Peshawar: As the evening descends over the narrow streets of Hashtnagri in Peshawar, it is time for the mostly lower middleclass clientele that frequent shops selling vegetables, fruit and winter clothes beneath the Faqir Abad Bridge to get back home. In a narrow street, dark and malodorous from an open drain, the shopkeepers bring down the shutters on shops. But in the tenements above, the lights come on at dusk as another “bazaar” opens its doors to customers.

In one of the apartments above the bazaar, Madhu* is getting ready for an evening of song and dance, tying up heavy anklets with conch bells around her ankles. She is one of the hundreds of transgender that live in tenements, offering sex and dance for a fee. She takes one last look in the mirror to to touch up her makeup before going out into the night to perform at a wedding party.

Madhu has lived with the transgender community here for 11 years. Born in the outskirts of Nowshera, a city east of Peshawar, she moved to Peshawar because of pressure and maltreatment from the family and society. She is one of the transgender who has gone through a successful sex reassignment surgery in Islamabad, the country’s capital. “It was tough time for me, both physically and psychologically” she says.  “It’s not just me but the majority of transgender community wishes to live with a vagina, not a penis, as we are born with a female souls.”

Madhu says having male genitals keep her from express her femininity. At the same time, she says, her female soul compels her and many others to rethink and make it “right” according to their psyche.  “To be honest, it wasn’t my body before surgery. It was the body of a strange person.”

Although Madhu says quite a few transgender have had sex change surgeries but no one is willing to speak on the subject. “Everyone wants to keep it secret. Only few of their colleagues know about it. They are afraid due to religious reasons and how the conservative society may view them.”

Naveed Azhar, an Islamabad based plastic surgeon, conducts about half a dozen sex-reassignment surgeries every month.  He says the operation is long and expensive.

“Only those who are psychologically, physically and financially sound can afford it,” says Azhar. “It takes 12 to 18 months to fully change the sex and estimates about PKR 1.5 to 1.8 million.”

In Madhu’s case, her boyfriend sponsored the expensive surgery. “Neither I nor the rest of transgender community wants to live with useless nafas (penis),” she says, shyly. “Beside other reasons, the ability to have a sexual union with the man you love is why we go for sex reassignment.”

Convinced that surgery is the right course to take, she says she is neither accepted by family or society, so why shouldn’t “I enjoy my complicated life.”

According to Farzana Jan, President of the transgender community in Peshawar-based transgender, sex change was a painful process involving bloody castration in the days before one could have a proper doctor to conduct a surgery. Even today, those who cannot afford a plastic surgeon do the “operation” at home, with help from a “senior” transgender – someone who has done the procedure before or has undergone one.

The guru, or the guardian transgender, takes her disciple to a deserted apartment or miles away from city. “Before castration of a transgender, the senior would tie up the penis in a rolling position with a chord at the base,” Farzana Jan demonstrates with her fingers shows the intensity and pain. “Not only the penis, but the testes have to be fastened with a chord to stop blood circulation to the genitals. It is not a long process. After an hour or two, the region would be numb, ready for the cut and the senior transgender would remove the genitals with a blade.”

Considering the taboo and the shame associated with it, the wound would be left to heal without care from a doctor or medicines. The transgender rely on traditional herbal concoctions or tootkas [ash] to heal the wound. “No doubt, it is a deeply painful and traumatic experience and very risky in absence of proper medical care.”

The transgender don’t like male genitals because negates their soul. “We consider it a stigma we are born with,” said another transgender on the condition of anonymity due to the taboo associated with the procedure. “In many cases the boyfriend sponsors the procedure or finances the expensive surgery.”

Qamar Naseem, Coordinator of Blue Veins, an organization working on gender issues, says only a “few doctors conduct the sex-reassignment surgery in Peshawar” without proper diagnostics or consultation. “In Pakistani legal system there is no rule in favor or against the sex-change surgery.”

Although the law is silent on the issue but plastic surgeons in Pakistan have designed a legal course for practices associated with sex-reassignment surgery, calling it a “code of conduct.”

“For any person who wants to change his/her organs, it needs a three month consultation period for the desired person with two psychiatrists and one plastic surgeon on the instructions of any court,” says Dr Naveed Azhar.  “It is in the light of these consultations that the court issues its verdict. This process provides a basis for the yes or no to proceed with the surgery.”

Dr Azhar says the trend of sex reassignment is mostly followed by the marginalised transgender community but in recent years young persons from elite families have also sought surgeries for sex reassignment.

Medical ethics provides for such operations in three more categories: “Gender dysphoria”, “locked in wrong gender” and “for pleasure”. The “pleasure” cases are treated as unethical but most surgeons who avoid operating such cases. About the initial consultations, some people start with removal of genitals, followed by surgeries to work on the rest of the body such as the breasts.

“Sex is a biological need and an interesting part of human life, which gives pure pleasure, joy and bliss,” says Madhu. “That is also reason why the transgender seek sex reassignment.”

*Name changed to protect Madhu’s real identity

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