“My heart drops when the siren wails”: cumulative structural violence, healthcare exclusion, and the search for a dignified death among older transgender women in Pakistan: an interpretative phenomenological analysis

Background Research on transgender aging has predominantly focused on younger populations and high-income countries, leaving the later-life experiences of older transgender adults in low- and middle-income settings largely unexplored. Transgender communities face a legacy of social and institutional discrimination in Pakistan, and little attention has been paid to how this discrimination affects their aging, health and end-of-life issues. This study examined the lived experience of transgender older women to understand how cumulative structural inequalities affect wellbeing of older trans women.Methods A qualitative study was conducted using Interpretative Phenomenological Analysis (IPA). Five transgender women aged 60 years and older were purposively recruited through community gatekeepers in Pakistan. In-depth semi-structured interviews were conducted in Punjabi and Urdu, recorded on audio, transcribed word for word, translated into English, and analyzed with reference to IPA framework. Interpretation was informed by Minority Stress Theory, Intersectionality, and Cumulative Advantage/Disadvantage Theory.Findings Four interconnected themes emerged: (1) embodied structural violence, in which decades of police brutality and institutional abuse remained psychologically and physically embedded; (2) healthcare exclusion, where repeated discrimination fostered mistrust and avoidance of medical services despite chronic illness; (3) enduring family rejection, which accumulated across the life course and intensified loneliness and insecurity in old age; and (4) faith and the search for a dignified death, where spirituality fostered resilience while concerns about identity-affirming burial and end-of-life care reflected culturally specific dimensions of aging.Conclusion Aging among older transgender women in Pakistan is profoundly shaped by cumulative structural marginalization rather than chronological age alone. Findings underscore the need for trauma-informed and gender-affirming healthcare, effective implementation of anti-discrimination policies, strengthened community support, and culturally responsive end-of-life care that recognizes dignity across the life course.