From silicone and hormone injecting to sex reassignment surgery the precarious roadto becoming female of transgender funeral performers in ho chi minh city, vietnam

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Culture, Health & Sexuality

An International Journal for Research, Intervention and Care

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From silicone and hormone injecting to sex

reassignment surgery: the precarious road

to becoming female of transgender funeral

performers in Ho Chi Minh City, Vietnam

Huong Thu Nguyen

To cite this article: Huong Thu Nguyen (2019) From silicone and hormone injecting to

sex reassignment surgery: the precarious road to becoming female of transgender funeral performers in Ho Chi Minh City, Vietnam, Culture, Health & Sexuality, 21:9, 999-1011, DOI: 10.1080/13691058.2018.1533144

To link to this article: https://doi.org/10.1080/13691058.2018.1533144

Published online: 07 Jan 2019.

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From silicone and hormone injecting to sex reassignment surgery: the precarious road to becoming female of

transgender funeral performers in Ho Chi Minh

City, Vietnam

Huong Thu Nguyen

Department of Anthropology, Vietnam National University of Hanoi, Hanoi, Vietnam

ABSTRACT

This paper examines aspects of feminisation among a group of

transwomen funeral performers in Ho Chi Minh City, Vietnam It

highlights the health hazards faced by members of this vulnerable

social group as the result of the use of non-medically prescribed

hormone therapy, silicone injection and sex reassignment surgery

in the absence of legal provision regulating these practices The

analysis is conducted against the backdrop of overlapping

dis-courses of sex and gender identity, class, medicalisation and

polit-ics, both locally and globally.

ARTICLE HISTORY

Received 14 April 2018 Accepted 3 October 2018

KEYWORDS

Sex reassignment surgery; hormone therapy;

transgender women; gender diversity; Vietnam

Introduction

I will fight for equality for transgender people Everyone wants to be happy, and so do transgender people We all want a good life where we are treated like everyone else and not discriminated against.

These are the words of Vietnamese singer Nguyen Huong Giang to the jury before being crowned winner of the Miss International Queen (transgender) beauty pageant in Pattaya,

Thailand on 9 March 2018 (Vietnamnet2018) She later declared she had no regrets

what-soever about her decision to become a transsexual person (BBC Vietnamese, 21 March

2018) Back in Vietnam the media hailed her success as a source of inspiration for the transgender community.1However, behind this media blitz and the aura of glamour sur-rounding Vietnam’s new international celebrity are the stark realities of the transition pro-cess facing many of her ordinary trans sisters, particularly the transwomen funeral performers of Ho Chi Minh City as revealed in this preliminary qualitative study

From the global to the local: some theoretical perspectives

The concept of ‘transgender’ entered public discourse in the early 1990s in the USA, along with the creation of transgender organisations and the emergence of

CONTACT Huong Thu Nguyen huongethno@gmail.com

2019, VOL 21, NO 9, 999–1011

https://doi.org/10.1080/13691058.2018.1533144

transgender theory (Stryker 2006, 5) According to the Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity, gender identity may be defined as,

each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body

… and other expressions of gender, including dress, speech and mannerisms (The Yogyakarta Principles 2007 , 6)

Persons whose gender identity does not correspond with the sex assigned at birth are transgender persons – a term which, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association, refers to

‘the broad spectrum of individuals who transiently or persistently identify with a gen-der different from their gengen-der at birth’ in contrast to transsexual, which ‘refers to an individual who seeks, or has undergone, a social transition from male to female or female to male’, which ‘involves a physical transition through cross-sex hormone treat-ment and genital surgery’ (American Psychiatric Association2013)

In Vietnam, the concept of transgender seems foreign even to members of the transgender population themselves (UNDP and USAID 2014) As Susan Stryker (2006, 14) remarks, ‘transgender is a category of First World origin currently being exported for Third World consumption’ The concept of sex as being biologically determined and gender as socially constructed are recent imports from the West, widely used by international organisations and local non-governmental organisations (NGOs) to pro-mote equal rights for sexual and gender minorities in Vietnam and elsewhere (Horton, Rydstrøm and Tonini2015; Horton2014; Newton2014)

In Vietnamese culture, various terms have been used to characterise those who

dif-fer from binary gender norms Vernacular expressions such as la:i c ai (effeminate),

b ong (shadow) and d-^ong (spirit medium) are used to describe effeminate men, some

of whom may cross-dress (Nguyen 2016) When transgender women are pointed out

to foreigners and named in English, phrases such as ‘half man half woman’ or ‘half boy half girl’ are used, or terms such as ‘gay’ or ‘gay boys’ (UNDP and USAID2014) In specific ritual contexts the Vietnamese generally tolerate individuals who engage in non-normative sex/gender behaviours without intervening to punish or penalise them (Salemink 2015; Endres 2015; see Hossain 2017 for a parallel account in Bangladesh),

and a few Vietnamese transgender persons choose to refer to themselves as giới thứ

ba (third gender) (Nguyen2016)

There is ample evidence that sexual and gender non-conforming persons are sub-jected to social stigmatisation and discrimination by family and friends, at school, in the community and in the media (Pham 2017; UNDP and USAID 2014) Particularly severe discrimination makes transgender persons the most vulnerable among those gender and sexual minorities (Nguyen2016; Newton2014) The queer visibility shown

by transgender youth often gives rise to unfavourable reactions and even open hostil-ity from others (Nguyen et al 2013) This situation not only reinforces deeply rooted social prejudice, but also makes it even more difficult for members of this group to gain access to jobs and social and health services (Hoang and Oosterhoff2016)

In recent years the National Assembly of Vietnam (NAV) has made a number of legal statements (NAV2017, 2015b, 2014) affecting members of the non-heterosexual,

queer and non-binary population; the most important of these is a Bill to recognise transgender people’s rights and allow those who have undergone reassignment to register under their new sex (NAV2015a) This is considered a landmark development for the transgender community while fulfilling the state’s commitment to protect the civil rights of all its citizenry

In search of a fitting female body

Southern Vietnam during the decade following reunification was a difficult place for transgender people in the wake of a social and cultural campaign to eliminate deca-dent Western influences and life styles left over from the war (Taylor2001) As society

changed with economic openness and rising incomes in the -D ^oi Moı (Reform) era, the

opportunity came for people in Vietnam to purchase products such as motorbikes and cosmetic surgery, and participate in the cinema and cafe culture that in the immediate post-war years had been branded as decadent and bourgeois (Earl 2013; Vann 2012; Leshkowich 2008) As Gordene MacKenzie (1994, 24) points out, since the mid-1950s the human body has become ever ‘more colonised by bipolar gender ideology’ But medicalisation also enables persons who believe they were born ‘in the wrong body’

to strive to have the body that they desire

There is evidence that cosmetic surgery was practised in South Vietnam in the 1960s and the 1970s by private doctors before the fall of Saigon (the former name of

Ho Chi Minh City) (Barsky1970; Kaplan et al 1974) However, there are no reports of sex reassignment surgery in capitalist Saigon before 1975 Regionally, the first male-to-female sex reassignment surgery reportedly took place at the Chulalongkorn University Hospital in Bangkok in 1975 (Chokrungvaranont et al 2014) Since then, Bangkok has become an important destination for those who seek transition surgical intervention It is estimated that 90% of the transsexual patients operated on in Thailand in the 2010–2012 period were foreigners (Chokrungvaranont et al.2014)

In Vietnam, while the Bill recognising transgender rights passed in 2015 still has to

be worked out in practical detail, transgender persons who wish to alter their sex and who can afford to do so continue to seek surgical intervention abroad Thailand remains the favourite destination for Vietnamese transgender people since the costs are much lower than in the West or other Asian destinations like Korea or Hong Kong (Chokrungvaranont et al.2014)

The feminisation process among a specific group of transwomen funeral performers

in Ho Chi Minh City examined here is therefore conducted against the background of overlapping discourses of sex and gender identity, class, medicalisation and politics, both locally and globally It highlights the health hazards faced by members of this vulnerable social group through the use of unsupervised hormone therapy, silicone injection and sex reassignment surgery in the absence of legal provision to regulate these practices While this paper focuses on transwomen, transgender men also make

a lot of effort – financially and otherwise – to transition in Vietnam However, their experiences are not the same, given that the gender order itself is hierarchical, with a consistently higher value being placed on masculinity than on femininity (Schilt and Westbrook 2009)

Study background

The participants in this study were transwomen (assigned male at birth but who iden-tify as female) working as funeral entertainers in some of the popular districts of Ho

Chi Minh City Transgender funeral performers derive from the old tradition of the kep

h at (actor/male singer) who performed in classical theatre productions called hat b^o:i,

providing entertainment both for the living guests and for recently departed family member at funerals in Southern Vietnam (Nguyen2018) The ceremony re-emerged in

the 1990s in a revised form whereby h at b^o:i was replaced by a repertoire of

trad-itional songs and dance mixed with modern numbers including pop songs, fire danc-ing and even striptease The funeral show provides a public space for transwomen to earn a living, while allowing them to live out their preferred gender identity for a short time

The data analysed in this paper were collected as part of a two-year study of trans-women funeral performers in Southern Vietnam The study involved participant obser-vation at funerals, shows and street performances, for example during the festivities celebrating Christmas Day in District 1st of Ho Chi Minh City in 2017 In total, the study team conducted 45 in-depth, unstructured interviews and two focus group discussions with transwomen performers in Ho Chi Minh City during fieldwork conducted in 2017 and early 2018 Participants were purposefully sampled based on inclusion criteria stip-ulating that potential participants must be at least 18 years of age and transgender women The first transwoman participant was introduced to us by the Ho Chi Minh City based G3VN organisation which promotes the interests of, and provides health care services to, men who have sex with men and transgender communities The remainder of the sample was recruited using snowball sampling strategy after initial participants introduced others to us This approach suited our purpose because by

narrowing our sample size we were able to concentrate on the particular habitus and hexis – to use Bourdieu’s concepts (Adkins and Skeggs2004) – of a specific group of transwomen performers as part of a research project on the intersectionality of reli-gion, culture and gender variance as embodied in the funeral performance of these transwomen

Approval for the study was given by the Institutional Review Board of the Hanoi School of Public Health This study was conducted in line with sensitivity, which included ensuring the research team conducted the project ethically, being non-judge-mental and maintaining strict confidentiality, while responding sensitively to potential participant concerns Informed consent was obtained from all potential participants before any data collection began Participants’ confidentiality was protected by not recording any names, identifying information sources or specific locations in research reports; informed consent forms were filed separately from any study data or reports Among the 45 transwomen respondents, the oldest was 67, and the youngest was

22 and the only one attending university Three respondents had migrated with their families from the Western provinces of Southern Vietnam; the rest were born and grew up in Ho Chi Minh City – mostly in 4th, 8th and 10th districts or in the outlying

Bınh Chanh and Hoc M^on Districts At the time of the research, 10 of the respondents were living with their families, while the rest were living on their own All respondents

had at one time or another worked as entertainers at funerals and at other functions such as weddings, anniversaries, class reunions and so on

All said they were or had been engaged in sex work Two, who were in their late 60s, said they had stopped with sex work due to old age One reported being HIV-positive and in receipt of antiretroviral therapy All 45 respondents used hormone therapy, and 18 had had breast implants Of these 18 participants, five had had genital surgery, and two and undergone voice feminisation surgery All respondents wore feminine clothes and had long hair

Findings

‘To be female’ (lam con gai) – desired body image

All the respondents said they had experienced the feeling of having ‘the wrong body’ and wanted to change ‘to be a girl’ Lily,2 a 43-year-old trans singer, who had silicone injected into her breasts since 2007, said:

Frankly, we have the frame of a male body, we cannot help being ugly, our hands, our legs, our faces cannot help being ugly With a male body how can we be like a woman? The feeling of being born ‘in a wrong body’ was common, but the male physical traits were seen as ‘ugly’ and ‘undesirable’, with bodily change being needed to cor-rect the situation Lily made the following point:

This desire is real One person or million persons, it’s all the same When you enter giới

thứ 3 (the third gender) you have strong desire to have surgery, to have hormones, to

nourish the body so that it can become supple like a woman Those who belong to the third gender who say that they do not want surgery, that’s a load of baloney.

This softening of masculine bodily features was a number-one priority in the transi-tion process All the interviewed transwomen believed that hormones and hormonal medication would help enhance their femininity Tristy, a 50-year-old well-known con-tralto singer within the trans community in Ho Chi Minh city, described the physical changes associated with the de-masculinising process:

It’s true if you take it (hormone) you are more beautiful, you feel a bit more feminine Your skin texture changes and your muscle (mass) decreases and will become a bit drier and thinner.

The hazardous use of female hormones

All the participants said they used birth control pills and/or hormone injections to quicken the desired body changes All said they administered the use of oestrogen themselves without consulting a medical professional, mainly relying on friends for advice on the dose and frequency of hormone injections All mentioned a common

supplier – a middle-aged chi

_or senior sister well known within the local trans commu-nity – from whom they could get hormones and silicone, supposedly imported from Thailand and Germany Forty-two-year-old Kim who earned her keep as a sale assistant

at her elder sister’s clothing shop, took a pack of injectable hormones (imported from Thailand) from her handbag and explained:

Hormones from Germany are the best but more expensive Hormones from Thailand cost

120 thousand Vietnam Dong (VND) per ca:p (a pair) Those from Germany cost 160–180

thousand VND per ca:p.

All transwomen respondents said they followed a prescribed dosage for contracep-tion pills, e.g one pill a day However, they mencontracep-tioned that some of their trans friends used up to 15 pills a day to speed up the feminisation process With regard to hor-mone injecting, how often this was done depended on the user’s financial means Tristy pulled up her blackao ba ba (loose-fitting blouse worn by Southern Vietnamese

women) to show off her round breast implants and recalled the physiological changes that occurred when she started using hormones 10 years ago:

When you inject hormones the breasts grow, the nipples also grow They help develop the breasts in a round, pointed form not the square shape like that of a man I injected hormones for a time but stopped because I ran out of money This stuff costs more than

a hundred thousand VND a pair When you stop, it all melts away.

Like Tristy, Kim and Lily, all the transwomen in this study administered unsuper-vised hormone replacement therapy themselves Apart from the high cost that gener-ally made them stop injecting hormones after about 12 months, a number of transwomen said its regular use could have undesirable effects Tristy recalled:

I bought hormones over there (Thailand) where they sell wholesale and retail I used just

few ca:p, but I did not inject much If you inject large quantities you’ll have great

discomfort, your breasts swell, get tight, so very painful.

Moreover, all the respondents reported that using female hormones led to a low testosterone level, thus lowering their libido As Kim explained knowledgeably:

Because (female) hormones sometimes block [the] male hormones, I don’t feel the need for sexual relations.

Most respondents used hormones for a limited period of time then stopped, because they had to balance their budgets between medication and food bills For

those who chose a silicone gel implant (d- a:t v u) instead of liquid silicone injection,

hor-monal use could be seen as a preliminary step to inducing the required bodily changes before breast implant surgery Lily recalled:

I used one ca:p per week, did it for 6 months I could see my breasts growing The lower

parts (genitals) became smaller Funny isn’t it? Only then [did] I arrange for breast implant.

All participants said that hormone use helps increase the fat beneath the chest muscles, therefore when the surgeon performs a gel implant, the breast will have a fuller, more natural look as compared to breasts formed by silicone liquid injections alone Those who already had pectoral fat around the areola might shorten or even bypass the hormonal therapy phase

The ‘pumping’ of liquid silicone

All transwomen participants said that they had ‘pumped’ liquid silicone (bơ m silicon s ^ong) into different parts of their bodies Some had injected their faces, jaws and hands

while others had injected to their breasts and buttocks Two respondents who did not undergo breast injections gave their reasons: the first, because of previous heart

prob-lems; the other, because of a family objection to her desire of ‘becoming female’ (lam con g ai) As a result, they limited silicon injection to their hands, faces and buttocks.

Like the sources of hormone supplies, silicone was provided by fellow trans friends

(người trong giới) Since liquid silicone has been banned in Vietnam for use in plastic

surgery, participants cannot go to registered medical establishments and have to do this among themselves Lily explained:

In hospitals no doctors would d-ổ (pour) this (injecting silicone) for us If you inject it into

the chest, and if it gets to the heart, you will surely die To tell the truth, to inject these things we transgenders help each other They do not dare to inject these things for us in the (public) hospitals … Those who did breast (augmentation) like me, their bodies are full of silicone We know this is very harmful to our bodies But since we want to be beautiful, we are obliged to inject this harmful product For example, if our hands or legs are ugly, we inject (silicone) to them.

Ignorance about the correct mode of usage often led to disastrous results Tristy recalled her experience with liquid silicone:

The nurse in my neighbourhood injected (silicone) into my buttocks, it stayed at one spot and didn’t spread around Horrible pain I only learned later that the stuff had to be immersed in warm water first before being injected It’s an oily stuff There are two ampoules, one black and one white You have to let the stuff melt before injection I was

in great pain and had to lie down with high fever The same happened when I got it injected to my hands Horrified, I gave the stuff away, all of it Costs me about a hundred dollars a box The box contained 20 ampoules I think.

Lily described her experience with liquid silicone as follows:

Very painful (cự c l am) It tears through your flesh (xi^et thi

_t xi ^et da) as it spreads inside your body The stuff is harmful to your body It doesn’t stay in one place but moves

around (cha:y t um lum) If you inject it into your buttocks, it flows down to your leg.

Some informants mentioned occasions where self-injection or injection by friends led to paralysis of arms and legs, or even a stroke Furthermore, since silicone injection

is illegal, when serious side effects occurred participants did not dare to go to hospi-tals for emergency help Instead they sought advice from friends who told them what medications to buy over the counter Lily explained:

After it was injected it was so painful I went to the pharmacy and told them I injected silicone and it caused lots of pain They sold me some pain relief pills, I didn’t know what those were.

Kim described how she had struggled to control the newly injected silicone inside her breasts:

A friend told me in details how to press (gan) here, block there, so that it (silicone) could

move to the right place to make (the breasts) look beautiful You put that corset on, tighten it so that it (silicone) doesn’t move, because this medicine (silicone) moves around.

For those who had undergone plastic surgery (using silicone fillers) on their faces or hands, all said that after 10 years they had problems caused by ‘silicone leak’ Five trans

informants had sagging cheeks, which gave their faces a bloated look Two participants who had injected silicone into their fingers developed lumps under the skin of their palms 10 years later Those who injected silicone into their breasts said they suffered a great deal of pain right after the injection, but later showed no signs of health

prob-lems except for an occasional sense of tension (tưng tức) in the chest and armpit areas.

Bangkok: a popular destination for sex reassignment surgery

Bangkok was the most popular destination for sex reassignment surgery at the time of research interviews Six study participants aged between 50 and 67 had gone there to have a sex change in the early 2000s, around the time when Cindy Thai Tai, a famous singer, considered by many to be the first Vietnamese person to make public her

gen-der change, also went to Bangkok for the transition (Ti ^en Phong Newspaper, 10

January 2018) Kim explained her own reasons for going to Thailand:

They [the doctors] have done this for many years They have plenty of experience Those who were operated over there do not die, that’s why I wanted to do it there too.

The popularity of Bangkok was enhanced by word of mouth recommendations by friends who had undergone surgery there previously Some of these later acted as caretakers who accompanied their trans sisters on the Bangkok journey Kim recalled her own journey abroad:

I knew that she had had surgery (in Thailand), that’s why I asked her to be my guide She went there many times She knew her way around, what hotel to stay in Then there’s this psychological test, you have to talk to the doctor You’ve got to know some Thai words, some English My friend is better than me in this, she translated for me If in the future somebody asks me to accompany her (to Bangkok for surgery) I [will] recommend

my friend instead I know how to get around as a tourist, but her language is better than mine.

In Thailand, most Vietnamese trans people visit one of two major clinics both located in Bangkok The first is upscale and expensive, while the second charges lower fees Tristy told me:

I stayed at an average clinic There were bigger ones, with prices twice or four times as high [Some of] my friends went to these clinics Much more expensive.

Elly, a 56-year-old transwoman who was the very first Vietnamese patient of one of these clinics, recalled how by chance she got to know about it

In 2003 or was it 2004, I went to Bangkok and first came to a [different hospital] They told me a breast job cost US$2,400, then post-surgery care [would] cost US$600 per night per patient It was too expensive I left and wandered around Just by chance I met a Vietnamese man who was selling balloons in the streets I asked him where I could have jobs done for ladyboys He told me to go and see Mr [Y] Mr [Y] said a breast job [would] cost US$1,300, the lower part cost US$1,800 Later, I acted as kind of intermediary, passing the word around so others also went to have surgery at his place.

The reputation of the more affordable services provided was quickly spread by word of mouth Elly’s cousin, 38-year-old Ana, who had had breast augmentation in Bangkok, spoke of her experience:

I had breast augmentation in 2006 in Bangkok At Dr [Y]’s clinic Gosh, it went so easy After landing at the airport, I just asked a taxi driver [Dr Y] He said OK, OK and drove me straight to the clinic It (the breast job) cost me US$1,500.

Not all was reported to go well in Thailand, however Most cases went smoothly, but some transwomen returned with uneven breasts or inverted nipples In the case

of vaginoplasty and labiaplasty, the results were sometimes disastrous Twenty-five-year-old Maika, who ran a trans clothing shop in one of the most bustling districts of

Ho Chi Minh City, reported:

My friend came back with two lips (labia) hanging like pheasant combs One lip fell off

… she didn’t even knew when.

Postoperative care and treatment: at one’s own cost and one’s own risk

The most daunting problem facing Vietnamese transwomen after undergoing vagino-plasty in Thailand was postoperative care A few wealthy transwomen could stay in Bangkok for standard care, but most patients returned to Vietnam very shortly after their surgery was over Back home, when complications occurred, they had little access

to public health services and had to rely on other transsexual women for advice and practical help, as Kim recalled:

These are close friends who had this surgery before, so they know about it They tell you things about hygiene or answer any questions you may ask.

Thirty-two-year-old Bebe, the cofounder of a famous group of drag performers in

Ho Chi Minh City, who underwent a vaginoplasty in Bangkok in early 2017, shared a similar experience:

If I have any questions, I ask those who [had done] this before me These things don’t really concern the hospitals, and even if I go there, I wouldn’t know who to ask, what section to approach I’m afraid to make contact because they may discriminate more against me Some (hospital personnel) said to me: ‘Go back to where you got your surgery, there they will help you’.

Those transwomen who had their vaginoplasty done by Dr [Y] were allowed to stay for three days at the clinic but then had to move to a hotel where they were looked after by their caretakers Most did not stay longer than 14 days because they could not afford the extra cost for themselves and their companions Tristy, who accompanied a friend to Bangkok as a caretaker, recalled the traumatic episode following a vaginoplasty:

Oh God, her body was heavily bandaged, it was horrible She lay there for a full day, full night She was under heavy anaesthesia I came to check with the doctor and nurses and slowly move her to the hotel where I looked after her.

Because the recuperation period was short, coupled with lack of proper postopera-tive care, many patients suffered from suppuration of surgical sutures, high fever and blockage of the urinary tract after their return home Bebe described the ‘unbearable’ postoperative pain she went through:

Back to Vietnam, it was terrible You had to cleanse the infected sutures Really terrible The product (new vagina) was just for show really, you couldn’t use it My God, when I