Elder abuse in the transgender community of Pakistan: A clandestine issue

Abstract

Transgender is a broad term that includes people whose gender identity, gender expression, and behavior are discordant with those typically associated with the sex assigned at birth. They are subject to violence, poverty, human rights violations, socioeconomic inequalities, a lack of education, and unemployment. The struggle rises with increasing age, and the elderly community suffers abuse, financial exploitation, physical injuries, cognitive decline, and mental health issues and is denied healthcare. A fair system inclusive of the third gender calls for reforms by the state and society.

Dear editor,

According to the United Nations Human Rights Council (UNHRC) definition, transgender is an umbrella term that includes trans-sexual people, those who identify as a third gender, and others whose appearance and characteristics are perceived as gender-atypical and whose sense of their gender is different from the sex that they were assigned at birth. ¹ Transgender people have struggled for legal recognition since the dawn of time and were counted for the first time in the 2017 census in Pakistan. The total transgender population of Pakistan, according to a health ministry estimate in 2015, is 150,000. Accurate numbers of the transgender population in Southeast Asia are unknown, as international-level quantitative data is unavailable. ² Khawaja Sara, Hijra, Khusra, or Murat are the different names used for the third gender in Pakistan. ³ They are underrepresented in the headcount because the state and society are both adjectively transphobic and in absolute denial of their existence. Transgender people are also afraid of coming out because of heteronormative attitudes, stigma, and discrimination. ¹ This article especially aims to highlight elder abuse in the transgender community. Abuse is inflicted upon them by the system, law enforcers, and medical providers and goes underreported due to a lack of trust in state authorities. ⁴ So far, little research has been done in this domain in Pakistan. Identifying this gap in research is of paramount importance as it can open the doors to future legislation in Pakistan and help secure the rights of this disenfranchised community.

In Pakistan, the transgender community is met with many challenges in day-to-day life. They strive for education and decent jobs, protection and provision of a safe environment, legal rights, and healthcare facilities. Their underrepresentation sets the ground for less resource allocation for this group naturally. Identifying as transgender wreaks havoc on their families and exposes them to religious biases, fear of physical and emotional assault, lack of opportunities for education and employment, and fear of rejection and abandonment. The elderly population is particularly vulnerable to societal cruelties and lack of employment. Studies have shown that transgender are highly willing to quit their usual sources of income like beggary, dancing at weddings and parties, and sex work and adopt honorable professions given the opportunity provided by the government. Bullying and discrimination make them flee school and all other educational opportunities, leaving them no other option than adopting jobs not considered respectable by society. ⁵

The Supreme Court of Pakistan granted them the right to vote, and five of them contested elections in 2013. ³ Most of the Hijra community belongs to the category of low income (less than two dollars a day), have difficulty in finding residence, and pay double fair for rented houses. ⁶ The conservative mindset in our country subject’s minority groups to prejudices, which can trickle down in the doctor’s attitude and induce an unconscious bias in encounters with lesbian, gay, bisexual, and transgender people (LGBT). ⁵ Due to cultural baggage, they are more prone to mental health disorders, substance abuse, and suicide and are hesitant to get help from healthcare workers. ¹

Conventionally, a person aged 65 years or older is referred to as elderly. ⁷ Elder abuse refers to an intentional action or failure to perform an action that results in harm to an older individual by a caregiver or another person in a relationship where there is trust. Common subtypes of elder abuse include neglect, physical, financial, sexual, and psychological abuse. ⁸ The analysis of several studies from different countries estimated that the prevalence of elder abuse is 15.7%, and in Asia, it is 20.2%. ⁹ The transgender population of Pakistan, facing social discrimination and many other economic and psychological problems, is a marginalized section of our society, and the situation worsens with increasing age. ¹⁰ Little is known about elder abuse in the transgender population. However, 22.1% of elders from the LGBT community reported harm and neglect in the limited literature available. ⁴

Older LGBT individuals have had lifelong experiences of discriminatory abuse due to their gender identity. They are at risk of “elder abuse” like gender-conforming people and at a higher risk of LGBT-specific abuse at an older age. Some transgender people have voiced their concerns regarding aging that it will hinder them they will not be able to communicate their medical history to a healthcare provider properly, and that the caregiver will not be trained to deal with the third gender health issue. They were afraid of not getting the most appropriate care or, worse, being ridiculed for the state of their body. ¹¹ Trans-related health care and coverage by insurance is an important issue for transgender women of all ages. The older women of the transgender community particularly lack access to cervical cancer screenings and gynecological care and feel the pressure to conceal their identity and thus become more vulnerable to diseases associated with age. ¹² The substandard quality of food with respect to their dietary requirements, the challenging situation of food pantries, and access to charitable food services are some of the obstacles that older transgender individuals face as compared to their younger counterparts. ¹²

In addition to decreased physical and cognitive ability in old age, some factors that lead to elder abuse, especially in the LGBT community, include their minority sexuality or identity, ostracism from family because of their LGBT status, social marginalization resulting in non-disclosure, discrimination, prior violence, and unavailability of specialist services.^4,13 LGBT adults, although they create their own families of choice, are less likely to get married and have children or grandchildren, which deprives them of age-related health care and social support. This underprivileged population becomes more reliant on social care services and long-term care, where they become prone to more abuse.^14,15 The invisibility of the older LGBTQ+ community and the absence of inclusivity in health care is partially because of the nonexistent and unreliable research or data on their problems. This calls for more research activities relating to older transgender individuals through an intersectional lens. ¹² Elder abuse and lifelong discrimination can lead to significant mental health issues like depression, psychotic disorders, elevated odds of suicide attempt, and substance abuse, including smoking and alcohol consumption, leading to premature mortality as well as financial exploitation and distress, a decline in cognitive abilities, physical injuries, disabilities, and admission to nursing homes.^8,16

Several measures that can prevent elder abuse include campaigns and community initiatives to raise awareness of public and service providers, extending existing programs like phone applications to record abuse against transgender people, introducing psychological programs, inter-generational programs, and behavioral therapy to reduce risk factors and improve attitudes. ⁴ Legal protections such as adult protection statutes and mandatory reporting of abuse, along with elder-friendly policies such as financial assistance, employment opportunities, better housing and transportation services, can reduce the occurrence of abuse. Tertiary protection can be provided through adult protective services, emergency shelters, support groups, counseling, and punishing the offenders. Some recommendations to improve the interaction between health care providers and the older transgender population to decrease abuse include interviewing participants alone, persistent interrogation regarding abuse, adopting a more inclusive approach like changing questions regarding social history and gender identity, and establishing committees to discuss issues due to discrimination. ⁴ Multi-disciplinary action involving forensic teams, elder maltreatment prosecution teams, and financial abuse specialist teams is required to tackle this problem.

To conclude, the transgender community is a struggling minority in Pakistan that has always been underrepresented and discriminated against, and with increasing age, they become more vulnerable to abuse. Isolation, fear of disclosure of their identity, lack of inclusivity at medical facilities, unavailability of employment opportunities, and lack of awareness predispose the transgender community to elder abuse. Individual and community-level initiatives, including awareness campaigns, legal provisions, employment, and housing opportunities, adopting more inclusive approaches for the transgender community, mandatory reporting of abuse, and social support, can reduce this menace of elder abuse in this community.