Shunned and ashamed, Pakistan’s trans community is finally getting help for tuberculosis

TTwo years ago, Honey developed a persistent cough, but she was afraid to go to the doctor. Experience had taught her that in health clinics she was likely to encounter abuse and insults from other patients and their relatives. And at best, the staff would ignore her and she would have to wait until all the other patients had been seen, even those who arrived after her.

The transgender community in Rawalpindi, the twin city bordering the Pakistani capital Islamabad, is close-knit and isolated. It has its own language and traditions that create a network of friends to replace the family relationships that have been lost – many of its members have been rejected and ostracized by their relatives and communities.

Isolation from wider society can have profound effects on their health. Many transgender people struggle to find work and are forced into sex work to make ends meet. This increases the risk of contracting HIV and other sexually transmitted infections (STDs).

They also often survive by begging or working as dancers at weddings or birth parties – jobs that carry a greater risk of violence and abuse.

Honey was eventually diagnosed with tuberculosis (TB) at a research camp run by the Dopasi Foundationa non-profit organization for transgender people. It brings portable X-ray machines to vulnerable communities, with scans analyzed by artificial intelligence.

The trans community is thought to have done that have among the highest TB rates in Pakistan, a country that already carries one of the largest tuberculosis burdens in the world: there were 686,000 new cases in 2022.

Even after her diagnosis, Honey had to change locations for her treatment several times after feeling unwelcome in clinics. She fears that attitudes towards transgender people are becoming increasingly worse, as a result of negative media reporting.

Her flat has a terrace overlooking one of Rawalpindi’s narrow streets, lined with stalls selling everything from raw meat to household lighting fixtures. Via a tight, dark staircase it is an extremely clean and tidy house, but busy. She shares a few rooms with five friends who are preparing to dance as entertainers at a wedding today.

The apartment has hosted a number of Dopasi’s transgender screening camps. “I just didn’t want anyone to experience the pain that I went through, the fear that I had,” Honey says.

Screening camps also take place at a community center run by the Dareecha Male Health Society, providing a rare space for transgender people to come together. On the day of our visit, Dopasi screened 15 people for tuberculosis at the center. One result was positive, pending a full diagnosis in a laboratory.

The Stop the TB partnership funds the screening program through the TB range Initiative, testing innovative approaches to reach vulnerable groups. Muhammad Usman, executive director of Dareecha, says: “No one is stigmatized here, no one is discriminated against.

“We are all equal. That’s why we usually hug each other. We usually have food on one plate. We are doing our utmost to reduce that stigma, which certainly still exists in our society,” he says.

The people he works with are at high risk for many types of infections, he adds. “They live in slums. There are (maximum) eight people living in the same room, so there is a high risk of tuberculosis or some other problem.”

The center provides access to a doctor and advice on preventing sexually transmitted infections. HIV, which one increases the health threat due to tuberculosisand other STDs such as syphilis are a major problem; Usman points to high rates of partner sharing, drug use and often a lack of precautions – trans sex workers can charge higher prices for sex without condoms.

The apartments shared by transgender groups are known as deras (which means ‘dwelling’, but also ‘monastery’), often led by a guru – an elder from the community who mentors younger transgender people, known as their chelas (“disciples”).

This often leads to the expectation of doing sex work, often with multiple partners per day, and passing on more than half of the proceeds to the guru, Usman says.

In some ways, transgender people are better protected than other LGBTQ+ groups in Pakistan because they are recognized in a 2018 law which aimed to prevent harassment and discrimination. It means that, unlike groups like gay men, they can be directly targeted by health care providers.

Rawalpindi police station has established the police Tahafuz Markaz (protection center) unit in 2020, specifically serving the trans population, and has now been expanded to other vulnerable groups. They can report crimes to the unit, but also seek help with accessing work and vocational training – a positive referral from police can remove a lot of stigma, officers say.

The unit is particularly proud of the recent conviction of a man who raped a trans woman he lured to a remote location on the pretext of performing at a wedding. He was sentenced to seven years in prison. In the past, such cases were often not even registered, they say.

Laher Mirza, a trans woman, now works at the police unit as a victim assistance officer. She says her experience reporting a rape in 2019 was less positive, with “a lot of insensitivity” making the process so painful that she didn’t pursue it further.

When Rania, who was isolated from her family because she is transgender, was forced into sex work, she went to live in a dera in Rawalpindi and noticed someone who rarely left her room. Sometimes her roommate would cough up blood.

“She used to call for people to come in, but no one (would),” says Rania. “She was spoken to from a window.”

Although there were sixteen people living in a two-bedroom apartment, that person – Rania’s guru – had one of the rooms to himself. She had a severe case of tuberculosis and difficult access to healthcare meant she died from the disease.

The memory has given Rania what she calls a ‘TB phobia’, which is why she wanted to be screened. Her test results were negative, but she began preventive treatment for tuberculosis, which was offered to transgender people because of their higher risk.

Rania now works as an outreach worker for Dareecha, accompanying other transgender people to public hospitals when they need healthcare. More work is needed, she says, to make those spaces accessible to transgender people. Even going there as an outreach worker is difficult, she says.

“I am stigmatized and isolated and not responded to – what can I expect from another transgender person?”

This reporting trip was supported by the Stop TB Partnership, which is funded in part by the Bill and Melinda Gates Foundation, a philanthropic organization that also contributes funds to support The Guardian’s editorially independent global development department.