Kai Hui Wong
Orked's plight - from med student to injecting black-market hormones
This article was originally published on Malaysiakini : https://www.malaysiakini.com/news/562419
SPECIAL REPORT | When Orked Luna decided to pursue a medical degree, little did she realise that it would lead her to the point of wanting to end her life.
Before she was born, Universiti Malaya Hospital had allowed transgender people to be themselves but much had changed since then.
"The way I speak is very feminine. And the way the doctors looked at me showed that they don't want people like me to become part of their profession,” she told Malaysiakini.
Unable to conceal her “trans-ness”, Orked, 21, said she fell into a “dark spiral” and was later diagnosed with schizophrenia.
"I had multiple suicide attempts and I was in a psychiatric ward for several weeks. In the ward, I told them I am a transgender person and the Malay psychiatrists refused to acknowledge our existence," she revealed.
"They tried to use religion to help me, asked me to pray and be close to God. I didn't see how that would help me because it (schizophrenia) is an actual pathology."
Last year, Orked quit her medical studies to embark on a journey of transition.
"At first, I thought that I should prove them wrong, to change their perception of people like me. But it was taking too much of a toll on me...
“If society or the medical field was more accepting, I would be inclined to complete my studies," she added.
Orked found work at a burger joint in Kuala Lumpur and with the money she earned, began purchasing hormones from the black market, which is the only option for her, knowing it could lead to adverse side effects.
"We didn't learn trans-specific healthcare needs (in medical school). I literally learned everything online. I learned how to inject myself with hormones from the Internet.
"I don't get to check myself. If my hormones exceed normal levels, the side effects would be bad but this is the life we are forced to live."
Furthermore, Orked said she could not afford the tests to determine hormone levels.
"I am not from a privileged family, I am from a B40 (bottom 40 percent of income earners) family. Being a transgender person, you can get your hormones checked every month if you are rich."
Although happier now that she is able to embrace her true self, Orked, however, is still saddled with concerns about her health.
This is because some of her transgender friends suffered from kidney, lung, and blood-related problems due to injecting themselves with black-market hormones.
“If we can have specialised medical services for old people, why not for transgender people? This is a violation of human rights,” said Orked.
No choice but to look for alternatives
According to Dr Subatra Jayaraj, a former government doctor who now runs her own clinic, trans-specific healthcare services gradually disappeared after the 1980s in Malaysia.
However, she said the transgender population still exists and their medical needs never vanished. This has forced them to turn to alternatives.
Dorian Wilde, the founder of Transmen of Malaysia (ToM), said the public might feel that transgender-specific healthcare is unimportant.
Stressing that it is a necessity, he said: "They don't understand. Banning it doesn't mean people would stop it (transitioning)."
ToM founder Dorian Wilde
Speaking from experience, Dorian said when a person is uncomfortable with his or her sexual identity, it would lead to dysphoria and anxiety as well as suicidal tendencies.
"Even though people are strapped for cash, they would still do it (turn to the black market). For us, this is important. It is life-changing,” he explained.
Trans-specific healthcare services include hormone replacement therapies, gender-affirming surgeries (also known as gender reassignment surgeries), and affirming counselling services.
Not all transgender people would choose to undergo surgery, preferring instead to take hormones to modify visible characteristics.
At the same time, appropriate hormonal therapy is required for those who undergo surgeries as well.
To ensure safety and to avoid complications with regard to hormonal therapy, experts note that medical advice is essential.
In certain countries, puberty blockers are used to suppress the development of biological secondary sex characteristics in children who identify themselves as transgender.
Despite having side effects, it helps reduce the medical cost for transitioning surgery and the trauma of developing sex characteristics that do not suit the transgender teenager's gender identity.
As there are no proper and open channels for the transgender community in Malaysia to access hormonal therapy, most undergo the transitioning process without proper medical supervision.
Subatra has been working with the transgender community for over five years and aims to provide non-discriminative, affordable, woman and trans-friendly healthcare for lower to middle-income individuals who cannot afford private hospitals.
Sexual and reproductive health expert Dr Subatra Jayaraj
Besides the high cost, she said transgender patients also faced problems such as discrimination amongst healthcare workers.
On the same note, Subatra said doctors also encountered difficulties in providing trans health facilities due to inexperience and stigma.
"They don't want to be seen as a 'transgender clinic'. There is also difficulty purchasing recommended medication as well," she explained.
Subatra said misusing hormones such as taking the wrong medication or dosage increased the risk of complications such as blood clots and stroke.
"Some transmen on testosterone are on a very high dose such as those used by bodybuilders which is harmful in the long run."
Emphasising that transgender healthcare should be holistic, Subatra, however, noted that the direction of healthcare development in Malaysia is impeded due to religiopolitical factors.
“We are a secular nation. We have doctors and clients from many religions - why should a particular religion dictate healthcare policies for all?”
However, a Muslim doctor, who spoke on condition of anonymity, argued that the healthcare system is inclusive of sexual minorities as well.
"Of course, transwomen are not allowed to do sex reassignment surgeries in Malaysia and cross-dressing is considered 'haram' (forbidden in Islam).
“But if a transgender person comes to our clinic, our service should be without boundaries. She should be regarded as another patient who needs medical attention," she stressed.
The doctor pointed out that men who have sex with men make up the bulk of HIV patients but are still entitled to free treatment.
She also cited how the Health Ministry has been collaborating with local NGOs to provide STI (sexually transmitted infection) screening and other services as well as to raise awareness among transgender people.
"We are still getting sufficient budget to run our STI clinic. Transgender people with diabetes or hypertension can still get their treatment from clinics or hospitals," she added.
To address the issue of transphobia amongst healthcare providers, the doctor said the ministry has organised numerous courses and set up "friendly clinics".
Offering a different view, transwoman Sulastri Ariffin, 60, expressed reservations about these so-called “friendly clinics”.
"They claim these are 'trans-friendly' clinics but there are no trans-specific healthcare services like hormone therapy or surgery. You can't even open your mouth to ask about it.
"I know the ministry would say they had been setting up some trans-friendly clinics. Of course, they need to be friendly because they have their KPI (key performance indicator) to meet,” she added.
Transwoman Sulastri Ariffin
Relating a personal experience, Sulastri said the assumption that transgender people are highly susceptible to STIs and HIV also contributed to stigma and discrimination.
When she visited a clinic for a nerve problem, the doctor appeared alarmed and asked her to undergo a blood test without any clear explanation.
It was later that Sulastri discovered she had undergone an HIV test.
“The doctor did not explain why I needed a blood test for a nerve problem. They seem to think that all transgender people must do an HIV test.
"I didn't mention any HIV-related symptoms. I have been educating the transgender community about HIV and STIs, I know what the symptoms are,” she said.
Despite the constraints, there are doctors attempting to serve the community by providing advice on safe hormone usage.
"We provide information on the effects of hormones on their liver, cholesterol level, circulation, and others. We also offer to do checks.
"Many of them are keen to know their hormone level. We don’t have that facility (at government clinics) but we help to take their blood and outsource it to a private lab if they can afford it," said one doctor, who declined to be named.
Include, not exclude
Last December, trans-led organisation Seed Foundation and Galen Centre for Health and Social Policy published a guideline titled 'Practical Guidelines for Trans-specific Primary Healthcare in Malaysia'.
Galen Centre chief executive Azrul Mohd Khalid
Galen Centre chief executive Azrul Mohd Khalid said a legal framework for the recognition of issues affecting transgender persons is essential for trans-friendly services.
"When the existence of this community is not properly recognised within the healthcare system, appropriate services will be difficult to set up even if done independently.
"When their existence is not recognised, their needs are not acknowledged and left unaddressed. The training of medical practitioners should also include the issues and challenges of trans-friendly healthcare services," he told Malaysiakini.
"Religious and social mores which seek to exclude rather than include people should be left aside. They have no place in a healthcare environment.”