Mehr Khan, an Indian transgender woman, arrived for a routine hormone therapy appointment only to discover the crucial treatment had been suspended after a recent change in the law narrowed the range of those eligible for such services.
"The doctor was really just hiding his face. He didn't know what to say," said the 26-year-old event planner, adding that she glimpsed "fear on the staff's faces" at the clinic in the southern city of Hyderabad.
Khan is one of many Indians grappling with denial of care after the option for self-identification of gender was scrapped in March, making legal recognition conditional on certification by a panel of doctors instead.
But the government has yet to specify the nature of specialists on such panels, leaving uncertain whether they owe responsibility to state or central authorities.
Before the 2026 law, transgender people could apply online to change their gender marker on the basis of a letter from a gender-affirming care provider, such as a surgeon or psychiatrist.
India says the change aims to curb misuse of welfare benefits and boost safeguards, but activists and doctors warn it could boost uncertainty for providers and cut many people off from key medication.
The government and Tata Trusts, which funds the Sabrang Clinic, where Khan was being treated, did not respond to Reuters' request for comment.
At least a dozen transgender people told Reuters the change had disrupted their care arrangements, with clinics pausing services and delaying surgeries.
Five doctors said they were proceeding cautiously, as some providers ask transgender people for declarations that they were seeking treatment voluntarily.
"Doctors are very concerned and confused as to what kind of care they are now allowed to give," said Arundhati Katju, a senior lawyer with a Supreme Court practice.
Global trend targeting transgender rights
The change comes amid a global trend to curb transgender treatment, as the United States has recently limited access to gender-affirming care, although in Asia, countries such as Thailand offer broader access but limited legal recognition.
Activists who once saw India as taking a progressive stance on such recognition say it is now moving toward tighter state oversight.
In the southern tech hub of Bengaluru, business development manager Ananya Balamurali, 24, said her July gender-affirming surgery at a private clinic in the capital, New Delhi, had been put on indefinite hold after the change to the law.
In the port city of Kozhikode in the southern state of Kerala, makeup artist Ichu, 30, said a government hospital had refused to approve her hormone replacement therapy, despite months of consultations.
Doctors were initially "ready to give the letter", but withdrew approval after a board meeting, she added.
The Association of Transgender Health in India estimates its transgender population at about 20 million among a populace of 1.4 billion, well in excess of a figure of about 500,000 in the most recent census of 2011.
The amended law undermines a landmark 2014 Supreme Court ruling recognising transgender people as a third gender, said association founder Dr Sanjay Sharma.
"This is a public health emergency," said Sharma, a former air force official and the father of a transgender child.
The legal provisions could be interpreted as penalising hormonal and surgical interventions and potentially expose doctors to prosecution, he said, besides fears that medical board checks could be physically and mentally invasive.
Although transgender people are usually pushed to the margins of society in India, they are invited to bless weddings and births in some areas, in line with traditional beliefs.
Members of such traditional groups, as well as intersex people and people "coerced" into being transgender, are the only ones the 2026 law recognises as "legitimate".
It also explicitly bars self-identification as a basis for transgender identity, ruling out gender changes on official documents for those outside the narrowed definition, Sharma said.
Spectre of unregulated care
Gender-affirming care includes HRT, making use of hormones such as estrogen or testosterone to align physical traits with individuals' gender identity, with surgery preceded by up to a year of such treatment.
Abruptly stopping HRT can disrupt endocrine function, causing bone density loss and symptoms similar to menopause, doctors say.
Restricted access could drive the transgender community to seek unregulated care, say activists.
"We're worried that the new law might push the transgender community into a shell," said Hyderabad-based activist Rachana Mudraboyina, adding that many might turn to quacks to avoid documentation hurdles.
Debbie Das, the owner of a design business in the tech hub of Bengaluru, said the uncertainty prompted her to delay starting HRT, as she is chronically ill and lacks steady income after the legal change led to cancellation of some projects.
"I didn't want to start HRT and then have to panic about whether I should stop," she said.
Transgender men may be especially vulnerable as the law does not clearly cover them, said Fred Rogers, a counsellor based in the southern metropolis of Chennai, who added that public understanding of transgender issues revolves around women.
As a whole, however, India's transgender community must battle persistent stigma and exclusion in a society largely still patterned on traditional lines, where disapproval by family and employers pushes many into informal work.
The government says the law aims to curb exploitation and trafficking and widen welfare access, but activists warn some aspects may have the opposite effect.
Ichu, who gave only one name, now seeks care at a clinic 50 km (31 miles) away from her home, while Khan relies on an older prescription after missing a planned dosage change.
"People at the clinic said, 'Give us a week or two, we'll figure this out,'" Khan said. "It's been months now and we're still entirely clueless about where to go, what to do."