title: Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community.
abstract: Transgender women (TGW) face compounded levels of stigma and discrimination, resulting in multiple health risks and poor health outcomes. TGW identities are erased by forcing them into binary sex categories in society or treating them as men who have sex with men (MSM). In Malaysia, where both civil and religious law criminalise them for their identities, many TGW turn to sex work with inconsistent prevention methods, which increases their health risks. This qualitative study aims to understand how the identities of TGW sex workers shapes their healthcare utilisation patterns and harm reduction behaviours. In-depth, semi-structured interviews were conducted with 21 male-to-female transgender (mak nyah) sex workers in Malaysia. Interviews were transcribed, translated into English, and analysed using thematic coding. Results suggest that TGW identity is shaped at an early age followed by incorporation into the mak nyah community where TGW were assisted in gender transition and introduced to sex work. While healthcare was accessible, it failed to address the multiple healthcare needs of TGW. Pressure for gender-affirming health procedures and fear of HIV and sexually transmitted infection screening led to potentially hazardous health behaviours. These findings have implications for developing holistic, culturally sensitive prevention and healthcare services for TGW.
authors.affiliation: a Department of Internal Medicine, Section of Infectious Diseases, AIDS Program , Yale School of Medicine , New Haven , CT , USA.
authors.forename: Britton A
authors.initials: BA
authors.lastname: Gibson
authors.affiliation: a Department of Internal Medicine, Section of Infectious Diseases, AIDS Program , Yale School of Medicine , New Haven , CT , USA.
authors.forename: Shan-Estelle
authors.initials: SE
authors.lastname: Brown
authors.affiliation: a Department of Internal Medicine, Section of Infectious Diseases, AIDS Program , Yale School of Medicine , New Haven , CT , USA.
authors.forename: Ronnye
authors.initials: R
authors.lastname: Rutledge
authors.affiliation: a Department of Internal Medicine, Section of Infectious Diseases, AIDS Program , Yale School of Medicine , New Haven , CT , USA.|b Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine , University of Malaya , Kuala Lumpur , Malaysia.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Wickersham
authors.affiliation: b Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine , University of Malaya , Kuala Lumpur , Malaysia.
authors.forename: Adeeba
authors.initials: A
authors.lastname: Kamarulzaman
authors.affiliation: a Department of Internal Medicine, Section of Infectious Diseases, AIDS Program , Yale School of Medicine , New Haven , CT , USA.|b Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine , University of Malaya , Kuala Lumpur , Malaysia.|c Division of Epidemiology of Microbial Diseases , Yale School of Public Health , New Haven , CT , USA.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
mesh_terms: D015492:AIDS Serodiagnosis / Q000706:statistics & numerical data; D000328:Adult; D017280:Condoms / Q000706:statistics & numerical data; D005260:Female; D005783:Gender Identity; D015658:HIV Infections / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D062985:Health Services for Transgender Persons / Q000331:legislation & jurisprudence / Q000600:supply & distribution*; D018451:Homosexuality, Male / Q000523:psychology* / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D007514:Islam; D008296:Malaysia / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D012068:Religion and Medicine; D012071:Religion and Sex; D012307:Risk Factors; D040242:Risk Reduction Behavior; D057830:Gender-Affirming Surgery / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D060386:Sex Workers / Q000523:psychology* / Q000706:statistics & numerical data; D063508:Social Discrimination; D063106:Transgender Persons / Q000145:classification / Q000331:legislation & jurisprudence / Q000523:psychology*; D035862:Vulnerable Populations
keywords: HIV/STI prevention; Transgender women; gender identity; gender-affirming care
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