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Transgender Women in Malaysia, in the Context of HIV and Islam: a Qualitative Study of Stakeholders’ Perceptions Sima Barmania1,2,4* and Syed Mohamed Aljunid1,3

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Transgender Women in Malaysia, in the Context of HIV and Islam: a Qualitative Study of Stakeholders’ Perceptions Sima Barmania1,2,4* and Syed Mohamed Aljunid1,3 Barmania and Aljunid BMC International Health and Human Rights (2017) 17:30 DOI 10.1186/s12914-017-0138-y RESEARCH ARTICLE Open Access Transgender women in Malaysia, in the context of HIV and Islam: a qualitative study of stakeholders’ perceptions Sima Barmania1,2,4* and Syed Mohamed Aljunid1,3 Abstract Background: Globally, one of the key groups considered to be at high risk of acquiring HIV are transgender women, often a marginalised group. In the Malaysian context there has been a scarcity of published research relating to transgender women, a sensitive issue in a Muslim majority country, where Islam plays an influential role in society. Furthermore, there has been a paucity of research relating to how such issues relate to HIV prevention in transgender women in Malaysia. Thus, the aim of this study is to explore the attitudes of stakeholders involved in HIV prevention policy in Malaysia towards transgender women, given the Islamic context. Methods: In-depth interviews were undertaken with stakeholders involved in HIV prevention, Ministry of Health, Religious Leaders and People Living with HIV, including transgender women. Thirty five participants were recruited using purposive sampling from June to December 2013 within Kuala Lumpur and surrounding vicinities. Interviews were in person, audiotaped, transcribed verbatim and used a framework analysis. Results: Five central themes emerged from the qualitative data; Perceptions of Transgender women and their place in Society; Reaching out to Transgender Women; Islamic doctrine; ‘Cure’, ‘Correction’ and finally, Stigma and Discrimination. Discussion: Islamic rulings about transgenderism were often the justification given by participants chastising transgender women, whilst there were also more progressive attitudes and room for debate. Pervasive negative attitudes and stigma and discrimination created a climate where transgender women often felt more comfortable with non-governmental organisations. Conclusion: The situation of transgender women in Malaysia and HIV prevention is a highly sensitive and challenging environment for all stakeholders, given the Muslim context and current legal system. Despite this apparent impasse, there are practically achievable areas that can be improved upon to optimise HIV prevention services and the environment for transgender women in Malaysia. Background population for HIV’ [1]. In a comprehensive meta- Globally, one of the key groups considered to be at high analysis and systematic review conducted by Baral and risk of acquiring HIV are transgender women, defined colleagues, an assessment of the relative HIV burden in for the purpose of this study, as women assigned the transgender women was undertaken including 15 coun- male gender at birth but who identify themselves as tries which revealed a pooled HIV prevalence of 19.1% being women. Transgender women often represent a in 11,066 women worldwide and the odds ratio of being marginalised population and a ‘very high burden infected with HIV for transgender women compared with all adults of a reproductive age was 48.8 [1]. The * Correspondence: [email protected] authors deduce that there is an ‘urgent need of preven- 1UKM Medical centre, Faculty of Medicine, International Centre for Casemix tion’ in transgender women in a group that are often not and Clinical Coding, National University of Malaysia, Jalaan Yaacob Latif, included in national HIV surveillance and identify fac- Kuala Lumpur 56000 Cheras, Malaysia 2United Nations University International Institute for Global Health, Kuala tors, such as engagement in high risk anal sex with men Lumpur, Malaysia increasing their vulnerability, as well as stigma and Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Barmania and Aljunid BMC International Health and Human Rights (2017) 17:30 Page 2 of 10 discrimination in health care settings as hindrances to transgender community in Malaysia. Lee argues that his- accessing HIV prevention services [1]. In the UNAIDS torically transgender women were more culturally Prevention Gap Report, key populations such as trans- accepted in Malaysian society, even up until the 1980s gender women are not reached by current prevention [13]. However, recently widespread conservative Islam efforts [2]. The Asia Pacific Trans Blueprint for Health both socially and legally has resulted in a culture of in Action clearly mentions ‘trans women as dispropor- ‘moral policing’ citing the example of a transgender tionately affected by HIV—yet there are still insufficient woman who was assaulted by Islamic enforcement offi- programmes or services targeted to meet trans-specific cers, sent to hospital due to her injuries and the staff need’ [3]. Studies have concluded that transgender told to write down the name of any transgender people women are at increased risk of HIV due to factors, such who visited her [13]. as high-risk sexual behaviour, commercial sex work and In Malaysia, Islam plays a strong role in influencing stigma and discrimination [4]. Operario and colleagues individual behaviour [14] as well as society, gender and conducted a meta-analysis and found the prevalence of sexuality [15]. Islamic rulings on transgender women HIV was higher in transgender female sex workers com- and sex work are embedded in the legal structure, a dual pared to transgender women who did not engage in sex system including criminal and Shariah law (Islamic law work, 27.3% and 14.7% respectively [5]. pertaining to Muslims only) which affects the law itself Furthermore, Transgender women often are at risk or and regulation of that law by the police and relevant have a high burden of health issues other than HIV such authorities. as mental health issues and substance misuse [6], as well The Syariah (Malaysian spelling of Shariah) Criminal as pervasive societal discrimination which can create a Offences Federal Territories Act specifically mentions barrier to accessing health care [7]. This is the case glo- transgender women under Section 28 whereby “any male bally as well as in the Asia-Pacific region in countries person who, in any public place, wears a woman’s attire such as, Malaysia [8]. and poses as a woman for immoral purposes shall be guilty of an offence and shall on conviction be liable to a Transgender women in Malaysia fine not exceeding one thousand ringgit or to imprison- In the Malaysian context, there has been a scarcity of ment for a term not exceeding one year or both” [16]. published research relating to HIV amongst transgender Section 29 of the Act refers to “any person who, con- women, a sensitive issue in the Muslim majority country trary to Islamic Law, acts or behaves in an indecent [9]. However, it has been estimated that the prevalence manner in any public place” is guilty of an offence. The of HIV amongst transgender women in Malaysia is 5.7% Act also refers to sex work which some transgender and it has been suggested that this could be underre- women may be engaged in “any woman who prostitutes ported and underestimated [10], with newer reports sug- herself shall be guilty of an offence” [16]. gesting dramatically higher prevalences in urban areas Added to this is the fact that in 1982 the decision was such as Kuala Lumpur [2]. made by the National Fatwa Council prohibiting sex re- The local term for male to female transgender women assignment surgery under Islamic law, apart from inter- in Malaysia is ‘Mak Nyah’ and earlier estimations sug- sex cases. gested that there were between 10,000–20,000 in the Research conducted amongst the Malaysian lesbian, country with the majority being Malay Muslims [11]. In gay, bisexual and transgender community, including 13 2002, Teh undertook the first large-scale study to assess transgender women, found that participants were separ- HIV/AIDS knowledge amongst transgender women, ately subjected to discrimination by Islamic religious studying 507 ‘Mak Nyah’, finding over 92% received pay- officials and also by health providers with some partici- ment for sex, although only 54% claimed they were sex pants feeling reluctant to access medical services due to workers [12]. Subsequent research involving 15 ‘Mak either being verbally abused or ill-treated by health pro- Nyah’ found that all respondents were aware of HIV/ fessionals [17]. It is worth pointing out that the afore- AIDS but lacked in depth information about the disease mentioned research noted that these health professionals and did not regard ‘HIV/AIDS as a primary concern for were often Muslim and influenced by their own percep- them’, as their main immediate worries centred around tion of transgender women, influenced by religious views financial problems, discrimination and ‘coping as a Mak as well as cultural and politics shifts, which can change Nyah in Muslim society’ [11]. In addition, although con- over time. Furthermore, the cultural, and political cli- doms were carried they were
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