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 third 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.

3. Making the transition

Sayyid Muhammad Abdullah was a 19-year-old medical student at al-Azhar university in Egypt. In 1982, complaining of extreme depression, he sought help from a psychologist who concluded that he was suffering from al-khunutha al-nafsiya (literally, “psychological hermaphroditism) – a condition which nowadays would be called gender dysphoria.

After treating him unsuccessfully for three years the psychologist decided the best course of action would be male-to-female sex reassignment surgery. A second opinion from another psychologist concurred with this and Sayyid was referred to a surgeon.

After a year being treated with hormones and experimenting with dressing as a woman, he consented to the operation and unwittingly triggered one of the biggest public controversies in Egypt during the 1980s.

The main cause of this furore was that before the operation Sayyid, in physical terms, was indisputably male. Had there been doubt about his biological sex, the religious issues involved would have been a lot simpler.

In previous centuries Islamic scholars had devoted much thought to the question of khunthas – people of indeterminate sex. They had concluded that God created everyone male or female, and that a khuntha must be a male or a female whose true sex is hidden. In order to apply the gender rules of Islamic society it was therefore desirable to “uncover” a khuntha’s hidden sex, and in modern times reassignment surgery began to be viewed as one religiously-permissible way of doing so.

Although there was clearly a mismatch between Sayyid’s male body and his female gender identity, he was not a khuntha in the familiar sense and the concept of gender dysphoria proved difficult for many people to accept.. 

Regardless of that, the operation went ahead and Sayyid re-emerged as Sally, with a newly-constructed urinary orifice and vagina. But problems began when she tried to return to al-Azhar for her final exams, since the university’s medical faculty was gender-segregated. The dean of the faculty refused to re-admit her to the male section and also refused to transfer her to the female section – at which point the story surfaced in the Egyptian press.

As far as al-Azhar was concerned, Sally was still a male, but a male whose body had been “mutilated” by the operation. Al-Azhar duly reported Sally’s surgeon to the Doctors’ Syndicate and the Public Prosecutor, accusing him of “inflicting permanent disease” on a patient. 

The Doctors’ Syndicate – a body dominated at the time by Islamists – decided the operation had been an assault on the principles, values, ethics and religion of Egyptian society, and duly struck the surgeon off its register. It also imposed a fine of LE300 (about $90) on the anaesthetist who had helped the surgeon.

Sally’s case also re-ignited old Islamic debates about “necessity” versus “choice”. While operating on someone with indeterminate genitals could be considered necessary in order to uncover their “hidden” sex, Sally’s dysphoria raised the question of whether her gender was a matter of choice – in which case her operation could be deemed as interference in what God had created. 

Such views are still very prevalent in the Middle East today. For example, in the Lebanese survey mentioned earlier, a small majority (55%) thought operations were acceptable "if there is a medical or biological (hormonal) condition" but the vast majority (83%) considered them unacceptable if "based on one's personal choice". (That survey, incidentally, used a representative sample reflecting the views of Lebanese Christians as well as Sunni and Shia Muslims.)

It should be noted in passing, however, that this insistence on surgery being “necessary” in order not to conflict with the Creator’s intentions tends to be applied selectively. Cosmetic surgery is very popular in Lebanon, for instance, and one of the most frequently-performed but unnecessary operations in Egypt is female genital cutting.

Where gender dysphoria is concerned, when people claim to be a woman trapped in a man’s body (or vice versa) it’s almost impossible for others to understand exactly how they feel. One reaction is to say they should try harder to control their feelings; another is to suspect they are making the whole thing up, possibly for some devious purpose.

In Sally’s case, al-Azhar basically accused her of lying. According to a professor of physiology at the university, she was motivated not by strong feelings about her gender identity but by “sodomistic inclinations”. If true, this would have meant she had subjected herself to three years of psychotherapy, a year of hormone treatment and a major operation simply in order to have sex with men (an activity which in any case is not specifically forbidden under Egyptian law). 

Evidence of her “sodomistic inclinations” was not forthcoming, though the authorities did look for it. At one point during the furore Sally was anally examined on behalf of the Public Prosecutor but her anus showed no signs of having been “recently” or “continuously” sodomised.

The Grand Mufti intervenes

The conflict over Sally was eventually defused, though not entirely resolved, by a fatwa from Egypt’s highest religious scholar, Muhammad Tantawi, the government-appointed Grand Mufti. Six months later, the Public Prosecutor dropped charges against the surgeon and stated that Sally’s operation had been carried out according to the rules. After a further delay of almost a year, Sally finally received a certificate officially recognising her as a woman. Al-Azhar continued to hold out against readmitting her to the medical faculty but a court eventually granted her the right to take her final exams at a different university.

Grand Mufti Tantawi: his fatwa defused the situation but avoided key questions

Tantawi’s fatwa is an important document which has often been cited since in connection with reassignment surgery. It has been translated into English by Jakob Skovgaard-Petersen, a Danish academic who at the time was researching the relationship between religious authorities and the Egyptian state. (The discussion of the Sally affair above is based mainly on Skovgaard-Petersen’s account of events.)

The mufti’s fatwa gives clear authorisation of reassignment operations … subject to certain conditions. In a key paragraph it says Islamic sources “grant permission to perform an operation changing a man into a woman, or vice versa, as long as a reliable doctor concludes that there are innate causes in the body itself, indicating a buried [matmura] female nature, or a covered [maghmura] male nature, because the operation will disclose these buried or covered organs, thereby curing a corporal disease which cannot be removed, except by this operation”.

The fatwa adds that while it is “permissible to perform the operation in order to reveal what was hidden of male or female organs” when “a trustworthy doctor advises it”, it is “not permissible to do it at the mere wish to change sex from woman to man, or vice versa”.

This did not directly address the hotly-disputed question of whether Sally’s surgery had been based on a “wish to change sex”, or whether, in Islamic doctrine, gender identity can be allowed to overrule anatomy as the true indicator of a person’s “hidden” sex. Tantawi’s reference to “curing a corporal disease” suggests not, though his talk of “innate causes” may hint at other possibilities.

Centuries earlier, in discussions about the mukhannathun, scholars had attempted to distinguish between innate (khilqi) effeminacy and effeminacy that was affected or acquired (takallufi). Unlike “affected” effeminacy, “innate” effeminacy was considered excusable so long as the person worked to overcome it, and Tantawi alludes to this in his fatwa:

“One who is like this out of a natural disposition must be ordered to abandon it, even if this can only be achieved step by step. Should he then not comply, but persist [in his manners], the blame shall include him, as well – especially if he displays any pleasure in doing so.”

In citing this Tantawi seems to be suggesting that Sally’s feminine feelings were innate and that she was right to seek treatment. However, the scholarly rulings could also be understood as pointing to a non-surgical kind of treatment – one that aimed to suppress her feminine feelings rather than altering her body to accommodate them.

In terms of tolerance for sexual diversity, the “innate-versus-affected” argument is something of a double-edged sword. When applied to homosexuality, for instance, it allows sympathy for those considered innately gay (so long as they try to be “cured”) but allows no scope for broader acceptance and provides an excuse for punishing those considered to be wilfully gay. Similarly, it can become a tool for bringing transgender people into compliance with the established male/female binary.

Saudi Arabia: letting God decide

In 2004, Arab News reported that five Saudi sisters aged between 19 and 38 were undergoing operations to become men at King Abdul Aziz University Hospital in Jeddah. Three of the operations had already been completed when the story became public. 

According to the surgeon in charge, they were not the first operations of this kind to be carried out in the highly-conservative kingdom and, unlike Sally’s case in Egypt, news them caused no great controversy. However, in the Saudi cases there was no suggestion of gender dysphoria and the surgeon, Dr Yasser Jamal, clearly aware of the religious issues at stake, was reluctant even to describe the operations as “reassignment”, insisting instead on talking about “gender correction” and restoring patients to their “original sex”.

Echoing Tantawi’s fatwa years earlier, he told Arab News:

“We are taking the person back to his or her original sex according to the intensive tests that are done, but we will not operate on people that are actually men or women to change them to the opposite sex just because they want to.

“If the [chromosome] test shows xx, the person is female, and if it is xy they are male. Also, tests are performed on the testicular or ovarian tissue as well as the patients’ internal organs – for example, does this person have a uterus? Then that is a strong indication that she is a female.”

Repeating the Islamic doctrine that every person is born male or female, Dr Jamal said the only problem that might cause sex “misinterpretation” was a defect in the external organs. He also suggested this misinterpretation might be the fault of “unqualified midwives assisting at home births”.

Misinterpreting the sex of new-born infants has been identified as a particular problem in Saudi Arabia, giving rise to increased demand for treatment as the children grow up. Citing research published in the Saudi Medical Journal, Scott Siraj al-Haqq Kugle writes that the single most important reason for misinterpretation was found to be the rather crude method used for determining an infant’s sex – by assessing whether or not the child had an “adequate penis”:

If a doctor examines an infant and determines, through cursory observation and stereotyped notions of genital normalcy, that the child does not have an “adequate penis” then the prevailing practice is to discount the child as male and declare the gender to be female. Female gender category is the default position if penile adequacy is missing or suspect, regardless of the possibility of the child growing up feeling “male" inside, having residual testes, or going through puberty with secondary sexual changes that might resemble male patterns.

This practice of registering infants as female if they did not appear to be a fully-developed male could easily result, later on, in internal conflicts with their assigned sex, for example when bodily changes occurred during puberty.

The researchers’ findings were published in 1995 and it is possible that practices have improved since then. Even so, infants whose sex was misinterpreted at the time would now be in their early twenties and, very probably, feeling the effects today. It may also be relevant to note that this research was carried out in the Eastern Province, a marginalised area which is home to many of the kingdom’s Shia minority, and it is unclear to what extent the practices described were applicable in other parts of the country.

Although correction/reassignment operations do take place in Saudi Arabia, the researchers found doctors reluctant to perform surgery on patients “later in life” (presumably after puberty). Kugle continues:

The Saudi doctors cite the “complexity of surgical operations involved, the associated psychosocial problems to patients and parents of a late gender reassignment, and the cosmetically and functionally unsatisfactory nature of the resulting small penis” to justify the policy of discouraging sex-change operations.

In their view, society’s judgment is more valid than that of the patient: the change will be traumatic to family and community and the surgery will only produce a penis that society judges as small, inadequate, and fake. They do not value the patients’ own sense of oppression at being forced by family and community to live in the wrong gender, or the patients’ sense of liberation and tranquillity should they gain a body that accords with their internal gender identity, even if the genital structures are not large or functional by patriarchal standards.

This approach can be criticised as not sufficiently patient-centred but the Saudi doctors may have a point. Reassignment operations are irrevocable: once done, they cannot be undone. So it’s important to weigh up the pros and cons and consider what effect an operation will have on the patient’s quality of life. In the conservative societies of the Middle East the benefits are certainly debatable. An operation may not improve the chances of the trans person being accepted by their family or community and, as we shall see, may also give rise to new problems. 

In 2014 the Saudi health ministry announced that all reassignment operations in the kingdom, in both private and public hospitals, would require the ministry’s approval in advance. While this would undoubtedly ensure that they complied with religious criteria, the edict seems to have been intended mainly to avoid family disputes. On the plus side, this would mean that patients could be sure of acceptance by their families after the operation. On the minus side, it would prevent patients from having surgery if their families disapproved.

The woman who changed the ayatollah's mind

Before the Islamic revolution of 1979, only a small number of reassignment/correction operations had been carried out in Iran but since then they have become increasingly common. A BBC television programme in 2005 
reported that the leading Iranian surgeon in the field, Bahram Mirjalali, had done 320 operations in Iran during the previous twelve years. There have been repeated claims in the media that Iran now performs more such operations than any country other than Thailand.

This became possible mainly because Iran is a predominantly Shia country and the Ja’fari school of Islamic jurisprudence is less resistant than the Sunni schools to innovative rule-making. Another important factor, though, was a series of direct contacts between Ayatollah Khomeini, Iran’s first Supreme Leader, and a trans woman called Maryam Khatoon Molkara.

There are records of operations being performed on intersex persons in Iran (those born with a reproductive or sexual anatomy which was not clearly male or female) as long ago as the 1930s. By the early 1970s this had been extended and at least two Iranian hospitals – one in Tehran and another in Shiraz – were also operating on non-intersex patients (i.e. those with gender dysphoria). In 1976, however, the Medical Association of Iran imposed restrictions, having decided that non-intersex operations were unethical. This early history is discussed (along with much else) by Afsaneh Najmabad, a Harvard University professor, in her book, Professing Selves: Transsexuality and Same-Sex Desire in Contemporary Iran.

Ayatollah Khomeini, then living in exile, had adopted a similar position: he saw no religious objection to surgery so long as it was confined to intersex cases. For Maryam Molkara, this offered no solution. Like Sally in Egypt, she was physically male but felt that she was really a woman and in 1975 she wrote the first of a series of letters to Khomeini, hoping to change his mind. In an interview with Guardian reporter Robert Tait she explained:

"I told him I had always had the feeling that I was a woman. I wrote that my mother had told me that even at the age of two, she had found me in front of the mirror putting chalk on my face the same way a woman puts on her make-up. He wrote back, saying that I should follow the Islamic obligations of being a woman."

The ayatollah’s reply was of little help and, following the revolution that saw Khomeini returned from exile and installed in power, Molkara was fired from her job, sent to a psychiatric institution and forced to have male hormone injections. Nevertheless, she continued lobbying senior religious figures, but to no avail.

Finally, she decided to confront Khomeini in person:

Donning a man's suit, she walked to Khomeini's heavily protected compound in north Tehran, carrying a copy of the Qur'an. In an additional piece of religious symbolism, she had tied shoes around her neck. The gesture –redolent of Ashura, the Shia festival depicting the heroism of the third imam Hossein – was meant to convey that she was seeking shelter.

At first, it failed to provide her with any. As she approached the compound, armed security guards pounced and began beating her. They stopped only when Khomeini's brother, Hassan Pasandide, witnessing the scene, intervened and took Molkara into his house.

Molkara was eventually admitted into the Supreme Leader’s presence – and duly fainted. Tait’s report continues:

"I was taken into a corridor," Molkara says. "I could hear Khomeini raising his voice. He was blaming those around him, asking how they could mistreat someone who had come for shelter. He was saying, 'This person is God's servant.' He had three of his trusted doctors in the room and he asked what the difference was between hermaphrodites and transsexuals. What are these 'difficult-neutrals', he was saying. Khomeini didn't know about the condition until then. From that moment on, everything changed for me."

Molkara left the Khomeini compound with a letter addressed to the chief prosecutor and the head of medical ethics giving religious authorisation for her – and, by implication, others like her – to surgically change their gender. It was the fatwa she had sought.

Maryam Molkara with a previous passport showing her as a man

However, Khomeini’s decision left many unanswered questions regarding the practicalities – questions which Iranian religious scholars (most notably Hojatulislam Muhammad Kariminia) have since explored in great detail: for example, whether married people need permission from their spouse before a reassignment operation, whether a marriage is automatically annulled afterwards and what should happen to the wife’s dowry money or inheritance rights if she becomes a man. A philanthropic organisation known as the Imam Khomeini Charity Foundation also provides financial help towards the cost of surgery.

Individuals diagnosed as having gender dysphoria can be granted a certificate which allows them to cross-dress in public before undergoing surgery. This protects them from arrest for infringing Iran’s gender segregation and dress codes. It also allows them to start hormone treatment.

At first sight these arrangements might look surprisingly enlightened, and to some extent they are – at least in comparison with most of the Arab states – but there are several reasons for concern. One is that people may be pressurised into operations they do not actually want. There are plenty of trans people who simply wish to be accepted as they are. Accepting people as they are, though, is not usually the Iranian way. On transgender issues government policy and social attitudes in Iran are often far apart: official recognition of a change of sex doesn’t mean it will be accepted by society.

“After completing their transition,” a report by Human Rights Watch noted, “many transgender Iranians are advised to maintain discretion about their past.” And Robert Tait, when writing about Maryam Molkara, the trans woman who changed Khomeini’s mind, commented that “two security monitors in her living room attest to her vulnerability in a society still intolerant of sexual unorthodoxy”.

The reality of life for transgender people, according to one Iranian quoted by Human Rights Watch, is that society does not accept what the law allows:

“The problem is not only with the lack of legal protection but with family and culture … Trans Iranians may be legal, but they are treated horribly. They can often not find work and society does not accept them … There are few who are actually able to have surgery and get married, work, and be active citizens in society.”

Iran’s approach to gender dysphoria and sex reassignment has been a welcome development for trans people who want surgery but in the words of Afsaneh Najmabadi, it is “not an unproblematically positive development”: it is one aspect of a system which views any kind of sexual or gender nonconformity as “diseased, abnormal, deviant, and at times criminal”. 

The Iranian government’s relatively sympathetic view of trans people contrasts dramatically with its criminalisation – and severe punishment – of homosexual activity. This creates a powerful incentive for gay people to legalise their position by registering – against their will – as transgender.

In theory there are mechanisms to prevent that happening. People seeking to register as transgender first have to go through several months of psychotherapy, along with hormone and chromosome tests. “The purpose of this process,” Rochelle Terman writes, “is to distinguish and segregate ‘true transsexuals’, for whom same-sex desires are symptomatic of their transsexuality from homosexuals, for whom same-sex desires are symptomatic of moral deviancy, seeking to ‘game the system’.”

The reality, though, is that in Iran the difference between trans and gay is not well understood, even within the medical profession. One gay Iranian 
described his experience to Human Rights Watch:

“I went to a psychiatrist on my own who helped me. At first she said you are a trans person and you can easily change. I told her I am a man and I will not change. I like men but I want to be with men as a man not as a woman. I have no problems with my manhood. I knew I would never do this. Despite this, she never used the word ‘gay’.’ She just called me a ‘weak trans’.”

In 2014 the BBC told of another gay man who had a narrow escape from reassignment surgery:

Psychologists suggested gender reassignment to Soheil, a gay Iranian 21-year-old. Then his family put him under immense pressure to go through with it.

"My father came to visit me in Tehran with two relatives," he says. "They'd had a meeting to decide what to do about me ... They told me: 'You need to either have your gender changed or we will kill you and will not let you live in this family'."

His family kept him at home in the port city of Bandar Abbas and watched him. The day before he was due to have the operation, he managed to escape with the help of some friends. They bought him a plane ticket and he flew to Turkey.

Part four: Struggles for recognition