Gender identity, healthcare access, and risk reduction among Malaysia'smak nyahcommunity

Abstract

Transgender women (TGW) face compounded levels of stigma and discrimination, resulting in multiple health risks and poor health outcomes. TGW identities are erased by forcing them into binary sex categories in society or treating them as men who have sex with men (MSM). In Malaysia, where both civil and religious law criminalize them for their identities, many TGW turn to sex work with inconsistent prevention methods, which increases their health risks. This qualitative study aims to understand how the identities of TGW sex workers shapes their healthcare utilization patterns and harm reduction behaviours. In-depth, semi-structured interviews were conducted with 21 male-to-female transgender (mak nyah) sex workers in Malaysia. Interviews were transcribed, translated into English, and analysed using thematic coding. Results suggest that TGW identity is shaped at an early age followed by incorporation into the mak nyah community where TGW were assisted in gender transition and introduced to sex work. While healthcare was accessible, it failed to address the multiple healthcare needs of TGW. Pressure for gender-affirming health procedures and fear of HIV and sexually transmitted infection screening led to potentially hazardous health behaviours. These findings have implications for developing holistic, culturally-sensitive prevention and healthcare services for TGW.

The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices

“…Some cultures acknowledge genders outside of the binary, sometimes referred to as “third gender” classifications, such as Native American berdaches or “Two Spirit” people, or the Fa'afafine of Samoa. Other terminology used to describe trans people includes the terms mak nyah in Malaysia [ 4 ], kathoey in Thailand [ 5 ], hijra in India, Bangladesh and Pakistan [ 6 – 8 ], waria in Indonesia [ 9 ], rae rae and mahu in French Polynesia [ 10 ] and travesti in South America [ 11 ].…”

Acceptability of a microfinance‐based empowerment intervention for transgender and cisgender women sex workers in Greater Kuala Lumpur, Malaysia

“…There are no known studies examining the impact of these types of interventions on TWSWs’ HIV risk profile; though evidence suggests that their behaviours are influenced by a similar set of factors to those of CWSWs [ 8 , 9 , 28 ]. Moreover, there are currently no reported microfinance interventions targeting either group in Malaysia.…”

Transgender women in Malaysia, in the context of HIV and Islam: a qualitative study of stakeholders’ perceptions

“…Research undertaken within the Malaysian context suggests that transgender persons may have reservations about accessing any form of health services [ 17 ] as they are hesitant about the reception they will receive from health care workers, doctors and nurses and whether they will be classified as ‘male’ or ‘female’ in any documentation. More recently, a study conducted with transgender women in Malaysia by Gibson and colleagues found that although the government health system was free “many reported avoiding it due to past discriminatory experiences”, while those who had utilised government clinics reported “denied care, mistreated, asked to change their appearance, or felt they had to present as male in order to receive proper care” [ 22 ]. A number of authors have concluded that there needs to be greater education of healthcare workers on transgender issues, [ 28 ] an increase in the capacity of ‘health and social service providers’ [ 29 ] to provide a sensitive service more responsive to their needs [ 30 ].…”

“…More recently, a qualitative study consisting of 21 in-depth interviews with Malaysian transgender women who were sex workers was undertaken which highlighted the stigma and discrimination faced when accessing appropriate health care [ 22 ]. The authors also conclude that while healthcare is accessible, the Malaysian government fails to provide the funding for HIV prevention which is specific for Mak Nyah and that the “healthcare and prevention system is poorly equipped to provide targeted HIV prevention and treatment” [ 22 ].…”