‘I know it’s bad for my health, but I want to be a woman’

Faced with discrimination and a lack of resources, the Kingdom’s transgender community are taking matters into their own hands – often at great risk

Rith Rasy fears the large doses of hormones she takes to maintain her feminine figure could cut her life short. But the happiness she gets from living as a woman, the gender with which she’s identified since she was seven years old, is enough for her to justify continuing to take six tablets each day, without any medical guidance. The regime she follows gives her breasts, thin, hairless arms and a more womanly figure. But it has also makes her prone to mood swings and memory loss and diminishes her sex drive.

Rasy was born with male anatomy but identifies and dresses as a woman. Charlotte Pert

Transgender women, who are born with male anatomy but identify as female, and transgender men are subject to discrimination in Cambodia – from banishment by their families to difficulty finding work.

“To explain all the bullying and discrimination, it would take an hour,” said Rasy, who is a Cambodian Muslim. She said she has been turned away from her mosque, and rejected from jobs based on her gender. She is also dogged by the slur for transgender women, a-khoey.

But one of the other major problems affecting the community, she and local LGBT activists say, is the lack of access to information about how to safely transition to another gender.

In many developed countries, transgender men and women are able to access medical professionals who can advise them about which hormones to take to minimise health risks, or else opt for surgery. But in the Kingdom a combination of discrimination and lack of surgical options means that transgender people have little choice but to resort to dosing themselves with over-the-counter birth control pills.

“What else can I do?” asked Rasy, sitting in a Phnom Penh pagoda complex, wearing evenly ripped blue jeans and black, tight-fitting T-shirt. “I know it’s bad for my health, but I want to be a woman,” Rasy said of the pills she’s taken each day for two years. “There are no places giving information, it’s just word of mouth.”

Rith Rasy faces unknown risks to develop a female body. Charlotte Pert

Tral Pov, a 45-year-old transgender sex worker, also said information about the birth control pills she uses came from a friend. Like Rasy, Pov also experiences negative side effects from the drugs.

“When I use the hormone pills, I get hot inside my body, but I still use it to grow my breasts,” said Pov.

Little research has been done into the long-term side effects of the misuse of birth control and other hormone pills on transgender women, but Dr Vic Salas, a consultant for the Reproductive Health Association of Cambodia (RHAC), is finalising the first-ever study on the health of transgender people in Cambodia, which may be released by the end of the year.

Salas said excessive use of oestrogen – female hormones – increases blood pressure and the risk of stroke, with the level of risk depending largely on whether the person has a pre-existing health condition.

Transgender men who travel to Thailand to surgically remove their breasts at a reputable clinic can expect to pay about $5,500. Rasy would like to travel to Bangkok for full gender reassignment surgery, she said. Anecdotal information tells Rasy the full surgery would cost $10,000 – an amount she never expects to possess. Even travelling there for injections to enlarge her breasts would be cost prohibitive.

Two other transgender men, Pipi and Panha, both 21, who asked their full names not be used, said they take a simpler approach.

“I just bind my breasts,” Pipi, said. The tight garment worn under his shirt flattens his chest in an attempt to make his breasts invisible. Panha does the same. He chuckled as he relayed a story of his younger days, when he and his mother had an ongoing tug-of-war with his breast-binder; his mother would hide it in the house, only for Panha to find and use it again.

Rasy heads off to her job. Charlotte Pert

Some believe that breast-binding increases the possibility of developing cysts, which can progress into tumours, but there is no firm evidence of higher cancer rates among people who bind their breasts.

More immediate side effects from his breast-binder bother Pipi every day though, he said. The undergarment is uncomfortable and, at times, makes it hard for him to breathe.

Other options for them are currently unavailable. Panha, who wants a mastectomy, said he believes doctors in Cambodia could perform the surgery but elect not to on transgender men because it falls outside societal norms.

“I think [doctors] can do it,” Panha said. “But it’s not popular in Cambodia . . . because they do not accept us yet.”

Many doctors in Cambodia can perform mastectomy surgery for cancer patients, Dr Salas said. But none of the activists or health professionals interviewed for this story knew of any who would give double mastectomy surgery and testosterone injections to transgender men.

Rith Rasy gets up at dawn each day and cleans her home before preparing for work. Charlotte Pert

Nuon Sidara, project coordinator of the Cambodian Center for Human Rights’ Sexual Orientation and Gender Identity program, said that doctors who are supportive of transgender people are extremely difficult to find in Cambodia.

Medical professionals in Cambodian hospitals and at NGOs who focus on treating HIV and AIDS have more exposure to transgender women than transgender men, because the virus disproportionately affects them, he said. But only a few in Cambodia offer medical assistance to transgender people beyond that.

“It’s a group no one cares about,” Sidara added.

Horn Bun Virak, a program manager of the Cambodian People with HIV Network, agreed with the assessment yesterday, adding that transgender clients often forego public hospitals, because of disapproving doctors.

“Most of the transgender people [I know] don’t like to go to public hospital, because doctors have spoken to them in a discriminatory way, so they prefer private clinics,” Virak said.

Many rural transgender people move to Thailand, searching for a place with a more accepting atmosphere with wider options for people in gender transition, LGBT activist Collette O’Regan said. Unlike Cambodia, where transgender women are relegated to the beauty and entertainment – including sex work – sectors and transgender men are relatively invisible, transgender people in Thailand work in many different industries.

Although Thailand’s society is comparatively more accepting of transgender people to Cambodia’s, government policy has not supported LGBT people, according to Narupon Duangwises, an anthropologist at Bangkok’s Sirindhorn Anthropology Centre.

“When Thai society transformed by the modernised process during the 1940s-50s, the culture of same-sex eroticism and cross-gender behaviour [were] discriminated [against] due to heteronormative political regime,” Duangwises wrote in an email. “In Cambodia, transgender people see Thai as romantic model of successful trans identity . . . This is very problematic.”

Transgender men and women have existed in Cambodia for generations, according to Dr Salas, who said evidence shows that they were present in the Kingdom 800 years ago, during the Angkorian era.

Writings from Chinese people who visited Cambodia during this time describe transgender women, Salas said. “Transgender people are everywhere,” Salas said. “They are not a Western invention.”

But for now, the ability to safely transition to another gender seems far off for men and women like Rasy. “The mindset of Cambodian people is still to discriminate against transgender people,” she said.

“[But] I want to make myself a woman . . . even if I won’t live for long.”