From Criminalization to Empowerment: Behavioral Strategies Against Systemic Inequities for Transgender Individuals in Pakistan. By Dr Mehr Muhammad Adeel Riaz and Dr Nagina Khan

There is intense debate in Pakistan around the question of whether gender dysphoria should be classified as a medical condition or viewed as an inherent aspect of a person’s identity. According to the ICD-11 classification and the Diagnostic and Statistical Manual of Mental Disorders- 5 (DSM-5) manual from the American Psychiatric Association (APA), gender dysphoria is an “incongruence” between the person’s perceived gender and the birth-assigned gender. It is worth mentioning that Pakistan does not have any national psychiatric guidelines to follow for transgender individuals. Most of the guidelines have been taken from DSM-5 and the Royal College of Psychiatry. While gender dysphoria is recognized as a condition in international diagnostic manuals, many argue that this classification should not be equated with regarding transgender identities as illnesses. Gender is a subjective perception that should be respected and affirmed.


In 2018, Pakistan celebrated a milestone achievement with the introduction of the Transgender Persons (Protection of Rights) Act, 2018, a progressive legislation aimed at protecting the rights of one of the country’s most marginalized communities. The act provided an opportunity for transgender individuals, who face persecution for simply existing, to finally receive legal recognition and support. However, on May 19, 2023, the Federal Shariat Court of Pakistan declared the Transgender Persons Act 2018 incompatible with Islamic principles.


The reversal of the above act was the result of years of what some perceived as malicious active national-level campaigns by the far right of the country, using their platform to discredit the Trans Persons Act and present. An alternative bill “Khunsa Persons (Protection of rights) Act, 2022” was introduced into the Senate of Pakistan by Senator Mushtaq Ahmad of Jamiat-e-Islami. Yet, the debate surrounding the Khunsa Bill has cast a shadow over this hard-won progress. Consequently, there has been much confusion relating to the use of confusing terms like “inter-sex”, “hermaphrodite”, “khunsa”, “and “mukhanis”, which seem to have created a wave of misinformation in the general public. Actions that allow some individuals to push the bill in the senate send out the message that  “gender dysphoria” as a curable disease; inferring that individuals are suffering from pathological conditions.” This platform and blog have been written to share a voice representing voices that are not heard to highlight that the Khunsa Bill has ignited a contentious national conversation in Pakistan, challenging existing guidelines for dealing with sexually and gender-diverse populations in psychiatry and general medical fields. Sections 14 and 20 specifically criminalize all gender-affirming care for transgender and intersex persons, criminalize gender variance and transgender identities, and deny protections based on gender dysphoria.

The transgender community seems to face systemic inequities at every level that the country has internalized into its system and the people who challenge the system seem to be targeted. The continuous propaganda against the community has increased in the community and the denial of basic healthcare provision from local hospitals. The transgender community in Pakistan faces systemic inequities across all levels of society. With prominent Pakistani transgender activists like Dr. Mehrub Awan allegedly facing coordinated gang rape attacks by organized transphobic groups called “beelaas” and conservatives turning up with acid bottles at Karachi municipal committee local body council and prominent transgender Shahzadi rai’s home, the situation is getting worse day by day.

Global leaders should be aware that such situations in LMICs lead to the worst kind of discrimination as occurring in the province of Khyber Pakhtunkhwa (KPK), Pakistan, where from 2015, 91 transgender women have been killed and over 2000 cases have been registered by transgender-run community organizations. Yet, at the same moment in time we have an example of the 95th Academy of Motion Picture Arts and Sciences shortlist for Best International Movie 2023 and 75th Cannes Film Festival 2022, standing ovation holder, a Pakistani movie titled “Joyland” centered around the life of a trans woman played by a trans woman, Alina Khan. But the movie was banned in Punjab, the largest populated province of Pakistan. Another example is the first transgender news anchor in any Muslim-majority country, Marvia Malik merely escaped the assassination attempt on her life. These are but a few examples of social injustice that the trans community is facing in Pakistan. From education and social welfare issues, related to burial rights and socio-economic conditions, the plight of such individuals remains dire. Despite the legal provision to identify as a third gender, symbolized by ‘X’ on national identity cards by the Transgender Persons Act 2018, the Khunsa Bill threatens to strip them of this hard-won recognition. The provision of the Khunsa bill is already posing a grave risk to the progress made by the Transgender Persons Act, pushing the transgender community further into the shadows of society. For example, currently National Database and Registration Authority NADRA has shut down the X national identity card services to any transgender person despite there being no state court ruling, stripping them of their constitutional right. As a result, transgender individuals holding X national ID cards cannot travel internationally. But recently, the decision was reverted.

Addressing the challenges faced by Pakistan’s transgender community necessitates a comprehensive approach that addresses systemic inequities within the socio-economic system of Pakistan.  While the Transgender Persons Act 2018, represented significant progress, systemic barriers to discrimination and marginalization persist. Key areas still demand attention. Quality education must empower transgender individuals through equal access, aided by nationwide awareness campaigns and curriculum integration. Healthcare tailored to their needs is essential, especially but not limited to comprehensive sexual education and mental health and psychosocial support systems (MHPPS) necessitating training for healthcare professionals. Economic empowerment via micro-financing can bolster self-sufficiency. Recognizing existing community / kahwajasara gharana system bonds and sensitizing biological families of transgender individuals is crucial, as is fostering dialogue and advocating for legal reforms. Media representation, alliances, data collection, and celebration of achievements complete this holistic strategy, promoting empathy, acceptance, and respect for transgender rights in Pakistan.


Dr Mehr Muhamamd Adeel Riaz

Dr Mehr Muhamamd Adeel Riaz

Mehr Muhammad Adeel Riaz, a junior medical physician located in Pakistan, possesses a substantial background in quantitative transdisciplinary research characterized by a commitment to scientific pluralism. His scholarly endeavors and investigative undertakings are primarily centered on the intersection of climate change, mental health, and the experiences of gender and sexual minorities within the context of Pakistan. Twitter : @MehrAdeelRiaz

Dr Nagina Khan

Dr Nagina Khan, BHSc, PGCert, Ph.D.

Nagina is a Senior Clinical Research Fellow in Primary Care, Centre for Health Services Studies (CHSS), Division of Law, Society and Social Justice, School of Social Policy, Sociology & Social Research, University of Kent. Nagina’s current research supports the Integrated Care Systems (ICS) to capitalise on emerging existing networks in its research duty and mitigate the current risk of future research being conducted in silos and without focus on priorities and underserved populations. This work will diversify the public voice listened to and strengthen ICS strategic links within local research infrastructure to support evidence-based practice, apply solutions, and spread innovation.

Nagina is also a visiting researcher, CHiMES, Department of Psychiatry, Oxford University. Nagina’s research has focused on social justice, equality, and fairness, in culturally appropriate mental health care and complex interventions. She carried out the                                                         staff data analysis of Experience based investigation and Co-design of approaches to Prevent and reduce Mental Health Act Use: (CO-PACT) study. Nagina has worked as a Scientist at Centre for Addiction and Mental Health (CAMH) on the mixed method study focused on the Cultural adaptation of CBT for Canadians of South Asian Origin. During the Covid-19 Pandemic, Nagina worked with Touro University Nevada, Las Vegas, on Professionalism in undergraduate medical Education and with the Royal College of Psychiatrists on Social Justice, Differential Attainment and Microaggressions in healthcare and medical education. She was a Medical Research Council (MRC) Research Training Fellow, her research was centred on complex interventions for people with depression, University of Manchester. Her post-doctoral studies were undertaken at the NIHR School for Primary Care Research, UK focusing on First episode Psychosis in Young People Using Early Intervention services. Other research interests include Incentivisation Schemes (P4P) in healthcare for HICs and LMICs and Global Health. Nagina is the Associate Editor at BMJ Mental Health, she is also the BMJ Leader Editorial Fellow and is an Editorial Board Member of the BioMed Central Medical Education Journal.


Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

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