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Article History

Received: 5 November 2025

Accepted: 8 February 2026

First Online: 15 February 2026

Declarations

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: Ethical approval has been received from the Khyber Medical University ethics committee (Ref: Dir/Ethics/KMU/2025/09/183). The study will be performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study involves a marginalized population with elevated vulnerability to stigma, discrimination, and mental health risks. Key ethical concerns considered include participant safety, management of suicidal ideation, confidentiality within close-knit transgender community networks, and ensuring voluntary participation free from coercion. Given the elevated risk of suicidal ideation among transgender populations, a structured suicidality assessment and management protocol will be implemented in line with mhGAP guidance. Participants identified as being at moderate or high risk will receive immediate clinical assessment, safety planning, and referral to specialist mental health services through predefined pathways, with on-call psychiatric support available as needed. To ensure consistent implementation across study sites, all participating general practitioners will receive standardized training in mhGAP suicide-risk management, supported by written clinical algorithms and access to supervisory consultation for moderate- and high-risk cases, including follow-up where clinically indicated. Written informed consent will be obtained from all individual participants included in the study. Participants will be remunerated for their time and travel. To address confidentiality risks within close-knit transgender community networks, all assessments and interviews will be conducted privately by the research team and GP, and no individual-level information will be shared with Gurus or community members without explicit participant consent, except where disclosure is required to prevent imminent harm. Data will be anonymised to ensure the confidentiality of all the study participants. Potential legal challenges anticipated in the local context include concerns related to identity documentation, fear of discrimination, and apprehension regarding engagement with formal institutions. To mitigate these risks, participation in the study will not require disclosure of sensitive legal or personal information beyond standard eligibility criteria. The study will not collect information related to illegal activities, and participants will not be asked to disclose details that could place them at legal risk.

: The authors declare no competing interests.