Some distance from Lahore’s Model Town courts, on the busy Peco Road, a narrow staircase leads up to a square terrace. Random pieces of furniture are scattered around, some chairs are occupied, some vacant. In one corner of the terrace, a khwaja sara (trans individual), dressed in jeans and T-shirt, is awkwardly bending over another khwaja sara. I find the posture intriguing. I look again, and see that the one standing is threading the other’s facial hair.

I’m at the office of the Khwaja Sara Society of Lahore. Jannat Ali, transgender activist and coordinator of the Society, leads me to the ‘drop in centre’, where I’m introduced to a bunch of other transgender people that make up the Society’s outreach team.

Ten days after Alisha’s death in Peshawar, I’m here to listen to their stories of frustration and of anger at a system that demands the impossible from them. As they relate their stories, some turn out to be darkly humorous and some too awful to bear.

Alisha’s murder and her tragic death in Peshawar’s Lady Reading Hospital is one grave example of the many roadblocks trans individuals face in accessing healthcare in Pakistan. While her gunshot wounds bled, doctors couldn’t decide whether to admit her to the men’s or women’s ward. She was first sent to the men’s ward, from where she was shifted to the women’s ward, where women complained. She was eventually transferred to a VIP section, where she succumbed to her injury.

Nirmal, another transgender activist associated with the Khwaja Sara Society Lahore, says, "We, here, are a group of a few privileged khwaja saras. We are aware and sensitised, and do not hesitate to avail healthcare facilities. But many others in our community refuse to see doctors because they think doctors might discriminate against them that will only make them feel worse. They will either take a painkiller to self-medicate or visit a hakim (quack) to get a purya (dose of medicine). And they do this because they see a fault in themselves, not a fault in medical professionals!"

When Neeli Rana, senior transgender activist, approached a doctor for a minor nose surgery some time ago, she was amazed by his reaction. "He asked, do khwaja saras also develop health issues? He probably thought my blood colour was different from his other patients," she chuckles, then adds with a sudden change in expression, "you know, hum bhi insaan hain (we are humans too)."

Transphobia, coupled with lack of information on gender identity issues among medical professionals, is a common occurrence. But even when doctors want to provide care for transgender people, if they are interested or see it as part of their duty, "they are scared of the social consequences. They are afraid their colleagues will mock at them," says Jannat Ali. Resultantly, those infected with sexually transmitted diseases face serious problems. "They have to compromise their privacy or many remain untreated."

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Usually private hospitals are easier to access. The process is simple -- if one is able to pay a fee, one is able to get a treatment. But there, too, they are ridiculed. "Doctors stand in corners to cat talk, giggle, and ask embarrassing questions. That obviously puts us off," says Ali.

Dr Izhar-ul-Haq Hashmi, an expert in public health, is associated with the Punjab Welfare Trust for the Disabled, where he directs a transgender programme in collaboration with Akhuwat and Fountainhead. His Trust assists about 375 transgenders of age 50 and above in gaining life skills and vocational training. They are also granted a nominal stipend of Rs1,200 every month. "About 25 per cent of 375 trans people associated with our programme are either patients of Hepatitis B or C, or carriers of HIV and survivors of Aids," he says, continuing that because they live in congested, dark and unhygienic conditions they are susceptible to TB, hypertension and diabetes. "Also their personal hygiene is so poor that their chances of acquiring dental and skin problems increase."

The gender orientation of the child is detected up to the age of 7 or 8 years in Pakistan. By then it is most likely that the child has received the basic healthcare and immunisation. It is when they start identifying themselves as the third gender that the problems start arising. "I can safely say that primary healthcare is not a trouble area, it is our secondary healthcare structure that lets them down," says Dr Hashmi.

Some of the complications people of the third gender face are rooted in their poverty, illiteracy and the desire to not improve their condition. For instance, transgender sex workers know the big risk of not using a condom, yet, according to him, they rarely use it, which makes their community a high-risk group for HIV/Aids. "In the absence of quality HIV/Aids healthcare, generally the treatment at non-government organisations’ clinics or other private or government setups is insignificant; they promote the disease rather than prevent it. There are no HIV/Aids centres specific to transgender needs, where they can access safe and effective treatment," says Dr Saleem Azam, who heads the Karachi-based Pakistan Society.

Lifestyle of trans individuals is a cause for many concerns too. They live in clusters headed by gurus whose consent is required for everything they do. "When they are approached for counselling in safe sex practices, their guru is generally very evasive. She’d rather spend that time earning money than listening to a practitioner for hours; hence missing an opportunity to make herself and her group aware of the risks of HIV/Aids and other sexually transmitted infections they may be exposed to," says Dr Azam.

Trans people usually avoid queries related to gender transition surgery. They mince words and evade questions. That’s natural, for such admissions invariably incite extreme reactions from the society. "We have to be very secretive about it," accepts one activist refusing to be named, admitting only that such a therapy is too expensive and specialised in Pakistan.

However, Dr Amir Taj, who is associated with the Hayatabad Medical Centre Peshawar, discloses that many transgender persons wish to change their sex after reaching adolescence because of their physical appearances. "Usually a gynecologist, a plastic surgeon, an endocrinologist may help them in getting the changeover to the opposite sex."

He confirms that gender transition surgeries are conducted in KP and other parts of the country.

Bindiya Rana, of Gender Interactive Alliance Pakistan in Karachi, contested a Sindh provincial assembly seat in 2013 but could not secure it. Representing her organisation, she says, a visit to a healthcare facility by trans people is usually made in groups, "together we can put pressure on the doctors to give us attention and are also able to pool in money for the treatment. Some of us cannot afford a nominal government hospital purchi (slip), which is mandatory for medical consultation."

Rana and her friends have rented a few deras (quarters) in the vicinity of Jinnah Hospital in Karachi, where trans people from far off areas of the city in need of medical attention are provided basic boarding. "They’re like musafirkhanas (guesthouses) where khwaja saras are kept comfortable for the time they’re undergoing treatment at the hospital. That’s because getting a bed at a government hospital is a long and winding process for us. We are neither wanted in the female ward, nor in the male."

In cases of emergency, Rana stays back at the dera. "It helps if I take them to the hospital myself. After working for the cause of khwaja sara for years, I have a lot of clout; doctors know me and pay attention to the ailing person."

Khwaja saras also endure hardships in commuting to hospitals. "If they sit in the women’s section of the bus, they’re pushed back to the men’s section, where they are pushed back to the front for being in the wrong section of the bus. This is harassment. It is frustrating, and prevents us from using buses. Most of us cannot afford rickshaw or taxi."

Even though talking on the phone, I am able to sense Rana take a deep breath, "Aap kia samajhti hai (what do you think), this street comedy unique only to us, going from car window to car window, begging, clapping our hands, flirtatiously twirling our hair while humming a popular tune, is easy? Is ke pechay kitni bebasi hai (we are desperate people)".

Additional reporting from Peshawar by Arshad Yusufzai.