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Substance Abuse among Transgender Individuals: Evidence from Pakistan.

Transgender individuals are known as khwajasara, hijra, or murat in Pakistani society. They are a marginalized section of the community that is still struggling for identity and basic human rights. In Pakistan people have a mindset in which they do not even consider transgender individuals as part of their society. According to the National Database and Registration Authority, which issued national identity cards to every member of the Pakistani community, the total population of the transgender community in different provinces throughout Pakistan is about 4,000.

In the earliest times, "third sex" people were respected and granted dignity and right of recognition. In particular, during the Mughal rule on the subcontinent, they were given respectful posts within the Mughal courts. In Islamic countries of the world, transgender communities have received a great deal of respect and have at times been elevated to the status of sacred communities. When the British colonists arrived on the subcontinent, they labeled the transgender community as eunuchs and considered them a criminal tribe. Transgender people were perceived as genetically criminal and faced discrimination under British rule. The implementation of the Criminal Tribes Act in 1871 marked a formal approval of the ill treatment of the transgender community (Khan, 2016).

A large proportion of transgender community members in Pakistan earn their living by singing and dancing during rituals marking life stage transitions such as the birth of a baby boy or wedding ceremonies. However, there is widespread misinformation about their participation in these rituals. The stigma against the transgender community cuts across socioeconomic classes in Pakistan. It is highly likely that the extreme discrimination faced by the transgender community is associated with a high incidence of drug abuse among its members. In many public schools transgender students face verbal harassment, physical and sexual abuse, and discrimination. The transgender community faces physical abuse from family members, customers, sexual partners, and the general public. This abuse leads to physical, emotional, and mental health problems. The most common method of dealing with mental distress is the use of drugs and alcohol. One study suggested that 80 percent of the transgender community uses cigarettes, 51.7 percent drinks alcohol, and 20.8 percent uses heroin or herbs (Abbas, Nawaz, Ali, Hussain, & Nawaz, 2014). Despite the high demand for mental health services, there are very few such professional services available in the country (Aurat Foundation, 2016).

In Pakistan there are no national data available on transgender individuals with addiction. Because of the importance of the problem and the lack of pertinent research, this study aims to determine the patterns of substance addiction among the transgender population. Substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in quantities or with methods that are harmful to himself/herself or to others (Hart & Ksir, 2002). Nonmedical or recreational use of substances is the first form of abuse. Paul Fuqua (1978) suggested that it is difficult to define the term substance abuse. The term is used without precise definition and can refer to different things in different circumstances. It is the consumption of a substance for reasons other than medical necessity or in unnecessary amounts (Muhammad, 2003).

According to a survey conducted in Pakistan by the United Nations Office on Drugs and Crime in 2013, approximately 6 percent of the population, 6.7 million people, used one of many controlled substances including prescription drugs for purposes other than medical necessity. The most common drug was cannabis, with a prevalence of 3.6 percent of the population of Pakistan. About 4.25 million people were considered dependent on the substances.

The drug culture is becoming a new trend among Pakistani youth today. At present, data on incidence of drug use in the transgender community in Pakistan are scarce. However, a few studies indicate a very high incidence of drug use among members of this community today. High rates of substance abuse including daily seizures appear to be associated with chain smoking, alcohol, and other substances.

In countries like Pakistan, India, and Bangladesh transgender people live under the shelter of a guru (leader). In these cultures they are not accepted in their homes. Gurus provide them with security and support (financial and moral) and love rather than blame (Abbas et al., 2014). Many prejudices are faced by the transgender community in these countries.

Research Objectives

There were four primary research objectives for this study:

1. To investigate the perceptions of the transgender community regarding substance abuse

2. To assess the prevalence and patterns of substance abuse in the transgender community in Islamabad

3. To explore the reasons for using different substances in the transgender community

4. To describe the experiences of the transgender community regarding the health consequences of substance abuse

More specifically, the research questions addressed in this study are how do transgender individuals define substances, what are the effects of substance abuse, and finally what are the high-risk behaviors associated with substance addiction.

Significance of the Study

Substance abuse and addictions are not a new phenomenon. In Pakistani society these issues have spread more rapidly since the late seventies until they have become a serious public health problem. In a country like Pakistan where the employed labor force is around 29 million people, the estimated number of people with addiction appears to be alarmingly high; the number of people with addiction is also increasing in the transgender population.

Methodology

The research design used in this research study is qualitative. This study uses a descriptive and interpretive case study method. In order to conduct the study, a sample of twenty-seven respondents was obtained by using the snowball sampling method. The universe of the present study was Noorpur Shahan Barimam, Islamabad. This study targeted transgender individuals who have been abandoned by their families and are living in slums or within a group led by a guru. The majority of transgender people were living in Deeras along with their gurus. In-depth interviews were conducted to get the details of these people's substance-related experiences. The interview guide was used as a tool for data collection. The data were analyzed through thematic analysis.

Participants

Twenty-seven transgender respondents from Noorpur Shahan Barimam, Islamabad, were included in the study. They all are migrants from different cities in Pakistan. As shown in Table 1, two respondents were graduates, four had completed their intermediate level studies, five were high school graduates, six had passed the eighth standard, four had primary school education, and the rest were illiterate. The majority left school when they revealed their sex identity and were faced with discrimination, stigmatization, and harassment. Some of them indicated that they did not got to school because of financial issues. They all left their homes because their families were treating them as objects of shame and burden. Their source of income was begging, dancing at functions, and sex work.

Main Analysis

Thematic Analysis

Thematic analysis is one of the most common forms of data analysis in qualitative research design. Themes are described from the data set and every theme is associated with a different research question. The researcher analyzed the qualitative information by identifying themes and by systematically gaining knowledge about drug use, as well as information on transgender individuals, from each of the twenty-seven respondents.

Theme 1: Twofold Selves

This theme encapsulates the dilemma of transgender individuals of living in an inbetween state of mind. Their family attributes a specific gender to them, but they cannot accept that gender assignment. They cannot adjust to the gender that was assigned to them at birth and act contrary to that gender. All the respondents have gender identities. They spent much of their time being confused about their identities.

One respondent mentioned that she was perceived as a boy when she was eleven years old; she had always been confused about her gender. She would wear boy's clothes, but her behavior (especially communication) was feminine. She said, "Mujhy sab daikh k yai e khty thy k yai larka ha. Main larka kaisy hun jab mera dil, meri rooh larkion wali ha?" (Everyone told me that I am a boy because of my physical appearance but how can I be a boy when my soul is girlish?) She also mentioned that she did not know whether to socialize with boys or girls. She felt comfortable with the girls. However, many girls spurned her presence. Moreover, when she used to dress like a boy, boys made fun of her. Her family beat her, and she decided to leave school.

One respondent was very shy and nervous. She said her parents died when she was very young. She continued: "I always liked to wear girl clothes and makeup. When I revealed my identity, my relatives asked me to leave their house so I left everyone. I was homeless for a week and now I don't have much to eat."

The next respondent said that she changed her name when she left home and joined the khwajasira. She said she has to wear men's clothes when going to a mosque or when she goes to her parents' house. They don't accept her as a woman. Another respondent was one of the gurus. She came across as being confident while sharing her experiences growing up as a boy: "I got education as a boy. My family is happily living in the main sector of Islamabad while I am here in the slums." She continued: "Hum saab Moraton k andar ek rooh ha auraton wali, hum mard kasiy ho sakty hain?" (We transgender people have a woman's soul; how can we be a man?) The experiences of the next respondent were similar. She grew up with her sisters; therefore, she acted, walked, and talked like her other sisters. However, her family did not accept her as a girl; therefore, she left her house.

During the data collection one of the gurus said that in the twin cities (Islamabad and Rawalpindi) there are more than one hundred thousand khwajasiras struggling for their identity.

Theme 2: The Trans World

This theme symbolically represents the lack of family life and legally accepted intimate relationships in the world of transgender individuals. Transgender individuals are not accepted by their immediate families and this persuades them to leave their home and live with fellow transgender people. They leave their houses because their families don't accept them as transgender. They want a peaceful life. The researcher found that transgender people who are in a relationship with their boyfriends are the happiest among all individuals in Deera. After losing their blood relations, they developed their own guru-chella (leader and follower) relationships. Some play the role of sons and some become daughters of their mother. One of the gurus said, "Hamary Rishty app logon say b ziyada mazboot hoty hain, or hum kise b Moraat ko ajnabi nahi smjhty, bilkul apny jeca smjhty hain or pyaar krty hain." (Our relationships are stronger than yours; we transgender people are a family and we love each other.)

One shy respondent said, "I fell in love with a guy and we both spent a long time together. I consider him as my husband and used to support him financially." When the researcher asked about the marriage she replied, "Yai Mashara hamain kahan karny dyty ha Shaadi or khusron ki shaadi nahi howa karti sahib!" (This society doesn't allow us to get married; transgenders never get married, sir!) She waved her hand in the air and gestured in a completely feminine manner.

When the researcher asked the same question of a very young transgender person, she remained silent, not initially responding to the question, and then smiled and replied, "I liked someone when I was in college. I always wanted to be with him forever but the guy recently got married with a girl." She looked down and said in a pained voice, "Hum say koi shaadi nahi karta bus ata ha mazzy lay k chala jata ha or ise trhan hum boorhy hojaty hain or maar jaty." (No one marries us--they just come, enjoy and go. We live our life and die.) Another respondent said, "Hum sirf shaadiyon pay Naach sakty hain, lakin hamari shaadi nahi ho sakti kabhi." (We only perform dances at marriage functions but we never get married.)

One of the senior transgender respondents shared her experiences and said that, whenever she wanted to meet her family, she would call them to find out if they would allow her visit. At midnight she would go there and before sunrise she would be back at her home. She revealed that her family would say
Aap raat ko milne aya karain jab koi na daikhy, Mohallay walay daikh
lain tu wo kiya bolain gay inkay ghr khusra ata ha or tarhan k sawal
karain gay. (If you want to visit us, then please come in the darkest
hour so that no one can find you. If they [neighbors] found you then
they would gossip about us.)


Within the transgender community, everyone lives in harmony and peace and respects their own created relationships.

Theme 3: Torture and Harassment Experiences in School

This theme illustrates the main reason for the respondents' poor adaptation as indicated by the difficulty transgender people encounter in school when they are young. School is often a place where there is enormous pressure to comply, especially in terms of gender roles. Transgender individuals are confused about where to sit, what to wear, and how to talk. They feel that there is no room for their sex.

The melancholy on her face was quite observable when one of the respondents was talking about her childhood. She experienced psychological and sexual persecution. She said that, when she was very small, she would wear a boy's uniform and sit with boys in the classroom. She shared her experience of being tortured by classmates. She said that some teachers exploited them sexually: "School is liyai choora k master khta tha mery sath Taiwan karo." (Teacher used to harass me; therefore I left the school.)

Moreover, almost every transgender person experienced stigmatization and discrimination at school. One of the very senior respondents mentioned that she was very good in studies and she had a lot of interest in them, but when she revealed her identity, hard times fell and she faced a lot of problems. Initially the boys in the school made fun of her; once when she wore nail polish, the master beat her. She still remembers how cruelly he beat her: "Agar wo Mujy na Marta tu Main b aaj Parhi likhe hoti." (I'd be educated too if he didn't beat me brutally.)

Another respondent graduated from high school in her hometown. She wanted to study because her father supported her but she left school because of her brothers. While sharing her experience, she said, "Mery Bhai mjy hamesha yai kehtay k hum ny nahi parha tu yai khusra parh k kiya kary ga." (My brother never went to school and he didn't allow me to study.) The next respondent was in the dumps while talking about her life experiences. She said that she studied until primary and left school because she had no interest. The students called her khusra and other terrible names that made her feel strange among other children.

Theme 4: Tobacco Smoking

Their smoking history plays an important role in the phenomenon of substance abuse among respondents. The researcher found that smoking cigarettes is very common in the transgender community. Although every individual has different experiences and perspectives regarding smoking, this study found that twenty-five respondents smoked at least one cigarette a day, fifteen respondents were chain smokers who smoked more than one package (twenty cigarettes) in a day, and seven respondents smoked thirteen to nineteen cigarettes per day.

The researcher found that the majority of respondents started smoking cigarettes at puberty. Only a few started smoking due to peer influence when they joined their transgender community.

One respondent mentioned that when she was in college her friends used to smoke cigarettes. She never tried there but when she joined her transgender companions here she started smoking: "Yahan saab peety thy tu mjy b adaat lag gaye." (Everyone smokes here; therefore I became addicted.) Another respondent said, "Jaab mjy ghr waly marty thy main chup k cigeratte peeta thi." (When my family beat me I used to smoke in hidden places.)

Most of them smoked a brand called Capstan, which is famous for its rough and hard tobacco. The price of this brand is quite low and it is easily available on every corner shop on the streets. One respondent said, "Yai sasta cigeratte ha or assani say mil jata ha." (This is the cheapest cigarette and easily available.)

Theme 5: Substance Abuse

This study found that nineteen respondents drank alcohol two or three times a week. One of the main respondents in the study mentioned that she was twenty years old when she smoked hashish for the first time. She said there was a time when she used to smoke fifteen to twenty double cigarettes in a day. She added, "Taab taak peeti the jab taak mjy charhti nahi thi." (I smoke and smoke and smoke ... until I get high.) She also mentioned that she now has a boyfriend and he is forcing her to stop so she is trying to stop her addiction in some way.

The next respondent was one of the professional dancers of the community. She performed various dances at ritual functions. She said, "Jaab taak main teen chaar pack na laga lun, tab tak main nach nahii sakti." (I never perform at the functions until I drink three or four glasses.) Another dancer mentioned that drink is very important before performing on the stage: "Once I am drunk I can perform the whole night." While explaining the relationship of alcohol and her profession, she said, "Drink k bagair main adhuri hoti hun or khul k naach nahi sakti." (Without drinking I am just incomplete.... I cannot dance properly.)

One of the respondents was addicted to hash. She said that it's important for her because it helps her breathe well; whenever she smokes three cigarettes of hash she can work properly and it also gives her the energy to work a whole day.

The researcher found that, of twenty-seven respondents, twenty-two were regular hash users, who smoked twice or three times in a day. One respondent said, "Mjy raat ko dawaee k bagair neend nahi aati." (Without hash I cannot sleep.) Drinking and substance abuse increased significantly whenever they sat in their gatherings and functions.

Moreover, two respondents said that they experienced almost every kind of drug in their adulthood but have now quit. When the researcher asked their reasons for quitting, they said that now they cannot support their substance addiction.

Perspective on Substances

According to 33 percent of respondents, "substance abuse is good for us because it helps us to work well and when we do our work properly then we can earn more." One respondent said that she was involved in sex work and on a daily basis she met with different people. She continued: "Once I met with a client who was drunk and he offered me a handsome amount so when I joined him... later on he forced me to drink. I never wanted to drink at that time but I drank.... I put a lot of alcohol in my belly."

Another respondent said, "whenever I lose my patience, then it helps me get back to normal."

Of twenty-seven respondents, thirteen said drugs are bad for health and it's just a waste of money. All of them said it's dangerous for health and it causes incurable diseases. One of the respondents shared her experience: "Naasha sirf waqti sakoon dyta ha. Omar k is hissay main aa k smjh aae k yai kitni khatarnak cheez ha." (At the last age of life I realized that drugs are the most dangerous thing; they only give you a temporary peace.) Another said, "Bura ha.Yai apki skin tabah kar dyta ha, daikhain meri skin kitni kharab ho gaye ha." (It is bad, it damages your skin; see my skin, how bad it is?)

The rest of the nineteen respondents said that they don't know what they think about substances. One said, "I don't know, maybe it's bad; everyone said it's bad."

Substance Expenses

Individuals' weekly expenses varied according to their income levels. The data were grouped into different categories. Those who were earning more than 10,000 rupees per week were spending almost 68 percent of their earnings to support their substance addiction. They were usually chain smokers and had high dependence on substances. They performed different dances at functions to support their addiction. One respondent said, "Jo kamati hun wo uraati hun, main bachat nahi karti." (Whenever I earned, I smoked. I don't believe in savings.)

For another category of respondents earning approximately 5,000 rupees a week, the cost of substance addiction remained at an average level. They spent almost 36 percent of their weekly income to support their addictions.

The third group of individuals was earning less than 5,000 rupees per week. They were found to have a low dependence on substances. One of the respondents said, "Main apny paisun say Naasha nahi karti agar koi kar raha ho tu us say mang lyti hun." (I never buy drugs with my own money; when someone is using drugs I can share with them.)

The researcher found that substance addiction varied according to income level. Some transgender people who were earning more in their community were found to be highly dependent on substances. The ones who lived below the average level had a low dependence on substances.

Reasons for Substance Addiction

The reasons for substance addiction vary from one person to another. The researcher's investigations identified the following factors that played an important role in substance use:

* Discrimination and stigmatization

* Domestic violence

* Peer influence

* Enjoyment

* Sexual abuse

* Necessity for work

* Homesickness

* Health issues

These reasons play a vital role in a transgender individual's involvement in substance addiction. The researcher observed that almost 79 percent of the respondents used substances due to peer influence. One of the respondents said, "Main jab say yahan aae hn tab say mjy bhee pakkay ki adaat ho gaye ha." (As soon as I shifted here... everyone smoked hash so I became addicted.) Another said, "Idr saab peety hain tu main bhee pee lyti hun." (Everyone smoked here so I enjoyed it too.)

The shy respondent revealed that when she was a child her parents died and her relatives forced her to leave the house. Therefore, she lived in the slums, and one night some boys beat her and raped her. After that she was very terrified and her transgender mother adopted her. While sharing her experience, she said, "Ghum bhulany k liyai peeti hun, is say mjy sakoon milta ha." (Alcohol helps me to remove sour feelings; it makes me feel relaxed.)

Moreover, one of the transgender dancers revealed that drinking alcohol is important because it always helps her to dance well. It gives her extra energy so that she can dance the whole night: "Pack lagany k baad main khul k naach sakti hun." (After a few glasses of alcohol... I dance properly.)

The researcher found that transgender populations often experience high stress due to marginalization, stigmatization, and discrimination in personal interactions and in society at large. Actual or even perceived stigma causes stress, and this study has shown that smoking rates are higher in transgender groups that experience high levels of stress. Among transgender youth, stress due to homelessness, coming out at an early age, rejection by family and peers, and discrimination are among the most frequently cited reasons for substance addiction.

Theme 6: Role of Transgender Companions in Substance Abuse

This theme describes transgender companions' views about substance abuse. Either they encourage or discourage other group members while abusing substances. One of the respondents said, "Guru mjy khti hain tu pee k nacha kar aisy tu sahi say nachti." (My master always said that... without taking alcohol you cannot dance properly.) She also revealed that her community usually supported her because they used to drink in a group. She noted that group members are of similar age and spend time and do things together (work, functions [dancing at private parties], and other social activities). The researcher found that transgender companionships are sustained by strong bonding. A small portion of the population discouraged the addictions of their companions. One of the senior respondents said, "Main apni chaila ko mana karti hun lakin main ziyada zabardast nahi kar sakti q k main khud b tu yai kam karti hun." (I asked my students not to use substances but I cannot force them because I myself used to take drugs.)

It's a fact indeed that birds of a feather do flock together. If transgender individuals surround themselves with peers who experiment with or abuse substances, it's only a matter of time before they decide to try, or worse, become a frequent abuser of the substances themselves.

Theme 6: Discrimination in the Health Sector

According to this study about 47 percent of transgender people reported verbal harassment, physical assault, or denial of equal treatment in a doctor's office or hospital. One respondent said, "Main jab be bemaar hoti hun tu Doctor k pas main Mard bun k jati hun." (Whenever I get ill, I dress like a man and visit the doctor.) Another respondent said that when she visits the doctor she never gets any kind of treatment and the paramedical staff treats her like an alien. Therefore, she decided that she will never visit the hospital again in her life. She also revealed that "Abhi main jab b bemar hun tu ghr pay khud k totkay karti hun or us say theak ho jati hun." (I have my own traditional healing ways; whenever I get ill I use them.) The researcher found that about 80 percent of his respondents used their own traditional methods for healing. They prefer to apply some traditional remedies instead of going to the hospital for proper treatment.

This research explored the consequences of substance use on the personal lives of transgender people. Most transgender people who use substances have no set patterns in life. They usually sleep or stay in bed during part of the day and use drugs mostly at nights. They have disturbed sleep patterns and never enjoy a peaceful sleep.

One of the young respondents said that, whenever she faces any problem in the hospital, she creates a disturbance there and then to some extent staff begin to treat her well. She also said, "Main udr ja k Rolaa paa dyti hun tu phr jaa k koi tawajah dyta ha." (I started speaking loud so that I could get the attention of doctors or nursing staff.)

Two types of people with addictions were observed by the field researcher. Transgender people who work usually go to work in the morning after taking their substance; they return in the afternoon and use the substance again. The other type of transgender person relies on transgender family support for purchase of substances and follows a different routine. Most of these transgender people just perform mujra (a dance staged at a night function). A majority of transgender people with addictions reported that their addictions had no effects on their bodies. They claimed that they are absolutely fine but they seldom seek proper treatment or checkups. Only a few mentioned that they prefer to visit private doctors instead of government hospitals. According to them, they face a lot of discrimination and stigmatization in government hospitals and therefore private health care is the only option they have.

Key Findings

In this study twenty-seven transgender individuals were interviewed. All respondents had consumed substances during the past six months. This study explored their living patterns and reasons for substance addiction. Key findings are as follows:

* Respondents said their biological family didn't accept them as a transgender person and they left home due to domestic torture and family pressure. The majority of them mentioned that the male members of their biological families were very much against them. Therefore, they chose to live with their transgender families.

* Respondents faced stigmatization, discrimination, sexual abuse, and torture in school. Two of the respondents had graduate degrees, four reached the intermediate level, and five completed their high school degree. All respondents faced some kind of torture when they revealed their identity and they were forced to leave everything (studies, families, and homes, for example).

* A large proportion of the respondents belonged to poor families and they said that their families do not support them. Their sources of income are begging, singing, and dancing; a very few were also involved in sex work to fulfill their needs.

* All respondents reported that they faced bullying and harassment by people on a daily basis. They said people called them by insulting names when they visited public places for their work.

* All of the respondents were used to smoking cigarettes every five hours. The majority of chain smokers smoked more than one package per day.

* The use of drugs, cigarettes, and alcohol in the transgender community is very common.

* The most common substance used by the transgender community is hashish. It is also known as Chaaras, Dawaee, Pakka, and Double in their settings.

* Some of the respondents explicitly admitted that they are addicted to substances and that their dependence level is fairly high.

* Dancers said that they cannot dance without alcohol. Alcohol gives them extra energy and vigor while doing their work.

* Transgender people face discrimination in every aspect of life such as health, education, employment, and housing.

* The reasons for addiction vary but most respondents stated that peer influence, stigmatization, enjoyment, and necessity for work were the main reasons for their substance addiction.

* The majority of the respondents reported that their transgender companions always support their substance addiction.

* The rate of substance use has been found to be higher among young transgender people as compared to older transgender people.

* A large proportion of the respondents said that they never visit the doctor due to the discrimination they face in the health sector. Twenty-three respondents mentioned that they prefer their own traditional methods of healing instead of hospitals.

* Sixty-five percent of respondents were aware of the consequences of substance addictions. They also knew about the severe diseases that result from substance addiction, such as lung and throat cancer.

Discussion

Transgender people experience social exclusion not only from their families and society but also from the state. The present research highlights the prevalence of substance abuse in the transgender community. Findings obtained from the study sample as well as from previous studies related to this issue revealed several reasons for this culture of addiction among transgender people. These factors include social stigmatization, domestic violence, discrimination by the family, lack of education, peer influence, and desire for recreation. These factors had a great impact on the behavior of transgender people. It is hoped that the experiences of transgender people documented in this study will be helpful in seeking solutions to cope with this social dilemma in the context of Pakistan.

The findings illustrate how stigma works to exclude transgender people from treatment settings. Specifically, many participants in this study ignored their treatment needs because of the stigma that they felt.

The results of this study show the number of difficulties that transgender people encounter as part of their daily routine, especially in terms of having gainful employment. Two respondents who had earned bachelor's degrees from well-known colleges were unsuccessful in securing employment and thus they had to rely on begging, dancing, and commercial sex work. This further added to their plight and made them more vulnerable to substance abuse.

In a society and culture that perceives transgender people as sick, abnormal, and having a disorder, it is not surprising that transgender people seek refuge from societal hatred, violence, discrimination, and misunderstanding through the use of alcohol and drugs. Trans phobia (the irrational fear and dislike of transgender individuals) is a part of our culture. Because they live in a society that discriminates against them, condones violence against them, and denies them basic civil rights, many transgender individuals have internalized the prejudices of their culture and ended up hating themselves. Substance abuse treatment providers may be some of the few people to whom transgender individuals may talk about their inner feelings and pain. The substance abuse counselor has an opportunity while helping transgender individuals with their substance abuse issues to refer them to resources in order to help them cope with their problems.

Suggestions

There is a wide field of research on this particular topic. This study was confined to different areas within the city of Islamabad, where the transgender community generally resides. It can be extended to other parts of Pakistan for more precise results. The researcher believes that, if the study of transgender substance abuse were conducted on a larger scale, the results would become more meaningful.

Governmental and nongovernmental organizations, institutions, and agencies that have been implemented for the effective control of drug abuse must have a real perspective, especially in terms of the transgender community.

To be effective, operational, acceptable, and equitable, any intervention must take into account the sociocultural specificities of the individual. In the case of the transgender community, it will require a work force with an understanding of transgender people to make these people feel safe, understandable, visible, and able to reveal sensitive issues.

Limitations of the Study

Conducting a study on the prevalence of substance abuse in the transgender community was both risky and sensitive. It was very difficult to conduct in-depth interviews with the respondents because many of them were reluctant to share their drug-related experiences. It was also difficult to probe what transgender people felt about themselves, and in some instances the researcher was not allowed to record details of the interviews during face to face discussions.

References

Abbas, T., Nawaz, Y., Ali, M., Hussain, N., & Nawaz, R. (2014). Social adjustment of transgender: A study of District Chiniot, Punjab (Pakistan). Academic Journal of Interdisciplinary Studies, 3, 61.

Aurat Foundation. (2016). Silent no more--The transgender community in Pakistan: A research study. Retrieved from http://sxpolitics.org/silent-no-more-the-transgender-community-in-pakistan/16362

Fuqua, P. Q. (1978). Drug abuse: Investigation and control. New York, NY: McGraw-Hill Education.

Hart, C., & Ksir, C. (2002). Drugs, society, and human behavior. New York, NY: McGraw-Hill.

Khan, L. A. (2016, May 23). Transgender dignity in Islam [Blog post]. Retrieved from https://www.huffingtonpost.com/liaquat-ali-khan/transgender-dignity-in-is_b_10089712.html

Muhammad, G. (2003). A sociological study of drug abuse in Pakistani society with special reference to heroin addiction, its causes and consequences. Department of Sociology, University of Karachi, Pakistan.

Sadia Saeed, PhD, is assistant professor, Department of Sociology, Quaid-i-Azam University, Islamabad, Pakistan. Mustajab Ahemd, MS, is project coordinator at International Human Rights Observer, Islamabad, Pakistan.
Table 1 Characteristics of study participants

Serial  Age  Education             Source of income
 No.

  1     48   Graduate              Begging
  2     22   None                  Dancing at different types of
                                     domestic and commercial functions
  3     23   Intermediate          Begging and dancing
  4     57   Primary               Begging
  5     36   Intermediate          Begging and dancing
  6     32   Intermediate          Begging and dancing
  7     25   None                  Dancing at different functions
  8     25   None                  Dancing at different functions
  9     23   Secondary             Begging, dancing, and sex work
 10     27   Graduate              Begging, dancing, and sex work
 11     20   Secondary             Begging and dancing
 12     39   Higher secondary      Begging and dancing
 13     55   Secondary             Begging
 14     25   None                  Begging
 15     54   None                  Begging
 16     28   Secondary             Begging
 17     37   Intermediate          Begging and dancing
 18     21   Primary               Begging, dancing at private parties,
                                     and sex work
 19     43   High school graduate  Begging
 20     48   None                  Begging
 21     29   Middle                Begging and sex work
 22     22   A levels              Begging and sex work
 23     26   Primary               Begging
 24     22   High school graduate  Begging
 25     32   Primary               Begging
 26     27   Middle                Begging
 27     23   High school graduate  Begging
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Author:Saeed, Sadia; Ahemd, Mustajab
Publication:Social Development Issues: Alternative Approaches to Global Human Needs
Date:Jul 1, 2018
Words:6013
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