Syndemic Pattern of Sexualized Drug Use and Mental Distress Among Trans Women/Khawaja Siras in Pakistan: Results From a Multicentric Latent Class Analysis.

Trans women, or Khawaja Sira, are a marginalized community in Pakistan. There is limited social inclusivity and high stigma for them in mainstream spaces. This leads to mental distress and compromised psychological well-being. The current study aims to identify latent classes of mental distress, substance use patterns, and their associated factors. A cross-sectional analytical study was conducted from 1 May 2025 to 10 June 2025 at seven community-based organizations. Self-identified trans women were recruited through the HIV community organization. Anxiety and depressive symptoms were measured using the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9. Ask for Suicide Screening Questionnaire was used. A total of 681 trans women participated in the study. About 23.94% reported illicit drug use, 2.94% reported injectable drug use, 14.54% reported sexualized drug use (SDU), and 5.14% reported amphetamine-type stimulant use in the last six months. The latent class analysis revealed two latent classes with high and low mental distress. The probability of at least moderate depression, anxiety symptoms, and past-week suicidal ideation was 92.30%, 90.82%, and 53.23% in the high mental distress class. There was a significant relationship between higher education and mental distress, with an adjusted odds ratio (AOR) of 3.032 (95% CI 1.434-6.297) for those educated up to college and an AOR of 4.226 (95% CI 1.841-9.535) for those with university education. SDU had higher odds of mental distress, AOR 3.361 (95% CI 2.032-5.527). The study suggests that trans women need sensitive mental health services that cater to SDU as part of essential healthcare for the trans women community.