Beyond family rejection: conditional acceptance, family-based gender policing and mental health among transgender women in Lahore, Pakistan.

Background Research on transgender mental health has consistently identified family rejection as a major determinant of psychological distress. Less attention has been paid to the everyday practices through which families monitor, regulate, and discipline gender expression short of outright rejection. Transgender women in Pakistan navigate ongoing family control organized around family honor and gender conformity, alongside, and often instead of, explicit rejection.Methods This qualitative study explored experiences of family-based surveillance, gender policing, and mental health among sixteen transgender women who remained residents within their families in Lahore, Pakistan. Participants were recruited through snowball sampling supported by community gatekeepers. Semi-structured interviews were conducted in Urdu or Punjabi between November 2025 and March 2026, transcribed verbatim, and translated into English with cross-checking by bilingual members of the research team; selected quotations were independently verified against the original audio. Data were analyzed using reflexive thematic analysis. The study was informed by Minority Stress Theory and by Foucauldian and Butlerian accounts of surveillance and gender performativity.Results Participants described continuous monitoring of appearance, movement, and self-expression, together with corrective efforts aimed at enforcing masculine norms. Many described this monitoring giving way to self-monitoring, shame, and withdrawal and linked family regulation directly to concern for community reputation. Across accounts, participants described cumulative psychological strain, including hypervigilance, loneliness, and diminished self-worth, that they experienced as a form of confinement without physical restriction.Conclusions Family surveillance and gender policing function as a chronic, ambient stressor that the acceptance-rejection framework does not adequately capture. Moving beyond that framework, this study proposes psychological confinement as a bounded, condition-level construct describing how concealment, anticipated rejection, and self-surveillance are sustained without relief for transgender women who remain, rather than are expelled, within the family home. Interventions should address everyday family control beyond overt rejection and expulsion alone.