Suspended Citizens: Inside the Challenges with Accessing Legal Gender Recognition and Gender Affirming Health Care for Trans people in Egypt.

By Mariam Chahine 

The civil rights of people in modern civil states, such as the right to life, freedom, name recognition, nationality, and legal personality, are recognized in universal human rights treaties and guaranteed by the constitutions of most of the world’s nations. But these “obvious” human rights are not for all individuals. On the ground, many individuals struggle to obtain those rights/privileges, the real value of which is not felt by most individuals living their daily lives. Those cards and papers with shiny official seals allow humans to attend university, work, book a ticket, pass through police ambushes, open a bank account, or rent or buy a property. Those cards and papers that fold negligently and hastily into bags, jacket pockets, and drawers appear to some as Willy Wonka’s golden tickets to the chocolate factory! [1].. about trans people and their suffering with existence, recognition, and integration we are speaking.

Who Are Trans People?

The sex of an individual is usually determined by determining the genitals as soon as birth, and the individual is given their name and is therefore expected to play the social role accordingly. But some individuals’ lives don’t go that smoothly. Some people have “gender dysphoria,” feeling that their mental identity/social type is incompatible with their biological body. Trans people suffer from gender discomfort, which varies in severity from person to person. Some trans people may seek to undergo gender-affirming health care, including hormonal therapy and gender reassignment surgery, to reconcile their gender identity with their biological bodies. However, these steps usually entail many legal and procedural obstacles, not to mention social stigma, discrimination, and threats to trans people, whether by the State or by unofficial citizens.

Legal Status of Trans People in Egypt

From time to time, surgeries are heard of here and there to change sex. In 1988, the case of Sally, an Al-Azhar medical student who underwent gender reassignment surgery, received a great deal of media attention and ignited a social and religious discussion about transgender people. However, there is no law in Egyptian legislation regulating the rules and procedures for changing sex or even recognizing the existence of “trans people.” This legislative vacuum seems deliberate, as recognition of “trans people” will necessarily be followed by their claim to civil rights under the international human rights instruments ratified by the Egyptian State, in addition to the requirements of the Egyptian Constitution and all national legislation. But if the Egyptian State does not recognize trans people and there is no law governing the rules and procedures for gender reassignment operations and, after that, changing official papers, then who conducts such operations, and on what legal or official basis do those processes take place even if rare?

Sex Correction Committee

As of early 2003, there were no laws or administrative rules governing the procedures for gender reassignment surgeries, which means that if they were conducted, they were carried out per the instructions and directives of some officials in different government agencies whose decisions may vary according to their different views and cultural, religious and social backgrounds in those processes. However, in September 2003, the Minister of Health issued the Code of Ethics, which for the first time in the Egyptian State’s policies and laws, addressed the issue of gender-affirming health care for transgender people. Article 43 of the Code stipulates that a committee for sex correction shall be established, and “the procedure shall take place after a hormonal analysis, examination of the chromosome map, and after the period of accompanying psychiatric and hormonal treatment for at least two years.”

However, the category addressed by the Sex Correction Committee is, in fact, “intersex” people, individuals born with sex characteristics that don’t fit the binary two sexes, and not transgender people. The Committee would only allow people who have a “biological need,” i.e., intersex people, to undergo the process and not people who wish to undergo the process for “psychological reasons only,” i.e., trans people. However, the Committee occasionally allows trans people to submit their applications without prior promises of acceptance or deadlines for responding.

Medical Syndicate’s Code of Ethics explicitly stipulates a ban on gender-affirming health care for trans people, using the term “sex correction” to indicate the treatments allowed only for intersex people; this is to not clash with official religious institutions that recognize intersex people only and not transgender people. Dr. Ali Juma al-Mufti, a former State member, stated: 

“It is only in the case of intersex in which there is both a male and female body organ (for example, the reproductive organs). It is forbidden by sharia law the use of behavior or sexual preferences for the identification of (the mixed intersex person) except only in two cases: First: When unable to determine based on the physical signs mentioned, and second: If they have neither a male nor a female reproductive organ, aside from these cases, they may not be placed into either sex based on their inner preference or what can be expressed today by the gut feeling that their soul belongs to the opposite sex”. 

Thus, we can conclude the opinion of the religious authorities on the majority of the requests for “sex change” sent to it by the Sex Correction Committee according to the men of religion’s understanding of the problem of gender transition. While welcomingly approving intersex people – Khuntha in Islamic jurisprudential terms – it strictly rejects trans people with “gender dysphoria” without biological disorders.

Committee Formation

The Committee consists of two psychiatrists, a professor of genetics, a professor of andrology, and the chairman of the Committee from the Medical Syndicate. The Committee is subject to direct supervision by the Syndicate’s ethics committee. A non-medical member from Dar Alifta -one of Egypt’s religious authorities- is also on the Committee. 

Since the Committee’s establishment, there has been no official data on the number of applications submitted to it nor on the number of applications approved or rejected, and there are, in fact, no specific procedures requiring the Committee to approve or reject within a specified period. But in September 2021, Dr. Osama Abdel-Hay, Chairman of the Committee, said: 

“There are 14 cases referred to the Fatwa Committee in Al-Azhar for the fatwa opinion on each case, as well as 27 case files awaiting presentation to the Committee after the patients have completed their papers. In addition, since 2013, only one case has received medical approval from the Committee, and Al-Azhar’s fatwa opinion has been issued for sex correction surgery. Still, the Syndicate has not yet followed up on the approval if the case has already been performed.”

These applications were for trans people with a gender identity disorder, while earlier stating that from 2014 to 2017, the Committee had approved 87 “intersex” applications. That is, within eight years, only one application for “gender dysphoria” had been granted, while 87 applications for “intersex” had been approved in only three years.

Therefore, trans people may wait for an indefinite period of up to years without the Committee’s determination of their requests for gender reassignment surgery, whether by acceptance or rejection. During this period of suffering, societal persecution, psychological stress, and gender disturbance, trans people are forced to choose between two decisions: The first is to wait for the Committee’s decision to hold on to hope for several years, knowing that the decision may ultimately come with rejection, risking the loss of many years of their age in suffering and pain. The second is to start undergoing hormonal therapy without waiting for the Committee’s decision, which might make it difficult to formally complete the procedures for changing their papers.

What is questionable about the “Sex Correction Committee” is that there is no explanation for why there is a need for a representative of Dar Alifta in that specialized medical Committee or the need for sending the requests of trans people to Dar Alifta with the opinions of the Medical Committee attached… Is that a religious guardianship? And why is there no representative of the Egyptian Church for Christian trans people?

Although the regulation did not specify which religious agency intersected with the work of the Sex Correction Committee, the Medical Syndicate nevertheless preferred to add a member of Dar AlIfta or send the applications of trans people to it to avoid any potential clash or attack by religious institutions against the work of the Committee. The fact that Dar AlIfta is involved in the work of that Committee raises many questions about the guardianship of religious institutions over the work of a specialized scientific committee of the Medical Syndicate and on a medical matter to which the knowledge of the workers of the Dar Alifta don’t extend at all.

Problems with Surgeries in Egypt

The human need for healthcare and the availability and accessibility of medical services are inherent parts of basic human rights. Still, since the Egyptian State does not recognize the existence of trans people, it does not allow them to access gender-affirming health care. The Sex Correction Committee’s approval is required for such procedures. According to the Code of Ethics, doctors are prohibited from performing “Sex Change” operations. A doctor who carries out sex change operations without the Committee’s consent may be subjected to disciplinary matters, which may go as far as getting them removed from the Syndicate. Only “Sex Correction” operated is allowed after proving that the person undergoing it is intersex. 

These circumstances compel many trans people to resort to some doctors who perform such operations in secrecy, especially with requests often getting rejected or with their fate remaining forever suspended. These operations are usually carried out in private clinics, in underground locations, without the minimum necessary medical care, which can sometimes cause the death of trans people. One of the most prominent incidents is the death of the transman Ahmed Faris, known as Ezz, in Egypt in August 2021.

However, the problems of gender reassignment surgeries in Egypt are not only limited to the risk of death if they are carried out outside the formal framework, but trans people also suffer because of insufficient availability of doctors specializing in such surgeries in Egypt. The Chairman of the Sex Correction Committee stated that:

 “The committee does not have the exclusive number of doctors who can perform transgender processes, in addition to the fact that the theoretical study is too short and limited, as this type of operations requires very precise and advanced specializations, not in the general specializations that are taught in medical schools.”

This means that trans people are taking a risk with operations that may not be under minimum medical standards compared to the success of such operations in other countries.

Economic Cost of Gender Reassignment Operations

Trans people suffer not only from societal persecution and lack of State recognition of their identity but also from the economic aspect. Even assuming that they have succeeded in obtaining approval from the Sex Correction Committee, this does not mean that the State ensures that the procedure is performed or even that trans people are directed to certain doctors trusted by the Committee. Trans people must search for a doctor familiar with this operation while obtaining all official approvals. The average cost of this operation until 2021 was approximately thirty thousand Egyptian pounds, without including healthcare and necessary medicine. This amount has certainly now doubled, especially after the Egyptian pound inflated at the end of 2022 and the beginning of 2023. This is certainly a significant burden for middle-class or poor trans people. The State or NGOs do not seem interested in supporting the financial cost of such operations as they do in supporting other operations, believing that gender reassignment is part of cosmetic procedures. Gender discomfort for trans people is a nightmare that may sometimes cause someone to commit suicide due to psychological and social distress caused by delays in the procedure.

If trans people do not obtain the necessary formal approvals, primarily the approval of the Sex Correction Committee, the situation worsens. Trans persons are usually forced to obtain medical services from the backdoor and sometimes face fraud or are placed in the traps of dealers and middlemen, as well as to pay double the cost of official operations in governmental or private hospitals as the price for conducting the operation without official approvals. Unfortunately, these factors make the necessary gender-affirming health care for trans people only accessible to those who can afford them socially.

Problems with Changing Papers (Legal Gender Recognition) 

According to the ideal scenario, trans people must apply to their civil registry and await the reply of the Committee for the Change of Registration; article 46 of the Civil Status Law No. 143 of 1994 stipulates that the Committee for the Change of Registration shall be constituted to regulate the status of the person who has lost the registration or to correct the data, etc. However, it does not provide for sex marker change cases but remains the competent Committee to receive trans applications. 

If the application is approved, the procedure for changing the official papers shall be carried out. The work ethic of the government bureaucracy in the Committee for Change of Registration is not different from other committees. Depending on a person’s social and class status, the strength of connections, and influence, the time required to finalize official papers can vary. Sometimes the application’s fate can even depend on these factors, either by acceptance or rejection! Even though this is the nature of matters in the ordinary governmental processes, the Committee will rule on a fateful decision, such as changing the official papers of trans people and thus giving them the kiss of life to continue to “live life” as Egyptian citizens, which cannot be impaired by the social and economic forces, especially among the poor and middle-class trans people.

But this ideal scenario is rare. Trans people usually wait for the approval of the Sex Correction Committee for several years, and in desperation to wait for the Committee’s reply or refusal, some trans people begin hormonal therapy and then apply for a change of registration before the civil registry. However, the decisions of the Committee of Registration Change do not follow a unified public policy in all of Egypt’s governorates but rather change from one civil registry to another according to the socio-religious attitudes of its employees. Thus, if trans people are lucky, they can submit their applications in a civil registry that sympathizes with their cases. Otherwise, the fate of their applications is rejection.

In the case of rejection, trans people can only litigate before the administrative court to oblige the State to change the papers, but the problem with that step is that if the case is dismissed, the person has no right to sue for the same reason again. In other words, trans people have no guaranteed way to obtain legal gender recognition from the State, even after they undergo gender-affirming health care. Therefore, trans people are exposed to a situation that can be called civil death! Their papers don’t reflect their gender identity; it is no longer easy for them to deal with society, government processes them, and they are not getting new papers!

We can imagine the State of trans people in this pending situation and them being obliged to explain their status. At the same time, they need to obtain work, rent a residence, or need to hire a lawyer to complete certain legal proceedings, claim their right to inheritance, or even renew their IDs or passports. In the eyes of the Egyptian State, they are citizens suspended until further notice!

  [1] Form the novel “Charlie and the Chocolate Factory” 1964 by the English author Roald Dahl.