This article was originally published on Malaysiakini : https://www.malaysiakini.com/news/562273
SPECIAL REPORT | Dr Subatra Jayaraj was preparing spinal anaesthesia when Che Nusrat (not her real name) was brought in for a diabetic foot ulcer operation.
Wearing a headscarf, the woman in her 60s had been in the hospital for two weeks and this was her third time under the knife.
"It was only on the third time that we realised she was a transwoman who had not undergone reassignment surgery yet," Subatra recalled.
"Unfortunately, as the health team had to report it, the decision was made to transfer her to the male ward because her ID refers to her as male.
"Can you imagine, this lady, who has probably lived and dressed her entire adult life as a woman in her community, having to move to a male ward because of policy and procedure?
"My heart went out to her, for the unfairness that the discriminatory health system insists on putting on patients with diverse gender identities," she added.
This is what transgender people experience when seeking medical treatment. Apart from health concerns, they have to deal with prejudice and discrimination as well.
Dorian Wilde, 33, who sports a thick moustache and beard, dreads going to a gynaecologist. In his identity card (IC), he is a woman.
"Can you imagine me, with this face, going there for medical help (as a woman)?
"Other men are there to accompany the women. Everyone stares at you. What makes it worse is that you have to spend hours to see the doctor. So I just put on my earphones to drown out these thoughts.
"It was a rough experience. It was so bad that I thought I should just leave. But I could not because I really needed to see the doctor," he told Malaysiakini.
ToM founder Dorian Wilde
Dorian is the founder of Transmen of Malaysia (ToM). He considers himself an empowered transman, who knows his fundamental rights.
"Many transmen do not want to visit the doctor because of these issues. They only visit the doctor when it is really severe, especially when it concerns the vagina, cervix, uterus or ovaries," he said.
Sharing another experience, Dorian said once he was “observed” by a group of doctors and trainees at a government clinic without his consent.
"They didn't even ask me if it is okay. They just did it," he said, adding that he felt his privacy violated.
In another incident, a receptionist bombarded him with questions about his body.
"The basic thing is, they are not treating us like other patients. We are someone you need to criticise, be told to 'balik ke pangkal jalan' (return to the right path) or someone who is seen as a 'special case' and bring others to see us as well,” he rued.
Strange glances, prying questions and verbal abuse are some of the obstacles transgender people are all too familiar with. Add institutionalised oppression into the mix, and it becomes a hostile environment.
Greater tolerance in the past
However, the healthcare situation was different before the 1980s. Things changed when the National Fatwa Committee (NFC) stepped in.
At present, trans-specific healthcare development in Malaysia has fallen behind other countries. There is rampant discrimination even in general healthcare services.
"People used to come to Malaysia to get surgeries done. At that time, surgeries were covered by the government (for Malaysians)," said Dorian.
Circa 1980, he revealed that a team of doctors and psychologists at the University of Malaya Hospital provided trans-specific healthcare services, including hormone replacement therapy, gender-affirming surgeries and pre-operation counselling services.
"After doing your surgery, you go to the National Registration Department (NRD) and say that you have done your surgery, and 'Bam! Your IC (gender) is changed'," he said.
He noted how some of his older transgender friends have managed to lead normal lives after changing their gender on their IC.
“For younger transgenders like us, it feels like we are moving backwards. It is not supposed to be like that,” he lamented.
The watershed moment was in 1982 when the NFC issued an edict prohibiting sex reassignment surgeries and change of gender status after such procedures, except for intersex (khunsa musykil) people.
According to a report published by Human Rights Watch in 2014, Dr Khairuddin Yusuf and his team, who had performed surgeries on transgender people, successfully lobbied the NRD to allow changing gender markers as the team found their post-operative patients faced difficulties in finding jobs.
"The NFC heard about it. They expressed concern. We then explained the science behind it to them," Khairuddin said, according to the report.
"Our languages were totally different. They didn't get the language of science. I understood what Galileo (Galilei) was facing. Science challenges conventional wisdom.
"I was explaining the importance of transgender people getting jobs, that we have to help our patients. They did not explain their reasoning... Our reasoning was not accepted, so I closed the services," he added.
Clinicians afraid of pushing boundaries
Commenting on this, Subatra said although the fatwa is not legally binding, many healthcare centres do not want to take the risk of violating it.
Sexual and reproductive health expert Dr Subatra Jayaraj
"In my opinion, the current system is more conservative in keeping with the religiopolitical direction of the country.
"There is a need to be seen to be more religious to get approval from your peers, colleagues and bosses.
"Clinicians are also afraid of pushing boundaries due to increased scrutiny by the government," the doctor added.
Subatra obtained her Masters in Medicine at the University of Sydney, majoring in sexual and reproductive health which covers issues of trans health.
After leaving government service, she started a clinic to provide primary care focusing on sexual and reproductive health. Her clients are mostly cisgender women, but there are also transmen clients.
Recalling her time in government hospitals, Subatra said she witnessed "internalised discrimination" and realised the gap in clinical understanding and willingness to learn clinical aspects of trans health in Malaysia.
For example, she said, medical staff referred to such patients with derogatory names such as "pondan" or "songsang". These terms cropped up during discussions and were even written down on documents.
"It makes for an uncomfortable environment that is not welcoming for the trans community," she said, adding that many clinicians are not familiar with concepts of sexual orientation, gender identity and expression and do not know what are the proper terms.
Pointing out that some transgender persons are told by medical staff to “return to the right path”, Subatra said this is the reality in Malaysia.
"Doctors should follow evidence-based medicine and treat our clients non-judgmentally and not based on their own beliefs and practices,” she added.
Sulastri Ariffin, one of the many transgender people Malaysiakini interviewed, is no stranger to being told to “return to the right path”.
Transgender woman Sulastri Ariffin
"We went to see the doctor, but why did the doctor give us a speech? It is not a surau or masjid, you are not an ustaz, you should focus on patients' symptoms and medical needs," she said.
Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib noted that the medical sector is affected by the rise of conservatism.
"Islamic orthodoxy and social conservatism have been on the rise since the 1980s, particularly among the Malay-Muslim community.
"This has affected policy-making structures, even in more secular disciplines such as medicine which are based on science and evidence obtained through research.
“The space for those who do not conform to socially-accepted norms is narrowing, especially for transgender people,” he said.
According to Azrul, institutional persecution and violence have compounded the problem for this vulnerable group.
"The increase in conservatism is primarily due to Malaysian society, in particular the Malay-Muslim community, needing to find comfort and stability in the rigidity of social and religious structures, amidst a changing world," he surmised.
Political leaders are also to blame for perpetuating this stigma towards sexual minorities.
Recently, PAS pushed for the formation of an anti-LGBT taskforce and making gender change an offence for Muslims, among others.
Part 2: Orked's plight - from med student to injecting black-market hormones