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Sally’s Story

Sixteen years ago, Sayed Mursi went under the knife to become Sally, sparking a national debate on sex-change surgery.Today, as more and more children are born with genital defects, are we ready for round two?

By Azza Khattab

I don’t know what drew my attention first: The imposing giant of a woman with the flame-colored hair, or the gargantuan chocolate sundae she was attacking with such obvious delight. Whatever else you care to say about her, know this: Sally Mursi is a woman with one hell of an appetite.

“Good for you,” I blurt out with a smile. “It doesn’t show at all!”

Sally, I quickly discover, takes compliments — and questions, criticism, barbs and simple observations — with a roaring laugh that rocks you back in your seat.

“I know how to spoil myself rotten,” she says triumphantly, feisty and cynical to the core. “To hell with dieting! Give me a break! No sane woman could say ‘No’ to this! What’s a kilo or two? Stand in front of the mirror, shake your booty and POOF — they’re gone!”

By this time, any doubts I had about this woman’s femininity have gone “poof” with her pearls of wisdom about chocolate ice cream. Only a woman could know such a basic truth.

As for shaking her booty? Sally knows a thing or two about that, too. Several times married and divorced, the former Azharite is known as Rahma, her stage name, in El-Haram’s most famous night clubs, where she takes on the role of the playful bimbo — the kind who winks, shoots you air kisses and croons “Hello, Baby!” as she belly dances around the floor.

On the dance floor or off, Sally is a woman in constant, fidgeting motion. If she’s not playing with her long, jangly earrings, she’s pulling a sour face as she combs the ends of her flowing red hair for split ends. Her eyes zip constantly between the mirror (Does the mascara need a touch-up?) and her hands (Does that fake nail need to be replaced?). You may not approve of the makeup, but you can’t help but appreciate the effort: The dark-brown eye shadow, the face powder, the lip liner and the thick eyelashes. So much work for one who used to keep it simple with jeans and a T-shirt.

Sally’s mobile rang as I was trying to be discreet about checking her out.

“Sorry — gotta take the call, ya Baby!” she coos to me.

By this time, the constant use of “baby” seems entirely natural, up there with her continual “bon soirs” and “au revoirs.” A very Sally vocabulary.

I wasn’t complaining about the call from her other “Baby,” though —it gave me the chance to examine her closely. I had been obsessed for years with the woman sitting in front of me. As a teenager, I kept track of her marriages and divorces; her taking and shedding of the veil; her blossoming belly dancing career; her legal battles with Al-Azhar (a suit for readmission) and the Ministry of Culture (for its refusal to issue her a dancing permit).

But really, though, I was trying to find some manly trace left in this woman who was born Sayed forty some years ago. Sally, you see, is the nation’s most infamous post-operative transsexual.

“One of my fans checking in on me!” she says when she finally hangs up, interrupting my stare with a smile. “I’m doing my exams these days, so they’re all making sure I’m being a good little student,” she finishes, bursting into another one of her signature laughs.

As her laughter tapers to chuckles, I find it hard to believe Sally was once Sayed, even harder to square the “au revoir” lady with her previous incarnation as an Azharite schoolboy. This woman in a kakola (Azharite uniform)? You’re kidding me, right? But it’s true: Sayed, already a graduate of Al-Azhar School for Boys, was just one year away from his diploma in medicine when the university kicked him out, declaring war on its own student.

Another physician — a prominent plastic surgeon by the name of Ezzat Ashamallah — had wielded his scalpel to change Sally’s sex.

“To be or not to be! That is the question! Don’t we love Hamlet?” Sally shoots at me with yet another laugh when I ask what made her decide to go under the knife. Most men physically cringe at the mere thought of something sharp near their exposed genitals.

“I simply decided to become Sally because I was never Sayed,” she says, the laugh now gone. “It was a matter of life or death. I’ve always had one foot in the world of men and the other in the world of women, so I stood in the middle of nowhere. When I played with boys, they would make fun of my girlish looks and behavior — I was always a cutie,” she says, laughing again. “Then I would go to the girls, but they rejected me because my name was Sayed.

“That’s when I knew I had to decide who I was. I needed to stand on solid ground.”

As I coax her further back in time, Sally explains that her identity crisis began the moment she became conscious of her own existence.

“I was studying at a French school, the Lycée. My mother was pretty sure her child was not entirely a boy, but my father thought I was just a sissy because I hung out with girls. So he sent me to Al-Azhar School for Boys to toughen me up, to have them teach me to walk and act like a man. It was a complete change in my life — but one that caused no change in my behavior. Instead, I isolated myself from the other boys, who used to make fun of me and call me Sue-Sue. I focused on my studies. I was a star student, among the top 10 in el-thanaweyya el-azharia.”

Uncomfortable in his own body, Sayed enrolled in Al-Azhar’s Faculty of Medicine for Boys to study anatomy and learn more about his own condition.

“When I hit puberty, I had never had an erection in the common sense,” Sally explains. “I had never even masturbated. Worse, my sexual feelings were for men, not women. I would watch a romantic scene between Omar Sharif and Faten Hamama and wish that I was the one being held in gorgeous Omar Sharif’s arms. I was so messed up! I would camp out in the library to try to learn more about my weird illness.”

That’s how Sally saw herself in those days: as a man suffering a psychological disturbance. As Sayed, she turned to psychiatrist Salwa Girgis, who diagnosed the young man as a transsexual — a person who identifies with the opposite of his or her birth sex. Often, Girgis told Sayed, transsexuals alter their bodies with surgery and hormone therapy, becoming the physical embodiment of what their minds tell them they are.

And why was Sayed a transsexual? According to Girgis, the disorder is thought to be caused by stress-related hormonal changes when the child is still in the womb.

“She told me that in order for the person to be a complete male, his spirit and psyche — not only his anatomy and external physique — must be male. Otherwise, it’s like being chained to two trains moving in opposite directions. It tears you apart,” Sally recalls.

Girgis handed Sayed a list of articles to look up in medical journals: Physician, heal thyself. “I never knew [transsexualism] was studied in gynecology, psychiatry and plastic surgery,” Sally says, explaining her shock at learning there were others like her out there. “For God’s sake, I got my references from Al-Azhar University itself! I was hooked —I started studying the issue around the clock.

“Have I told you I’m an internet freak?” she suddenly interjects, then becomes serious once more. “Strangely, though, the more I read, the worse I felt. I slipped into depression. That’s when my parents noticed something was terribly wrong with their boy’s behavior, and they didn’t like it at all. Still, they didn’t discuss it with me or even try to understand. My father forced me to see an endocrinologist, who started injecting me with male hormones. That didn’t work out very well, though: My body didn’t respond. The brain is the maestro of the body, and it rebelled. By my second year in medical school, I rebelled, too, insisting I’m not some kind of experimental farm.”

Things quickly went from bad to worse, Sally says. In her third year, she became sexually attracted to her cousin, then a recruit at the Police Academy.

“God almighty that was bad! He may never have believed in my masculinity, but he also had zero [sexual] feelings for me. It was emotionally devastating,” Sally says in a loud voice.

As I shrink slightly in my seat, I notice we have an attentive audience: our waiter. Sally shoots him a glare that drives him away for a time, then turns back to her story.

“My fourth year was a landmark in my life: I decided to have the surgery, and there was no changing my mind. My mom begged me to finish my studies, then do whatever the hell I wanted, but I saw no point in waiting. We only get one life, and I was on the edge of losing mine. I actually slashed open a vein and was hospitalized. That’s when I met a doctor who told me to do whatever I felt like doing, so long as I knew what I was getting myself into.

“That was damn good advice, so, yeah, I opened a door that got me nothing but trouble, but I knew I would be able to deal with the trouble so long as I knew who I was.”

The troublemaker got what she expected: In early January 1988, Al-Azhar’s medical faculty referred Sayed to a disciplinary committee for posing as a woman in class.

“I told them [that adopting the attire and mannerisms of a woman] was part of the therapy designed to help me adapt to the life I would soon start as a woman, but they wouldn’t listen, they didn’t get it. I was suspended for two months and told I couldn’t come back until I changed my deviant behavior. It was like, ‘We’d rather you be a homosexual in the dark than a woman in the light’.”

But Sayed knew he wasn’t gay because he wasn’t a man. He submitted to Ashamallah’s scalpel, becoming Sally on January 29, 1988.

“I was all alone, my fate in my own hands. My parents offered neither blessings nor curses — they simply washed their hands of me,” Sally says. “And when I had recovered and finished my suspension, I went back to school as Sally. I figured they might change their minds after the operation, but they flew off the handle: ‘So, you’re challenging us?’ Who am I to challenge Al-Azhar? I did what I had to do, but no one listened. They expelled me from the university, and that’s when the battle began,” she laughs.

Both doctor and patient’s endurance were put to the test. Sally was barred from Al-Azhar’s medical schools (neither the men’s nor the women’s colleges would take her), and Ashamallah was kicked out of the Physician’s Syndicate for a time after colleagues raised allegations of malpractice.

“We became the most infamous doctor-patient couple in Egyptian history,” Sally smiles. “We were summoned by the State Prosecutor’s Office, which was investigating charges against us, claiming I conspired with Dr. Ezzat Ashamallah to cause myself a permanent deformity that stirred up ‘social instability and public disorder.’ Don’t you dare underestimate me,” she jokes. “I’m as dangerous as any terrorist!”

Although the judges declared both Ashamallah and Sally not guilty of all charges, the two were soundly convicted in the court of public opinion.

And the heated debate between physicians for and against sexual reassignment surgery? That hasn’t died down yet, either, despite a Physician’s Syndicate decision to ban transsex operations altogether — a decision that has driven transsexuals either to the handful of physicians who might fudge a diagnosis sheet by declaring their patients “intersex” (more on that in a moment), or outside the nation’s borders.

While some declare sexual reassignment surgery an affront to religion (most conservative Christians and Muslims agree on this point), others are equally adamant that it’s a medical matter best left between doctor and patient. Society, they say, must be taught to accept transsexuals instead of turning its back on them, driving some to suicide and most to lives of quiet misery.

If transsexualism is rare in our society, intersex cases (boys wrongly sexed at birth as girls, and vice versa, generally as a result of defects in the genitalia) are on the rise due to both genetic and environmental factors. Ignorance and shame in a society that is so often uncomfortable with the word “sex” see many families misinterpreting their kids’ conditions as sexual deviancy best kept quiet at home instead of seeking medical help.

Of late, though, the fate of intersex children has crept back into the headlines, with a handful of medical experts and some in the media saying the condition is increasingly common and definitely curable. Many surgeons are offering free sexual reassignment surgery for intersex cases. And optimists think families — particularly in Upper Egypt — may finally be getting the message that inbreeding, which drastically increases the rate of birth defects of all forms, particularly those of the genitalia, has to stop.

Transsexuals Homosexuals

What exactly is transsexualism? As Ashamallah, the surgeon who turned Sayed into Sally, explains it, it’s a person whose sexual identity and desires are turned upside-down.

“The patient will tell you he feels his private organs aren’t his, that they don’t belong to him. If he’s a man, he’ll feel uncomfortable in men’s clothing. It’s out of his hands, and it’s a nightmare for his family. There’s no miracle cure for most people like this: They stay as they are forever, or undergo surgery,” Ashamallah explains.

“And it has absolutely nothing to do with homosexuality,” he notes. “The moment someone hears that a man wishes to become a woman, they condemn that person as a homosexual. But gay men don’t say ‘I’m a woman.’ A gay man knows he is a man, just one who happens to be interested in men instead of women. Gays don’t want to change their sex — they want to be gay. That’s how they are,” he says, his frustration plain to see.

Dr. Ahmed Okasha can sympathize with Ashamallah’s frustration. A professor of psychiatry at Ain Shams University, Okasha is also president of the World Psychiatry Association. Perhaps that’s why he prefers the term “gender identity disorder” to “transsexualism.”

“Remember Sally’s case?” Okasha asks. “People mistakenly confused her as a homosexual. What people should understand is that homosexuality and lesbianism have nothing to do with ‘mental disorders.’ We consider them lifestyle choices. They may not be accepted in our society, but homosexuals do not suffer from a mental disease. Gender identity disorder is a completely different issue.”

With the patience of the teacher he is, Okasha walks me through the symptoms and treatment.

Patients must exhibit a strong and persistent identification with the opposite gender, not merely a desire to change sex for some perceived cultural advantage, to be diagnosed with gender identity disorder.

In children, Okasha says, the disorder manifests itself in the patient’s insistence that they belong to the other sex. The key is that they repeatedly state a desire “to be” the other. They regularly cross dress and persistently adopt the play habits of the opposite sex. Many fantasize about changing their sex or becoming “double sex.”

“There’s a constant desire to play with the other sex,” Okasha says. “Boys will prefer to play with girls and dolls. Girls will dress as boys and play roughly.”

The desire to become the other sex — and to be acknowledged by society as such — is often made far more acute with the onset of puberty, leading many patients to adopt the habits of the other sex. Perhaps most surprising: Sexual pleasure plays little, if any, part in the decisions of most patients, Okasha claims.

“Girls will urinate while standing up, while boys will urinate sitting down,” the doctor explains, breaking his examples down into layman’s terms. “If you warn the patient that he’ll never become pregnant if he becomes a girl — and may not even enjoy the act of sex — he shrugs his shoulders. He really doesn’t care [about sexual pleasure] as long as he’s going to be and live like the other sex.”

The decision to move ahead with surgery is never taken lightly, Okasha and Ashamallah agree. No good plastic surgeon will make the cut without first requesting a battery of medical, psychiatric and social tests: chromosomal and hormonal assays have to come back normal. The gender identity disorder can’t be secondary to a mental disease or personality disorder (such as schizophrenia and manias) or to an organic brain disorder.

And before attempting the surgery, most physicians will put a patient on hormone therapy and have him or her live for as many as two years in the role of the opposite sex, all to help them prepare for the transformation.

Only in cases where the transsexualism is the result of some other mental disorder can the patient be successfully treated with psychotherapy or drug therapy, Okasha says. And while transsexuals who go under the knife need the support of a good therapist before the surgery, he adds, it’s even more vital in the post-operative adjustment period.

“To sum it up,” Okasha notes, “we need a complete clinical psychiatric examination, full psychological batteries for the personality and for the femininity and masculinity ratios, and for any other associated mental disorder. Sometimes, we resort to neuro-imaging of the brain and EEGs to rule out organic reasons. Then, finally, we do the hormonal and chromosomal assays.”

Only then will surgeons make the first cut.

Society and religion

In the wake of his surgery on Sally, there was a time when Ashamallah started to question the old axiom that there is no such thing as bad publicity — a time when every single newspaper and magazine in the nation had his photo on their front pages.

“I became the most notorious doctor at the time,” he remembers with a smile, sitting in his Downtown Cairo clinic. To this day, he insists he did nothing to deserve the notoriety.

“Contrary to what people think, I wasn’t the pioneer of these operations,” Ashamallah asserts. “I can’t claim the honor of the breakthrough when the procedure has been in the books for years — similar surgeries were performed here in Egypt as early as 1920. The real problem is society’s take on the issue, and it’s our responsibility to educate people, to help them understand scientific fact. Once people understand that [sexual reassignment surgery] is a medical issue, they’ll be more understanding and accepting. Once upon a time, society was more tolerant of these surgeries because society itself was more relaxed and tolerant.”

Any issue associated with sex, the doctor thunders, is automatically treated with suspicion and unconcealed embarrassment.

“It’s like sex education! Even though it’s a basic scientific process, we’re still debating whether or not it should be taught in schools! Our intellectuals and thinkers should be helping physicians educate the public about these issues.

“Sex-change surgery is legal under Egyptian law,” he continues, “and it’s practiced around the world. That’s precisely why I won in court: The Egyptian judicial system concluded that it was a medical issue, not a legal one, and many doctors came out to testify on my behalf. They endorsed the surgery! And how could they not,” he repeats, “when it’s in the medical textbooks along with hernia operations, for God’s sake?”

The lion’s share of Ashamallah’s rage is reserved not for society at large, but for other physicians who can’t accept transsexualism as a legitimate medical condition.

“In the scientific world, there’s always room for differences of opinion. For example, some believe stomach ulcers should be treated with drug therapy, others prefer surgery. Both can be right — it depends on the patient’s condition. Medicine is not a battlefield, yet sexual reassignment surgery has been discussed to death. Some doctors say yes to it, others object. And that should be fine. We shouldn’t ban an operation simply because some condemn it.

“Strangely, though, I’m relieved,” Ashamallah says of the ban. “It spares me the headache of arguing, whether it’s with parents, the media or society. Losing the chance to do two or three operations is worth the peace of mind.”

“But the patients don’t see it this way,” he suddenly growls. “They want a cure! Nowadays, they have to travel to have the operation. Thailand, Greece and Turkey are popular. Then they come home, get new documents and lead normal lives.”

(Sally adds that while many go abroad for the surgery, others have it done here if they can find a physician willing to diagnose them as inter-sex, not transsex.)

Does Ashamallah think religion is at the root of society’s problem with transsexualism? After all, I tell him, many believe it’s haraam.

“Listen, we can’t talk about religion here. We don’t want to open the gates of Hell, do we? All I can tell you is that science is science, and I’m not a religious scholar who can talk with you about the connection between science and religion. I work from medical texts.”

Then, as if remembering something, his face brightens up: “This great man! Sheikh [Al-Azhar, then Mufti] Sayed Tantawi! He issued his own fatwa during the controversy [over Sally], saying that it’s a medical situation best left to the doctor’s discretion if he sees the need to operate. I have tons of respect for this enlightened man.”

While many claim the controversy erupted because Ashamallah, a Christian, operated on Sally, a Muslim, the surgeon will have none of that. “Some in the foreign press wanted to turn it into a religious strife story, asking me whether my willingness to do the surgery had something to do with me being a Christian and the patient a Muslim. That had nothing to do with it,” he flatly states. “Besides, the majority of the judges who declared me not guilty were Muslims. The issue was blown out of proportion because anything involving sex is usually entertaining and exciting.”

Okasha has similar, if less emotional, memories of the role of religion. “During Sally’s case, we had a meeting with Egypt’s religious leaders to explain the issue, and they reached the consensus that if it’s a medical disorder recorded in medical literature, it’s the physician’s prerogative to decide on the course of treatment.”

Sally, naturally, is the most effusive in her praise of Tantawi, whom she declares is one of her idols. But she’s equally furious that some religious leaders are convinced she’ll burn in eternal Hell.

“Some people see me as a woman, yet they listen to these preachers who declare over and over, ‘This is an abnormal boy who took hormones and deluded himself into believing he’s a girl.’ I’m not talking about their influence on strangers, but on my own relatives, who were dramatically affected by what Al-Azhar said. They boycotted me.

“Anyway, it’s their loss,” she says.

Acceptance and adjustment

Unable to hide the sadness in his voice, Okasha says it’s clear Egyptian society doesn’t accept transsexuals, and the consequences can be dire for the patient: depression and even suicide can follow.

Sally certainly remembers the fallout from her operation. First, Al-Azhar accused her of being a homosexual. Next, she was accused of trying to wriggle out of her mandatory military service.

“One day,” she remembers, “I found an army officer at my door telling me to report to the police station the next day for induction into the army or else. I tried to explain, but all I got was, ‘It’s for your military draft!’ I told him, ‘Excuse me, but maybe you need to see an optometrist? I’m a she!’ He shrugged his shoulders and said he didn’t care.

“Anyway, I went. A team of doctors examined me and — surprise! surprise! — they said the obvious: That I’m a girl. They refused to include their brilliant finding in their report, writing instead that ‘Sayed is not medically fit for military service’.”

The laugh that accompanies her last words is hysterical. Okasha and Ashamallah know from academic experience that society doesn’t tolerate transsexuals. Sally knows because she lives it.

“Our society doesn’t accept change,” she says. “That’s fine. I don’t want to change them because I’m happy with my life. I’m not locked in a room begging for forgiveness. I was disappointed when Al-Azhar refused to let me finish my studies in the Faculty of Medicine for Girls. I filed two lawsuits against them and won two rulings — rulings that weren’t enforced, of course, because Al-Azhar is a law unto itself.

“I tried my best to enroll in other faculties of medicine in Egypt, to no avail. It seems Al-Azhar let them all know it would be unhappy if I was accepted. Fine. I didn’t collapse. Instead, I signed up with Cairo University’s Faculty of Literature, and I’m finishing my last year. Today, I go everywhere; I make friends and many don’t know that Sally was Sayed. There’s no sign on my forehead that says ‘Formerly Sayed.’

“I even saw my cousin at a traffic light the other day and he didn’t recognize me, for God’s sake!”

But Ashamallah isn’t certain Sally’s adjustment has been ideal. “In many countries, patients who undergo these surgeries are advised to change where they live and work, but it’s too difficult for people here to do this. I heard Sally moved several times, and society still refuses to completely accept her as a woman, with some people calling her Sayed even though her legal documents say she’s Sally.

“It wasn’t enough that she married — it wasn’t proof enough. People can’t be convinced about that which they can’t understand. Tell them a basic scientific truth like the fact that we all have some male and female inside us, and some people go ballistic. To tell them that sex is determined by both the brain and the anatomy, that mind and body have to be in harmony, is even more incomprehensible.

“In Sally’s case, her body was male, but her brain was female. She acted like a woman, wanted to dress, live and get married as a woman. It may not seem normal to some, but it was natural for her,” Ashamallah concludes.

The dissenters

Only one thing would be completely unnatural, the doctor claims: to leave someone without a cure when one is clearly available. “To not treat someone suffering from transsexualism is to condemn the patient and all those around him to a living hell,” Ashamallah asserts.

But that’s not to say he would happily transform anyone who asks into the opposite sex.

“It’s unacceptable and unethical, for example, to try and have one of your daughters transformed into a boy because you don’t have a son. Some people think that’s easy to do, but it’s a horrible crime. It’s destroying that person’s being,” says Ashamallah, who still operates on intersex cases.

“So I ask the patient, ‘Are you a girl?’ And she nods her head ‘Yes.’ ‘Do you feel like a girl?’ I get another ‘Yes.’ So what’s the point? Even if you change her body, she’ll still live and act like a girl. You can amputate a man’s organ, and he’s still a man. Some girls are born with virtually no breasts or no vagina, yet they’re undeniably women. The brain is what counts, not the figure.”

If we accept intersex, why can’t we accept transsex? It’s a question Ashamallah has often asked. “Why would we approve of a man spending his whole life living like a woman, but not becoming one? And since we all agree that sex is what you see and gender is what you feel — and both are crucial to someone’s life — why not apply it to our reality?”

Dr. Abdel Monem El-Gergawy, head of urology at Assiut University Hospital, isn’t at all sympathetic to Ashamallah’s call. He treats intersex cases, but gives transsex a very wide (and very snarky) berth.

“One day, a girl visited us with another girl whom she claimed to be her fiancée. She insisted she’s a male and begged us to help her change her sex. We examined her and found she was female. A 100 percent female, in fact. She had regular periods and was physically and organically a complete woman. We advised her to go to a psychiatrist. Her condition is listed in their books — tomboys and sissies are mostly psychological problems, not physical ones. How can someone convince me to help her change her sex when all her cells are female?

“‘Because she feels that way’ isn’t a good enough excuse, really,” El-Gergawy asserts. “Abroad, God help us, they have no problem changing a man into a woman,” he continues. “That’s deforming God’s creation! It’s mutilating someone’s organ, for God’s sake! It’s the ultimate deterioration of human ethics. The surgery is easy, but what if the patient wants to go back to his genetic nature? [Sexual reassignment surgery for transsexuals] is a crime of the worst order.”

Dr. Magdi El-Aqad agrees. Like his colleague, the deputy dean of medicine at Assiut University says it’s unethical to perform sex-change surgeries at the whim of patient or doctor.

“Human rights activists would say a person is free to be whatever he wants, but we can’t approve of this surgery, at least not from a religious perspective,” El-Aqad says. “Sally was a psychological transsexual. This is about deviant behavior, and if we open the door to such operations, it would be disastrous. It’s our duty to fight against it. Many sexual aberrations are psychological, others are genetic. In Sally’s case, it was a behavioral anomaly. He had a deviant personality — he was a sexual deviant.

“I had a patient once,” El-Aqad continues. “He was homosexual, but completely male. He was 28 and wanted to become a female. I refused, so he threatened to commit suicide. His insistence on becoming a woman was unbelievable. Later, he came to me with a sheikh who happened to be a relative of his. The sheikh basically told me, ‘We’re a rich family in our village, and this boy is meeting other men in the attic. It would be better for all of us if you make him into a girl. He’s shaming us.’ I examined him again, but he was male.

“He’s a deviant. Maybe someone raped him when he was young — sexual humiliation at a young age can be a key. That’s why he wants to dress like a woman, and maybe he wants to be molested. I sent him to a psychologist, then one day he came back to me with his penis cut off. It was an obsession.”

But don’t get El-Aqad wrong: He has no problems doing sex-change operations, particularly when girls want to become boys. He’s treated 18 of those patients to date, making him one of the nation’s top experts in the field.

“Most of those I treat then choose Magdi as their new name,” he says with a proud smile. “We work on cases in which a boy was diagnosed at birth and reared as a female when he’s actually male. That’s why I prefer we call it sex-correction surgery, not sex-change surgery. We simply restore the patient to his original sex.”

When he became a she

Which brings us to intersex cases. Traditionally, El-Gergawy explains, a physician or midwife determines a newborn’s sex by a simple visual inspection of the infant’s genitalia.

“If the child has a penis, scrotum and testicles, the attendant declares the child male. If he doesn’t, he declares the child female, recording the finding on the birth certificate. There’s no examination of the child’s chromosomes, no testing for hormonal or other biological abnormalities,” he says.

Sometimes, though, the genitalia is ambiguous. Even more problematic are cases of internal genitalia or hormonal imbalances that can’t be detected by the naked eye.

According to El-Gergawy, congenital defects (of all forms) in sexual anatomy have been on the rise for nearly two decades. “We used to see a case once every six months,” he says, “but today we see them weekly.” The surgeon says the increase is the result of several factors, including inbreeding, pollution, the ingestion of certain drugs during pregnancy, exposure to radiation and certain diseases during the first two months of pregnancy.

Cases of ambiguous genitalia are those in which it is difficult to classify the infant as male or female by a physical inspection. The extent of the ambiguity can vary widely: It’s entirely possible for a newborn to look like a “normal” infant the exact opposite of its genetic sex.

“Typical ambiguous genitalia in genetic females include an enlarged clitoris that has the appearance of a small penis,” El-Gergawy begins. “The urethral opening can be anywhere along, above or below the surface of the clitoris, which are common abnormalities in urethra placement. The labia may be fused, resembling a scrotum. The infant may be thought to be a male with undescended testicles; sometimes, a lump of tissue is felt within the fused labia, further making it look like a scrotum with testicles.

“In a genetic male, findings of ambiguous genitalia include a small penis, less than 2 to 3 centimeters, that may appear to be an enlarged clitoris.” The clitoris of a newborn female is often proportionately larger at birth than it is later in development. “The urethral opening may be anywhere along, above or below the penis; it can be as low as the peritoneum, further making the infant appear to be a female. There may be a small scrotum with any degree of separation, resembling labia,” El-Gergawy explains.

The most common scenario the surgeon faces involves a midwife or a doctor who hands out the wrong diagnosis. The family then raises the child as a female until they notice that their girl doesn’t get her period and is acting “like a boy,” so they rush to the hospital to see what’s wrong — only to discover that she is genetically a he.

Yet the biggest complication El-Gergawy has to contend with in Upper Egypt isn’t genetic, but cultural: female circumcision. The doctor notes that many of the genetically male children his team has treated have had their penises amputated at a young age because they were mistakenly identified as females. The penis, seen as an oversized clitoris, was simply reduced or excised completely.

“Circumcision is an informal law in Upper Egyptian families. In most villages, they circumcise the girl 40 days after her birth. So in intersexed cases, they simply cut off the penis, putting us and the patient in a more difficult situation,” he says. “We then have to start from scratch, constructing a new penis. Female circumcision is a crime that should be banned by all means. As you can see, it doesn’t only damage a girl’s life, it can also destroy the future of a male.”

Female-to-male surgery for intersex cases is complicated, El-Gergawy explains.

“It’s a 12-hour procedure in which we correct the urethra, bring down the testicles and construct a compensatory penis. Through microsurgery, we implant it in the original penis’ place. We get the nerves, veins, arteries, bones and skin from the patient’s arm. We make two ducts, one for the urinary tract and the other for the compensatory penis to help them have sex later in their lives.

“By the way,” he interjects, “some normal men have these prosthetic appliances.”

As with transsex cases, mental health professionals are key players before and after the surgery. El-Gergawy, like most surgeons, won’t try the operation without first consulting a psychiatrist.

“All of my cases accepted the fact that they would become boys,” he says. “They wanted to get out of the women’s prison — and they did, only now they’re locked in the men’s cage,” he laughs.

The psychiatrist’s verdict is particularly important in cases of hermaphrodism — patients who have both ovarian and testicular reproductive tissue. In those instances, the surgeon could go either way.

“We conduct clinical exams, physical exams, blood chromosome analysis, magnetic resonance imaging and consult a psychiatrist to see whether the child is tending more toward male or female. It’s best if we can correct the problem early in childhood, because the child can forget its past life and adjust to the new role without serious complications. But ignorance delays early detection.”

Most of the eight girls El-Gergawy has turned into boys welcomed the surgery, he claims.

“One of my patients came to me in a skirt, with two braids and burqa. After examining her, I found myself saying, ‘How about we speak man-to-man?’ And she smiled: ‘I know I’m a man. But I’m a prisoner in a woman’s life. How can I get out of here?’ Not a big deal! You see, we do magic here, and this patient left the hospital wearing the ‘emma and galabeyya baladi. Now, he’s a pretty famous animal trader, and he still comes back to visit. He blames me, though, because his old girl friends pelted him with stones to make certain the secrets they shared with him remain sealed.”

But not all patients jump at the chance of becoming men, El-Aqad notes, recalling Fatma, a masculine but attractive married woman referred by her gynecologist, to whom she went complaining of amenorrhea and problems getting pregnant.

The gynecologist quickly determined that Fatma had no vagina. Worse, she had been having “intercourse” with her husband through her abnormally large urethra, which was stretched and torn by the act.

“It was intolerably painful and inhumane,” El-Aqad says, “but strangely enough, they satisfied each other sexually. Our [genetic and physical] tests indicated Fatma was born as a boy, but her penis was amputated during circumcision. Ignorance on her part and that of her husband —to say nothing of her physician and parents — saw the problem go from bad to worse. In her case, we kept her a female.

“At the end of the day, it’s the patient who makes the final decision. She loved her husband and was [sexually] excited by being with a man, so we removed the remains of the testicles and constructed a vagina. Now, she’s having intercourse in a much more pleasurable environment, which is better for her. We gave her female hormones, so her breasts grew bigger and her body hair thinned. Her husband married another woman so he could have a child, but he didn’t divorce her,” El-Aqad says.

It’s at this point that Ashamallah nearly loses it, furious that doctors would bless someone like Fatma by allowing her to make a choice between her birth and preferred sex, yet deny transsexuals the same chance.

“You may find a woman whose gender is male,” Ashamallah says. “She dresses like a man and goes to work in the vegetable market like a man, and nobody knows she’s a woman except her parents. She lives like this because she can’t afford the cost of an operation.”

El-Gergawy sees no such contradiction, noting that Assiut University sees intersex surgery as part of a mission to better the lives of the area’s families. That, he says, is why the hospital generally foots the bills for sexual reassignment surgery, which can easily top LE 20,000 per patient for the operation alone.

“Forget about some parents’ initial reluctance to face the problem,” he says. “These people are so frustrated and anxious to find a cure. Once the hospital started publicizing these operations — and explaining their urgency and success rates — patients started pouring in from many governorates.”

El-Gergawy is practically on his knees as he pleads for mothers and fathers with even the slightest doubts about their children’s genitalia to take them directly to a physician.

“Can you imagine that I had a mother telling me she usually avoided looking at her child’s genitals? Ignorance can lead to disasters. Worse, even when noticed, shame and the belief that sex-change operations are scandalous hold them back from finding a cure. Some families would rather turn a blind eye and lock their child up. They fear for their reputations, they worry that rumors would spread that their family carries some weird inherited illnesses, so they live with the fact that they have an abnormal child who won’t get married or lead a normal life.

“They need to understand that [congenital defects in the genitalia] are a kind of malformation, just like heart problems. It’s not something to keep in the closet.”

Men in the making

Reda Sedik, 13, sits in a treatment room at Assiut Hospital with her younger sister Bekheeta, a dumb look plastered on her face. As I look them over, they appear for all the world to be, well, girls.

I was speechless when Dr. Adel Gogar introduced them to me as his “latest cases,” encouraging me to speak with them about their upcoming sex-change operations. Maybe it was their youth, or the blank looks on their faces, but I was more comfortable questioning Shadia, the elder sister dispatched by their parents to chaperone them to Gogar’s office and a meeting with me.

Shadia puts it in the simplest of terms: “Reda never looked normal. She never acted like a girl. She always wanted to stay outside and play football. Then we found her figure wasn’t changing the way it should, so we took her to the doctor and the doctor sent us to the hospital. That’s when he suspected my other sister,” she says, suppressing a smile as she glances at Bekheeta. “They examined her as well and broke the good news: We have two more boys coming to the family. We were happy. Whatever God brings is good. We used to be seven girls and a boy. Now, we’ll have two more boys. A gift from God.”

El-Aqad, who accompanied me to visit Gogar, asks his colleague whether the team examined Shadia as well. I found myself blushing as the young physician assured the more senior surgeon with a smile that “This one is a confirmed female.”

Gogar says Reda and Bekheeta are both lucky to have been diagnosed at such an “early” age.

“In Upper Egypt,” he says, “girls get their periods earlier than normal — at the age of 10, let’s say. The fact that she was three years late raised doubts in Reda’s family about her femininity. But some families don’t come to us until the girls are in their 20s — they come after they get married and find they can’t get pregnant. Then we have to tell them, ‘Sorry, she’s not a woman.’

“The earlier the case is detected,” he says, “the better it is for the patient, who will thus have spent less time in a role that will suddenly change. And the younger they are, the smoother the hormone therapy goes because the body’s sex hormones haven’t kicked in as they do at puberty. As for Reda and Bakheeta? They’re not likely to be able to have children,” Gogar continues. “And the fact that the testicles haven’t descended makes them more vulnerable to tumors.”

So are the two ready for the change? “They’re too young and nave,” Gogar says. “They’re probably not fully aware of how complex the operation is. Their family, though, is ready to have more boys. We love boys in Upper Egypt. Social and financial circumstances favor more men in the family, so it was thrilling news to them.”

But what about the girls themselves? After some coaxing, Reda admits she never felt she was a “he.” The thought never crossed her mind. But after thinking it over, she doesn’t think the surgery is a terrible idea.

“When I came here, they told me I would be a boy. I said okay. Boys are good,” she says simply.

Has she chosen a new name for herself? “No. I’ll take whatever name they choose for me.”

Will she miss being a girl? “I don’t have many girl friends to miss. Besides, boys are better in everything. They can go out whenever they want. They play more and get to run more errands. They have more fun.”

Gogar can’t help but smile at her words, his look suggesting the words he won’t say: “Well, if that’s what you think.”

One last laugh

Mena Morris, 20, is every Upper Egyptian mother’s nightmare. The sweet, shy young man sitting in front of me remembers himself as Taghreed the Tomboy.

“I was a rebel — especially when it came to dresses and skirts,” Morris says. “I used to wear only trousers and shirts, I cut my hair à la garon and bossed around everyone near me. My mother used to scream at the top of her voice, ‘Wear a skirt or a dress! Put on some earrings!’ But I’m stubborn: If I don’t want to do something, forget it — save your breath.

“I’ve always loved to ride bicycles and go out. I was so naughty, such a troublemaker that I broke both of my arms. I’ve bruised every inch of my body. Worse, I never liked the girl’s life. My sisters cook, clean and wash clothes, but I washed my hands of household chores. My sisters do what I tell them to do — I’m the bossy member of the family.”

“Definitely male genes, Mena,” I find myself saying with a laugh.

Morris’ parents simply attributed her behavior to her being “a little devil” until, one day in her secondary-school years, the young woman sprouted a husky voice and a lean physique instead of breasts and hips. Worried, they sent Mena to a physician, who quickly ordered a chromosome analysis and other tests.

“And thank God,” Morris says, “they proved I am a man.”

The family had no idea what to do until Mena read about a similar case in a weekly newspaper. That was how she learned of El-Gergawy. After a visit to his Luxor clinic, he sent her to Assiut University Hospital, where they successfully performed sexual reassignment surgery.

“I was so happy — so was my family. We were two boys and seven girls. I’m the latest addition to the boys’ department. My sisters were the happiest because at least now I have a reason to be so bossy! Still, it shocked many [in the extended family], because the majority of them had never heard of such a case.”

Before the surgery, Morris spent four months living in the girls’ dorm at Assiut University, where she was studying science.

“Call it feminine intuition, but they used to suspect me,” she says. “Some wouldn’t even shake my hands, and many of the university’s security guards were suspicious. They would spend so much time staring at my ID, making sure I was really a woman. Sometimes I had to fight to get them to let me in. God, that was so embarrassing!”

That was two years ago. Today, Morris says, his life has changed “360 degrees.”

“I kissed the girl’s life goodbye. I lost my female friends, and most won’t even shake hands with me now, but I have male friends. I adapted easily because I have so much more freedom now —I can travel anywhere, any time. I can stay out late without being yelled at. Manhood is way better for me. I was such a frustrated girl! Oh, God! There were so many chains!”

So can he empathize with women better than most guys? “Let’s say I’m more understanding than others,” he says with a sly smile.

There’s one thing Morris, unlike Sally, can’t get used to, even after two years: celebrity. “The television and the press brought my story to every village in the country. Some people were accepting, others were shocked, but I explained my case to my friends at the faculty and they were okay with it. After all, they’re science students.

“Sure, some people harassed me,” Morris admits, “but teasingly, not seriously or too nastily. And I was ready for it, to tell the truth. I was introduced to other patients and we encouraged each other. My psychiatrist warned me [that there might be adjustment problems], but he found I’m a tough cookie. Believe me, though: If someone is operated on and he’s not ready for it, the initial rejection will be too much. He could become depressed and commit suicide.”

Does Morris have any regrets? His closest friend from before the surgery, he admits, couldn’t stop crying when she learned the truth. “Whatever,” he adds. “Women never run short of crocodile tears.

“Sometimes…” he adds, shyly. “I miss my female friends and the time we spent together. Those were pretty good days, in a strange way. I have cute memories. Now, I can even laugh when I remember the times when people suspected I was a man.”

And on the romance front? “You can say that my relationship with the other sex is superficial,” Morris admits. “I’m focused only on my studies but, to tell you the truth, there’s this girl I secretly admire.”

Sally’s swan song

Sally Mursi, the symbol of sex-change surgery in Egypt, is still determined to shake up those who cling to what she calls “old-fashioned ideas.” It shouldn’t surprise you to learn Al-Azhar University is at the top of her list.

“They think they’re rid of me? Think again! I’ll haunt them as long as I have a legal right! I’m going to apply for my master’s there — let’s see what they think of that! They don’t want to take me because I was a belly dancer? Fine! They didn’t want me back when I was a veiled woman begging for mercy and looking for my right to a seat in the Medical College for Girls, either!

“Listen, I have a simple message for them: Don’t judge me! Only God can do that, and if the Creator can forgive even a prostitute, why can’t they accept me? Their job as religious men should be to try to include me in the fold. Besides, they’re the ones who forced me to dance — they threw me into the street!

“Don’t get me wrong, though,” Sally says. “I’m not fishing for sympathy. I’m responsible for my own actions and my own sins, but only before God.”

As for dancing, Sally’s legions of fans will be disappointed to learn she doesn’t plan to make it her career. “It was a good way to make money, to cover my expenses. After all, good lawyers in this country are damn expensive,” she says with a laugh. “But my competition can relax: I’m not here to stay. I’ll probably wind up as a translator for some tourism company.”

Other belly dancers, it turns out, have been least accepting of all. “They give me a nasty word, I fire back with a nasty paragraph! I’m a belly dancer, and I get snarky comments all the time. Pity the drunk who teases me — he’s messing with the wrong woman! No one can step on my dignity! I’ll stop dancing and give him a lecture on the spot, telling him he’s a lucky bastard who should be grateful I deign to dance in front of him. That usually shuts him up!”

Suddenly, Sally falls silent. Then: “I chose Rahma as my stage name for a simple reason: In the hope that people might have mercy and leave me alone.”

The name is Arabic for “mercy.”

Then, the quiet is over as quickly as it fell — she’s chuckling her way through another anecdote about rowdy fans.

Whatever hand fate might deal her, Sally Mursi is convinced she’ll have the last laugh. et

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