In 5 Middle East nations, gender-affirming health care is illegal
Transgender people in the Middle East — in particular in Egypt, the U.A.E., Saudi Arabia, Jordan and Oman — have seen their rights dwindle in recent years with the adoption of laws restricting or banning their access to gender-affirming health care and official gender recognition..
Legal repression of trans people in the Middle East is analyzed in this commentary by Nora Noralla, a human rights researcher and consultant who works on a variety of issues, including sexual and bodily freedoms, and the effects of Sharia law on human rights. This essay, modestly edited here, was published last month by The New Arab.
The Middle East has an anti-transgender bills problem
The already marginalised transgender communities of the Middle East have seen their rights dwindle even further in the past several years as an alarming number of Arab Middle Eastern countries have passed laws restricting or banning their access to gender-affirming health care and legal gender recognition.
The result is that transgender people in these countries are pushed into risky underground medical treatments, or compelled to seek asylum in more tolerant countries rather than stay in places where being transgender is, as one Egyptian activist described it, “a death sentence.”
Egypt began cracking down on transgender people nearly 20 years ago: In 2003, the country’s medical syndicate amended its code of ethics and added Article 43, which banned doctors from providing any sex-change treatments.
Such restrictions are often driven by conservative religious narratives and the façade of protecting the values of society – and resisting the West.
“Conservative socio-religious narrative has been labelling transgender identities as Western and a danger to the concept of family,” says Ayouba El-Hamri, regional coordinator of Transat, a regional transgender advocacy group. “These legal changes are a product of those narratives and the moral panic religious figures have been promoting against transgender people.”
According to some interpretations of Sharia, a person who wishes to receive gender-affirming health care must prove that they have a “biological need” to do so. That led to a new term being coined in Arabic to describe the kind of surgeries allowed under Sharia, “sex correction” or “tṣḥīḥ al-ǧns” in Arabic.
This term refers to sex reassignment treatments for individuals with intersex characteristics. In contrast, the phrase “sex change” was used to describe treatments for transgender people.
Under this interpretation of Sharia, “sex changes” were banned and only “sex corrections” were allowed.
In Egypt, Article 43 stipulated that sex-change medical interventions are only allowed after a full chromosome map to ensure that the person has a “biological need” to receive that medical treatment.
That article also mandates that gender-affirming health care will be made available only after receiving approval from a sex reassignment committee.
The committee was established in 2003 to review applications from those who wish to receive gender-affirming health care and included a representative of Al-Azhar – Egypt’s highest religious authority – to ensure that every case is medically compatible with Sharia.
Violation of this rule placed doctors in professional and criminal liability. In several incidents after 2003, doctors’ professional licenses were revoked or suspended and they were criminally prosecuted under Article 244 of Egypt’s penal code for “causing a “permanent disability” to transgender patients.
Medical establishments can also be punished. For example, in 2010, a hospital was shut down by health officials for providing gender-affirming health care for a transgender person.
Other countries in the region followed in Egypt’s footsteps and introduced their ban on sex-change treatment through medical liability laws from 2016 through 2019:
- The UAE‘s law no 04/2016,
- Jordan‘s law no 25/2018, and
- Oman’s law no 75/2019.
The same wording can be found in these laws as in their Egyptian forerunner: Doctors are prohibited from providing any medical treatment that may result in a change in one’s sex, while sex correction is only allowed after receiving medical approval and providing medical evidence that the individual carries intersex characteristics.
The three laws also provided an almost identical definition of what are considered to be illegal “sex changes”.
Similarly, Saudi Arabia, which is ruled primarily by Sharia, has issued several medical directives since 2014 to ensure that only individuals with intersex characteristics have access to gender-related medical intervention. It has established a medical committee to review those cases.Yasser Jamal, the head of the sex correction surgical centre at King Abdulaziz University Hospital, said in an interview with a local newspaper in 2020: “We follow Sharia in our work; thus, sex correction is good because it corrects a wrong, however, sex change is sinful as it turns what is already correct to a wrong.”
Criminal liability for doctors was only one impact of these laws. Access to gender-affirming health care became an impossible task for many transgender people. Those who were privileged enough could travel abroad to receive the care they needed. Turkey, Iran, and Thailand became popular destinations for those who could afford them.
In Egypt, underground medical markets sprang up to take advantage of transgender people’s desperation. Those markets often come with huge risks, as sources of hormones are unknown, and surgeries often take place in ill-equipped home clinics.
In 2021, Ezz El-Din, a 26-year-old transgender man, died after a botched surgery in an underground Egyptian clinic.
Furthermore, legal gender recognition is out of the question, as courts often rely on Sharia to make their judgment on the matter and employ medical opinions to verify whether the person truly has intersex characteristics or not.
In 2019, the UAE’s Federal Supreme Court rejected a gender-affirmation request from three transgender men after finding that they had failed to prove their “biological need” for the treatment they underwent. While Saudi Arabia’s Civil Status Law article 39 allows for a gender marker change only if medical certificates prove the existence of intersex characteristics.
Not receiving legal gender recognition can be a death sentence for transgender people, as it limits their access to health, education, and employment. Throughout the region, transgender people are one of the most vulnerable groups to social and governmental violence, including arrest and prosecution under vague morality laws existing in these countries which criminalise “public decency”, “crossdressing” and “sodomy”.
“The mismatch between their gender identity and their ID papers makes them an easy target for vice police,” says Maryam Chaine, a Cairo-based lawyer.
“I receive different cases where transgender people are just targeted or harassed for who they are. Even in cases where transgender people are the victim of social attacks, the police arrest them instead. In detention, verbal and physical abuse are common and transgender people are especially targeted because of their identity.”
Thus, for many transgender people in the region, seeking asylum or immigration is the only viable solution.
“Being transgender in Egypt or other Middle Eastern countries is a death sentence,” says Salma, an Egyptian transgender activist who now lives in the Netherlands.
“I am not the first or the last person to leave – many of my friends from different countries also left for Europe, and many more will. A drastic change in the region’s policies is needed to allow us to breathe.”
Other nations
The judiciary in several other countries in the region — for example, Bahrain, Syria, and Kuwait — treat transgender issues much as their counterparts do in Egypt, Saudi Arabia, and the UAE, even though they do not have the same anti-sex-change laws.
Those courts’ decisions accept legal gender recognition only for individuals with intersex characteristics, not for transgender people.
Legislative attacks on transgender identities are not a problem that is unique to the Middle East, but they have largely gone unnoticed by national and international human rights groups.
In the future
Human rights actors, lobbyists, policymakers and national foreign governments need to take a more active approach to address present and future anti-transgender bills in the region.
Countries need to be reminded of their international and national obligations towards their transgender populations, since the right to adequate health care is enshrined in those nations’ constitutions and several international treaties to which they are signatories.
Currently, the Egyptian parliament, together with the medical syndicate, is discussing plans for a new medical liability law. One can be hopeful that this new law will remove the discriminatory ban that the current code of ethics has imposed on transgender bodies since 2003.
If so, Egypt would become a leader in reversing the repressive bans that it pioneered almost 20 years ago.
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