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Transgender Malaysians Forced To Spend Out Of Pocket For Health Care

The Malaysian transgender community is often denied prescriptions for hormone therapy at public health clinics, while most insurance companies don’t cover trans people.

Doctor giving patient an injection. Photo by Thirdman from Pexels.

KUALA LUMPUR, April 20 – The transgender community have trouble accessing health care to meet their specific needs due to inadequate understanding, affordability, and government policy, said activists from the transgender community.

Transgender people have the same basic health care needs as the larger population, including basic physical exams, preventive care, and sexually transmitted disease (STD) testing, said Mitch Yusof, executive director of transgender group SEED. In addition, they also require trans-specific health care services to support their transition.  

“The lack of information and knowledge on transgender issues, needs and concerns create disinformation and misconceptions,” said Mitch at a webinar on April 9 organised by Malaysian Medics International on ‘LGBTQIA+: Discrimination and Stigma. 

“For example, not all transgender individuals seek gender transition. A subset may choose to transition medically and surgically, while some may only choose social transition, acting and living according to their gender identity.”

Access to health care is also hindered by affordability. 

“Most insurance does not cover transgender persons unless they are willing to use their dead name (birth name) and go for a full medical check-up,” said Mitch.

This will involve unwanted scrutiny if they have gone for breast surgery or a hysterectomy or taken hormone replacement therapy (HRT).

“In Malaysia especially, when we talk about trans-specific health care such as hormone replacement therapy, trans-affirming surgery and so on, the transgender community always has to spend out of their pocket,”said Minisha Deepu, a trans activist.

She pointed out that trans-specific health care is free in Sweden, while in certain countries like the United States, insurance will cover its costs. Minisha lamented that insurance companies in Malaysia are not transgender friendly.

“As soon as they know you altered your body, how many years…20 years of premium will be cancelled. You’ll waste how much you have paid overall.

“And this is a reality with the insurance companies. And if you ask them, it’s back to the government. They’ll say it is a government policy and there’s nothing we can do about it because trans-inclusive health care is not an approved health care under the Ministry of Health (MOH).”

Transgender People Unable To Get Prescribed Hormone Therapy 

While not all transgender people want to physically modify their body through hormone therapy or surgery, the World Professional Association for Transgender Health (WPATH) maintains that hormone therapy and surgery are medically necessary for many transgender and transsexual people who have gender dysphoria.

“Gender dysphoria” refers to the discomfort or distress that is caused by a discrepancy between someone’s gender identity and that person’s sex assigned at birth (and their associated gender role and or primary and secondary sex characteristics).

According to WPATH, in general, the goal of hormone therapy is to align the external appearance of the body in line with the experienced gender. For female-to-male trans people, hormone therapy needs to produce masculinising effects, while male-to-female trans people should experience feminising effects from the therapy.

Physicians who provide hormone therapy do not typically receive specific training, nor is there any standard certification for this type of health care.

Throughout the world, hormone therapy for transgender adults is provided by physicians from different specialities, including family medicine, internal medicine, obstetrics and gynaecology, and psychiatry.

In Malaysia, the issue with HRT is that many from the transgender community are only able to obtain over-the-counter hormones, which are meant for post-menopausal women, or unprescribed hormones that they may get from another country, said Minisha.

“I’m also under the unprescribed regime. I try to procure my hormones on my own. But that does not mean you cannot monitor your hormones.”

She said there are health care providers who are amenable to assisting transgender people with monitoring their hormone levels at the clinic.

“So, you can always go and monitor. When we talk about government clinics, there are some doctors who can do it for you. They can test your HIV but they can also help you to test your hormones and so on. Of course, they are not very open about it, we wish they could be open.”

Whenever she asked for a prescription, Minisha said she was always denied. “The answer was always: no, we can’t because if the Ministry of Health (MOH) finds out, we would be in trouble.”

However, she said the health care providers would provide advice on where to get the hormones. “If a doctor or expert in HRT tells you where to get them, I think it’s better than listening to people who are not doctors or are not medical professionals.

“In the hormone world, there’s a phrase they use: your mileage may vary. For example, there are certain hormone injectables or certain oils that I use to mix the hormones together and some people may be allergic to it,” she said.

“We know that an allergic reaction can be lethal and fatal. That’s one of the things you need to be concerned about when we talk about unprescribed hormones.”

Certain hormones may not be safe, she emphasised, adding that some are derived from dangerous synthetic resources.

“Some of the hormones from Thailand, you don’t even know how they manufacture it. You don’t have a lot of details, as opposed to going to a health care provider or doctor who can explain it to you.”

Since she started a hormone forum on Facebook, Minisha has shared her particular experience with a hospital where she does her testing and monitoring. She said this has encouraged others from the transgender community to come forward for testing and monitoring as well.

“Again, it is about overcoming stigma and discrimination. They (transgender people) are afraid of going to certain health spaces. So, this is a big issue within the community — how can we monitor HRT?”

Ultimately, providing trans specific care and clinical management requires a lot of planning, according to Mitch.

“It needs to be tailored individually through sound clinical judgement which is dependent on many factors including compassion, professionalism, respect, knowledge and inclusion.”

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