Transgender Women in Malaysia: A review of health related issues and challenges

Transgender refers to individuals who perceive their gender differently from their original gender assigned at birth. Transgender women are those who were assigned male gender at birth but expressed themselves as female later on in their life. The numbers of transgender women in Malaysia have been increasing rapidly. Along with this increment, health problems related to this population has grown. Despite this, there is no specific local guideline about the health issues and its management related to this population. Many health professions out there did not know what to expect when dealing with transgender women. Unlike the original male or female, transgender women have their own unique needs as well as health problems related to their lifestyle. Furthermore, some of their health problems are related to the general population, such as Human Immunodeficiency Virus (HIV) infection and sexually transmitted disease (STD). Failure to identify and manage the problems among transgender women will eventually contribute to an increase in cumulative HIV and STD cases in our country. Hence, the aimed of this article was to review current knowledge on transgender women’s health issues and challenges, especially in the context of the local population. This review also emphasizes that healthcare professionals in Malaysia need to have at least a basic knowledge of transgender women’s health issues.

Transgender, Women, Health, Issues, Challenges A Transgender refers to individuals who perceive their gender differently from their original gender assigned at birth. Transgender women are those who were assigned male gender at birth but expressed themselves as female later on in their life. The numbers of transgender women in Malaysia have been increasing rapidly. Along with this increment, health problems related to this population has grown. Despite this, there is no speci ic local guideline about the health issues and its management related to this population. Many health professions out there did not know what to expect when dealing with transgender women. Unlike the original male or female, transgender women have their own unique needs as well as health problems related to their lifestyle. Furthermore, some of their health problems are related to the general population, such as Human Immunode iciency Virus (HIV) infection and sexually transmitted disease (STD). Failure to identify and manage the problems among transgender women will eventually contribute to an increase in cumulative HIV and STD cases in our country. Hence, the aimed of this article was to review current knowledge on transgender women's health issues and challenges, especially in the context of the local population. This review also emphasizes that healthcare professionals in Malaysia need to have at least a basic knowledge of transgender women's health issues.

INTRODUCTION
It was reported that the transgender community is one of the most underserved, highly stigmatized and under represented subgroups in society (Gupta et al., 2016;Reisner et al., 2016;Draman S, 2019). Transgender is an umbrella term that includes individuals whose gender identity differs from their original assigned birth sex, while cisgender refers to the individual whose gender identity or expression aligns with their assigned birth sex (Gupta et al., 2016;Braun et al., 2017;Dinno, 2017). Transgender is further classi ied into 3 main categories include transwomen or transgender women, transmen or transgender men and nonbinary (Gupta et al., 2016;Reisner et al., 2016). Transwomen are assigned with the male gender at birth but with feminine identity and vice versa for transmen, while nonbinary are those who do not identify with either male or female gender categorization (Reisner et al., 2016;Braun et al., 2017;Gibson et al., 2016).
The previous studies showed an increment of the transgender women from 10,000 to 50,000 people from 2001 up until 2016 in Malaysia (Draman and Hashi, 2019). However, based on worldwide estimation, the number would have been between 151, 500-424, 200 transgender women (Vijay et al., 2018). In Malaysia, this population was known as 'Mak nyah' and they are a well-known community in Southeast Asia that exist in Malaysia before the year 1983, with 80% of them dominated by Malay peoples (Draman S, 2019;Gibson et al., 2016). Some of this Mak nyah population can be found in a small and dark alley like a backstreet or known as 'Lorong' at late night (Draman S, 2019). Due to the mismatch between assigned birth sex and gender identity, these transgender women face considerable challenges either in the form of physiological, social or psychological, which in turn can have a negative impact on their quality of life (Nobili et al., 2018).
However, issues related to transgender women in Malaysia continue to be under the radar, especially health-related issues. It is not openly discussed and there is no formal guideline about the management of health-related issues pertaining to transgender women in Malaysia. As a result, healthcare professionals are unable to provide the appropriate medical care whenever they have a transgender woman as their patient. With this in mind, this article aimed to discuss the health-related issues and challenges faced by transgender women in Malaysia in the most comprehensive way. It is hopeful that this article will help healthcare professionals to realise all these issues and deal with transgender women in the best possible way in the future.

Information Sources And Search
An electronic literature search was conducted, including using PubMed and Google Scholar. A total of 32 articles which were from Malaysia and International, were reviewed, with most of the articles chosen only from 2015 up to date and only around 10% of the total articles taken before the year 2015. The search used the following keywords in the title and/or abstract.

Health-Related Issues
Globally, transgender women experience a devastatingly high burden of adverse health outcomes, including a high prevalence of human immunode iciency virus (HIV) infection, sexually transmitted infections (STIs), mental health illness and substance use disorders (Reisner et al., 2016;Vijay et al., 2018;Rich et al., 2018). The rates of mental disorders, interpersonal violence, workplace discrimination, mental abuse, suicide risk, substance abuse, and HIV are highest in this group (Gupta et al., 2016).

Human Immunode iciency Virus (HIV)
Transgender women were among the populations that had been named by the Centres for Disease Control and Prevention as being hardest hit by HIV (Wiewel et al., 2016). A meta-analysis of global studies showed at least 19% of transgender women documented with HIV and in comparison to all adults of reproductive age, transgender women were 50 times more likely to acquire HIV infection (Reisner et al., 2016;Gibson et al., 2016;Rich et al., 2018). Historically, Malaysia's HIV epidemic has been driven by people who inject drugs; however, the trend change due to the harm reduction programmed with the majority of new infections are attributed to sexual transmission, especially man who have sex with men whom transgender was regarded as one of the most-at-risk populations (Wickersham et al., 2017;Parsons et al., 2018;Abdullah F et al., 2019).
In Malaysia, based on the data from Integrated Biological and Behavioural Surveillance studies showed increment from 4.8% -12.4% of transgender women were HIV positive, with higher estimation among those who engaged in sex work (Rutledge et al., 2018). HIV transmission risk in transgender women increases with various exposures such as violence victimization, polysubstance use, depression, frequent alcohol use, multiple partners, lack of knowledge in HIV/AIDS, negative attitude towards HIV/AIDS, transactional sex and history of sex with adults before the age of 18 years (Gibson et al., 2016;Samsul D et al., 2016;Iwamoto et al., 2019). Transactional sex or known as survival sex (sex in exchange for money), had been the main risk of HIV as they are at greater risk for engaging in unprotected receptive anal sex (condomless), which usually motivated by high payment (Parsons et al., 2018;Baral et al., 2013;Shan et al., 2018). Locally, it was estimated about 21000 transgender women engaged in this sex work, with most of them resid-ing in Kuala Lumpur (Gibson et al., 2016;Lim et al., 2017;Colby et al., 2016).
Despite the high prevalence of HIV among these community, they also contributed to low screening levels, most probably due to denial of having the illness (Gibson et al., 2016). HIV prevention, treatment and care should be priorities around the world, but these population experience many barriers to treatment ranging from incorrect pronoun use of their name, judgmental and insensitive statements, unwillingness to provide care, asked to change their appearance or felt they had to present as male to receive proper care, societal stigmatization, a lack of knowledge by the healthcare about transgender needs and the refusal of many national health systems or health insurance providers to cover their care (Gupta et al., 2016;Vijay et al., 2018;Iwamoto et al., 2019).

Sexually Transmitted Diseases
Sexually transmitted disease or known as STD, are diseases that caused by either bacteria, virus or parasites, which spread predominantly by sexual contact including vaginal, anal or oral sex and nonsexual via blood, blood product or from mother to child during pregnancy and childbirth. The diseases include Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Hepatitis B Virus, Human Papilloma Virus and HIV. However, HIV remains the main STD and the most commonly occurred (Zin et al., 2019). The risk of STD increased mainly due to the practice of multiple sexual partners.
In comparison with HIV, bacterial STDs such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) remain particularly understudied in transgender women (Pitasi et al., 2019). A study done among Australian transgender showed that the rates of bacterial STD in transgender women were higher compared to the cisgender heterosexual patients, with the prevalence of Neisseria gonorrhoea has increased over the past decade from 3% to nearly 10% (Callander et al., 2019). A study done among transgender women in Indonesia showed a high prevalence of syphilis and rectal origin STD due to receptive anal sex with a syphilis prevalence of 26.8 % and rectal STD prevalence of 47.0 % (Colby et al., 2016).
This STD can occur either alone or together (coinfection) with other STD, which can be seen in the study done among transgender women in Argentina where the most frequent single infection was HPV (23.8%) and the most frequent co-infection was HBV-HPV-Syphilis (15%) and followed by HBV-HPV infection (13.8%) (Schulman and Erickson-Schroth, 2019). The prevalence of STD among transgender women is increasing with the actual number could still be underreported.

Mental Illnesses
Stigma and discrimination were common in transgender women who contribute to high rates of depression, anxiety, suicidal ideation, substance abuse, and other mental illnesses within this population (Gibson et al., 2016;Valentine and Shipherd, 2018;Hughto et al., 2015). Psychiatric disorder diagnoses were two times more common in the transgender community, with more than threequarters of them having at least one psychiatric disorder (Hanna et al., 2019). In a national study of transgender women in the USA, 41% of participants reported attempting suicide while an Australian national study found that 56% of transgender women had been diagnosed with depression and 38% had been diagnosed with anxiety and the study showed almost equal result with a study done among transgender women in Ontario with 61% diagnosed with depression (Schulman and Erickson-Schroth, 2019;Winter et al., 2016). However, to date, there is no local study to determine the prevalence of mental illness among transgender women and this should be the future focus for the local researcher.
Suicidality, either in the form of suicidal ideation or suicidal attempt and self-harm, is also a major concern among transgender women. It was reported that 25-76% of the transgender women had considered a suicidal attempt (Schulman and Erickson-Schroth, 2019).

Gender Af irmation Treatment and its related issues
Gender af irmation refers to the social process of being recognized or af irmed in one's gender identity, expression, and/or role. World Professional Association of Transgender Health (WPATH) have developed a guideline for the treatment of transgender and nonbinary known as Gender Af irming Treatments (GAT) which include puberty suppression, Cross-sex Hormonal Treatment (CHT), Chest Reconstructive Surgery (CRS) and Gender Af irming Genital Surgeries (GAGSs) (Braun et al., 2017;Nobili et al., 2018). However, this guideline is not applicable in Malaysia as gender af irmation treatment is not locally accepted, mainly due to health issues and the religious background of the local population. Cross-sex hormonal treatment usually being used to achieve the desired masculinization or feminization. Feminizing medications used in transgender women include Oestrogen and Spironolactone, which used to suppress serum testosterone levels and block the androgen action (Gupta et al., 2016;Iwamoto et al., 2019). The majority of feminizing oral hormones used were birth control pills which can be easily purchased at any pharmacy or obtained from friends or prescribed by a physician (Colby et al., 2016).
Feminisation procedures, either by hormonal or surgical procedure, play a dual role in both af irming an individual's gender with their appearance and also helping them to attract more 'customers' (Gibson et al., 2016). Breast enlargement is very important to transgender women because it represents their new gender (Draman S et al., 2018). To get the desired breast, these population usually will take a high dose of exogenous Oestrogen without knowing the complication of the medication (Braun et al., 2017;Iwamoto et al., 2019;Draman S et al., 2018). Several complications of these medications include depression, venous thrombo-embolism, myocardial infarction, stroke, hypertension and reduction in insulin sensitivity which in turn lead to diabetes Mellitus (Iwamoto et al., 2019;Draman S et al., 2018). Hormone-related malignancies in transgender women can also occur due to the prolonged use of these high dose medication, especially breast and prostate cancer (Braun et al., 2017). In Malaysia, it is not the usual practice for physicians to prescribe contraceptive pills to transgender women. However, it is widely available and easily accessible in any private pharmacy around the country. Most of the time, transgender women in Malaysia took the treatment without any proper prescription, and they only come forward to see healthcare professional whenever they have developed a side effect related to the treatment. Hence, healthcare professionals still need to be well equipped with adequate knowledge on all the gender af irmation treatments available and its possible side effects.
Meanwhile, gender-af irming genital surgeries for transgender women include non-genital surgeries such as breast augmentation, liposuction, facial feminization surgery, lipo illing, voice feminization surgery, thyroid cartilage reduction, and gluteal augmentation, as well as genital feminizing surgeries, which include bilateral orchidectomy, penectomy, and neovaginoplasty (Gupta et al., 2016;Draman S, 2019). However, these genital surgeries themselves can increase the risk of malignancy of Human Papilloma Virus -related cancer as well as increase the risk of getting HIV due to the chronic laceration and in lammation postvaginoplasty (Draman S, 2019;Braun et al., 2017). A study showed 80% of transgender women in southeast Asia have a certain type of HPV organism in anal canal, with a higher prevalence among HIV positive compared to HIV negative (Poteat et al., 2018).
In Malaysia, these surgical procedures were only applicable to nonbinary people and not to the transgender population (Draman S, 2019). Most of them need to travel to Thailand and Singapore to get this surgical treatment due to the religious rule, Malaysia's rule, as well as the cost in Malaysia, which is much more expensive compared to Thailand and Singapore (Draman S, 2019;Gibson et al., 2016).

Stigma and Discrimination
Stigma refers to a social process of devaluing a group of people based on an attribute labelled as negative (Poteat et al., 2018). Stigma is a fundamental cause of adverse health in these transgender population as it works by inducing stress and restricting access to health-protective resources. Stigma and discrimination may restrict this population from health-seeking behaviour. This may result in an increased risk of poor health outcomes, including depression, suicide, polysubstance use, as well as HIV (Gupta et al., 2016;Gibson et al., 2016). Even though the government healthcare system is cheap, this population may still avoid going there due to extreme discrimination (Gibson et al., 2016).
Discrimination by healthcare providers can be in the form of poor or unfair treatment of certain groups of patients, being unsupportive of the patient's condition, judgemental, ridiculing and coercing (Gupta et al., 2016;Vijay et al., 2018). A study done among physician in a medical centre in Kuala Lumpur found that Muslim physicians had greater discrimination compared to Hindu physicians. It was also found that physicians from other specialized had a higher level of discrimination compared to the psychiatrist (Vijay et al., 2018). Besides, healthcare providers in Malaysia also had a lack of knowledge on health issues speci ically faced by transgender women, which caused them to neglect many crucial steps in managing transgenderism (Draman S, 2019;Winter et al., 2016). Some transgender women reported that they were reluctant to access health services where they were not sure whether the providers would be familiar with treating transgender women, as well as worried about having to deal with clinic staff that might be transphobic (Sevelius et al., 2014).
According to the inding from the National Transgender Discrimination Survey done in the United States of America, 90.0% of the participant reported experiencing discrimination at work, with 47.0% reporting being ired, not hired, or denied a promotion and 19% reported being refused a home or shelter because they were transgender (Schulman and Erickson-Schroth, 2019;Poteat et al., 2018).
The multiple levels of discrimination faced by these transgender women cause many of them to turn to sex work or transactional sex as their primary source of income (Reisner et al., 2016;Gibson et al., 2016). Studies done in Malaysia showed that more than 80% of them ended up in the sex trade (Draman S et al., 2018). Other than getting discrimination in the health care setting as well as at work, transgender women also faced discrimination at a religious place such as a mosque as some of them were denied access to the mosque (Draman S, 2019).

CONCLUSIONS
Efforts should be made to educate the general public as well as healthcare professionals to reduce the involvement of transgender women in sex trade activities. Transgender women need to be advised about abstinence from having sex with casual partners or having multiple sex partners. Healthcare professional should be well equipped with knowledge on how to manage health issues related to transgender women without stigma and discrimination. Discrimination and stigmatisation from healthcare professionals were merely one of the many reasons why transgender women could not escape the sex trade. Healthcare professionals also need to continuously educate transgender women on common health issues related to them, such as issues related to gender reaf irmation treatments. With all these efforts, it is hopeful that we can reduce the country's health burden related to transgender women, including the number of our HIV patients.

Con lict of Interest
The authors declare that they have no con lict of interest.