“It’s called basic biology”
“There are only two sexes, XX and XY”
The above statements are examples of anti-transgender narratives that aim to dehumanize transgender people, using pseudoscience as justification. The architects of those narratives believe that sex and gender are the same, discrediting the work of gender theorists as nothing but a greater conspiracy against the traditional family. To prove their point, “the chromosome trap,” a method that mixes pseudoscience and biology, is used to justify denying transgender rights by focusing on the fact that a person’s chromosomes never change even after transitioning. In the Middle East and North Africa region, “the chromosome trap” became integral to a wave of laws and policies that limit transgender rights.
To understand why this trap plays such a role in the region, one must go back to the 1980s, when gender-affirming healthcare was becoming more accessible and transgender people more visible. In Egypt, Islamic scholars were worried about this “new phenomenon” reaching countries in the region and disturbing the status quo, so they decided to regulate it by issuing fatwas, religious rulings, which labeled transgender people as “mentally ill” individuals who should seek mental treatments rather than gender-affirming surgeries, reserving surgeries for intersex people, who are “biologically ill” and deserving of undergoing the surgeries. While these fatwas may seem outdated today, they reflect the medical standards on transgender identities at the time, when international medical professionals were still debating whether being transgender is a mental illness and whether conversion therapy was a suitable treatment for transgender people.
Egypt was the first country to codify such religious opinions into medical policy in 2003, when the Ministry of Health issued an updated code of ethics in the medical syndicate, which stipulated that “Doctors are strictly prohibited from performing sex change operations. Sex correction is only permissible after receiving approval from the review committee in the syndicate.” Surgeries will only be conducted after two years of psychiatric evaluation and hormonal treatment and after conducting a full examination of hormones and the chromosomal map of the applicant.”
The policy established a new “sex correction committee” to oversee any treatments that may alter one’s sex and to receive applications from those wishing to undergo those treatments. The committee was also required to host a representative from Dar Al-Ifta, an Islamic governmental body, to ensure that all approved applicants are vetted and meet the criteria—in other words, being intersex—for accessing those treatments.
This policy coined a new term, “sex correction,” to label surgeries permitted for intersex people while using the term “sex change” to label any gender-affirming healthcare for transgender people, which is not permitted.
Thus, this policy coined a new term, “sex correction,” to label surgeries permitted for intersex people while using the term “sex change” to label any gender-affirming healthcare for transgender people, which is not permitted. The chromosomal map became crucial for deciding who can have access to these treatments and to disqualify transgender people from accessing gender-affirming healthcare.
This policy is still used to this day. It was soon replicated in several regional medical liability laws and policies. As of 2023, Oman, the United Arab Emirates, Saudi Arabia, Kuwait, Jordan, and Egypt have “chromosome trap” clauses to deny transgender people from accessing gender-affirming healthcare. Doctors who continue to provide gender-affirming healthcare to transgender people in these countries are subject to both criminal and professional disciplinary actions, as they can lose their medical licenses or be prosecuted for performing illegal medical treatment. In 2010, in Egypt, a hospital was shut down and doctors were referred to the public prosecution on charges of “inflicting bodily harm on a patient” after performing gender-affirming surgeries on trans patients.
More hardship but not impossible
“Accessing gender-affirming healthcare is a herculean task since the sex correction committee hardly receives new applicants and the religious representative often rejects those who are not intersex, citing chromosomes,” says Sarah*, an Egyptian transgender person. “I personally applied to the committee way back in 2013 and never received an official rejection, only a verbal one that Dar Al-Ifta did not accept my chromosome map,” adds Sarah.
Still, these policies and laws largely failed at their main objective of denying transgender people access to gender-affirming healthcare and making conversion therapy the only available option. Instead, they only made life a lot harder for transgender people.
Still, these policies and laws largely failed at their main objective of denying transgender people access to gender-affirming healthcare and making conversion therapy the only available option. Instead, they only made life a lot harder for transgender people. Since official routes are closed, an underground business emerged to fill the void in ill-equipped underground clinics with under-trained doctors who are not capable of providing adequate medical care to transgender people. This underground business did not emerge to assist transgender people but rather to take advantage of them by providing them with the bare minimum of healthcare in exchange for large sums of money. “There is a network of doctors and clinics that transgender people in Egypt know where they can access gender-affirming healthcare. However, it’s not cheap. A private doctor visit that lasts for 15 minutes can set you back 1,000-1,500 EGP [$32 to $48],” says Salma*, a transwoman from Egypt. “Surgeries, on the other hand, are very expensive and can cost anywhere from 10,000 to 40,000 EGP [$330– $1,300] per surgery,” adds Salma.
These prices are out of reach for most trans Egyptians. Egypt is currently undergoing a harsh economic crisis due to poor economic governance. Between March 2022 and January 2023, the currency lost 50 percent of its value and is expected to sink lower. The current minimum wage for government employees stands at 3,500 EGP ($113) per month, while the average wage is 4,480 EGP ($145) per month, ranking it the lowest among MENA countries. Similarly, the inflation rate reached 40 percent in February 2023. The country’s economic prospects do not show signs of improvement in the near future. Egypt’s current external debt stands at approximately $158 billion, and the country is trapped in a vicious debt cycle in which the government mostly borrows new money to pay old debt.
Thus, in this economic environment, even a doctor’s visit seems like an economic burden for the average trans Egyptian, who, on top of suffering under the economic crisis, may also not have access to employment due to their identity. “Access to the job market is very hard for transgender people, including myself. You either are lucky and have high-end skills like English, IT, Graphic Design that can land you a decent paying job online, or you are stuck working minimum wage jobs, where the salary is hardly enough for food,” says Shady*, a transman from Cairo, Egypt. “I personally fit the second category; I work random jobs just to survive. I cannot transition now, as I do not have the financial base to do so and also to be independent of my family, who would definitely oppose my transition,” adds Shady.
Thus, transition in Egypt highly depends on your socioeconomic class. Coming from a more privileged background and having better access to education could mean better access to the gender-affirming healthcare underground business or, even better, being able to travel abroad to get surgeries and treatments done in places with higher quality medical care. Traveling abroad is a more attractive option for those who can afford it, as the quality of the surgeries in Egypt is inadequate, even deadly at times. In 2021, a transman named Ezz died after being prematurely discharged after a botched gender-affirming surgery in a Cairo clinic. Ezz’s family and friends can never receive justice since performing such surgeries is technically illegal, thus the doctors and the hospital ensured having no paper trail connecting them to Ezz’s surgery and death.
A legal limbo
Even if a trans individual is privileged enough to access gender-affirming healthcare and not suffer any permanent damages from it, there is still one final challenge that lies ahead: legal gender recognition. Like other countries in the region, Egypt does not have any laws on providing legal gender recognition for transgender people, leaving transgender people who finished their surgeries in a legal limbo. Article 46 of the Civil Status Code is the legal basis for allowing legal gender recognition for trans-Egyptians. According to the article, any individual who wishes to change their legal records, including transgender people, must apply to the corresponding committee in the governorate where they live. However, this article does not have any direct reference to transgender people, making the process essentially arbitrary: in the absence of explicit reference, it is up to the reviewing officers to decide if being transgender constitutes a valid reason to approve the application. “Since transgender people are not mentioned by name, changing your documents really depends on the mood of the officer reviewing your application or your connections; if you know someone in the office, they can change your papers quite fast,” says Mariam*, a Cairo-based lawyer. “Otherwise, the officers will refer you to the Department of Forensic Medicine, where you will be medically examined to ensure that you did transition correctly, including doing a chromosome map to ensure you did not violate the current medical policy,” adds Mariam.
Even if a trans individual is privileged enough to access gender-affirming healthcare and not suffer any permanent damages from it, there is still one final challenge that lies ahead: legal gender recognition.
While some transgender people manage to have their application accepted through this committee without undergoing further medical examinations, others are not so lucky, and “the chromosome trap” prevents them from accessing legal gender recognition. If the application is rejected, the transgender person must lodge a case at the Administrative Court to request legal gender recognition through a costly, lengthy, and unpredictable judicial process. In 2016, a Cairo Administrative court rejected a legal gender recognition request from a transman using “the chromosome trap” after subjecting him to forensic examinations that found that his pheromone map is that of a biological woman, holding XX chromosomes. The court added that since there are no existing legal frameworks for such matters, it will resort to Islamic Sharia principles stipulated in Article 2 of the Constitution. Since Sharia only permits such surgeries for intersex people, the court rejected the request from the transman.
The use of the “chromosome trap” by courts to deny transgender people their rights is not unique to this court; Egypt has had other similar cases, while other countries in the region, such as Kuwait and the UAE, have also used the same argument to justify blocking transgender people from accessing legal gender recognition, even after they have undergone a complete hormonal and surgical transition.
The way forward
The sentiment that the chromosome trap is outdated and should be abandoned is shared by transgender activists and medical professionals alike. In 2013, doctors on Egypt’s sex correction committee staged a silent protest against Dar Al-Ifta’s representative and approved applications of people who were not intersex but had gender identity disorders, and these included transgender applications. Approving these applications angered Dar Al-Ifta’s representative, who withdrew from the committee and refused to sign off on any applications until the doctors stopped approving transgender applications. This attempt eventually failed, as the committee could not go against the religious establishment. The committee was allowed to continue working after giving the Dar Al-Ifta’s representative veto rights to reject applications using “the chromosome trap.” Despite the failure of this action, it still signals that Egyptian doctors do believe that transgender people have the right to access gender-affirming healthcare.
Having medical opinions on your side can be the first step toward changing the current outdated policies. However, given the strength of the religious establishment in Egypt and its unique position in Egyptian politics, it is essential to build allyships with religious figures who may support the medical opinions. The Egyptian parliament and the medical syndicate are currently discussing a new medical liability law. So far, the draft bill contains no articles banning doctors from providing gender-affirming healthcare to transgender people. Whether this was intentional or just a coincidence is not known at the moment. Still, if the law is passed, private doctors can publicly provide healthcare to transgender people without fearing negative consequences. Since Egypt was the first to implement policies or laws using the “chromosome trap,” abandoning it creates the hope of a domino effect around the region.
Nora Noralla is a Nonresident Fellow at TIMEP focusing on gender and sexuality in the Middle East and North Africa region.