Gender Identity, Healthcare Access & Risk Reduction among Malaysia's Mak Nyah Community

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.

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By:  Gibson BA1, Brown SE1, Rutledge R1, Wickersham JA1,2, Kamarulzaman A2, Altice FL1,2,3.

• 1 Department of Internal Medicine, Section of Infectious Diseases, AIDS Program , Yale School of Medicine , New Haven , CT , USA.
• 2 Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine , University of Malaya , Kuala Lumpur , Malaysia.
• 3 Division of Epidemiology of Microbial Diseases , Yale School of Public Health , New Haven , CT , USA.
• Glob Public Health. 2016 Jan 29:1-16 

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Effectiveness of Culturally Appropriate Initiative on Drug-Related Harm Reduction for Sex Workers on the Thai/Malaysian Border

Drug use can harm to sex workers. Abstinence intervention, however, may not be appropriate since drug use fosters their career performance. The objective was to develop the culturally appropriate model for sex workers participation on drug demand reduction at the Thailand/Malaysian border

This study was a pre-post quasi-experimental design. Tripartite participation was used to develop the model aiming to reduce harm regarding drug use. The study carried out during June 2010-May 2011. Data were collected from 150 key informant interviews, 56 focus group discussions, 22 participant observations in various situations, and numerous related materials. Descriptive statistics, survival analysis and 95% confidence interval were utilized for quantitative data. Qualitative data were analyzed by content analysis.

Drug related harm reduction was evaluated at two-week time along implementation period of 12 months. 89.5% of all sessions introduced could decrease drug related harm. Of all sex workers participated in the study, intended to treat analysis showed 86.9% success rate (95% CI; 77.1, 96.7). Of these, 32.6% became abstinence, 39.1% reduced most of drug related harm. 13.0% reduced partial drug related harm either less frequency, less quantity, less concentration, decrease types of drugs/switch to safe drugs or safer method of administration. 2.2% was infancy stage, which needed further support.

Key success of the model was tripartite participation. With active leaders and strong support, sex workers were continually motivated to reduce harm regarding drug use.

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By: Nunun W, Kanato M.

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The Syndemic of HIV, HIV-Related Risk & Multiple Co-Morbidities among Women Who Use Drugs in Malaysia: Important Targets for Intervention

Substance use and HIV are syndemic public health problems in Malaysia. Harm reduction efforts to reduce HIV transmission have primarily focused on men with substance use disorders.

To explore HIV risk behaviors, substance use, and social factors associated with poor health outcomes among women who use drugs in Malaysia.

A cross-sectional survey of 103 drug-using women in Kuala Lumpur, Malaysia were recruited to assess their medical, psychiatric and social comorbidity as well as their engagement in nationally recommended HIV testing and monitoring activities.

One-third reported having ever injected drugs, with most (68.2%) having recently shared injection paraphernalia. Sex work (44.7%) and infrequent condom use (42.4%) were common as was underlying psychiatric illness and physical and sexual violence during childhood and adulthood. Most women (62.1%) had unstable living situations and suffered from an unmet need for social support and health services. HIV prevalence was high (20%) with only two thirds of women eligible for antiretroviral therapy having received it. Suboptimal HIV testing and/or monitoring was positively associated with interpersonal violence and negatively associated with drug injection.

Women who use drugs in Malaysia demonstrate considerable medical, psychiatric and social co-morbidity, which negatively contributes to optimal and crucial engagement in HIV treatment-as-prevention strategies. Mental health and social support may be key targets for future public health interventions aimed at drug-using women in Malaysia.

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By: Loeliger KB1, Marcus R2, Wickersham JA3, Pillai V4, Kamarulzaman A3, Altice FL5.

• 1Yale University School of Medicine, New Haven, CT, USA; Yale University School of Public Health, New Haven, CT, USA.
• 2Yale University School of Medicine, New Haven, CT, USA.
• 3Yale University School of Medicine, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
• 4Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
• 5Yale University School of Medicine, New Haven, CT, USA; Yale University School of Public Health, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Electronic address: frederick.altice@yale.edu. 

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