Challenges faced by marginalized communities such as transgenders in Pakistan

Challenges faced by marginalized community such as transgender in Pakistan

Hassan Bin Usman Shah^1,&, Farah Rashid¹, Iffat Atif¹, Muhammad Zafar Hydrie², Muhammad Waleed Bin Fawad¹, Hafiz Zeeshan Muzaffar¹, Abdul Rehman¹, Sohail Anjum¹, Muhammad Bin Mehroz¹, Ali Haider¹, Ahmed Hassan¹, Hassaan Shukar¹

 

¹Department of Community Medicine, Yusra Medical & Dental college, Islamabad (YMDC), Pakistan, ²Joint program of family and community medicine, Directorate of Public Health, Ministry of Health Jeddah Region, Jeddah, Kingdom of Saudi Arabia

 

 

^&Corresponding author
Hassan Bin Usman Shah, Department of Community Medicine, Yusra Medical and Dental College, Islamabad, Pakistan

 

 

 

 

Trans sexuality and transgender communities have gained little visibility in our society as we are taught to believe in strict binaries of male and female genders. We tend to consider them taboo, distancing ourselves and humiliating them without trying to understand their problems [1]. In Pakistan, the most commonly used word for the transgender is 'Hijra'; an umbrella term covering various forms of gender deviances. It covers anyone who bends the common societal constructions of gender including cross-dressers, homo and bisexuals, true hermaphrodites, eunuch, transsexuals, transvestites, genderqueer youth, drag queens and transgender [1]. Injustice, poverty, illiteracy, social and cultural boycott, lack of opportunities and non-dominant social identities are some reasons for social exclusion for this marginalized group. This cornered minority have the extra stress of coping with their sexual orientation in our society [2]. Studies show that social exclusion is pushing the transgender community into inappropriate conducts/habits [2,3]. Most of the members of this jeopardized minority are forced to indulge in risky and dangerous ways of earning their livelihood, including sex work, dancing, begging and substance abuse etc [1,3]. Literature shows that vulnerable groups who are engaged in one problematic behavior are more likely to engage in others also [2]. We need to rethink about these forgotten people and listen to their plight before they reach a point of no return (i.e. more suicidal ideation and tendency) [4]. Furthermore, once their sexual orientation is disclosed they may face harassment, violence and lifetime of repeated victimization not only from the society, in schools from class fellows, and even by the other members of their home. Thus, the already stigmatized and cornered group is subjected to unending and systematic oppression [5]. Studies conducted with transgender population demonstrated violent physical victimization rates ranging from 43% to 60% [6,7]. Such factors force them to run away from their home, increase drop outs from schools, violating laws and indulging in activities which can harm not only their but others health too; common being prostitution, and I/V drugs use [6,7].

 

Moreover, suicidal ideation and attempts has been identified as an additional life threatening issue associated with victimization [8]. A four-fold increase in suicidal ideation is seen in transgender associated with physical victimization [9]. Once transgender leave their house or are forced to do so; they start living together in the traditional commune arrangement of five or more disciples (commonly famous as "Chelas") supervised by a "Guru (teacher)." Each house has its own history, rules and identified by its Guru. Once transgender reaches there, training in singing, dancing and other activities are given enabling them to earn a livelihood. The Guru is responsible to manage the funds of his house and meet chelas needs; so, the chelas are expected to turn their earnings over to the guru. [1,10]. Most of the times guru is unable to make both ends meet and chelas start indulging in commercial sex for financial support [10] Moreover, with increasing modernity the income generating role from dancing and blessing births, has declined, forcing them into begging and sex trade [1,10]. Rarely someone would opt sex work as a profession by choice because of the stigma, discrimination, religious prohibition and the risks attached to it [1,11]. In most of the cases they are forced to sell sex to earn a living, making themselves vulnerable and a source of spreading of sexually transmitted diseases [1,12]. It is important to understand the social context and identify the causes of these risk behaviors which are pushing transgender to inappropriate conducts/habits. Early recognition of the factors leading to increase in substance abuse, forcing transgender into commercial sex and suicidal tendency can bring change in their lives. This will help in designing an effective intervention that would aim to improve the behaviors, protect the people based on their gender identity and expression [11,12]. This study summarizes the diverse factors and gives an insight of how and what this group themselves experience and paints a picture of how our social exclusion is pushing them to cross the line.

 

 

A cross-sectional study was carried out in different locations of Rawalpindi and Islamabad. The total duration of the study was 6 months, from 1^st June to 1^st Dec 2016. The data was collected from 189 transgender people selected through snow ball sampling technique. Sample size for the transgender people included in this survey was calculated using Epitools sample size calculator. Calculated sample size was 139 by keeping expected transgender population at 10% (taken from other regional studies) [10,13] with 0.05% desired precision and 95% confidence level. Researchers approached 207 transgender people but n= 18 (8.6%) refused to participate, so the response rate of 91.4% was noticed. Before the interview multiple meetings with the Gurus were held to develop a rapport and to get permission from the decision maker of the house (i.e. Guru). The interviews were conducted privately mostly at their place of residence since they are usually suspicious on strangers and this helped in breaking the ice and gave the participants a chance to express themselves completely. Information was obtained through direct interview from the transgender, using standardized close ended questionnaires whose components were incorporated from internationally standardized instruments [5,10,13,14]. This validated close ended structured questionnaire; translated in local language with slight modification was used. It was translated from English into Urdu, by two bilingual professional translators who understood content. The translated instrument was then back- translated into English by two other bilingual translators and compared to its original version. This procedure ensured clarity and comprehensibility of items. Any discrepancies in comparison were discussed and a few minor adjustments were applied after pilot-testing. Data on demographics, identification as being transgender, source of income, housing, substance abuse, sexual history, risk behaviors, family and society support, receiving psychotherapy, physical victimization and gender based discrimination along with suicidal tendency was gathered from the study participants. Along with these, questions related to community's behavior, treatment given at the health care facilities and law enforcing agency's behavior were also included.

Discrimination based victimization was assessed on responses to two question [14]; including ever been physically/verbally attacked (like jeered, grabbed, punched, stabbed, hit by a rock etc). An affirmative response led to question identifying/asking gender identity being primary reason for these attacks. We derived two measures from responses of above mentioned questions. A confirmation that gender identity being main cause for these attacks was coded as discrimination based victimization (yes = 1; no = 0); and non-discriminatory victimization, if reported physical attack was not due to transgender status (coded as yes = 1; no = 0). Similarly, any institutional discrimination experienced by the respondent was also assessed. These include being fired/denied from the job, lost and denied housing, discrimination at the hospital, school and denied enrollment in insurance schemes etc. (coded as yes = 1; no = 0). For this study, we defined suicide risk in three ways; suicidal ideation only (thought about suicide but never attempted), suicidal ideation total (who actively considered suicide including those who attempted) and suicidal behavior (who had attempted suicide but not think about it anymore). If transgender have neither contemplated nor attempted suicide ever, they were classified as "No risk for suicidal behavior" which served as our reference group. (All were coded as yes = 1; no = 0) [14]. The interviews with the participants were done during the day when the participants were not working and available to participate in the study. Moreover, they were also provided with information regarding spread of infection and modes of prevention. Eligibility criteria included individuals 18 years or older and willing to provide informed consent for this study. Ethical approval was taken from ethical review board of Yusra Medical & Dental College (ERC# YMDC/01/17/ERB/109). Data analysis was done using SPSS 22. Frequencies and percentages were calculated for the categorical variables. Bivariate logistic regression analysis was conducted to determine whether discriminatory victimization, non-discriminatory victimization and institutional discrimination, forced sex and community/family support (in addition to several co- variates) are related to suicide risk, sexual behavior and substance abuse. Multivariate regression analysis was also conducted while controlling for sociodemographic and psychosocial variables.

 

 

The mean age of our study population was 29