“I used to tell my dad I’m a boy… this is the first thing I ever remember”, said Bassem recounting his childhood. “I was an angry child back then, I didn’t understand why I was different”.
Bassem’s skin is smooth, but hair has recently begun sprouting out of his chin. In actuality however, he is older than he looks. He is 24 years old and the new facial hair, which he is delighted about, is the result of hormone therapy recently started. Bassem is transgender. He identifies as a male, but was born female.
Ever since realizing he had Gender Identity Disorder (GID), Bassem has been receiving professional psychiatric support. Since 2011, he has seen three different private psychiatrists on and off, but according to him they were expensive and “kinda useless.”
However, since starting the new course of therapy at the beginning of this year, he has finally started attending regularly. “I didn’t want to come at first” he recalled, given his previous experiences. However much to his surprise and relief, this treatment turned out to be different and in his own words, “amazing!”
The treatment Bassem receives is indeed unique and advanced for a country like Egypt, where most psychiatric professionals are uncomfortable with dealing with transgender patients, often not even willing to acknowledge the existence of GID as a medical condition.
Even more unexpected is that this treatment is neither expensive nor private, but is free and provided by a government hospital. Moreover, it is headed by one of Egypt’s most experienced and leading psychiatrists on transgender therapy, Dr Hashem Bahary.
Stranger still, the hospital in question is not just any government hospital, but Egypt’s foremost Islamic authority Al-Azhar’s Al-Hussein University Hospital.
A HISTORY OF HEALTHCARE FOR TRANSGENDER PATIENTS IN EGYPT
Dr Bahary, who has been working with transgender patients for 25 years, has been at Al-Hussein Hospital for nearly 10 years now. For almost half of his career, gender reassingment operations were prohibited in Egypt. In 2003, they were allowed only for cases of intersex (when an individual has both male and female organs).
Though transgender patients were not allowed to have gender reassignment surgery, allowing them to become transsexual, many were still able to see psychiatrists and some would go abroad for operations.
However, in 2013, in what is considered a major landmark moment for the transgender and transsexual community, the Egyptian Medical Syndicate issued a new Code of Ethics, which essentially recognised GID as a medical condition and permitted transgender patients, who could prove they have GID, to have gender reassignment surgery in Egypt.
According to Article 43 of the Code, patients must get approval for the operation from a committee specially set up within the Syndicate for this purpose. Under this article, applicants are required to have carried out relevant medical and hormonal checks, and must have had a minimum of two years of psychiatry at the end of which they obtain a report from the psychiatrist to confirm they have GID.
NAVIGATING EGYPT’S MEDICAL SYSTEM
Dr Bahary’s department at Al-Hussein Hospital, where he currently has around 20 transgender patients, is unique also in that it is the only place that offers group therapy to complement one-on-one therapy sessions. Once a week, patients come together with Dr Bahary, their own individual therapists and other transgender patients, allowing them to share stories and discuss how to deal with problems they collectively face.
These sessions, introduced last year are proving to be very popular and useful for his patients. According to Bassem, this is “because we all have the same problems and it makes us feel like we’re not alone”.
After the two years of psychotherapy – and when provided with the all-important report from the psychiatrist diagnosing them with GID – patients are then able to apply to the Egyptian Medical Syndicate for the sex reassignment operation. The committee that approves operations consists of five members; two psychiatric specialists, one andrology specialist, one hereditary and chromosomal studies specialist and a member of the Al-Azhar Board.
According to the President of this committee, Dr Osama Abdelhay, Al-Azhar is represented because “it is an ethical committee and this is an ethical issue”. He said that up until recent months, on medical issues “they always respect medical opinion.” He says that, until recently, the committee (which must agree unanimously on each application) “always respects” the diagnosis of the psychiatrist. However, this has become a point of conflict, with Al Azhar recently suspending gender reassignment approvals for GID patients.
Figures provided by the Egyptian Medical Syndicate show that for GID cases, they approved 10 operations in 2013 and 11 in 2014.
Gender reassignment operations for GID patients are possible in Egyptian government hospitals free of charge, such as Cairo University Hospital. Dr Mohammed Abdou Abdel-Rassoul, a urology consultant, who performs surgeries here claims that it is difficult to provide accurate figures for the number of operations that have been performed because “most of the operations are done unofficially…not with approval of the committee”, mainly in private hospitals.
Dr Abdel-Rassoul says however that since he started treating GID patients in November last year, he has been approached by between 8 and 10 GID patients to perform surgery and has performed the first stage for 4 of them (all female to male).
The more complex female to male operations consists of a minimum of 3 stages / operations over at least a year (but likely longer). However, Dr Abdel-Rassoul is not aware of a male to female operation on a GID patient ever happening to date in an Egyptian government hospital, though he does have one such patient awaiting surgery with him. As such, the vast majority of the operations performed on GID patients in government hospitals at least, are likely to be female to male.
One possible reason for this is that there are more transgender people like Bassem, who identify as male, willing to get treatment and to acknowledge they have GID. Certainly in Dr Bahary’s clinic at Al-Hussein Hospital, there is an overwhelming majority of such transgender patients, though there are a few there who identify as a female.
Gehane Helmy, a therapist in Dr Bahary’s team, suggests this is likely to be the case because society is tougher on men perceived as effeminate. Many therefore do not come forward because they “fear the stigma of homosexuality” and what this can bring. In her experience, transgender patients who identify as male “feel more free in discussing this problem.”
Dr Abdel-Rassoul also accepts that there are also fewer doctors willing to perform male to female operations, than the other way round.
“I certainly thought no doctors in Egypt performed male to female operations, or lacked the expertise,” says Nourhan, who is transsexual. Consequently, she decided to travel to Thailand last year for gender reassignment surgery, where the standard of treatment is considered to be much higher than in Egypt. For the same reason, Bassem is also waiting while he saves enough money to go to Thailand for the surgery.
Bassem already has permission from the Egyptian Medical Syndicate for the operation, and although he has completed the two-year requirement of psychiatry, he has found it beneficial enough to continue with it. However he admits that whilst it is easier and of course significantly cheaper to have the surgery in Egypt, “no one wants to have it here” due to concerns over surgical outcomes.
Dr Abdel-Rassoul 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 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.”
RECONCILING WITH RELIGION
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. 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.”
Given the attitudes of the medical community to GID, it is unsurprising then that Al-Azhar is also uncomfortable. The Egyptian Medical Syndicate recently temporarily suspended approvals for GID related operations “to clear misunderstandings with the Al-Azhar side” after its representative expressed unease about GID cases and stopped attending committee meetings to decide on applications, its President Dr Abdelhay told Egyptian Streets.
Though other options to resume the process are being considered – such as a majority decision-making process or even the exclusion of Al-Azhar on the committee – both he and Dr Abdel-Rassoul prefer that the issue be resolved with Al-Azhar, as their presence and approval helps foster acceptance of gender reassignment surgery in such a religious society.
The position of Al-Azhar on GID remains unclear. Dr Bahary insists he has not had problems with the religious side in recent years at Al-Hussein University Hospital. But Al-Azhar University suspended Nourhan, who was teaching there, in May this year after realising she is transsexual – though she had approval from the Syndicate for her operation. Nourhan is awaiting a final decision from the Al-Azhar Sheikh.
STUCK IN THE SYSTEM
Most transgender patients wanting to become transsexual feel that they are left in a state of limbo by the Egyptian medical system. With many already dealing with depression and suicidal thoughts, family estrangement and social exclusion – the medical process often only prolongs their suffering even further.
It is particularly difficult to make progress because, for many, the whole process is unaffordable. For example, the cost of seeing a – normally private psychiatrist – for two years is particularly steep and therefore unviable for many. Even after completing this and gaining the committee’s approval for the operation, concerns over the quality of medical treatment in Egypt means many are determined to go to Thailand or Malaysia for expensive surgery, which most have to save for.
Adding to this, National Identity Cards in Egypt cannot be changed until the successful completion of the operations. This means that for many like Bassem, who are yet to have surgery but have changed their appearance and name and fully identify with their chosen gender, they no longer match their ID. Bassem, who now lives alone and has to provide for himself because of lack of family support, is desperate for work and is keen to go to university to study psychiatry. However this is difficult because for both he is required to show his ID.
Bassem, and others like him just want to get through the process so that they can get on with their lives, like Nourhan. Since her successful gender reassignment, Nourhan is happily and legally married in Egypt to a man and has the option to adopt if she wanted.
However Nourhan is an exception. For both Dr Bahary and Dr Abdel-Rassoul, better education and training of the medical community on GID is the only way to make such success stories more commonplace.
However, according to Dr Bahary, the training programmes he would like to see are unlikely to happen any time soon because “as a priority it is not important right now” for the Egyptian Medical Syndicate. Dr Abdelhay agrees the Syndicate can’t give the issue more attention because, he says, the Syndicate “has a lot of problems” at the moment and is trying “to survive.”
But this means that despite the glimmers of hope in the medical system, Nourhan’s case is likely to remain an exception, and Bassem and other transgender patients like him will remain stuck somewhere in the system, unable to move.