Suvati Jaiyshrie, 28, celebrated her Sadangu late in life. The Hindu coming-of-age ceremony is marked by Indian-Malaysian families when their daughters begin menses. Jaiyshrie had missed out on the ritual during her childhood because she was assigned male at birth. But shortly after returning from sex re-assignment surgery in Thailand she had her day; resplendent in a gold and red sari, wearing a garland of flowers and gold jewelry, Jaiyshrie sat on a golden throne while her partner, mother, and community blessed her with food and money, wishing her the best in her life as a woman.
It was one of the happiest days of her life, she says. But only a couple of weeks after an evening in which she felt surrounded only by love and support—not often the case for trans women in Malaysia—Jaiyshrie found herself on a 12-hour bus ride from Kuala Lumpur to Thailand, bent over in crippling pain.
She was experiencing a complication—urethral stricture caused by scar tissue build-up—that prevented her from urinating. She had tried to seek care at a government hospital in Malaysia but was turned away, told that the doctors don't treat transgender patients. She then went to a private doctor who said all he could do was drain her bladder and that she would need to go back to Thailand, where there are doctors trained in transgender health, to repair the problem.
"I had to control my pain, my tears, and I go to Thailand again" Jaiyshrie says. "I don't know whether [Malaysian doctors] don't want, or they don't know how to treat transgender women."
Jaiyshrie's trip was complicated by the fact that only a couple of weeks earlier she and her partner had lent her friend Soniya 2,000 ringgit—about $500—to travel to Thailand to have a urethral stricture repaired. Jaiyshrie, who at the time earned $508 a month as a financial administrator at a metal factory, had spent her life savings on her SRS surgery, which cost more than $5,500. She sold her gold jewelry to afford her own emergency procedure, which cost about $1,000. Due to her financial constraints Jaiyshrie stayed only one night in a hotel before taking a bus home with 12 stitches around her urethral opening.
Thailand is reportedly the most popular overseas destination for SRS due to the availability of high-quality and inexpensive medical care and a preponderance of doctors trained in gender-affirming surgery, as the procedure is known in the transgender community. But despite enduring an often painful journey at great financial cost, women like Jaiyshrie and Soniya are not necessarily guaranteed the care they require. Malaysian activists and patients interviewed by Pacific Standard complain that the procedure is highly commercialized, and that some of the doctors aren't well-qualified. One trans man who had "top surgery"—a double mastectomy—in Thailand, says office staff brought a money counting machine into his room shortly before the surgery. They believe this has led to a high incidence of complications—particularly urethral strictures. Jaiyshrie says that a doctor in Malaysia told her the 12 stitches put in during her urethra procedure were "barbaric" when she went for follow-up care.
Dr. Curtis Crane, who trained in SRS in Thailand and works now in Austin, Texas, says about 1 percent of his male-to-female patients experience urethral strictures. The repair is an outpatient surgery in which the scar tissues is cut away and flaps are created in the urethra to prevent scar tissue from building up again, he says.
"If they're having a really high incidence my first question would be: Did you get any urology training? If so, are you a urologist? Are you a plastic surgeon just dabbling in this? Is there a reconstructive urologist on your team?" Crane added that plastic surgery programs don't include reconstructive urology training, so one of the team members should have completed a urology residency.
Dr. Preecha Tiewtranon, one of the pioneers of SRS in Thailand, says a urethral stricture may be the result of an "improper" surgery.
Difficulty accessing health care is a common problem among transgender individuals in the vast majority of countries, including the United States. A 2013 study in Massachusetts—a state with universal access to health care and a non-discrimination policy—showed nearly one-quarter of transgender people surveyed had been unable to access transition-related health care due to their insurance not covering it or being discriminated against at medical facilities. Thailand is also a popular medical destination among Americans.
"For someone who doesn't have insurance or who can't afford surgery in the U.S., unfortunately that's their only option," Crane says. "But this is a surgery that has some complication rates, and the thing that Americans have to think about before they go 12 time zones away to have surgery is, 'What am I going to do if there's a complication?' And that's when you'd rather have your surgeon at least in the same country, if not the same time zone, as you. But I understand the desperation that some of these patients have."
Khartini Slamah, a transgender health advocate who worked in LGBT advocacy in Bangkok for several years, says many Malaysians go to Yala and Hatyai, areas in southern Thailand that they say offer far cheaper surgeries, but some of the doctors there aren't sufficiently trained in transgender health. She added that many of her transgender friends have experienced urethral strictures after SRS.
Malaysia's ministry of health declined a request for an interview on transgender health and did not reply to questions sent by email on the reported lack of access to care for transgender individuals available in government hospitals.
Transgender health care has diminished alongside a creeping crackdown against Malaysia's LGBT community over the last four decades. The hostile environment has manifested most publicly as police raids justified by Shariah laws criminalizing "a man posing as a woman." Most transgender Malaysians say they are most affected by the government refusing to change their gender on official IDs, which has been the policy since at least 2012, according to Human Rights Watch. This has opened trans women and trans men up to everyday harassment by police, rejection by potential employers, and stigmatization or even refusal of service at institutions like hospitals and banks. This discrimination also presents significant financial challenges to the community, which struggles to access employment and often faces sexual harassment in the workplace. Shortly after her surgery Jaiyshrie was forced to quit her job when her manager refused to allow her to use the women's restroom, and six male co-workers followed her into a gender-neutral bathroom and peered over the top of the stall at her. She says her manager told her he couldn't do anything about it, and she left.
This is a dramatic change from the historical attitude toward gender diversity in Malaysia. Before Islam and Christianity came to the Malay Archipelago through colonization in the 13th and 16th centuries, respectively, the region was "quite decidedly queer"—embracing "not just a third gender, but ... a greater acceptance and affirmation of gender diverse individuals," according to Sharon Bong, a gender and religion professor at Monash University Malaysia. She says that, to this day, there is greater acceptance of transgender family members in the ethnically Malay community because, "fundamentally, the Malay culture has been not just tolerant but quite affirming." But in Malaysia, she says, "what it means to be Muslim has just changed, for some people for the worse because it has made them more intolerant."
Activists and analysts point to a variety of factors driving increasing Islamic conservatism in Malaysia, including political pandering to more conservative rural voters, as well as regional trends and influences, such as Saudi Arabia's fundamentalist interpretation of Islam. Activists say recent rhetoric may be due to the LGBT community being used as a political tool ahead of upcoming presidential elections. Increased organizing by the LGBT community is also driving a government backlash.
The Malaysian government stigmatizes the entire LGBT community in various ways. The religious department runs free weekend camps for Muslim trans women and gay men that some participants say are tantamount to conversion therapy. In June of 2017, the health department ran a public competition encouraging youth to submit videos on ways to "prevent" homosexuality (after widespread criticism, the ministry later revised the competition). Malaysia's censorship board delayed the release of Beauty and the Beast in the country because of a "gay moment" in March of 2017. Reflecting more widespread attitudes toward people who are LGBT, in February a leading newspaper published a list of ways to identify gay people.
Homosexuality is illegal in Malaysia under a colonial-era sodomy law that carries a 20-year jail sentence.
This shift in thinking has also affected health-care access for people who are transgender. Until 1982, when a fatwa against Muslims undergoing SRS in Malaysia was issued, transgender Malaysians were allowed to undergo sex re-assignment surgeries locally, and they were even available at the public University of Malaysia hospital in Kuala Lumpur. According to HRW the fatwa was not technically legally binding, but fatwas are generally followed in Malaysia as if they were. The hospital stopped performing the surgeries the following year.
Now there is little other option than to travel to Thailand. While the discrimination has disproportionately targeted transgender Muslims, it has also made transgender health care virtually inaccessible for the rest of the community—which more broadly in Malaysia is close to 40 percent non-Muslim—thanks to both discrimination and a lack of knowledge.
And beyond the physical health consequences of a lack of care, transgender health advocate Sulastri Ariffin pointed out that most SRS offices in Thailand don't provide mental-health support, and that therapists who would be supportive of transgender people in Malaysia are in short supply as well.
"Right now, if you have money, you just go to Thailand, pay the doctor, and they just chop it off," Ariffin says. "So that is very dangerous to the psychological [health]."
Back when sex re-assignment was performed at Malaysia's Malaya Hospital patients had to go a two-year period of talk and hormone therapy, as well as post-procedure counseling, according to Slamah.
While the World Professional Association for Transgender Health doesn't require psychotherapy before or after SRS, it does strongly recommend it. Crane says he always recommends patients to follow up with a therapist after their surgery.
The lack of treatment options available to transgender patients is particularly striking in a country with high quality and affordable public and private health care. Activists say there are virtually no doctors in Malaysia well-versed in transgender health issues. A physician who specializes in treating HIV and works closely with the trans community says transgender health isn't included in medical curriculums: "It is up to us. If we are interested in this group of people, then you go on your own initiative to find out how to [treat them] ... most of the time I have to admit that I learned from the transgenders themselves. And I google, I found out from [World Health Organization] booklet."
The doctor, a general practitioner at a government hospital, spoke on the condition of anonymity—both in name and gender—as they hadn't gone through officials channels to speak to the press. Despite desiring to help the community, the physician doesn't see transgender patients often. When a transgender person does come in, they have often been brought to her by an non-governmental organizations because they are already dealing with a health crisis. The doctor chalked this up largely to a fear of being stigmatized at hospitals and clinics, where transgender patients are called by their birth name now that the government won't allow name and gender changes on IDs. Hospitals also admit patients to gendered wards based on the sex listed on their ID.
One trans woman told Pacific Standard she once refused to be admitted to a hospital for a bad virus, fearing sexual harassment or even assault in the male word.
And the doctor adds that, even if transphobia were addressed in the medical community, a lack of education prevents doctors from being able to properly aid patients.
On one occasion, a trans woman who had jumped off a second-floor balcony fleeing religious police came to the hospital for treatment. The woman's breast implant had burst when she fell, and she had been to several general practitioners who hadn't been able to help her. This doctor couldn't either, and didn't know anyone in Malaysia to refer her to.
The doctor says none of their transgender patients had ever seen an endocrinologist to evaluate their hormone therapy—most take high doses of over-the-counter birth control and guess at the appropriate dosage. The physician says many take such high doses that it puts them at risk of high blood pressure and pulmonary embolisms. But the country's endocrinologists and gynecologists are not specialized in and do not want to prescribe hormone therapy for transgender patients.
"That's why education is important. I wish somebody, some organization, would come teach us—even if not all, those who are interested in the care of transgender. How to deal with emergency cases, if the implant bursts, or ... when problems arise after the reconstruction surgery—what to do, what to look for."
But the doctor adds that, even among medical practitioners, there is very limited willingness to help patients who are LGBT. "Even my own friends they often criticize me, because sometimes I am sort of accused of promoting [LGBT] 'activities.'"
"I am a Muslim ... a good Muslim doctor should help everybody."
Even in the rare cases where people who are transgender are able to access emergent health care in Malaysia, the process of searching for a doctor who is able and willing to help them is likely to be lengthy and traumatic.
In 2015, then-21-year-old Nithya Chandrasaker needed surgery both to remove a kidney stone and repair a urethral stricture. She saw several doctors in Malaysia, all of whom told her she would have to go back to Thailand to be treated. She borrowed $380 from her sister for an agonizing trip but the surgery didn't work.
"After that I was suffering," she says. "I go into clinic, I go into hospital, I go into anywhere, I suffer, suffer like that. Then I feel like I want to die. Then I want to commit suicide."
Finally, Chandrasaker's parents helped her find a doctor who would treat her in Malaysia, although it cost more than $3,800. She says the doctor took pity and lowered the bill to about $1,500 because she couldn't pay the full price. The surgery was successful, and she made a full recovery. But she says that, in the last two years, she has gained a significant amount of weight, which she believes is related to her surgery or hormone therapy. In Malaysia, she hasn't been able to find a practitioner versed in trans health to help her.
Slamah, who has been worked in LGBT advocacy in the region for 27 years, says that, while life for transgender Malaysians has always presented significant challenges, before the decades-long crackdown the community was largely left alone.
"In the '80s, '90s, we thought there was no such thing as harassment by the authorities. We thought: 'We free. We can have anything we want."
Courtney Brooks reported from Malaysia on a fellowship from the International Reporting Project.