Transgender Struggles in Pakistan: Navigating Medical, Cultural and Religious Barriers to Gender Affirmation

In Pakistan, transgender individuals face significant challenges despite gender affirmation surgery being legally permitted since 2018. Bunty, one of the few trans women financially able to undergo safe surgery, describes her experience as "underground" despite visiting a qualified professional in Lahore.

Despite paying double the standard rate charged to cisgender women, Bunty was hastily discharged after just two hours due to fears of discovery. "I was in extreme pain," she told AFP, highlighting the secretive nature of her procedure.

This experience compounds the difficulties Bunty has endured, including family rejection and employment termination, which ultimately forced her into sex work to cover medical expenses.

The hospital's reluctance stemmed from concerns about negative reactions from staff and patients. Dr. Mudassir Mahboob, who performs legal gender-affirmation surgeries, explains: "Gender transitioning is still controversial. Doctors fear they will be judged."

Dr. Mahboob deliberately chose to practice in Islamabad rather than his conservative home province of Khyber Pakhtunkhwa. He frequently treats patients who suffered complications from procedures performed by unqualified practitioners, including one individual who sought help "to fix what went wrong" after an improper castration.

Reem Sharif, a member of a communal trans household known as a "dera," reveals that only two doctors in Pakistan openly provide legal, safe gender affirmation procedures. Public hospitals commonly refuse such services, citing religious objections.

"They would say: 'Have fear of God, how can you try to do this?'" Sharif recounted. "Gender transition is legal according to the law, but practically it is not, and it is not accepted in society."

Pakistan lacks reliable data on its transgender population. Historically, the country has recognized a third gender called "khawaja sira," who have traditionally held spiritual roles in society, offering blessings at celebrations.

The 2018 legislation aimed to enhance transgender rights amid increasing violence but faced significant opposition from religious conservative groups that spread misinformation claiming it would legalize same-sex marriage in a country where homosexuality remains illegal.

While the law remains in effect, it faces ongoing legal challenges, including a review of its compatibility with Islamic law, which exists alongside Pakistan's secular legal framework.

Psychiatrist Sana Yasir noted an increase in transgender patients seeking support during the three years since these legal challenges began, as they struggle with uncertainty about potential legal changes.

Human rights organizations emphasize that transgender individuals who receive transition support report improved quality of life, while those denied assistance frequently experience mental health issues, including suicidal thoughts.

Mehleb Sheikh, an independent trans rights researcher and activist, explains that according to Pakistan's religious and cultural norms, gender confirmation surgery is considered "a sin" even when it aligns physical characteristics with gender identity.

Gender affirmation surgery is available in some other Muslim nations with varying degrees of accessibility. In Egypt, the procedure is legal but requires approval from medical and religious authorities, severely limiting access. Iran legally permits and subsidizes such care, though activists report transgender people still face daily discrimination.

Violence against transgender individuals appears to be increasing in Pakistan, although precise statistics are unavailable due to severe underreporting. The Gender Interactive Alliance reports 56 transgender people have been killed since 2022, including three trans women whose bodies were recently discovered with gunshot wounds in Karachi.

"My brother threatened to kill me and demanded that either I be thrown out of the house, or he would hurt me, blaming me for ruining their honour and their reputation," revealed Zarun Ishaque, a 29-year-old transgender man from Islamabad.

Despite these hardships, Ishaque expressed that "this happiness after my transition is the dearest thing. My inner self has come out, and I am very happy with my life like this."

Haroon (a pseudonym used to protect his identity) has managed to undergo breast removal and bottom surgery despite family rejection and medical resistance. He describes feeling "very comfortable with myself" following his transformation, adding, "If you have the capability, if you've taken this step and made the decision, then you don't step back."