The response was unexpected for Sophia-Layla Afsar, a bespectacled corporate lawyer turned UK-qualified mental health counsellor in her mid-thirties, based in Karachi. She thought that a television news package featuring her therapy sessions designed specifically for gender minorities would just come and go without making much impact. Little did she know that, for the next few days, her mobile would be buzzing with calls and social media notifications, and friends would be asked by their acquaintances to set up an appointment with her. She found herself cancelling personal plans because of the increased workload.

In 2016, Afsar founded Spectrum Therapy and Mediation in Karachi, a project which focuses on mental healthcare for trans people. To build her gender therapy practice, Afsar eventually quit her prestigious legal job, a decision she doesn’t regret.

“The decision was all worth it,” she says. “It is such a neglected area, where even a small amount of work creates huge impact. Since mental health workers are not usually trained for trans mental health, Afsar stepped in to try and fill the gap in mental healthcare.

Afsar offers intensive training for mental health professionals, doctors, teachers, HR professionals, and friends and family of trans people so as to enable them to be supportive towards them. “Without specialist training, I have seen professionals fail trans people time and again,” says Afsar. “This increases risks of negative mental health outcomes such as chronic stress, severe anxiety and depression, self-harm and suicidality.”

It all started when Afsar came out as a trans person herself. “I realised how lacking the counselling sphere was to work with the issues I had,” she says. “I went from highly recommended excellent therapist to excellent therapist but to no avail, as they didn’t understand my issues.”

Pakistan may have recognised trans people as a gender but facilitating them to live a normal life, especially addressing their mental health issues, still seems a bridge too far for the state

A brief pause in the conversation indicates her slight unease, however she still retained her soft, generous smile. “I could see that even well-trained, experienced therapists weren’t able to understand trans issues or offer me the kind of support that I needed. And then I decided to create that space. I extensively studied literature on gender therapy and found an experienced UK-based clinician specialising in gender to supervise my work.”

Trans individuals have a different internal sense of their gender right from birth, when their sex is pronounced and they become known as khwaaja sira in Urdu. Individuals who belong to this category of gender in Pakistan have constant exposure to traumatic events, unreasonable hate crimes, discrimination by society and their biological family members as well as barriers in legal policies, and sexual, physical as well as mental abuse beginning in childhood. They face housing and workplace discrimination as they grow up and discriminatory attitudes from health care service providers escalates their vulnerability to developing psychopathologies and psychological distresses.

A collaborative research study of USAID and Aurat Foundation, published in September 2016, found that a majority of trans people in Pakistan earned less than 10,000 rupees per month, placing them below the poverty line. Dr Abdul Ghafoor Shoro, general secretary of the Pakistan Medical Association, Karachi, notes that it is not surprising to see that the baseline of mental health issues for trans people is much higher in Pakistan, primarily given the lack of support systems by family and the blatant institutional discrimination by the state.

“Society continues to push them to the margins,” says Dr Shoro. “While their families are reluctant to accept them, the state has not ensured equal opportunities, hence it leaves them all alone to fight a battle for their survival, with no strong support system. When they go out to earn their bread and butter, they confront issues on a daily basis by [having to deal with] arrests, rape, harassment and even killings.

“Just imagine their state of mental health,” he says. “It is not hard to know why members of trans community have more suicidal tendencies. Just because we don’t have quantitative research findings on these issues, because of a lack of monetary resources to conduct studies or just [because of] blatant apathy for the community, it doesn’t mean that the issues don’t exist.”

While the general apathy towards the issues faced by trans people exists across the board, in a pleasant surprise, on March 7, 2018, the Pakistani government passed the Transgender Persons (Protection of Rights) Act. Under the law — which extends to the whole of Pakistan — the government undertook an ‘obligation’: “[To] Establish Protection Centres and Safe Houses to ensure the rescue, protection and rehabilitation of Transgender Persons in addition to providing medical facilities, psychological care, counselling and adult education to the Transgender Persons.”

“It was a historic day for the Pakistani trans community, because finally we were seeing that the state was owning us — at least on paper,” says Mahnoor Shehzadi, a Karachi-based trans activist, previously associated with a non-profit organisation. “A tiny drop in the ocean, but the consideration matters.”

When it comes to on-ground implementation of this Act, however, it appears that little action has been taken by the federal and provincial governments. Since the passage of this Act, under a six-member government body known as Mental Health Authority, a single ‘trans ward’ was opened in Sir Cowasjee Jehangir Institute of Psychiatry in Hyderabad, where regular doctors on rotations see trans clients.

“The passage of the Trans Act has little or no value until and unless there is an effective implementation on the ground,” says Dr Sana Yasir, a Karachi-based intersex educator and physician. “It has been nearly three years since the passage of the Act, but no provincial or federal government has taken action according to its spirit. Gender clinics are yet to see the light of the day.”

She reiterates that counselling and training of medical doctors in terms of gender sensitisation is the need of the hour as, without it, medical and para-medical staffers are inducing stigma instead of treating trans patients.

“Gender studies must be part of the medical curriculum because, without it, we aren’t producing professionals who can provide the mental healthcare that our trans people deserve,” says Dr Yasir. “The buck stops at a three-step process — sensitisation, training and application — but for some reason, the state and the medical fraternity isn’t taking the issue seriously.”

Afsar believes that trans people are generally reluctant to opt for mental health practitioners as these professionals lack gender training.

“Individuals belonging to marginalised communities face a specific trauma known as ‘minority stress’, and understanding it is vital for supporting gender minorities,” Afsar says. “Without it, mental health workers can further deteriorate the mental health of trans clients, instead of helping them address their conditions.

“Many people call themselves allies of trans people, but they are missing in action when their help is needed,” Afsar’s smile finally disappears. “Instead of assuming that they know what trans people need, aspiring allies need to ask themselves whether they have genuinely listened to trans people’s concerns, whether they have taken the action trans people have requested, and whether they have taken the uncomfortable steps of pushing for inclusive and affirming practices in their homes, workplaces, hospitals and other public spaces.”

Compared to the past, trans visibility in our society is finally being acknowledged, if not celebrated. Civil society is giving trans people space on feminist forums to hear their concerns while the state is, at least, owning them on paper. If not today, will there be quality mental healthcare available for the trans community in the near future?

Afsar chuckles as she quotes the Persian proverb, “Hanuz Dilli dur ast” [Delhi is still far away].

The author is a graduate of Politics and International Relations from Royal Holloway University of London. He tweets @ebadahmed

Published in Dawn, EOS, April 18th, 2021