"The hardest and most difficult days of my life": Mental health of khwaja sira in Swat, Pakistan during the COVID-19 pandemic.

Introduction: Khwaja sira (third gender people) in Pakistan experience several forms of social marginalization, which were likely exacerbated during the COVID-19 pandemic. Methods: We completed 45 interviews with khwaja sira in Mingora, Khyber Pakhtunkhwa, Pakistan to understand the impact of the COVID-19 pandemic on their daily lives. Interviews were conducted in Pashto, digitally audio-recorded, and analyzed using Minority Stress Theory, which posits that sexual and gender minorities are at increased risk for mental health disorders due to the psychosocial stress resulting from experiences of stigmatization and discrimination. Results: We identified three overarching themes: (1) financial insecurity; (2) social vulnerability; and (3) resilience. Under the theme of financial insecurity, we identified three subthemes: (1) loss of income and financial stress; (2) dependence of khwaja sira's family members on their income; and (3) risk from engagement in sex work. Under the theme of social vulnerability, we identified three subthemes: (1) heightened social isolation; (2) psychological distress; and (3) the inability to access medical care. There were no additional subthemes under the code of resilience. Conclusion: Findings demonstrate that although khwaja sira experienced heightened vulnerabilities throughout the pandemic, they identified resilient coping strategies to handle these challenges. [ABSTRACT FROM AUTHOR]