The structural violence of cisgender norms: A participatory qualitative study of access to health and social welfare for older transgender women in Indonesia.

Background: Transgender women commonly experience poor health outcomes. However, little is known about older transgender women's experiences of government healthcare and social welfare programs in low and middle-income countries, in the context of discrimination and neglect. Aims: This article discusses older transgender women's barriers to accessing government health and social welfare programs in Indonesia, and how intersecting factors like gender, age, and poverty contribute to poor health outcomes. Method: A transgender community-led participatory study utilized rapid ethnographic assessment (REA), comprising surveys with 48 older transgender women, interviews with a subset of 15 transgender women, and interviews with five government officials. Results: Applying an intersectional lens, the following themes were identified from the data: 1) document ownership and program enrollment; 2) healthcare needs and challenges; 3) employment and poverty; 4) housing, family, and social network; 5) barriers to accessing government health and social security programs; 6) consequences of exclusion from programs; and 7) enablers of accessing government health and social security programs. Across these themes, cisgender norms embedded in Indonesia's bureaucratic practices exacerbated participants' vulnerability to poor health. Discussion: A transgender-led research project helped to identify barriers and advocate for the government to adopt a transgender health equity lens. Exclusion from government health and social welfare programs was due to both gender expression and criteria centered on nuclear family structures, which were misaligned with all participants, who were unmarried. These cisgender norms are a form of structural violence that results in poor health, exacerbated by poverty, old age, and housing insecurity.