barriers faced by transgender individuals in accessing healthcare, which highlights the biases and insufficient empathy exhibited by healthcare providers in delivering high-quality care [35]. However, the experiences presented in this study revealed that dental care workers鈥� empathy and compassion significantly improved encounters, highlighting the importance of individual provider attitudes in patient satisfaction. This could be explained by the Therapeutic Alliance Theory, which describes how practitioners鈥� displays of empathy and compassion improve patients鈥� experiences [36]. Further, studies from other high-income countries emphasise the need for healthcare provider training to mitigate such biases, which is a critical point for improving dental care for transgender individuals [37].

The economic constraints noted by participants in this study reaffirm the restricted accessibility of quality dental care in private dental settings due to high costs. These experiences mirror findings in the literature on healthcare inequities for transgender individuals [22, 38]. In middle-income countries, even when transgender individuals can afford oral care, they are less likely to possess dental insurance to access private care [38]. The findings from this study, in contrast, differ from evidence from high and middle-income countries, which have identified a certain level of affordability in public healthcare services [22, 25]. To address health inequities, the Pakistani government has launched initiatives to build social healthcare packages, such as the Sehat Sahulat card, which is available to all citizens, including transgender individuals [18]. However, there is still an urgent need for more inclusive public healthcare programs that include social health packages targeted to the oral health needs of vulnerable populations, including transgender individuals. International examples, like the United States Affordable Care Act (ACA), also point to the benefits of such inclusive healthcare reforms that target marginalised groups [39]. The Sehat Sahulat card represents a positive first step, but it must be coupled with more targeted interventions in oral health to improve transgender individuals鈥� access to dental care.

Social stigma experienced by participants, stemming from wider cultural beliefs, aligns with existing evidence indicating that social stigma and prejudice, particularly structural stigma, significantly contribute to health disparities experienced by transgender individuals [40]. However, this study highlights the importance of supportive relationships in healthcare settings, in contrast to the primary focus of prior studies on familial support in addressing these difficulties [41, 42]. Participants in this study reported that dental practitioners鈥� lack of empathy regularly worsened their experiences of social isolation outside of healthcare settings.

This study鈥檚 findings provide valuable insights into the systemic barriers faced by transgender individuals in accessing dental care in Pakistan. These barriers, including social stigma, provider biases, economic constraints, and the lack of specific healthcare policies, reflect broader global trends [35]. Drawing on international examples of policies and training programs aimed at reducing healthcare disparities for transgender individuals [37, 39]. Given the qualitative nature of the study and the small sample size of eight participants, the findings provide valuable insights but may not be broadly generalisable. Further research with larger and more diverse samples, including cross-sectional studies, analytical research, and intervention-based evaluations, could strengthen the evidence base and guide meaningful policy reforms.

Implications for practice, policy and research

A consistent recommendation from participants is the need for separate treatment and waiting areas, along with specialized registration counters, for transgender individuals in public dental care hospitals. This approach would help ensure privacy and reduce discrimination. Research from both low- and high-income countries supports the creation of secure healthcare environments tailored to the needs of transgender groups, emphasising their importance in fostering dignity and safety [33, 34].

To combat discrimination, healthcare systems should prioritise mandatory cultural competency training for all staff, focusing on gender identity, pronouns, and transgender health needs. This training should be integrated into ongoing professional development to reduce biases and enhance care quality. Additionally, implementing clear anti-discrimination policies within healthcare settings is essential. These policies should protect transgender individuals from mistreatment and provide formal channels for reporting discrimination, creating a safer and more inclusive healthcare environment.

Financial barriers are a significant challenge for transgender individuals in accessing necessary healthcare. Expanding insurance coverage to include gender-affirming care, such as hormone therapy, surgeries, and mental health services, is critical. Implementing subsidised healthcare options based on income would make these services more accessible. Financial assistance programs for gender-affirming treatments and trans-specific care would alleviate some of the financial challenges faced by transgender individuals, ensuring they can access essential healthcare without facing financial strain.

Future research in Pakistan should focus on evaluating the impact of these measures. Specifically, studies could examine how social healthcare packages compare to public healthcare in meeting the needs of transgender individuals and improving health outcomes. Additionally, assessing the effects of structural changes, such as secure healthcare spaces, on patient satisfaction and safety could provide valuable insights into the effectiveness of these interventions. Research should also explore the role of community advocacy and public health campaigns in raising awareness and reducing stigma, helping to foster a more inclusive environment not only in healthcare but across society.

Strengths and weaknesses of the study

This qualitative study explored the personal experiences of discrimination, marginalisation, and financial barriers faced by transgender individuals in dental care settings in Pakistan an area not widely addressed in existing research. This approach allowed for a deeper understanding of the participants鈥� lived experiences, offering insights that add to our knowledge in ways that quantitative studies often cannot. A strength of the study is that it included transgender women from both rural and urban settings, using maximum variation sampling, which allowed for a diverse representation of experiences and perspectives across different educational backgrounds and geographic contexts.

Potential bias may have been introduced by using study team members instead of a professional translator for the transcript translation. However, attempts were made to reduce this bias by conducting regular supervisory meetings and checks to ensure the accuracy and objectivity of the transcription and analysis process. Additionally, member checking was conducted, allowing participants to review and validate their transcriptions to ensure their views and experiences were accurately captured. Member checking adds qualitative rigour by enabling participants to confirm that their responses were interpreted correctly, enhancing the credibility and trustworthiness of the findings [37].

Involving a non-profit organisation (NGO) may have strengthened the findings, as it included participants who are actively engaged in social support networks and more aware of healthcare challenges. However, the connection to the non-profit also introduces some limitations. The small sample size, typical in qualitative studies, may limit the representation of the broader transgender community. Additionally, findings mainly reflect the experiences of individuals connected to the NGO, potentially overlooking those less engaged or without access to similar support. The study participants were exclusively transgender women; transgender men were not interviewed due to cultural sensitivities and social visibility limitations; transgender women are more commonly recognised than transgender men in Pakistan. This exclusion may have influenced the findings, as the experiences and challenges faced by transgender men such as distinct challenges related to gender identity, societal acceptance, and access to healthcare, might be influenced by their social visibility and the prevailing cultural attitudes towards masculinity and gender nonconformity in Pakistan. Including these groups may have provided a more comprehensive view of the barriers faced by transgender individuals in accessing dental care. Overall, while this study provides important insights, it may capture only part of the larger reality faced by transgender individuals in Pakistan鈥檚 healthcare system.

Conclusion

This research highlights the discrimination and systemic barriers transgender individuals in Pakistan face in accessing dental care, leading to delayed treatment and poor oral health. Financial constraints and a lack of empathy from dental care professionals exacerbate these issues. Policy reforms are needed to improve access, including anti-discrimination laws, cultural competency training, and targeted health initiatives. Future studies should evaluate these interventions to promote inclusive healthcare. Fostering an empathetic and equitable dental healthcare system is essential for providing dignified, high-quality care for all patients in Pakistan.