Naghma Rehan  ( Research Associates Family Planning Association of Pakistan,Lahore. )
Iffat Chaudhary  ( Research Associates Family Planning Association of Pakistan,Lahore. )
Syed Kamal Shah  ( Research Associates Family Planning Association of Pakistan,Lahore. )

Objective: To assess risk behaviours including number and type of sex partners, condom use, knowledge of STIs and HIV/AIDS among hijras (eunuch) of Lahore.
Methods: Two hundred hijras were recruited through Respondent Driven Sampling and interviewed by a team of experienced interviewers.
Results: The mean age of the respondents was 29.2 ± 6.3 years (Range 18 - 55). More than two third (68.5%) were illiterate; 23% were married. Among married, 89% were married to women and had 1 to 7 children.  Sixty percent had taken some hard drug (Cocaine, Heroin, Morphine and Amphetamine) during the last 12 months and 3% had injected drugs. Eight percent had sex with a woman during the last year.  During the last one week, 82% respondents had 1 - 21 new clients and 69.5% never used condom; 21.5% had oral sex with new clients. During the same period, 72% respondents had 1 - 12 regular clients and 71.5% of them never used condom while 7% respondents had 1 - 5 non-paying partners. During the last one month, five hijras had paid women to have vaginal sex. Nineteen hijras paid another man to have sex with them. Only 27.1% were not aware of any symptom of sexually transmitted Infections. Majority of the hijras (81.5%) were familiar with HIV/AIDS. However knowledge about its mode of transmission was faulty.
Conclusion: Due to low level of accurate knowledge regarding STI/HIV and pernicious risk behaviours, hijras may become a potent source of HIV transmission, if necessary remedial measures are not taken (JPMA 59:380; 2009).
Introduction
The word "hijra" is an Urdu word meaning eunuch or hermaphrodite. Eunuchs - castrated males - have been in existence since the 9th Century BC. The word Eunuch has been derived from a Greek word meaning "keeper of the bed" because castrated men were in popular demand to guard royal harems. The practice is believed to have started in China, where at the end of the Ming dynasty, there were as many as 70,000 eunuchs in the grand palace.1 Hijra is an umbrella term used for those men, who are transgender, eunuch, transvestites, hermaphrodites or intersexed, bisexuals or homosexuals.^2,3 However, a great number of hijras are men, who identify themselves as feminine than masculine, mostly because their sexual desire is for men and not women. The Hijras — men who dress and act like women — have been a presence in India for generations. Within South Asian society, they maintain a third-gender role that has become institutionalized through tradition. Numerous references to eunuchs in the royal courts of India's Muslim rulers are cited. Hijras in Indopak draw their cultural heritage from the Khawjasara of Mughal era. Khawjasaras were eunuchs or hermaphrodites, who were employed by Mughal rulers as care-takers of their harems. Khawjasaras played potent roles in the courts, held effective sway in the affairs of the state, and also acted as confidants of their masters.^2-5 Hijras refer to themselves using feminine pronouns and expect others to do so. They typically live together in the traditional commune arrangement of five or more "chelas" (disciples), supervised by a "guru." When a new chela is accepted into a Hijra household, she assumes not only the guru's surname but also membership in the guru's "house". Each house has its own history and rules of behaviour. She receives training in singing, dancing, and other activities to enable her to earn a livelihood. Chelas are expected to turn their earnings over to the guru, who manages the funds for household upkeep. Gurus are expected to meet chelas' needs for food, clothing, and pocket allowance. Sources of livelihood include performing at marriage and birth celebrations, begging for alms and prostitution.⁴ The studies conducted during the last decade suggest a disturbing scenario and identify hijras as a potent source of sexually transmitted infections including HIV/AIDS. During 1999, Baqi et al6 studied 208 hijras in Karachi and found that 37% of them were positive for syphilis. National Study of Reproductive Tract and Sexually Transmitted Infections of high risk populations in Lahore and Karachi during 2004 showed that 60.2% hijras in Karachi and 35.9 % in Lahore were suffering from Syphilis7 and 0.5% Hijras in Lahore and 1.5% in Karach were HIV positive. The pilot study conducted by Canada-Pakistan HIV/AIDS Surveillance Programme (HASP) during 2005 in Rawalpindi and Karachi showed that 0.5 % Hijras in Rawalpindi and 1.4 % in Karachi were HIV positive.[8] According to data from Round - II (2006-2007) of Second Generation Surveillance in Pakistan, the HIV positivity among Hijras ranged from 0.5% in Faisalabad  to 14% in Larkana.9 Unfortunately, in Pakistan, the issue of male to male sex has never been scientifically studied till early 2000. This has resulted in perpetuation of harmful practices. Even the number of Hijras is controversial. The social assessment and mapping of men, who have sex with men (MSM) in Lahore, conducted during 2002 by Khan and Khilji,10 reveals an estimates of 25,000 zennanas i.e. hijras engaging in passive anal sex, whereas the 2006-007 assessment of HASP shows only 14,750 hijras in eight cities of Pakistan including 2600 in Lahore.9 Ignoring the dispute on their number, the mere high mobility of this population and their unsafe sexual practices can play a major role in further dissemination of HIV into the general population.11 The present study was undertaken to assess risk behaviours including number and type of sex partners, condom use, knowledge of STIs, HIV/AIDS and drug/substance use among hijras of Lahore.
Subjects and Methods
The study was conducted in Lahore during October - November, 2007. The sample size was calculated through Epi-Info 3.4.3 using population of Hijras in Lahore as 1950, knowledge about HIV/AIDS as 78.4 % as mentioned in National Report Round-I of HIV Second Generation Seroprevalence in Pakistan,12 margin of error as 10% of reported level of knowledge, confidence level of 95% and power of study as 80%.The estimated sample size was 101. Since random sampling was not possible, a design effect of 2 was added and a sample size of 200 was fixed for the study. Respondent Driven Sampling (RDS) was used. The data was collected by two teams of interviewers. Each team comprised of 2 interviewers and one supervisor. The teams were provided with transport and communication facilities. The team members received training on the questionnaire of the study.  Hijras were recruited through RDS. Each respondent was explained the purpose of the study and all his concerns were addressed. The confidentiality of all information was assured. Those, who finally agreed to participate, were asked to give informed consent. The respondents were brought to a central place through the transport at the disposal of the team. The interviews were conducted in a comfortable environment ensuring complete privacy and respondents were provided with refreshments. At the end of interview, each respondent was dropped back to his residence.  The data was entered by two different Data Entry Assistants and cross-checked for internal consistency and validity. SPSS version-14 was used for analysis.  Results
Demographic Characteristics:
The demographic characteristics of study population are given in Table-1. The age of the respondents ranged from 18 to 55 years. The mean age (± SD) was 29.2 ± 6.3 years. The majority of them (40.5%) were between 26 and 30 years followed by 20.5% between 21 and 25 years.   More than two third hijras (68.5%) were illiterate. The maximum educational attainment was matric i.e. 10 years of schooling, achieved by 3% respondents.  The mother tongue of 91.5% respondents was Punjabi followed by Pushto (3.5%), Urdu (3%), Saraiki (1.5%) and Hindko (0.5%). Forty six respondents (23%) were married and 154 hijras (77%) were unmarried. Among those, who were married, 41 were married to a woman (89%) and only 5 claimed to have been married to a man (11%).  One hundred fifty four unmarried hijras were asked about their current living arrangements. Fifteen respondents (10%) did not answer the question, 27% were living with a regular sex partner while 63% were living independently. Forty two hijras, who were living with a regular partner in non-marital union, were asked about the sex of their partner. Seventeen percent did not answer. Only one person (0.5%) was living with a hijra, while the remaining 82% were living with a male partner.  Forty one hijras married to women were asked about the 

number of children. Three respondents refused to answer the question and two did not have any child. The number of children among remaining 36 married hijras ranged from 1 to 7 children.  The number of years in sex work ranged from less than 1 to 35. The mean duration was 10.4 ± 6.1 years. More than half of the respondents (51.5%) were in this profession for 6-10 years.
Risk Behaviours:
The mean age at first sexual intercourse was 13.5 ± 2.5 years (Range7 to 22 years). The maximum number of respondent (21%) had first intercourse at 12 years followed by 14 years (13.5%).The first sexual partner in 84% hijras was a male; 6.5% had their first sexual intercourse with a female and 5% with a hijra  Twenty nine percent of hijras had sex with a woman during their life. Sixteen respondents (8%) had sex with a woman during the last one year.  Selling Sex: During the last one month, 88% respondents had anal sex with a male or hijra and 21.5% had oral sex with a male.
New Clients:
During the last one week, 82% respondents had 1-21 new clients. Nearly seventy percent respondents (69.5%) never used condom; 19.5% always used condom while 10% used condom most of times/sometimes.  Forty three respondents (21.5%) had oral sex with new clients during last week. The number of clients asking for oral sex ranged from one to 10. Eleven respondents (5.5%) reported that during the last week, women had bought their services to have sex with them. 
Regular Clients:
During the last week, 72% hijras had regular 1 - 12 clients. More than two third (71.5%) of them never used a condom. Only 23% always used condom. Forty two regular clients (21%) asked for oral sex. Majority of them (83.3%) never used condoms.
Non-paying Partners:
During the last one month 67% respondents had non-paying partners. Their number ranged from one to five. Majority of them were friends (77.4%), followed by acquaintances (14.9%), police (3.7%), influential persons (1.5%) and relatives (0.8%). 
Place of soliciting clients:
In nearly half of the cases (47.9%), men contacted hijras at their homes.  Functions, where the hjras had gone to perform were the next common source of getting their clients (16.3%) followed by Roads (14.2%) and Parks (8.3%). 
Buying Sex:
During the last one month, 19 hijras (9.5%) paid another man to have sex with them. In all cases, hijras served as receptive partners. Four men (21%) used condom during anal sex. During the same period, three hijras (16%) had insertive anal sex with men, whom they had hired for sex. No condom was used. Three hijras (16%) asked the paid persons to perform oral sex on them. Five hijras (26%) had paid women to have vaginal sex with them during the last month. 
Condom Use:
When shown a condom, ninety percent of respondents were able to recognize a condom.  Nearly a quarter of them (22.9%) had used the condom during the last sex. Only 0.6% had got a condom from a government health facility. Two third of them did not specify the source of condom supply. The most common source (15.1%) was a shop.  Knowledge of Sexually Transmitted Infections: More than one quarter third of the respondents (27.1%) said that they were not aware of any symptom of STIs. The most frequently mentioned symptom was genital ulcer/sore (23.8%), followed by anal discharge (11.2%), and swelling in the groin (10.4%). Penile Discharge was mentioned by only 4.8% and burning micturition by 5.6% respondents.  During the last 12 months, 8% hijras had suffered from penile discharge, 18% from anal discharge and 19.5% from genital ulcers/sores. Nearly half (40.9%) of those, who suffered from a sign of STIs got the treatment from a private doctor /clinic, 15.5% resorted to self medication, 11.3% went to a traditional healer (Hakims), 8.5% sought advice from friends and 9.9% did not bother about any treatment. Only 2.8% went to a government hospital for treatment.
Knowledge of HIV/AIDS:
Majority of the hijras (81.5%) were familiar with HIV/AIDS. However knowledge about its mode of transmission was faulty. When asked if HIV/AIDS can be transmitted through mosquito bite, 49.5% either did not know or did not answer the question. Nearly one fifth (19.5%) said that HIV/AIDS can be transmitted through mosquito bite. Similarly 25.5% said that HIV/AIDS can be transmitted by sharing meal with a person suffering from HIV/AIDS.  Only 24% said that the risk of HIV can be reduced by using a condom correctly at each sexual act and 29% were of the opinion that people can reduce the risk of HIV by avoiding anal sex. 
Risk Assessment:
Nearly half of the respondents (47%) considered them at risk of acquiring HIV/AIDS. Three major reasons for considering themselves to be at risk were high risk job (38.5%), frequent anal sex (29.1%) and non-use of condom (4.4%). 
Discussion
Although in terms of HIV/AIDS Pakistan may be deemed a low prevalence country, all the factors that produce high risk of HIV infection are prevalent. Since transmission of HIV is primarily sexual, it is important to look at all male sexual practices and evaluate the level of risks that are being taken.¹¹ It is known that anal sex represents the highest form of risk taking sexual behaviour, in particular for the penetrated sexual partner. It cannot be assumed that the patterns of male to male sexual encounters fall into 'heterosexual or homosexual' binary division that is often assumed.10 While there is little documentation about the extent to which men engage in sexual activity with other men in Pakistan, the limited evidence available suggests that such activity does occur throughout the country. Anecdotal evidence indicates that sexual activity between men occurs relatively frequently in boys' hostels and jails; additionally, research suggests that sex between men is often practiced among long distance truck drivers. Finally, there is a small but highly mobile population of transvestites, transsexuals and eunuchs known as the hijra, who are known to engage in unsafe sexual practices. Pakistan has a large community of males having sex with males. This community is heterogeneous and includes Hijras, Zenanas (transvestities, who usually dress as women) and masseurs. Many sell sex and have multiple sexual partners.¹¹ Shah et al13 studied 300 Hijras in Karachi during 2001 to know the risk behaviour of this population and prevalence of HIV/AIDS among this group. The findings showed that 91% reported exchange of sex for money; 93% practiced receptive anal sex; 35% reported more than 5 sexual partners per day, while 19% reported more than 10 sexual partners per day; 91% Hijras reported no condom use; 45% were drug addicts and 1% injecting drug users; 60% of their clients were youth and 30% were migrant workers. The data collected by HASP during pilot testing (2005) and Round-I (2005 - 2006) as well as Round-II (2006 - 2007) show similar multiple risk factors and low level of knowledge about sexually transmitted practices among Hijras.9,12 The social /sexual behaviour of hijras seems to have remained constant over the last five years. Table-3 compares the findings of the present study with previous studies conducted since 2004.  The data corroborates with the findings of Khan and Khilji, who reported that MSM in Lahore, at least those assessed in their study, appear to be significantly sexually active with multiple sexual partners as the norm, along with anal sex practice. In the last month, 200 respondents reported some 3388 sex partners between them. During this time, 75% of respondents had more than 7 partners in the previous month, with 15%reporting partner levels of 21 or more; 5% of respondents reported more than 51 partners each.  While 79% reported using condoms, this was highly irregular, with only 55% of the reported insertive acts and 11% of the receptive acts were condom covered. Of the 3388 reported sex partners for the previous month, 58% were strangers, 16% were friends, while 14% were stated as customers (regular partners). Sex partners were met on the street (49%), private homes (21%), and public places (24%). These included parks, public toilets, railway station, truck depot, neighbourhoods, bazaars, cinema halls and tea stalls/restaurants.14 According to World Bank, Pakistan still has a window of opportunity to act decisively to prevent the spread of HIV/AIDS.14 Although the estimated HIV/AIDS burden is still low, there have been outbreaks of HIV among injecting drug users in Sindh15 as well as Punjab9 and HIV prevalence among hijras has gone as high as 14%.9 Without vigorous and sustained action, Pakistan runs the risk of experiencing the rapid increase in HIV/AIDS among vulnerable groups seen elsewhere. The World Bank recommends that emphasis should be laid at general awareness and behavioural changes. 
Acknowledgements
The financial support of the South Asian Regional Office, International Planned Parenthood Federation through Family Planning Association of Pakistan, is gratefully acknowledged. 
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