Usually shunned by their families, the victims of beatings and rapes, they are often condemned to a life of begging or prostitution.
The situation is complicated by the deeply conservative, traditional Muslim country’s views of sex and sexuality.
The law only permits heterosexual relationships within marriage. Sexual relations outside marriage are punishable by imprisonment.
For women, virginity is an important condition for marriage, the vast majority of which are still agreed and arranged by parents and family members.
The suspicion of an unlawful love relationship, or even regular communication with a man, could see a woman killed by her relatives in the name of “honour”.
Homosexuality, prohibited by Islam, is punishable by 10 years imprisonment or even 100 lashes.
While homosexuals are viewed with derision, in the case of men, few would identify themselves as gay so long as they are the “active” partner.
Homosexuals identified as “passive” are ostracised in patriarchal Pakistan. Known as zenana, they wear men’s clothes but display effeminate behaviour. Some from this group form a community who are traditionally both close to and rivals of the hijras, the third sex.
Lesbians, meanwhile, are all but invisible.
Hijras, or khawajasiras, are those born male but who identify as women. They are perceived as a third sex and have been able to hold Pakistani identity cards since 2009.
There is no term for women who identify as men.
In Islam, a Surah popular among the hijras says Allah “creates what He wants” – “girls”, “boys”, or “both boys and girls”.
Sexual intercourse between a man and a hijra is not considered homosexuality, even if it amounts to the same action.
Almost all hijras claim they have been born in a man’s body with “a woman’s mind”.
They say they are cultural heirs to a glorious past as eunuchs during the Mughal dynasty, when they were part of the elite – as harem guardians, artists, but also generals, like Malik Kafur in the fourteenth century.
Some hijras use hormones and silicone to enhance their feminine features, often injected without proper medical supervision, to shape their bodies – but full, expensive sex-reassignment operations cannot be done in Pakistan.
Their effeminate behaviour can cause families to reject them, and they often end up in the power of a so-called “guru”, with the risk of commercial sexual exploitation that implies.