Transgender issues in the Middle East

While there is much debate about the rights of women in the Middle East  and the rights of gay and lesbian people have also begun to attract some attention, consideration of transgender rights is long overdue. 

In a region where gender segregation is widespread and dress codes are sometimes enforced by law, the problems of transgender people are especially acute. When so much of the social structure is based around a clear-cut distinction between male and female, anything that obscures the distinction is viewed as a problem and sometimes even as a threat to the established order.

This is the fourth in a series of "long read" articles which aim to give a broad but detailed overview of transgender issues in the Middle East. 

The complete series can also be downloaded as a printable 23-page PDF.

4. Struggles for recognition 

Amal, a Kuwaiti woman, had been registered at birth as a boy, though she always felt and acted like a female. As a child, she loved to try on her mother's dresses and shoes. Her family, thinking this was just a phase, humoured her at first and even agreed to call her by a girl's name. But it wasn’t a phase, and in 2001, at the age of 26, Amal travelled to Thailand for sex reassignment surgery.

Returning to Kuwait, however, she was suspended from her secretarial job with the education ministry, pending an official determination of her sex. Still in limbo three years later, she went to court. Citing the 1988 ruling by Egypt’s Grand Mufti, her lawyer argued that Amal’s case was “a case of illness, not a case of switching gender or as they call it in Kuwait a third-sex case". 

The court accepted this and declared Amal to be a woman. But her life as a legally-recognised woman did not last long. The Kuwaiti government, encouraged by a group of Islamist lawyers and Amal’s father (who complained that the case had brought shame on his family), launched an appeal and the lower court’s decision was reversed. In 2006, Amal made a final appeal to Kuwait’s highest court – the Court of Cassation – but without success

Zainab Rabie was raised in Bahrain as a girl, though as medical reports later revealed, she had "obscure external genitals” and a preponderance of male chromosomes. As a child, she preferred playing with boys but nobody realised there was anything physically wrong. When her periods failed to start at puberty doctors suggested contraceptive pills might kick-start the menstrual cycle.

It was only at the age of 25, when she got married, that the truth began to emerge. "I actually found out on my wedding night and my husband took me to several hospitals where they ran checks on me and declared that I was actually a man," Zainab – now known as Hussain – told the Gulf Daily News. The couple separated shortly afterwards.

Following mastectomy, Hussain travelled to Thailand to complete reassignment surgery and the Bahraini government helpfully provided 5,000 dinars (just over $13,000) to cover the cost. Hussain then applied through Bahrain’s court system to be officially recognised as a man under his new name and in 2008 his application was granted


Lawyer Fawzia Janahi: dozens of new cases

For Hussain’s lawyer, Fawzia Janahi, media reports of the case had an extraordinary effect: she received more than 100 enquiries and eventually took on 50 new transgender cases in the Gulf region.

In 2014, Bahrain’s High Administrative Court gave permission for two more trans men – again represented by Janahi – to begin the process of obtaining legal recognition. The procedure established by the court was that a medical examiner would record “their current situation” before they travelled abroad for surgery. 

"They will then be brought back to the examiner, who will inspect them for a last time before their medical documents are submitted to the court,” Janahi 
said. "The medical examiner does not choose if the two women will undergo a sex change operation, he only examines them and records their medical situation."

Bahrain, a repressive monarchy, spends vast amounts of money employing PR firms to polish its image in the west and the trans cases in 2014 bolstered the picture of a progressive, liberal country (despite the fact the nine men had been jailed just a few years earlier for cross-dressing at a New Year party). Welcoming the court’s decision, a Bahrain government propagandist in Washington tweeted “May Bahrain always continue to modernise and pioneer in the region, in all spheres”, while Global Health MENA hailed it as a “win” for the Middle East. 

But such cases actually do little more than illustrate the region’s profound confusion. Transgender is primarily a social issue – a question of how societies should respond to gender non-conformity – but the preoccupation with sexual anatomy in the Arab countries leads to it becoming over-medicalised. That in turn leads Ms Janahi, the lawyer, to portray her clients as defective beings. “These people are seriously ill whether they have a birth defect or [are] homosexual and they need to be treated," she told GDN Online, calling on the Gulf states to establish “at least one health facility specialised in sex change cases and even homosexuality cases”.

Legal confusion

Preoccupation with sexual anatomy also results in reassignment surgery becoming the sole criterion for changing a person’s sex in the official records –  which is a completely wrong-headed approach. Firstly, many trans people look for acceptance without undergoing surgery, and shouldn’t be forced into doing so. Secondly, withholding legal recognition until surgery has been completed creates numerous problems while people are transitioning – a process that can take several years. In the Gulf states a transitioning person runs the obvious risks of arrest for cross-dressing or homosexuality, plus complications from the gender-separation rules. 

In Bahrain, for example, trans man Hussain complained that while he was transitioning gyms refused to admit him either as a man or a woman, and he was suspended from work on the grounds that female employees “would be ashamed” if he joined them again as a man. Hussain also said he faced problems whenever he used the airport because he looked like a man but his passport still said he was a woman.

Trans people resort to the courts in the absence of national laws setting out administrative procedures for changing a person’s sex in the official records. This results in different courts making different decisions – decisions which often seem to be based on the personal opinion of an individual judge.

In Lebanon recently, a trans man diagnosed with gender dysphoria won his case in the appeals court after it had been rejected by a lower court. In the lower court’s opinion, changing the records to match his gender identity would have been inconsistent with what the court called his “reality”.

However, the appeals court came to the opposite conclusion: the judge ruled that he had the right to change his gender and also has a right to surgery since this would allow his “reality” and gender identity to match. A person's right "to receive the necessary treatment for any physical and psychological illness is a fundamental and natural one," the ruling said.

"What is important in the decision is that it was stated as a matter of fundamental rights. It was not stated as a matter of humanitarian policy or for clemency purposes," Beirut lawyer Youmna Makhlouf told Reuters.

This particular ruling was also significant in that it came from the appeals court, creating a legal precedent which can be cited in future cases. But while it’s certainly a step forward, it’s still no substitute for a consistent, government-organised recognition system, as LGBT activist Tarek Zeidan explained: 

“This is one individual judge and one individual ruling. It doesn't mean that there is legislation to make it legal, it doesn't mean it is across the board, it just means that now it is slightly more likely, and that other judges can feel empowered by this and that it could become more and more of the norm.”

De-medicalising gender 

Countries outside the Middle East have a variety of approaches. In Britain, for instance, sexual anatomy is ignored and the main requirement is a diagnosis of gender dysphoria by a professional working in the field. Applicants must also provide evidence that they have lived in their “acquired gender” for at least two years. Producing all the necessary documentation is a complicated business and processing applications can take a long time.

Britain's exclusion of anatomical issues from the requirements was a step forward but it also raised questions about why gender dysphoria had to be included. Why not de-medicalise the process entirely and let people to assert whichever sex they felt more comfortable with?

The first country to adopt this radical idea was Argentina which introduced a Gender Identity Law in 2012 allowing people to have their sex changed in official records without government approval and without any medical requirements. The law stated:

“In no case will it be necessary to prove that a surgical procedure for total or partial genital reassignment, hormonal therapies or any other psychological or medical treatment has taken place.”

Since then, Ireland, Malta, Denmark and Colombia have followed suit and introduced self-declaration systems. In Ireland, all it requires is a legally-notarised statement using these words:

“I do solemnly and sincerely declare that I 
(i) have a settled and solemn intention to live in the preferred gender of male/female (delete as appropriate) for the rest of my life, 
(ii) understand the consequences of the application, and 
(iii) make this application of my own free will.”

This is now regarded as the gold standard in gender identity law, though activists point out that it still assumes a male/female binary and makes no allowance for people who identify with neither sex. To quote one post in an internet discussion thread

“I myself am transsexual, but I do not live in a reality in which the world is divided into ‘male’ and ‘female’ biology. I identify as neither and do not want to be a man or a woman, nor any conflation of masculinity or femininity.”

Arguments such as this have raised questions about the necessity (or otherwise) of recording people’s sex in official documents. In Britain, for instance, there has been talk of removing it from passports and driving licences.

Swift and simple arrangements for self-declaration probably would not have been possible without moves towards greater equality between the sexes and the outlawing of gender-based discrimination: the less difference there is between the sexes in practical terms, the less it matters whether someone is male or female.

This, of course, is the direct opposite of the situation in much of the Middle East where strict gender divisions are not only still considered necessary but are actively defended. Viewed from the Middle East, the solution adopted by Argentina, Ireland, Malta, Denmark and Colombia looks suspiciously like allowing people to choose their sex – exactly what Grand Mufti Tantawi warned against in his 1988 fatwa

But it’s not as simple as that. The idea that anyone might change sex on a “mere wish” (to use Tantawi’s phrase) grossly trivialises what it means to be transgendered. Nobody suddenly wakes up in the morning and thinks: “Today, I’m going to change my sex.” To imagine that anyone might do so shows a complete misunderstanding of the feelings caused by gender dysphoria and the stresses of transitioning.

However, the question of gender “self-declaration” is also wrapped up in more fundamental cultural issues. Personal “choice” – often equated with selfishness – is a problematic concept in traditional Arabic-Islamic societies where freedom of the individual tends to be subsumed by the perceived interests of family and the community. This applies particularly in the areas of sex, gender and marriage but in other areas such as career choices too.

Suppressing personal freedoms becomes especially important in societies where inequality and discrimination are institutionalised. The trick here is to convince people that such injustices are simply the natural order – and then get them to accept it. As usual with things that can’t be justified rationally, the easiest way to do this is to claim they were ordained by God. 

Islam is by no means unique in this respect and a 19th-century Christian hymn originally intended for children instructs them to accept their lot:

The rich man in his castle,
The poor man at his gate,
God made them high and lowly,
And ordered their estate.

In Islam, the religious justification for telling transgender people to accept their lot hinges on five words in the Qur’an: min kul shay’ khalaqna zawjayn (“We created all things in pairs”). Extrapolating from this, scholars have concluded that God has assigned a sex – male or female – to everyone, even if it is not immediately apparent from looking at their body. In intersex cases, where the divinely-assigned sex is believed to be hidden, “uncovering” it through surgery is both permissible and religiously desirable. This also reinforces the idea of a clear-cut male/female binary by bringing the intersex person into conformity with established gender “norms”.

However, the insistence that God creates only male or female causes problems for others on the transgender spectrum: for those who identify as gender-neutral and those whose sexual anatomy is clear but conflicts with their gender identity. Sunni Islamic jurisprudence tends to view this as rejection of the sex assigned by God. Underlying that, there also seems to be an assumption that the evidence of anatomy is a more reliable indicator of God’s will than the evidence of psychiatry.

Shia jurisprudence, as practised in Iran, is better able to handle these issues, though the Iranian government’s enthusiasm for reassignment surgery seems more focused on maintaining gender “norms” than helping trans people to live more comfortably. As a side-effect of this, there are also suspicions that Iran is using reassignment surgery to “normalise” the sexual orientation of gay people.

Egypt steps forward and backwards

In Egypt, three decades after the Sally case caused huge controversy, the debate about reassignment surgery continues. Surgery in intersex cases – in religious terms the easiest to accept – has been allowed since 2003. 

In 2013, the Egyptian Medical Syndicate issued a new Code of Ethics, which essentially recognised gender dysphoria as a medical condition – allowing people who had been diagnosed with it to have reassignment surgery in Egypt. Activists welcomed this as an important landmark, but there was a snag: the code also said operations had to be individually approved by a special committee within the medical syndicate.

Ten operations were approved in 2013 and 11 in 2014, but in 2015 the Egyptian Streets website reported that the committee had suspended further approval for dysphoria-related cases because of “misunderstandings” with al-Azhar, Egypt’s foremost religious authority. Al-Azhar was said to have expressed “unease” about surgery in this type of case and its representative had stopped attending the committee’s meetings. Around the same time, al-Azhar university suspended a female teacher after discovering that she had undergone reassignment surgery – surgery which had previously been approved by the medical syndicate’s committee.

One of the more positive developments in Egypt during the last few years is that people with gender dysphoria can now get help free of charge at the government-run Al-Hussein Hospital. This includes both group and one-to-one therapy (see BBC video report).

Interestingly, according to medical sources cited by Egyptian Streets, almost all the reassignment surgery carried out in government hospitals is female-to-male. This may be because trans women are less willing to come forward, which one therapist attributes to fear of being tarred with “the stigma of homosexuality”. 

If so, homophobia in Egypt has created a situation which is the reverse of that in Iran, where more than three-quarters of operations performed by the leading surgeon in the field are reported to have been male-to-female. This may be a reflection of the pressure on gay Iranian men to de-criminalise themselves through sex reassignment surgery.

However, another explanation for the low number of male-to-female operations in Egypt may be a lack of doctors who have the necessary expertise – with the result that those who can afford it often go to Thailand for surgery. Among trans people in Egypt, confidence in the medical profession is also pretty low. The Egyptian Streets article continues:

Dr Abdel-Rassoul [a urology consultant] maintains confidence in the surgical expertise available in Egypt but acknowledges that horror stories such as the male organ dropping off “can happen”.

He is more concerned by the refusal of most the medical profession in Egypt to accept GID [gender dysphoria] as a medical condition and considers this one of the biggest obstacles to improving treatment for GID patients. He says this is because “you meet people who are more religious than scientific even within the medical community.” Therefore “they keep away from issues that are controversial.”

This problem also extends to psychiatric services, where most psychiatrists in Egypt will do everything they can to change their patients’ minds on gender reassignment, according to Dr Bahary [of Al-Hussein Hospital]. Methods used include putting patients on anti-depressants and anti-psychotic drugs. Failing this, there’s the possibility of hospitalisation and electroconvulsive therapy for the patient. 

They also often enlist the support of local religious leaders to apply pressure and some advise their patients to “isolate themselves in a religious place and go into a deep, deep relationship with God”.

Meanwhile, during the last couple of years, trans people – and trans women in particular – have become caught up in the Sisi regime’s crackdown on homosexuality. Although trans women and effeminate gay men tend to gather socially in the same sort of places and may be indistinguishable in the eyes of the public and the authorities, there are important differences between them: homosexuality is about sexual orientation, while transgender is about gender identity.

According to one report in mid-2015, more than 150 trans people had been arrested since the campaign began. Many of these cases have been documented by LGBT researcher Scott Long and the Egyptian news website, Mada Masr. (Gay sex, incidentally, is not actually illegal in Egypt but the police get around that by charging them with the vague crime of “debauchery”.)

Egypt's targeting of trans women and effeminate men seems related to anxieties about masculinity, Long told Global Post:

“It may be that … the people who are in charge have a conception of what men should be that is shaped by the military experience and is not only very heterosexual but also macho. There’s also a sense that youth in general have gone astray and that long-haired revolutionaries are part of a continuum with people who have forgotten how to behave in a manly way.”

Shielding the Gulf from trans people

In the Gulf states, another way of protecting Arab masculinity is to keep transgender foreigners out.

Jen Janice was refused entry to the UAE

Jen Janice, a trans woman working for a multinational company in the Netherlands, decided to stop off in the UAE on her way back from a business trip, in order to visit friends there.

Arriving at Dubai airport, she joined the queue for passport checks. "When it was finally my turn, the customs official studied my passport,” she said. “He then called for help from [a] colleague." Although Janice – originally from Singapore – was living as a woman, her passport showed her as male because she had not had reassignment surgery. The Emirati officials took her out of the queue and into a separate room. She continued:

"Another man joined them and together they started asking all sorts of questions. What I wanted to do in their country and why I looked the way I do? One of the officials just could not understand why I am a man but look like a woman …

“When I asked if I could call one of my friends, they reacted rigidly that that was absolutely not possible. They also asked me why I wanted to be a woman. They were very intimidating. On top of that, it was very humiliating that more and more customs officials came into the room just to have a look at me. They all started laughing/giggling.”

At this point it dawned on her that she was not going to be allowed into the country.

“I was told officially that I would have to leave the country immediately. I felt dismayed and could have easily cried. My dignity was at stake. No reason was given as to why I had to leave.”

Keeping out the occasional traveller is one thing, but the Gulf states employ millions of expatriate workers – and who knows how many of them might be secretly transgendered? In 2013 the trans panic reached new heights when Arab News reported a plan to exclude transgender workers from the GCC countries (Bahrain, Kuwait, Oman, Saudi Arabia, the UAE and Qatar):

The Kuwait Ministry of Health has proposed tightening genetic tests for immigrant workers in order to prevent transgender migrants from entering the GCC job market.

Tawfiq Khojah, director-general of the Executive Office at the GCC Health Council, said, “The health checklist for migrant workers now contains a mandatory examination to determine gender.” 

These constrictions are necessary to preserve Islamic principles, he added ... 

Youssef Mendkar, director of the Public Health Department at the Kuwait Ministry of Health, confirmed that the proposal aims to prevent transgender migrants from working in GCC countries.

Another report quoted Mendkar as saying that the screening process for expatriates might also be used to “detect” any who were homosexual. “We will take stricter measures that will help us detect gays who will be then barred from entering Kuwait or any of the GCC member states,” he said.

News of the screening plan provoked a furious reaction from activists and rights organisations, and also from a few GCC officials. Amid this furore Kuwait – which had put forward the plan – backed off, saying it was “a mere proposal”. But it also emerged that the Kuwaitis had not been proposing something totally new; they were seeking to extend what was an existing practice in some GCC countries – and make it mandatory for all of them. As one of the officials proposing the scheme explained, more than two million expatriate workers had already been submitted to gender tests during the previous year.

Among those critical of the plan was Fawzia Janahi, the Bahraini lawyer who had made her reputation supporting transgender clients in the Gulf. Speaking to GDN Online, she suggested issuing trans people (though not gay people) with a special document that would allow them to travel:

"Homosexuality is allowed in Europe but in [the] Gulf is not acceptable. Kuwait should differentiate between people who are homosexual and transgender, as in the latter case they can get a medical report from concerned authorities that allows them to travel freely."

Ms Janahi’s views about excluding gay people from the Gulf may be objectionable but at least she deserves credit for knowing there is a difference between homosexuality and transgender – which is more than can be said for many others in the region.

  • This concludes the transgender series … for now. I’m hoping to return to it in future blog posts looking in more detail at the lives of trans people in the region today. If you would like to get in touch about it send me an email or contact me through Facebook.