A young woman, appearing to be in her 20s and dressed in a shalwar kameez, walked into Dr Raza’s (not his real name) clinic. When asked about the reason for her visit, she hesitated and looked away shyly.
Dr Raza assumed that the young woman had reservations sharing her medical problem with a male surgeon. He went out and called a female nurse so she could speak comfortably.
What followed was something quite unexpected: not only did it lead to the nurse’s jaw dropping in shock, it also placed Dr Raza in a quandary.
“I want to be a man.” The shy young woman declared. “Can you help me?”
Feeling startled, Dr Raza looked over at the girl’s mother, and she nodded, silently confirming her daughter’s declaration.
The doctor went outside to get a female surgeon to examine the young woman so he could ascertain whether there were any physical abnormalities that had necessitated such a request.
However, the female surgeon refused categorically upon hearing the background of the case, and stated that “she did not want to get entangled in such issues.”
Dr Raza probed what the young woman meant by wanting to become a man. She said insistently, “I have always felt like a man. Now I also want to appear like a man.” Her mother also corroborated, “Since her childhood, she has always behaved like a boy. She always wore men’s clothing.”
He tried to explain what the transformation from a woman to a man would entail: “It would mean that right now you can get married and have a child, but if you choose to do this, you will not be functioning fully as a male.” The young woman replied that she was aware of this but did not see it as a deterrent.
In a quest to help the young patient, Dr Raza approached a series of physicians in various specialties, including gynecologists and urologists, who could help with the case, but all of them refused to be involved.
Statements such as “She will want a hysterectomy. I am not going to take a healthy uterus out” and “She will want her breasts removed. This is not medical treatment” were thrown around.
A psychiatric evaluation revealed that the young woman was not mentally ill or 'abnormal', but had a condition known as gender dysphoria, which involves a conflict between a person’s internal gender identity and the biological sex assigned to them at birth, and can be addressed through surgeries or hormone therapy.
She asked, “Are there ways to get this addressed in Pakistan? If I had more money, I would have gone abroad to get it done.”
Dr Raza had a painful answer to her question: no, not at any recognised medical clinic.
Despite the deep mental distress his patient was going through, he was unable to find any reputable physician, be it a gynecologist or plastic surgeon, who would be willing to perform such a procedure.
Whenever he discussed the case, it led to medical and also religious debates. Many of his colleagues considered such a procedure to be un-Islamic.
Dr Raza’s account depicts the issues that arise when physicians with little or no experience of treating transgender individuals are approached by patients whose gender identity does not match their biological sex.
There are an estimated 25 million transgender people worldwide, and in Pakistan, the latest census grossly underreported the transgender population to be over 10,000. Mistreatment of this population along with stigmatisation and bias is common in Pakistan and access to basic health services is a continuous struggle for the community.
At health facilities, transgender patients may be turned away, mocked and harassed. This is partly due to widespread societal ignorance about individuals who are different from the mainstream binary, but also because of health professionals’ lack of experience in dealing with individuals who simply do not fit the 'normal'.
Consequently, many transgender individuals do not seek help for legitimate medical issues because, as a recent report by Forum for Dignity Initiatives on transgender health illustrated, the majority expect harassment at health facilities.
They particularly face obstructions when they seek to undergo transition to the sex that corresponds with their gender identity, as powerfully demonstrated through Dr Raza’s narrative. Based on a real story, the case highlights the reluctance of healthcare professionals to perform gender reassignment procedures.
Discussing the issue with some surgeons, we discovered that they had received such requests only once or twice in their entire medical career, showing that few transgender individuals actually approach recognised health facilities for gender reassignment.
This can partly be attributed to the lack of support and understanding from their families, but also to overall societal discrimination.
In a conversation with Dr Sana Yasir, founder of LEAP for Intersex, an organisation that supports intersex and transgender individuals, we heard stories of the brutal treatment that some transgender persons received because they expressed their gender identity through their mannerisms.
Mistreatment ranged from bullying in schools — where transgender students were mocked by other children and teachers to the extent that they often chose to leave school — to emotional and physical abuse by families who believed they could 'beat the problem' out of the 'errant' child.
One particularly horrific story centred on a transgender male, born a female, who had his breasts punched by his brother while screaming, “See, you have breasts! Do you still consider yourself a male?” Such abuse resulted in constant suicidal ideation, anxiety and multiple suicide attempts on his part.
Many individuals leave their homes to escape this abuse, but greater troubles await them. When they wish to transition biologically either through hormone replacement therapy or surgical procedures, they find themselves in a fix.
Unable to find trained medical professionals willing to help them, they often end up as victims of dangerous back alley procedures performed by quacks wanting to make a quick buck.
Dr Sana Yasir related that many transgender individuals within the khawaja sira community self-medicated with hormones provided by other community members or went to untrained individuals for surgical procedures.
Due to this, health problems are common, including early onset of diabetes and hypertension, along with early mortality to name a few. Botched surgical procedures often end up in more disfigurement, which compounds psychological distress.
Of all the transgender and intersex individuals who have come to Dr Yasir for assistance so far, there is not one who has been able to get surgery performed by a trained medical professional.
So, what are the reasons for healthcare professionals’ unwillingness to perform such procedures or recommend regimented hormone therapy treatments?
“God has made them this way. I would not want to change them in any way,” was one of the reasons provided by a surgeon who would not perform a mastectomy (removal of breasts), since she believed that this would be tampering with nature and going against God’s will.
Another physician stated that even though she understood the plight of the transgender community, she would find it hard to perform such a procedure herself. When questioned about this obvious paradox, the physician stated that she would innately feel as if she was actually inflicting harm, asking, “How can you remove healthy breasts?”
One physician also believed the reluctance was partly due to limited exposure to such procedures during medical education and training.
She stated, “Yes, if it was part of my routine training, then yes, perhaps I would take it in my stride. But right now I am not comfortable doing it.”
Dr Yasir expressed a similar viewpoint, stating that during medical training, lack of exposure leads to complete ignorance on the part of healthcare professionals about how to deal with intersex and transgender bodies.
She also holds the perspective that an obvious hesitancy to perform this procedure also occurs due to the fear of backlash from society which may consider this as something averse to the tenets of Islam.
Dr Raza explained that he was unsuccessful in getting the young woman the treatment that she needed. While he could have performed part of the procedure, he would have required a team of physicians including a plastic surgeon, a gynecologist and an endocrinologist, to result in a full transformation.
In the end, he did not perform any part of the transformation because he believed that in isolation, it was simply “mutilating.”
He was unable to recruit such a team, and while the patient is now lost to follow-up, he remembered that she was undergoing psychotherapy to tackle the psychological anxiety triggered by her discordant identity, and had become increasingly suicidal.
This is where the debate on the harm principle, which is the cornerstone of medical practice, comes into play. While the surgical procedure can be considered mutilating since there is perceived physical harm being done on an otherwise healthy body, it should also be noted that refusal to conduct such a procedure also results in significant psychological disturbances.
In fact, the rates of mental illnesses such as anxiety and depression among the transgender community are significantly high, occurring primarily because of stigma and discrimination being a part of their routine lives.
The harm principle applies generally to both physical and mental harm, and the balance between the two can sometimes become difficult to attain. It is also worth considering that many of these transgender individuals ultimately resort to back alley procedures that lead to more harm than good in the long-run.
Apart from the issue of harm, physicians are also concerned about possible legal repercussions of gender reassignment procedures.
In May 2018, the National Assembly passed the Transgender Persons (Protection of Rights) Act, so far one of the most progressive bills passed in any country of the world.
The act states, “A transgender person shall have a right to be recognized as per his or her self-perceived gender identity, as such, in accordance with the provisions of this Act.”
The document defines the term ‘transgender’ as including three categories: intersex individuals, eunuchs and “a Transgender Man, Transgender Woman, Khawaja Sira or any person whose gender identity and/or gender expression differs from the social norms and cultural expectations based on the sex they were assigned at the time of their birth.”
On paper, at least, the act enables transgender individuals to have their self-perceived identities recognised on all identifying documents and protects their access to education, healthcare and employment opportunities.
In fact, clause 12 expressly states that the government will ensure that medical curricula are reviewed in light of transgender issues and will “improve research for Doctors and nursing staff to address specific health issues of Transgender Persons in cooperation with Pakistan Medical and Dental Association (PMDC).”
Ironically, although a Pakistani who has attained 18 years of age can be legally identified by their self-perceived gender or change the gender assigned to them at birth, there is no healthcare framework that allows such individuals to physically transition to their desired gender.
At present, individuals needing gender reassignment surgery are required to requisition the court for permission, as in the case of a 22-year-old woman who approached the Peshawar High Court in November 2018.
Another important question is whether sex reassignment surgeries constitute part of medical treatment, and if they are, whether it is the duty of the physician to perform them. There is no consensus on this issue, especially since despite the 2018 ruling on the subject, this is an issue that is still not discussed in Pakistan’s medical circles.
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While there are no clear answers currently with regards to the ‘medical’ status of sex reassignment surgeries and hormone replacement therapies, the health problems (physical and mental both) among transgender individuals remain.
Although we believe that physicians should not be obligated to perform reassignment surgeries, the onus is still on medical education and training programmes to provide medical students and trainees with greater exposure to the specific health issues of transgender patients.
A study in a medical college in the United States demonstrated that exposure to the transgender community increased medical students’ comfort in dealing with the transgender population and led to overall increased competence.
The inauguration of a transgender ward at Pakistan Institute of Medical Sciences in December 2018 is a promising step, although the results are yet to be seen. The Transgender Persons Act has not yet been followed up by any widespread changes to the medical curriculum, which falls under the PMDC’s domain.
We believe that this important law must be followed by increased exposure to transgender patients and their health requirements in medical colleges. If the transgender population’s right to health is to be recognised, then it is important to increase awareness and knowledge within the medical community about their unique needs.
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