Challenges faced by marginalized communities such as transgenders in Pakistan

Pakistan's HIV high-risk populations: Critical appraisal of failure to curtail spread beyond key populations

Pakistan has been a hub of several HIV outbreaks over the last 2 decades, with four major outbreaks being registered since 2018. There has been a recent rise in HIV infections, especially in high-risk populations, mainly consisting of people who inject drugs, men who have sex with men, prisoners, the transgender women community, and female sex workers. Consistently poor infection control practices, unregulated unsafe blood transfusion, questionable ethical practices by healthcare providers, and a general lack of awareness are the main drivers of recent HIV outbreaks, with these issues exacerbated by the presence of untrained health care providers. To stop the spread of HIV systemically and sustainably, aggressive measures need to be taken at all levels by all concerned stakeholders that not only deal with building up testing, tracing, and treatment capabilities but also address underlying grassroots problems that have largely been ignored to date.

"I would prefer to be dead than to live this way": Lived experiences of stigma and discrimination against khwaja sira in Swat, Pakistan

Due to their identification as third gender people, khwaja sira have historically been subjected to experiences of social marginalization. However, the extant literature has not fully explored the lived experiences of stigma and discrimination against khwaja sira in the Swat Valley of Khyber Pakhtunkhwa, Pakistan. To address this gap, we conducted 45 interviews with khwaja sira in Mingora, Swat, Khyber Pakhtunkhwa to better understand their experiences of gender-nonconformity stigma and discrimination in various social contexts, including within their families, in accessing health care, and within education and work contexts. Applying Minority Stress Theory and utilizing thematic content analysis, the present study identified three dimensions of gender-nonconformity stigma: (1) internalized stigma, namely feelings of shame and embarrassment; (2) perceived stigma, namely opinions others had of khwaja sira regarding lack of employability or engagement in sex work; and (3) enacted stigma, namely exclusion from families, in educational settings, in religious spaces, and in healthcare settings. Findings should inform future social intervention and community practice engagements with khwaja sira communities in Pakistan.

The Impact of Stressful Life Events on Suicidal Ideation in Gender Dysphoria: A Moderator Effect of Perceived Social Support

Factors associated with suicidal ideation in the gender dysphoria population are not completely understood. This high-risk population is more likely to suffer stressful events such as assault or employment discrimination. This study aimed to determine the association of stressful events and social support on suicidal ideation in gender dysphoria and to analyze the moderator effect of social support in relation to stressful events and suicidal ideation. A cross-sectional design was used in a clinical sample attending a public gender identity unit in Spain that consisted of 204 individuals (51.7% birth-assigned males and 48.3% birth-assigned females), aged between 13 and 59 (M = 27.95 years, SD = 9.58). A Structured Clinical Interview, a list of 16 stressful events, and a functional social support questionnaire (Duke-UNC-11) were used during the initial visits to the unit. The data were collected between 2011 and 2012. A total of 50.1% of the sample have had suicidal ideation. The following stressful events were associated with suicidal ideation: homelessness, eviction from home, and having suffered from physical or verbal aggression. Also, there was an inverse relation between perceived social support and suicidal ideation. There was a statistically significant interaction between a specific stressful event (eviction) and perceived social support. The study suggests that the promotion of safer environments could be related to lower suicidal ideation and that networks that provide social support could buffer the association between specific stressful events and suicidal ideation.

Differences in Alcohol and Other Drug Use and Dependence Between Transgender and Cisgender Participants from the 2018 Global Drug Survey

Purpose: The purpose of this study was to compare five gender groups (cisgender women, cisgender men, transgender women, transgender men, people with nonbinary/other identities) on measures of use of and dependence on seven substances. Methods: A two-stage approach to assessing gender allowed 126,648 participants from the 2018 Global Drug Survey (GDS) to be classified to one of these five gender groups. Participants were asked to disclose use of each substance in the preceding 12 months. The Alcohol Use Disorders Identification Test and the Severity of Dependence Scale were used to assess dependence. Multivariable logistic regression generated odds ratios (ORs) to measure the association between gender and each substance use/dependence outcome, with cisgender women as the reference group. Results: The sample comprised 43,331 cisgender women, 81,607 cisgender men, 215 transgender women, 254 transgender men, and 1241 people with nonbinary/other identities. Relative to cisgender women, nonbinary/other participants reported greater odds of last 12-month use of all substances (adjusted odds ratio [AOR] = 1.66-2.30), except alcohol (lower odds; AOR = 0.42), and greater odds of dependence on cannabis (AOR = 2.39), 3,4-methylenedioxymethamphetamine (AOR = 1.64) and alcohol (AOR = 3.28), adjusting only for age (all p < 0.05). Conclusion: Transgender 2018 GDS respondents, particularly those with nonbinary/other identities, had greater odds of reporting most substance use outcomes than cisgender women. These findings suggest that a nuanced approach to gender reporting in surveys and treatment centers is required to understand the needs of transgender people who use substances.

A literature analysis of scientific research on gender incongruence in Muslim nations

This study aims to chart and review the unexplored transgender research portfolio of Muslim countries using bibliometric method. Data retrieved from the Scopus database were analyzed using CiteSpace, VOSviewer, Biblioshiny, and ScientoPy software. It was found that barring Turkey and Iran, transgender research has been minimal in most Muslim countries. The collective productivity is gradually but surely rising. Around 84% of the publications have been collaborative efforts. The keyword analysis revealed that gender dysphoria, human immunodeficiency virus, LGBT, and vaginoplasty were the most frequently used keywords. The socio-economic circumstances of the transgender community are generally deplorable in most Muslim nations. Overall, there is a dire need for high-quality multifaceted transgender research in the Muslim world to raise general awareness. Resolving disputes on gender dysphoria or sex reassignment surgeries and reinstating the social rights of the transgender community should be the utmost priority of future research in Muslim countries.

Health Problems & Barriers to Healthcare Services for the Transgender Community in Lahore, Pakistan

Objectives:

To find out the major health problems and barriers in getting health care by transgender community in Lahore, Pakistan.

Methods:

An analytical cross-sectional study was conducted in transgender community of Lahore from January to October 2020. The study included 214 participants from different areas of Lahore by targeting their “gurus”. Non-probability, snow-ball sampling technique was used to collect required sample size. Data was collected by using a structured questionnaire. Data were analyzed using SPSS version 23. Results were generated in form of tables and graphs. Chi square test and Fischer’s exact test were used to find out associations between health seeking behavior with their transgender status and p value was fixed as ≤ 0.05 as significant.

Results:

Among total 214, 78.5% were transgender females and 21.5% were transgender male. Among the common health problems were depression (56%), anxiety (59%) and genital tract ulcers (45%). About 70% transgender seek health care from government hospitals. Among total 214 participants, 70% reported that they receive poor quality of health care. The main reasons of not getting proper care is non acceptance (20.7%), feeling ashamed (28.7%), non-availability of CNIC (44.5%) and un-affordability (6.1%). Significant association of transgender female with consultation with doctors (p=0.013), seeking care at government hospitals (p =0.038) poor experience at health care facility (0.050), neglect during medical treatment (p=0.015) and feeling of discrimination during treatment (p= 0.042).

Conclusion:

Transgender community face physical, mental, social and reproductive health issues. About 70% trans-genders receive poor quality of health care services. Non acceptance, feeling ashamed, non-availability of CNIC and non-affordability have been reported as major barriers in getting desired health care.

Treatment outcomes among tuberculosis patients in Jeddah, Saudi Arabia: Results of a community mobile outreach directly observed Treatment, Short-course (DOTS) project, compared to a standard facility-based DOTS: A randomized controlled trial

INTRODUCTION

Tuberculosis (TB) remains a global public health threat affecting people in many developing countries, including the Kingdom of Saudi Arabia. Maintaining a long-term treatment regimen has always been the cornerstone of successful treatment outcomes among tuberculosis patients. In the Jeddah region, the National Tuberculosis Control and Prevention Program is now treating TB patients by means of a community mobile outreach team approach.The objective of this study was to compare the effectiveness of the community mobile outreach approach in improving treatment outcomes (success rate) among local tuberculosis patients with those being treated with a facility-based directly observed treatment, short-course (DOTS).

STUDY DESIGN

Our study consisted of a two-sample, parallel design [1:1], statistician -blind randomized control trial with 200 newly diagnosed, TB patients as subjects.

SETTING/PARTICIPANTS

The patients had all presented at the Madain Alfahd Primary Health Care Center, Jeddah. Between Nov 2017 and Nov 2018, a total of 221 TB patients were screened of whom 200 were randomly selected using randomly generated sequences.

INTERVENTION

Patients in the intervention sample group were treated by means of mobile outreach teams with oral anti-TB treatment under the DOTS, and control group patients were given the traditional facility-based DOTS treatment according to the WHO recommendations and national guidelines.

MAIN OUTCOME

The primary outcome was the level of overall treatment success rate. It was finally determined and compared in the two sample groups using chi-square analysis and relative risk assessment.

RESULTS

In the analysis stage, 97 patients were in the intervention group, while the control group consisted of 76. The overall response rate was 86.5% (173/200). We found that the percentage of overall treatment success rate among the patients served by the mobile outreach team was 97%, compared to 76% in the non-mobile team treated patients. The relative risk of treatment success rate among the intervention group was 1.27 (95% CI = 1.13-1.43) times greater than that amongst the control group. Log-rank test (log-rank statistics = 18.91; p < 0.001) identified a significant difference in the default rate after six months of treatment.

CONCLUSION

This study has shown that a mobile outreach DOTS approach is an effective and acceptable strategy for treating TB patients. It also provides important data on the efficacy of using mobile outreach teams to improve TB treatment outcomes in Jeddah. Our results provide evidence and highlight the positive and significant impact of mobile outreach teams in mitigating TB recurrence rates and in improving TB treatment outcomes.Clinical Trial Registration: Clinicaltrials.gov: NCT03787914.

Prevalence and correlates of substance use among transgender adults: A systematic review

INTRODUCTION

Minority stress theories suggest that high rates of discrimination experienced by transgender people are precipitants of substance use. This risk is likely exacerbated by an inadequate provision of trans-inclusive substance misuse services. However, the exclusion of transgender people from the general substance misuse literature makes it difficult to determine the extent to which transgender status influences substance use. A systematic review was undertaken to better understand the prevalence, patterns and correlates of substance use among this group.

METHODS

In accordance with the PRISMA guidance, a literature search was conducted to 29th May 2019 on PubMed, PsycINFO, Embase and Global Health databases. Primary quantitative studies, published in English, that reported the prevalence, patterns or correlates of substance use by transgender people were included, with no restriction on methodological design.

RESULTS

653 unique records were identified, and 41 studies were included. Half the studies reported on both transgender men and transgender women and half transgender women only. There was high and excess prevalence of substance use among transgender compared with cisgender people, but insufficient evidence to estimate prevalence or quantify the risk for substance use. Correlates of substance use included transphobic discrimination or violence, unemployment and sex work, gender dysphoria, high visual gender non-conformity and intersectional sexual minority status.

CONCLUSIONS

The sparse findings lend support to the minority stress model. However, the overreliance of the literature on disproportionate investigation of transgender women with multiple intersectional disadvantages, means there are significant gaps regarding the wider transgender community. To ensure substance use treatment services are inclusive, gender identity should be recorded and targeted interventions available. Clinicians should be aware of the multiple, complex drivers of substance use and be prepared to ask about substance use and offer support. Given the high prevalence of trauma experienced by transgender people, trauma-informed psychosocial interventions may be useful in the management of problematic substance use in transgender adults.

The Need for Transgender Healthcare Medical Education in a Developing Country

PURPOSE

The single most significant barrier to healthcare for people who identify as transgender is poor access to healthcare providers trained in trans-health. Despite this, trans-health education is far from being a routine component of the undergraduate medical curriculum in developing countries like Pakistan. This study aimed to assess knowledge and attitudes regarding people who identify as transgender, as well as the perceived need for trans-health in the curriculum, amongst medical students in Pakistan.

MATERIALS AND METHODS

A cross-sectional study using a self-designed questionnaire was carried out amongst undergraduate medical students at the Aga Khan University. Stratified random sampling was used, whereby students were stratified based on their current year of medical education.

RESULTS

A total of 249 students were included in this survey. The majority (61%) had poor overall knowledge, with a significantly higher percentage of pre-clinical students (79.6%) having poor knowledge regarding differences in transgender health needs compared to clinical students (60.3%; p = 0.001). Most students acknowledged that individuals who identified as transgender faced a lack of access to healthcare (78.3%), were poorly integrated into society (92.0%) and were treated differently in a clinical setting (58.6%). Many students were unsure of how to address (49.8%) and clinically examine (38.2%) patients identifying as transgender. However, most students demonstrated good (49.4%) or fair (45.0%) attitudes towards individuals who identified as transgender, and the majority reported a high (54.6%) or moderate (42.2%) perceived need for the inclusion of trans-health in the medical curriculum.

CONCLUSION

Despite deficiencies in trans-health education in the medical school curriculum, positive attitudes and a high perceived need among students lay the foundation for developing a medical curriculum that gives due priority to trans-health. In developing countries, this can help bridge disparities in healthcare provision to people who identify as transgender.