December issue 2010
At Risk: Sex, HIV and the Community
Around 15 years of age, clad in a dirty shalwar kameez, the boy walks around the park, zeroes in on a customer and having struck the deal, takes him to the filthy public toilet located on the premises. The ‘transaction’ takes a few minutes and the boy is out looking for his next client. He makes 30 to 50 rupees per job and in one day he can service several customers – and all of this unprotected sex.
Wearing a green shalwar kameez, kajal on her eyes, sporting bright pink thickly applied lipstick, painted nails and dangling earrings, Anmol, the transgender beggar in Jinnah Super Market greets me with a wide smile. “Baji aaj tu kuch dey do. Itney din baad ayee ho.” Anmol is not the only one of her ilk here. Over the past one year there has been a huge influx of transgender people (hijras) on the streets, in market places and in the public parks of all major cities, where they actively ply their trade – usually one that places them on the fringe of society.
“People perceive transgenders as sex workers, beggars or dancers. Unfortunately that isn’t too far from the truth. A lack of education and employment opportunities forces them to make their living in these ways,” says Sarah Gill, a transgender medical college student in Karachi, who is actively working for transgender peoples’ rights and to end the violence and discrimination faced by them. Gill is president of the Moorat Interactive Society (MIS) and general secretary of the Gender Interactive Alliance (GIA). “There is no acceptance for our community in society. We are a symbol of shame even for our blood relations,” says Gill, who launched the first helpline for transgender people in Pakistan and is working to bring them from being a marginalised community into the mainstream, by creating an enabling environment in which “they can be treated like, and have the same rights as, males in our society.”
“The term MSM has gained currency over the years. It basically refers to males who have sex with males, not men who have sex with men; the latter are just homosexuals. But MSMs includes transgenders who are not men. Actually, there are many who would fall into the MSM category. An MSM could also be a man who has had a sexual experience with another man once in his life, but is essentially heterosexual. By that definition, a majority of the men in the world would be considered MSMs,” says Qasim Iqbal.
HIV-positive since 1999, Iqbal has been working in the HIV sector in Pakistan since 2006. Educated in the US, he holds degrees in Fashion Design and Computer Engineering. Says Iqbal: “In the West when you talk about men who have sex with men, you can clearly identify the majority of them as being ‘gay’ or ‘bisexual.’ However, in our part of the world things are a bit different. Due to our cultural and religious values that result in a general inaccessibility of women, men satiate their urges with other men. Most of the time it is with peers, friends, classmates or neighbourhood kids; at times also with relatives. Sex is also quite common between clerics and their students. And often young waiters at roadside chai wala hotels are sexually abused by truckers passing by.”
“In the north,” adds Iqbal, “‘bachabazi’ is culturally accepted, where an affluent, older man has a young boy as an apprentice of sorts. Everybody knows there is a sexual relationship between the two. Even the wives know it, but look the other way. In the ‘civilised world’ we consider this sexual abuse, but often the boys invite it. They get taken care of and lead a life they would not otherwise. Whether they enjoy it or not, is moot.”
According to Iqbal, Pakistan has a large MSM population. However, he admits, “We have no idea how large, and it would be very difficult to estimate. The number of hijras can be roughly estimated, as they are recognisable. Explaining the difference between the two, Iqbal says that many MSMs would fall into the category of ‘gay boys,’ but unless they acknowledge they are gay, nobody can say so with any authority. By western definition they would not be considered gay, because eventually most of these men in Pakistan do get married to women and have families. However, there are large underground gay communities in the country, comprising such men, who meet and mingle at gay parties every month. And considering there are between 400 to 600 people at a party, you can imagine the numbers.”
Iqbal continues, “Condom use among MSMs is very rare, even within MSM sex workers. If you ask them why, they say, ‘We are not going to get pregnant.’” And they seem oblivious to the dangers of sexually transmitted infections (STIs), including HIV, which they have heard of as a la ilaj bemaari (incurable disease), but ponder over little. Thanks to the HIV ad campaign, a lot of stigma has been attached to the disease, so it has done more harm than help.
When the HIV infection, (called AIDS at that time) first erupted in the gay bath houses of San Francisco, the media started calling it the ‘gay cancer.’ And in the West, the gay community is still at highest risk of the disease. In Pakistan, since 1987, over 5,000 cases of HIV positive people have been reported to the National AIDS Control Programme, Ministry of Health (NACP). UNAIDS however, estimates that there may be 96,000 HIV-positive individuals in the country. Certainly, the number of HIV-positive people in Pakistan is burgeoning, prominent among them injection drug users and their sexual contacts, including male and transgender sex workers (MSWs), forming the core of the epidemic.
According to a study, sex work has a long tradition in Pakistan. Over the past three decades, this has transitioned from a predominantly brothel-based sex-work culture to a diverse and dispersed pattern where women, men and transgenders sell sex. Male sex workers (MSWs), hijras and a third of all female sex workers (FSWs) operate in public spaces such as parks or streets; the remaining FSWs operate out of homes or kotikhanas. Only about 400 work in brothels. The extrapolation of surveillance data in the study suggests there are around 125,000 FSWs and about 35,000 each of the MSW and transgender sex workers in the country. Mostly young (22 to 28 years), they debut early in the sex trade (the average age is 16-17 years for MSWs and hijras) and engage about 7-10 clients a week. Only about 20% (MSWs/hijras) of the sex workers report condom use with clients.
Dr Ayesha Khan, an infectious diseases specialist, states, “Transgenders are clearly at an increased risk of HIV and other STIs. Part of this is due to the fact that they engage in receptive anal sex, have multiple risk partners with the lowest condom use among the Most at Risk Populations (MARPs), and initiate sexual activity at an earlier age than male sex workers. The use of lubricants is also rare among transgenders and that increases risk of transmission as well.”
Dr Khan’s study HIV Epidemic in Pakistan, indicates that “Anal intercourse transmits HIV more efficiently than vaginal intercourse, and once established among key MSM/bisexual groups, HIV may spread rapidly to the general population, particularly women who are married to these men.”
“Globally,” she adds, “transgenders have been more reluctant to use the healthcare system and face greater stigma and barriers to access, and Pakistan is no different.”
Reflecting on the Supreme Court ruling two years ago, that gave transgenders equal citizenship, community member Bindya Rana, 40, says, “We were so happy that we went to the Press Club to show our gratitude.” The ruling involved collecting data on the number of transgenders in the country. Thousands were registered, but when the hijras started demanding ID cards, the authorities said “we need to get you physically examined to determine whether you are male or female,” says Rana. “Why should we get medical check-ups? Why can’t we have just ‘transgender’ written in the sex column?” Rana asks.
Rana maintains that in Sindh alone there are around 16,000 to 17,000 transgenders. The Sindh government says the number is 2,547. She continues, “Hijras are victims of taunts and mockery. If we go to a health facility, the doctors ask questions such as, ‘Is your name Reema – Meera? Where do you feel the pain?’” Although she runs a boutique for a living, Rana spreads HIV awareness and prevention messages and gets transgenders tested for HIV/STIs. Says Rana, “It’s a pity that the world has moved on so much, but a segment of our society is so deprived – fighting for the most basic human rights. My struggle shall continue.”
“The case [pertaining to transgenders] remains pending before the Supreme Court; the orders relating to transgenders are basically in the nature of interim orders,” says Anees Jillani, advocate Supreme Court. He adds, “So far nothing has changed on the ground. If all the hijras are issued ID cards, it would help resolve some of their problems, like opening bank accounts. However, merely obtaining ID cards is not going to revolutionise their lives.”
According to Jillani, the only thing that can help this segment of the population is “to give them proper jobs. How many of us have the courage to hire hijras whether at home or for our business? These are social issues and the public needs to be made aware about them and to muster courage and help them.”
Religious edicts and social norms strongly forbid male to male or homosexual sex, deemed crimes punishable under the Pakistan Penal Code. Mufti Saifullah Khalid, Punjab Coordinator Inter-Religious Council for Health (IRCH) says, “Male to male sex is a ‘ghair fitri amal’ (unnatural act). Qaum-e-Loot was destroyed due to this very reason. The punishment for this act is very severe.” According to Khalid, “Men and women should be identified as male and female through their apparel. As far as hijras are concerned, in all aspects they are men, not women.” As a member of the IRCH, Khalid has conducted many workshops on awareness and given prevention messages on HIV and AIDS.
Says Qasim Iqbal, “An important challenge vis-à-vis reaching MARPs is that they are often marginalised, stigmatised and discriminated against. Partly as a result of this, and partly as a result of self-segregation, there is often a lack of information about these groups.” Iqbal recently started work on a project to prevent the spread of HIV among MSMs and transgenders in South Asia. The goal of the project, he says is “to reduce the impact of HIV and AIDS on men who have sex with men and in transgender populations (TGs). The project is being implemented in seven countries of South Asia. Of all these countries, Pakistan is getting the largest amount of money. Iqbal maintains, “This project will give the MSM community a sense of belonging, a place to turn to. We are not going to advertise it as an MSM clinic, but a ‘male health initiative.’ Sex workers will be hired as field workers.”
The truth is, in Pakistan, we are still largely in denial about HIV. This is a dangerous thing because AIDS affects not only the person who contracts it, but can affect entire families, or in some cases entire communities or villages.
Shivanand Khan, CEO Naz Foundation, believes, “Social exclusion needs to be addressed in ways that can encourage MSMs and transgenders to change patterns of risky behaviour that arise from low self-esteem and self-worth.” According to him, the populations most at risk comprise both injection drug users and MSMs/TGs, and they are the main drivers of the epidemics.
Talking to Newsline about the provision of health services for MSMs, he says, “While several NGOs are supposedly providing services, the quality of that service delivery is inadequate, top-down, and does not engage MSMs/TGs in service delivery. Ownership of the issue is thus very limited, and makes it very difficult to empower MSMs/TGs to shift from high-risk behaviour to low-risk behaviour. As a consequence, poor services lead to poor access, and therefore low numbers accessing services. To address low coverage requires an increase of funding for MSM and transgender HIV services.”
Given that HIV/AIDs is now a household term around the globe – even in many Muslim and developing nations, it is time Pakistan woke up and smelled the coffee. Denial will not make the problem go away.
To read about the gay community in Bombay, see the post “Men Seeking Men.”