In 2015, Malak was with her colleague Reem in front of Al Hussein university hospital on her way to see her psychiatrist. She noticed the nurses’ stares and whispers mocking her medical situation. “The boy who’s a girl has just arrived,” they said. Malak, who was in her 20s, saw in Al Hussein university hospital a possible solution to her case, one which neither her family nor her community had. But it was the beginning of a journey in which nurses would bully her and doctors would avoid diagnosing her case. In an attempt to answer the ongoing question of “Who am I?”, Malak endured over two years and a half of psychological treatment at the hospital, and had seen three female therapists. Her first therapist had failed her after six months of treatment, at the end of which she asked her whether she smoked cigarettes. This triggered Malak to wonder: “What does my personal behavior have to do with my treatment and diagnosis?” Her second therapist dropped her case without giving any justification. Malak saw her third therapist as a ‘sister’ and ‘friend’, and continued to see her, eventually having her case diagnosed. At a time where the number of individuals with gender identity disorder (GID) has increased worldwide, this case mustn’t be left behind closed doors or go unmentioned under the pretext of taboo, religion or society. In Egypt, official numbers reveal that 31 individuals have had their cases presented before the sex reassignment committee of the country’s Doctor’s Syndicate. Many have been diagnosed with Gender Identity Disorder (GID), which is now referred to as gender dysphoria. That is a small number that does not reflect a reality where many resort to private hospitals to undergo sex reassignment surgery in secret, or opt not to discuss their issues fearing the reaction of those around them.

Malak’s story

In mid-October 2017, in an official report issued by Al Hussein university hospital, Malak was diagnosed with GID. The report stated: “The medical examination has proven that he identifies himself psychologically as a female. Thorough examinations have shown that the aspects pertaining to thinking and orientation are more inclined towards the feminine side than the masculine side which applies to all personality aspects.” The diagnosis elaborated, “This person is mentally capable and doesn’t suffer from any physiological or psychological illness that could prevent him from accepting himself. Meticulous examinations proved he doesn’t show any indication of a deterioration in the cognitive functions.” “He succeeded in perfectly embodying a female self,” the report added. “He doesn’t exhibit any homosexual tendencies or desires.” The report concluded: “After sufficient psychological treatment and its failure, and considering his psychological and physiological state, a sex reassignment surgery is the most medically appropriate solution”. Malak told Raseef22 that after she obtained her medical report, she approached the doctors’ syndicate to initiate the process of sex reassignment surgery on the government’s expense. However, for five months, she was unable to even submit her examination results and medical file to the syndicate, and the reason of delay remains unknown. Malak became desperate – she looks like a woman on the outside but has a male organ and an ID bearing the name Abdulrahman. Eventually, in March 2018, the syndicate accepted her medical file, but placed her on a waiting list. Malak like several others who are seeking a sex transition and hold medical reports issued by Al Hussein university hospital stating that they have GID are still on the sex reassignment committee’s waiting list. This led her to question why such a small number of cases required five years of waiting for sex reassignment surgery. Malak couldn’t bear waiting any longer, and had the surgery in a private hospital in Cairo, spending out of her own finances. Malak sees herself as the luckiest amongst the 31 individuals who, to date, didn’t have the chance to have the sex reassignment surgery at a public hospital. The importance of presenting the case to the sex reassignment committee lies in two things, the first is to have the operation covered by the government, and the second is to facilitate the process of gender change on official documents. Today, Malak walks the streets of Cairo as a woman but with an ID bearing the name of Abdulrahman. She also carries on her the diagnosis document issued by Al Hussein hospital so that she can fend off a daily question posed by police and security at public institutions she has to visit: “How do you walk with a male ID and a female body?” According to Malak, gender change on official documents had been easy until 2015 owing to the regular meetings of the sex reassignment committee that had previously permitted such surgeries to well-publicized cases like Sandi and Mohamad Allam. However, as the committee no longer convenes, changing Malak’s gender on official documents has become impossible. Commenting on this complicated situation, the Egyptian MP Margaret Azar, a member of the Human Rights Committee, said that the legislature didn’t receive any complaints from transgenders who have been unable to change their IDs despite having their sex reassignment surgeries done. Ms. Azar told Raseef22 that once they meet, listen to and examine their demands, only then, and if these justifications are persuasive, these requests will be discussed and passed on to the concerned authorities in order to facilitate the process.

Legal challenges

Atef Abu al-Enein, a lawyer and human rights activist, told Raseef22 that there is no law in Egypt that regulates sex reassignment surgery. According to him, the process is subject to the judgment of the doctors’ syndicate committee established by decree no. 238 on September 5, 2003. The sex reassignment committee consists of seven members, including a professor in genetics, an andrologist, a psychiatrist and a member of Egypt’s Dar al-Iftaa, the body that issues Islamic legal edicts, and whose role is to decide on the Islamic legality of the process. Abu al-Enein told Raseef22 that the sex reassignment committee had stopped convening after the Dar al-Iftaa member, Muhammad Wissam Khedr, stopped attending its meetings in late 2014, because he objected to having his name in the committee. GID had been considered a purely medical issue and had been permitted by Muhammad Tantawi, the former Grand Imam of al-Azhar, the center of Islamic learning in Cairo. Abu al-Enein said the committee had partially halted its work in early 2015, but continued to approve sex reassignment surgeries. Khedr, however, filed an objection given that the permits were provided without his approval, prompting a complete halt in the committee’s work in late 2017. Abu al-Enein said Khedr’s absence was not “a personal choice, but rather the Azhar and the Iftaa institutions completely oppose sex reassignment surgeries.” These actions took place despite the fact that Article 53 of the Egyptian Constitution criminalizes discrimination against individuals, and Article 11 guarantees medical care to all individuals through existing health facilities.

Helena’s story

Helena has endured physical and psychological violence, locked for six months in a mental institution after declaring, to her parents, that she would no longer accept being identified as a male. Helena’s story begins with three individuals raiding her home, handcuffing and severely beating her whenever she tried to resist. Helena was then sedated and taken to a distant location, so that she would retract her demand of becoming a woman. A day later, Helena, who is in her 20s as well, regained consciousness only to find herself in an unknown location next to people showing signs of beating and torture. Her request to speak with a member of her family was denied, and when she asked to speak with the person running the facility, she was yelled at: “You will stay with us for a while, sit still.” Helena later learned from the people there that she was in a mental institution. After six months there, Helena was released and later found out that she was held in an unlicensed facility which her parents chose to put her in hoping that she would retract her wish to change her sex. Helena, a medical student, couldn’t specify when she started experiencing GID, but says that, for years, her feelings indicated that she was a female. She couldn’t tolerate socializing with men and preferred playing with girls, particularly her sister. She used to wear make-up and her sisters’ dresses. After years of battling with herself to get an answer for “Who am I?”, and research online, she discovered GID and found out that it can be treated in Egypt. But this was not the end of her ordeal but its beginning. While continuously attempting to get a treatment, she found out how difficult it is to have the operation in Egypt due to the deadlocked meetings of the sex reassignment committee. It would be difficult to obtain a report diagnosing her with GID, and having the operation in a private hospital was too expensive for her.

The necessity of a social dialogue

Reda al-Danbouki, a lawyer, human rights activist and the executive director of the Women's Center for Guidance and Legal Awareness, said that transgender individuals in Egypt face several problems, and that a societal dialogue ought to take place to discuss the issue. Al-Danbouki told Raseef22 that transgenders endure the worst violations and are subjected to discrimination from all groups in society, highlighting the persecution of transgenders from both sexes. Despite that, their suffering is perceived to be minor, and it does not receive the attention of the media that it deserves nor the attention of human rights defenders. On the contrary, media practitioners address this subject in their shows in a demeaning manner. He pointed to the many ridiculing epithets directed at transgenders on the streets, such as a colloquial expression that literally means “you boy girl,” and the high suicide and school drop-out rate among them. If they continue their education, they won’t be able to secure a job because most institutions refuse having them among their staff. Al-Danbouki added that there is no census on the number of transgenders in Egypt. According to the doctors’ syndicate, between 2013 and 2017, 31 cases were presented to the sex reassignment committee, 19 of whom are still under consideration. Al-Danbouki also emphasized the fear in some parents of their children coming out due to the associated stigma. Al-Danbouki said that the Women's Center for Guidance and Legal Awareness focuses on the transgenders file and offers them training sessions on their legal rights. The center also provides psychological support and assists them in living and integrating in society. The anti-discrimination against transgenders project of the center has issued recommendations on medical conduct with transgenders. These recommendations consist of establishing a specialized hospital, and providing training for doctors and medical staff, in addition to the activation and inclusion of special curricula pertaining to transgender issues in medical faculties. The recommendations also include facilitating obtaining documents from the doctors’ syndicate, and the creation of specialized psychiatric departments capable of dealing with transgender issues, in addition to providing necessary treatment and hormones on the government’s expense. These recommendations addressed the confidentiality of their personal data and the necessity to include the transgenders file in the medical honor code. The anti-discrimination against transgenders project has issued other recommendations regarding dealing with social stigma: the inclusion of transgenders in television and cinema and showcasing it in a realistic manner without censorship, updating academic curricula to cover their issues during various academic stages, the use of activities, art and other means to highlight this issue, in addition to the provision of work opportunities. As for the official and legal handling of transgenders issues, the anti-discrimination against transgenders project has recommended the issuance of a legislative order that protects them from discrimination, violations and inequality, their inclusion in the government’s official narrative, particularly in media and academic programs, ending religious oversight of sex reassignment surgeries and the creation of effective mechanisms for complaints. The project has also recommended the necessity of their inclusion in social security and health insurance programs, as well as having their medical needs covered by the government. The project has also addressed the need to draft a code of conduct for handling transgenders by government officials, to create an entity that protects them from discrimination, and to also adhere to international recommendations provided to Egypt regarding this matter, as well as learning from the experiences of other countries.