Resham was 25 the first time she visited a public health clinic.

"I never knew that we can also visit public health facilities," she explained. "I always thought these services are only for females and males."

Resham is one of thousands of transgender people in Pakistan who do not access public health services. Despite a 2018 law that guaranteed basic rights for transgender citizens and outlawed discrimination by employers and private business owners, the group is highly marginalised. The effects of this marginalisation are keenly felt in the health sector.

In a survey of transgender persons in Pakistan conducted by the Forum for Dignity Initiatives (FDI) and Blue Veins, 81% of respondents stated that expected harassment prevented them from seeing a qualified doctor. 79% felt they don’t have access to qualified health providers, and 92% reported facing some form of discrimination when trying to get healthcare.

When Sahiba, a transgender individual living in Pakistan's Punjab Province, was diagnosed with an ulcer and a high fever, she was taken to the public hospital, but the nurse refused to admit her into the ward and Sahiba had to stay on a bench in the waiting room. When her friends complained, the staff told them there was no place for transgender people there.

"We do not visit public health facilities because neither other patients nor facility staff treat us with respect," Saba, also of Punjab Province, explained. "Even doctors refuse us for consultation."

As a result of the discrimination, transgender individuals often visit quack doctors or have to pay for private clinics that will accept them. Many never receive the necessary health services.

The stigma associated with sexually transmitted infections, including HIV, makes this a particularly worrying issue in sexual health. HIV incidence among transgender people contributes to up to 17% of the entire HIV population in Pakistan. While there are likely to be many more transgender individuals in Pakistan than the official 2016 census figure of 10,000, this 17% is still an alarming percentage considering the country’s population of 204 million (193 million in 2016).

Lack of transgender-friendly services, stigma around sexually transmitted infections (STIs), and a fear of losing their jobs if they have STIs all contribute to these statistics. In addition, transgender people often refuse laboratory tests, including blood tests not necessarily aimed at identifying STIs.

Small Step for Better Healthcare

When blood tests were recommended for Resham to check for malaria, she refused on at least two occasions to get them done. This changed when she was told of recent changes at a local government health centre - Khangah Sharif -  in the Bahawalpur District of Punjab Province. Staff at the centre had been trained on how to work better with transgender individuals, and Resham was able to speak to a psychologist about her concerns about the test. Resham got the test and continued to visit the centre to use its services.

The changes at the centre were specifically aimed at encouraging transgender individuals to seek healthcare there and to get the same level of care as everyone else. In addition to training for 77 of the centre's staff and the set-up of a new counselling service, there is now a separate waiting area and washroom for transgender people.

The changes were implemented by the Samaj Development Foundation (SDF) in cooperation with local government. On top of focusing on the centre itself, SDF also worked with the community and transgender people to raise awareness of transgender health rights. SDF spread the word through the local media and held meetings with rural communities. It also found champions for transgender rights among religious leaders who were encouraged to promote health rights through sermons, injecting messages of the humanity of transgender individuals.

"Today I am surprised to see that we are also being treated as humans," Saba said after visiting the Khangah Sharif centre after the changes were implemented.

SDF also helped transgender people get health insurance cards called Sehat Cards, which facilitate treatment at public health facilities. This had been difficult if not impossible in the past because the Sehat Cards can only be obtained by citizens who have their Computerized National Identity Cards (CNICs). But transgender people often do not want to apply for CNICs because to do so they would need to reveal their family identity. Many families reject transgender individuals and so they are often adopted by ‘gurus’ who offer them shelter and support in exchange for a share of their earnings once they start working.

Since a recent Supreme Court ruling, a guru can be listed as the family member when applying for the CNIC. But many in the transgender community still do not have a CNIC or Sehat Card, either because of lack of knowledge or lack of opportunity to get them.

SDF worked with government representatives to help the transgender community get the Sehat Cards. The Social Welfare Department set up a registration desk at a government facility and the SDF raised awareness of the desk among the transgender individuals who came to the health clinic. Over 200 transgender individuals have been registered for the CNICs, 107 of them in Bahawalpur, but also 117 in a neighbouring district. Once that process is finished, they will be able to apply for the Sehat Cards.

Overall, more than 1330 people were reached during the eight months of this project, including 277 transgender individuals, many of whom continue using the Khangah Sharif health centre. While the project was relatively small in scale, the Social Welfare Department and SDF have since signed a memorandum of understanding to work together to register more transgender individuals for the CNICs and Sehat Cards. The SDF is also trying to convince the government to replicate the health centre improvements in other centres in the province.

SDF was supported in this project by the Empowerment, Voice and Accountability for Better Health and Nutrition (EVA) project, funded with UK aid from the British people and managed by Palladium.

This article originally appeared in Medium and was republished with permission.