“No one touches them”: access to gender-affirming care for khwaja sira in Khyber Pakhtunkhwa, Pakistan

Introduction Individuals who identify as khwaja sira (hijra, transgender or third gender) in Pakistan face significant challenges in accessing gender-affirming care (GAC), particularly in Khyber Pakhtunkhwa (KP). This study had two main objectives: (1) to explore the viewpoints of religious scholars and leaders toward GAC for khwaja sira in KP and (2) to identify the barriers that khwaja sira in KP face in accessing GAC.Methodology We conducted 85 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 and leaders in Mansehra. We used abductive analysis to identify barriers, challenges, and facilitators to access GAC.Findings We identified three major themes across the collective set of transcripts: (1) access to GAC as a human right; (2) Islamic viewpoints on GAC; and (3) barriers to accessing medical care. These themes explain how lack of institutional support worsened khwaja sira’s access to healthcare, resulting in delayed access to care. We also highlight a disconnect between the healthcare needs of khwaja sira and the beliefs of many religious scholars and leaders regarding GAC. While most interviewed religious scholars and leaders believed in recognizing the rights of khwaja sira, several believed that gender-affirming surgeries were religiously unacceptable, as they altered the “natural” state of the human body. Only very few respondents supported GAC as a harm reduction approach.Conclusion These findings underscore both points of agreement and contention between khwaja sira communities and religious leadership in KP. Findings also highlight the need for healthcare systems that better support khwaja sira. Ensuring greater community engagement and fostering dialogue between religious scholars and khwaja sira could assist in building more inclusive systems of gender-affirming care for khwaja sira in Pakistan.