Precarious Aging: Transgender Lives, Health Systems, and Social Exclusion

Pakistani transgender people experience lifelong exclusion due to family rejection, institutional abandonment, and social protection. Forced from their families at a young age and initiated into collective households through the guru-chela system, they are socialized outside the main social structures. This enforced separation generates cycles of migration and compounds marginalization across the life course. As they reach old age, the burden of exclusion from family and labor markets, health care, and the law leaves older transgender people in a dire situation. This paper explores how gendered discrimination, migration, and age shape access to health and social welfare, and how it draws on sexual politics to understand discrimination. It draws on Butler's theories of gender as performativity (1990) and precarity (2004), and Bourdieu's theories of social suffering and symbolic power (1991). The present study conducted three focus group discussions and 14 in-depth interviews with people who identify as transgender and are 50 years and older, using interpretative Verstehen. A sample of 35 participants was recruited. We explored the experiences of aging, family abandonment, and discrimination in health. Participants described severe mental illness, depression, loneliness, and gender dysphoria. Family abandonments in early life and subsequent migration were reported as continually undermining a sense of connection and identity, and participants' self-esteem was low. Participants lacked health insurance and reported being denied medical care, even during a crisis. Joint pain, due to hormonal imbalances, was widely reported, as was the use of black-market hormones by some, leading to severe health complications. Despite the risk of sexually transmitted diseases, knowledge and access to prevention strategies were low. In line with the transgender training program of Punjab Skills Development Fund, the present research identifies its best practices and its gaps. It advises non-discriminatory health care, education, and social security reforms to eliminate prejudice, as well as community care and counseling centers that offer health care and support for registration.