Access to Gender-Affirming Care for Khwaja Sira In Khyber Pakhtunkhwa, Pakistan

Background and Purpose. Khwaja sira are members of Pakistan’s third gender or gender non-binary community. The right to access gender-affirming care (GAC) is a widely debated topic among policymakers and Islamic scholars in Pakistan. While the 2018 Transgender Person Act legally recognized khwaja sira as a third gender and prohibited the discrimination of khwaja sira in the receipt of public benefits and services, the implementation of this act has faced challenges from conservative groups, which has entailed the restriction of access to GAC. The purpose of this study was to explore access to GAC for khwaja sira in the context of the Swat Valley in the northwestern province of Khyber Pakhtunkhwa (KP), Pakistan, bordering Afghanistan. We examine how religious beliefs, healthcare systems, and social stigma influence the lived experiences of accessing GAC for khwaja sira in Pakistan.

Methods. We conducted interviews in two phases in KP. In Phase 1, we interviewed 45 khwaja sira in Mingora, Swat; in Phase 2, we interviewed 40 Muslim religious scholars in Mansehra. Thematic analysese were used to identify barriers and facilitators to access to GAC. We recruited participants using convenience and purposive sampling, in partnership with the nongovernmental organization, SEEK, based in Mansehra. Interviews were digitally audio-recorded in Pashto or Urdu, then translated and transcribed directly into English. We utilized open line-by-line coding to segment the data into analytic units. Codes were revised, merged, or eliminated by a team of eight researchers, using the qualitative data analysis software, Dedoose.

Results. We identified the following three major themes regarding GAC for khwaja sira: (1) access to GAC as a human right; (2) Islamic condemnation of GAC; and (3) barriers to accessing medical care. Within the first theme, we identified the following subthemes: (1) GAC as a means of aligning the physical body with a sense of gender identity and (2) GAC as a means of gaining social acceptance. Within the theme of Islamic condemnation of GAC, we identified the following subthemes: (1) rejection of altering the body and (2) regret over surgeries. And within the third theme, we identified the following subthemes: (1) absence of inclusive and accessible healthcare; (2) the COVID-19 pandemic context; (3) socioeconomic and cultural influences on gender-affirming care; and (4) stigma and discrimination in healthcare settings.

Conclusions and Implications. Khwaja sira participants believed that GAC was a basic human right, yet still faced many barriers, especially in healthcare settings. Financial hardship worsened this access, forcing some khwaja sira to rely on unsafe, unregulated methods of gender transition, including obtaining hormones on the black market. In contrast, although some religious scholars supported harm reduction approaches to gender transition, most believed gender-affirming surgeries were religiously unacceptable, as they altered the "natural body." Study findings highlight the disconnect between the health care needs of khwaja sira and the religious beliefs of some scholars. Findings reflect a need for healthcare improvements that support gender-diverse individuals, as well as more communication between medical providers, policymakers, and religious leaders to build respectful and inclusive care.