Introduction: stigmatization, social exclusion and consequent banishment from the society makes transgender's life even tougher; isolating, pushing and forcing them into inappropriate conducts/habits like selling sex. This study investigates the association of social exclusion/victimization with high-risk behaviors among transgender community of Rawalpindi and Islamabad (Pakistan).

Methods: through a cross-sectional study design, a sample of 189 transgender community living in twin cities of Rawalpindi and Islamabad was selected using snowball sampling technique. A validated close ended questionnaire was used to estimate the high-risk behaviors. Multivariate logistic regression was used to explore the competing outcomes associated with suicidal risk, selling sex and substance abuse.

Results: majority study participants 77.8% experienced physical attacks with institutional discrimination even higher (91.5%). Commercial sex work and drug abuse was reported in 39.2% and 37.6% respectively. The prevalence of suicide ideation was high (38.6%) however, suicide attempted rate was less (18.5%). In the multivariate logistic regression, compared to those with no risk, being physically attacked increased the odds of both attempting (OR=2.18) and contemplating suicide and selling sex (OR=4.10). Nevertheless, the relative impact of institutional victimization on suicidal behavior was higher among those who were targeted on the basis of their gender identity or expression (AOR = 6.20, CI = 1.58-24.29, p=0.009).

Conclusion: the transgender community is socially excluded by the Pakistani society where they experience high levels of physical abuse and face discriminatory behavior in daily life. Such attitudes make them vulnerable for risky behaviors; forcing them to become commercial sex workers, begging, drugs use and even suicidal ideation.