Trans women sex workers in Northern Malaysia: A Qualitative Study

This study aims to understand in-depth the factors that motivate sex work among trans women, how they source their clients, and to explore their knowledge, attitude, and practices on safe sex. In this qualitative study, a case study approach was selected to explore the motivating factors related to sex work, the factors that encourage sex work, and the safe sex practices among trans women in Northern Malaysia. The snowball sampling method was used and thirteen in-depth interviews were conducted using a semi-structured interview guide. Financial reason was the main motivating factor for sex work. Most of them used online applications or websites to source clients and some used pimps who play an important role in sex education and protection. These trans women were well aware and equipped with knowledge on safe sex, and the use of condoms and attended regular check-ups and counselling when needed. Trans women should not be discriminated against and denied proper employment which can lead them to sex work.


Introduction
The term 'transgender' or trans refers to an umbrella term for people whose gender identity and/or gender expression differs from their birth sex.((UN), 2013; Said et al., 2022; Zoli, Johnson, Cingolani, & Pulcini, 2022).Trans men, also known as transgender men or transsexual men, refer to people who are born with female bodies but consider themselves men and live socially as men.Likewise, trans women, transgender women or transsexual women refer to people born with male bodies but live socially and consider themselves women (Liaw & Tharumaraj, 2023;Said et al., 2022;Sevelius, 2013).AFIQAH & RASHID, Current Research Journal of Social Sciences, Vol.06(2) 207-218 (2023) In Malaysia, transgender woman is also known as 'Mak Nyah', and they are usually shunned by society because they are considered to have violated the tenets of Islam, the official religion of Malaysia (Barmania & Aljunid, 2017; Koon Teh, 2008;Koon, 2002;Said et al., 2022; Yik Koon Teh, 1998).The 'Mak Nyah' in Malaysia, the majority of whom are Malays Muslims (70-80%) are labelled as sexual deviants.Malaysia has been reported as the second worst country in the world because of the discrimination, limited work opportunities and criminalisation of transgender people (Morden, 2023).
According to the Department of Statistics Malaysia, Islam is the main practised religion in Malaysia (63.5%) followed by Buddhism (18.7%),Christianity (9.1%), Hinduism (6.1%) and others (2.7 %) (Malaysia, 2022).Islam and Christianity are said to have the lowest tolerance toward transgender in Malaysia (Lee Wei, Baharuddin, Abdullah, Abdullah, & Por, 2012; Rahim, Abdul Rahman, & Yusof, 2020).According to traditional Islamic beliefs, Islam forbids males from behaving like females i.e. dressing, putting on make-up, using hormones to enlarge their breasts or sex reassignment surgery(Y.K Teh, 2001).The Syariah Criminal Offence, under Section 28, Act 1997, a Muslim transgender can be charged for immoral behaviour and liable to a fine not exceeding RM1000 (USD1=RM5) or to imprisonment not exceeding one year, or both.The non-Muslim transgender person too can be charged with indecent behaviour for cross-dressing under Section 21 of the Minor Offense Act 1955 (Yik Koon Teh, 1998).
Sex work is a non-stigmatizing term for "prostitution".According to Nadal et al. (2013), sex work is defined as engaging in promiscuous acts in exchange for money (K.Nadal, Davidoff, & Fujii-Doe, 2013).Other scholars describe sex workers as women, men and transgender people who exchange sexual services, performance, or product for material compensation for money, goods, housing, food, drugs and also to generate income even if those practising do not consider sex work as their occupation (Fisher et al., 2023;Max Nicolai, 2021;Overs, 2002 The Ministry of Health Malaysia (2015) reported that there were an estimated 24,000 trans women sex workers ((MOH), 2015; Said et al., 2022) in the country.Another recent study stated that it is estimated 15, 000 trans women are sex workers in Malaysia (Said et al., 2022).A study conducted by Teh Yik Koon in 2002 in Malaysia stated that 54% of trans women in her study admitted to being sex workers and 92% said that they had received payment for sex.
Trans women in Malaysia are commonly labelled as sexual deviants and perverts (Sa'dan, Awang, & Rahman, 2018) resulting in discrimination by family and society, social stigma, low social status, and lack of qualifications as the majority of them are unable to secure good job (Liaw & Tharumaraj, 2023) and they turn into sex workers who work part-time just to gain some income (Rahim et al., 2020).Transgender in Malaysia deal with limited opportunities for formal employment and face workplace struggles (Liaw & Tharumaraj, 2023).Many run away from family to avoid conflicts.These factors push trans women to engage in sex work (Jenkins,  Historically, trans women at some degree faced unequal treatment from society Difficulty in getting jobs and earning a decent salary to sustain a fair lifestyle are the most common driving factors toward sex work (Lee Wei et al., 2012;Liaw & Tharumaraj, 2023).Besides economic reasons, sex work has also been used as a self-development tool, to be desired and admired for their beauty and feminine expression.It provides an avenue for them to feel confident, experience pleasure, provide an opportunity to meet a long-term partner and affirm their gender identity (Vartabedian, 2017;Sam Winter & King, 2011).In Malaysia, the majority of trans women sex workers solicit clients in dark alleys.However, with the advent of technology, they now source clients online using websites or apps available on their mobile phones.This new technology has enabled the marketing and promotion of prostitution (Hughes, 2003) (Barmania & Aljunid, 2017).This study aims to understand in depth the factors which motivate sex work among trans women, how they source their clients and to explore their knowledge, attitude and practices on safe sex.

Study Design
This qualitative study was conducted among the trans women community living in the Northern Region of Peninsular Malaysia and it is part of a larger study.

Population and Sample
This study was conducted among members of a Non-Governmental Organization (NGO), which work with transgenders, specifically among trans women in the northern region of peninsular Malaysia.The committee members of the NGO helped in identifying and recruiting participants.Trans woman aged 18 years old and above who or had worked as a sex worker was eligible to participate.A convenient sampling method was used to recruit participants.Because of the sensitive nature of the study and because of the difficulty to get access to the respondents with the target characteristic, the snowball sampling method was applied.These respondents were approached with the help of the NGO representative.All respondents gave their written and oral consent before the interviews.

Tools
In-depth interviews were conducted using a semistructured interview guide.The interviews focused on why and when they became a sex worker; how they sourced their clients, their knowledge and practice regarding safe sex and challenges faced as a sex worker.The data were collected from April 2019 to April 2020 using face-to-face interviews conducted in the Malay language and recorded.However, because of the COVID-19 pandemic halfway through the study, five of the interviews were done using the google meets application.Data were collected until saturation was achieved (Charmaz, 2006).Thirteen of the respondents were interviewed in-depth and based on Hennink and Kaiser's paper in 2022, saturation is achieved after 9-17 interviews (Hennink & Kaiser, 2022).

Analysis
An inductive approach was used to analyse the data obtained from the in-depth interviews to identify and generate codes and themes.Verbal data retrieved from the face-to-face interviews were transcribed verbatim.Repeated reading was performed by the researchers to familiarise themselves with the contents.The researchers re-read the transcripts and identified codes after looking at the patterns of data, taking important notes and marking ideas for the coding process.The coding framework identified mirrored the idea of experience, perception and knowledge of sex work.Meaningful statements were assigned to the relevant codes using NVivo version12 software.The codes were sorted into potential themes and sub-themes, and this step was established after a consensus through discussion among the research team members.The extracted data were reviewed to determine their relevance and relationship with the themes or sub-themes.

Ethics
The research received ethical approval.All respondents were given an information sheet which provided information concerning the study including the objectives, benefits and their rights as respondents whether to participate or not and the right to withdraw from the study at any time.
Once the respondents read the information sheet, written and verbal informed consent and permission to audio-record the interviews were obtained from the respondents.Each respondent was given a unique identifier code to ensure confidentiality of the respondents.Data is stored on the principal investigator's laptop who is the sole person with access to the data.

Results
The socio-demographic characteristic of the respondents is presented in Table 1.A total of thirteen respondents were interviewed, and their ages ranged from 22 to 56 years old.The majority of them were single except one who was a divorcee.Ten of them were working full-time, and the rest had part-time jobs.Most ( 9) had the highest level of education up to secondary school.Their monthly income ranged from RM900 to RM8,000 and most of the respondents were living with their families.

Themes
The findings from this study are laid on the axial themes which are derived from the three main themes.Sex work and two sub-themes; the reasons for being a sex worker which is money and enjoyment are shown in Table 2.
Twelve respondents were categorized under the sub-theme "money" and five respondents under "enjoyment".Most of the respondents lamented financial problems despite most of them having jobs.Sex work was a way to get money.Some of the respondents also mentioned that they needed more money as their salary was insufficient to purchase hormones, attires and cosmetics.A number of the respondents claimed that limited opportunity to get employment had compelled them to become sex workers.
From these two sub-themes, several axial subthemes were obtained: extra money, living expenses, employment, easy money, lust and fun.

Axial Theme 1: Extra Money
Most of the respondents mentioned that they worked as sex workers to supplement their income

"I need money… I get extra money by doing this job (sex work)...extra money for life necessities, extra money to buy all the necessary things like make-up, nice dresses and also to buy hormones... hormones are expensive" (Respondent 5)
Unemployment and not having a steady job were commonly cited for sex work."...yes, when I stopped working at the factory because the factory was not doing well at that time, I needed money…my friends said I needed to be independent and source my income… I had to do this work (sex work) to ensure that I had enough to eat… this is why I do this (sex work)…I do this because of the money, not for fun...if the customer wants it (sex) for free, sorry, I won't take that customer.." (Respondent 3) Axial Theme 2: Living Expenses Some lamented that sex work has become the only source of income to support them after being chased out of their homes by family members, mostly because their parents could not accept their decision to become a trans woman.Others moved from their family homes because of stigma and conflict and thus had to supplement their insufficient income.Even when they were employed, because of their meagre income, they couldn't wait for the end of the monthly salary (in Malaysia, salary is commonly paid at the end of the month) and sex work provided an opportunity for quick cash.Most did not like doing sex work because of the unsavoury characters and desires of their clients.There were others, who did not like becoming a sex worker but eventually adapted to the work.
"When I worked as a waitress in Kuala Lumpur, I also worked as a sex worker part-time...I became a sex worker to cover the cost of my education.Because I was chased out of my home, I had no income… so my senior suggested that I do it (sex work)… I did not enjoy it even a bit and if I followed what my heart wanted, I would not do it… it is not what I liked because I had to attend to all kinds of whims and fancies of clients… also I was worried of getting STI (sexually transmitted illnesses) and I was afraid of that" (Respondent 1) Axial Theme 3: Hard to Get Proper Employment Some of the respondents faced discrimination when seeking employment.Employers often rejected transgenders because of their appearance and gender expression, disregarding their qualifications.Respondents said because their outlook was different from that stated on their national identification card, employers found excuses not to employ them."...that time I did not see any other opportunity as a transgender… it was the 90s, that time, it was very hard for transgenders... when it came to transgenders, it was always connected to sex work… that time it was very hard, people (society) were judgmental, no opportunities were given to transgenders, we were discriminated and became victims...many become sex workers..." (Respondent 2) Even when they were qualified, employers did not hire them with no reason given.Because of this, they had to work harder and work multiple jobs to support themselves and also at times their family.

Axial Theme 4: Easy Money
Easy and fast money are other reasons cited.They felt that they could be paid immediately instead of waiting for a salary at the end of the month.They can earn daily and not wait until the end of the month.

Axial Theme 5: Lust
For some transgenders, they enjoy being sex workers because it gives them pleasure and it fulfils their lust

"...I still do this job (sex work) now… I do it because of the lust… I desire for it (sex)" (Respondent 3)
However, not all transgenders are cut out for sex work, as narrated by Respondent13; "Sex work is not for all, sex work is a talent and if you do not have the talent or desire, you will be depressed dong it…some transgenders do sex work because it is one of the quickest ways to get money... secondly, to get the emotional connection from men.

Axial Theme 6: Fun
The only respondent to fall under this axial theme was R12 who claimed that she did sex work because it was fun for her, as she narrated: "I worked as a showgirl, after the show was over, I will do sex work...just for fun...just to enjoy the time… I can wear all the nice and beautiful dresses and make-up... it is fun...it is more fun if we can grab the attention of the clients..

. and clients are looking at us with lust… sex worker's life is glamour and fun " ( R12)
The second theme found in the interviews is how they sourced clients with two sub-themes and axial themes which are laid down in Table 3.
All the respondents have their way to get clients.Some of them get help from pimps while others use dating applications or online websites.

Axial Theme 1: Help From the Pimp (Mak Ayam)
When asked about how they sourced clients, two respondents mentioned that they have pimps to help them.These pimps called 'mak ayam' not only help with getting clients but also provide a room for a minimal fee.Interestingly the respondents had no complaints about the 'mak ayam', rather they claimed that the mak ayam were the ones who usually reminded them to wear a condom when having intercourse

Axial Theme 2: Application or Website
The majority of the respondents mentioned that they were using online apps, websites and other social media avenues to source clients.The availability of these applications and websites made it easy for them.They will usually post their profile on these websites and wait for the clients to call.The charges for their services ranged from RM100 -RM500 per session.

"..I use an app…usually, they will come to my house, the charge is RM200 per hour...the most expensive I have ever charged is RM500...it is cash transaction…if it is Facebook, they can see my face and I can see his face too…usually, I will choose based on if he has a good job, (look) hygienic and good looking…importantly, look hygienic and clean.." (Respondent 10)
Axial Theme 3: Dark Alleys or Entertainment Clubs Besides using online sources to source clients, three respondents narrated that they stood in dark alleys or The third theme that was found was safe sex practices.The sub-themes and axial themes are presented in Table 4.

Axial Theme 2: The use of a Condom
The use of condoms is ubiquitous and they ensure their clients wear a condom during sexual intercourse.However, some said they don't mind not using condoms when their clients are good-looking. "

Axial Theme 4: Counselling
The respondent's level of awareness of STI is attributed to the NGOs working with them.The older trans women sex workers interviewed now counsel the young and those unaware of STI and how to prevent it.

"Trans women in Penang are very lucky because we have a reference place (STI clinics)… the new generation of trans women when they see real-life cases of HIV/AIDS, become scared and want to learn more on STI and how to prevent it… the advocacy on
HIV and AIDS should be continuous to make them (the new trans women sex workers) understand it" (Respondent 13)

Discussion
Findings from this qualitative study showed that money was the main motivation for being a sex worker mainly because of the inability to be gainfully employed, supplement their income and support their living expenses.Lust and fun activity were also cited.Most solicited clients online, whereas others used the services of a pimp and few would stand in dark alleys or get clients in entertainment clubs.All of the respondents were aware of safe sex and regularly tested for STIs every 6 months.
Very few studies in Malaysia looked at the factors related to trans women as sex workers.Although the term sex work conjures up an idea of working but not all sex workers identify themselves as sex workers but instead just as means to achieve their ambitions to become dressmakers, hairdressers, florists or cosmeticians etc. (Koon, 2002).Most were forced to work in the sex industry to earn a living and for survival (Equal Right Trust, 2011; Lee Wei et al., 2012) because most trans women are not accepted by society and some, even by their own families.They are rejected at home and school.They run away from their homes usually in their teens to avoid conflicts such as verbal and physical abuse and discrimination by family members, neighbours, workplace and community (K.Nadal, Davidoff, Davis, & Wong, 2014; K. Nadal et al., 2013;Sa'dan et al., 2018;Said et al., 2022).They grow up feeling rejected by people who were close to them and when they leave their homes or were kicked out at an early age, they were not able to complete their studies.Very few of them hold a tertiary level certificate or degree (Sa'dan et al., 2018).Lack of qualification has limited their abilities to find high-paying jobs.Unable to locate or maintain employment due to gender discrimination is another common problem (Maliya et al., 2018) Studies have suggested that sex work is associated with the emotional needs of trans women to become a true woman and to be sexually desired as a woman in a social environment (Howe et al., 2008; Infante, Sosa-Rubi, & Cuadra, 2009).According to Juleita Vartabedin (2017), sex work is an empowering activity which allows trans women not only to earn money but also to develop self-confidence and at the same time experience pleasure from it (Vartabedian, 2017).Nadal, Vargas and colleagues (2012) study reported that transgenders were involved in the sex work industry because they felt appreciated as real women by their male clients, an appreciation that they did not receive in other aspects of their lives (K.L. Nadal, Vargas, Meterko, Hamit, & McLean, 2012).A recent case study among the transgender women in Malaysia found that majority of the respondents admitted that they work as sex workers because of their desire and the struggles to secure formal employment due to discrimination (Said et al., 2022).In fact, study done by Liaw and Tharumaraj in 2023 acknowledged that transgender women in Malaysia have limited opportunity in seeking formal employment because of various factors including safety concern, suppression by government bodies and discriminatory practices by the employers (Liaw & Tharumaraj, 2023) A study conducted in Malaysia more than 20 years ago mentioned that soliciting clients was done by waiting at railway stations and mostly involved using the services of a pimp.However, with the advent of information technology (IT), sourcing clients online has become the most common medium to get clients (Farley & Kennedy, 2020;Hughes, 2003;Vartabedian, 2017).
Trans women in Malaysia are marginalized and vulnerable, more so trans women sex workers.They are at high risk of contracting HIV/AIDS and STI (Barmania & Aljunid, 2017;Gibson et al., 2016;Koon Teh, 2008;Said et al., 2022).A study by Gibson et al. (2017) revealed that most of the 'Mak Nyah' in Malaysia avoided being tested for HIV or STI because they fear the stigma of a positive test result (Gibson et al., 2016).These findings are contrary to the findings of the present study where all the participants in this study mentioned that they were aware of HIV/AIDS and they were aware of safe sex and the importance of using condoms.They get themselves tested every six months and also frequently get counselling for safe-sex activities.

Conclusion
The primary objective of this study is to gain a comprehensive understanding of the underlying motivations that drives trans women to engage in sex work.Additionally, it seeks to investigate the methods employed by trans women to source their clients, as well as to examine their level of awareness, attitudes and practices pertaining to safe sexual practice.The findings indicate that the key motivation for trans women engaging in sex work is predominantly influenced by financial reason and enjoyment reason.The challenges associated with obtaining employment and the necessity to meet basic living expenses leads to monetary issue.Consequently, many resort to engaging in sex work as means to get quick and accessible monetary resources.In addition to this, it is worth nothing that these transgender women have chosen to participate in sex work because of the personal pleasure it provides.These individuals were having fun socializing and this activity satisfy their sexual desires.
A significant proportion of the trans women sex workers utilise internet applications to source for their client and some with the help of intermediaries commonly referred to as pimp.Trans women who engage in sex work sometimes frequent dark alleys or entertainment clubs in order to solicit clients.The study's findings indicate that there exists a notable degree of knowledge and awareness regarding the importance of safe sex, engaging in preventive measures and undergoing HIV and STI testing.This qualitative assessment contributes to the limited information available on trans women sex workers.

Strength and Limitation
The design of this study provides an opportunity to gain a comprehensive understanding of the reasons for sex work and the factors associated with sex work among trans women.However, the sample size of the study population is small, it cannot be extrapolated to the entire trans women sex worker population, not the trans women population as a whole.The author recommended that more studies will be conducted in future to understand how these trans women are involved with sex work. ).

Table 3 : Theme 2 : How to source clients
The knowledge and awareness that they received from the NGOs have made these sex workers aware of the importance of blood testing for STIs.All of the respondents conducted blood tests once every six months or sometimes even once every three months.Only one respondent gave a history of having been infected with an STI.
"I am afraid of STI...I am scared…but what to do, my work is such… I need to be careful and need to wear a condom...I test every 6 months… so far I don't have any experience and problems with any infections" (Respondent 11)

Table 4 : Theme 3: Safe sex
(Howe, Zaraysky, & Lorentzen, 2008;nd that being unable to find gainful employment was a reason for part-time sex work and for making quick money (Equal Right Trust, 2011; Koon, 2002; Said et al., 2022).Studies in 2016 and 2022 stated that the difficulty in getting a job has forced them to work as sex workers for financial reasons (Said et al., 2022; S. Winter et al., 2016).A review by Sam Winter and Mark King in 2014, mentioned that trans women in South East Asian countries were unable to obtain employment except in 'ghetto' occupations such as sex work (Sam Winter & King, 2011).Even in high-income countries like the United States of America financial survival is cited for trans women to turn to sex work(Boles & Elifson, 1994).Besides the fundamental financial requirements, those in the process of transition require money for hormone injections or pills, sexual reassignment surgeries, cosmetics and all the necessary items to fulfil their desired feminine appearance which is costly and expensive(Howe, Zaraysky, & Lorentzen, 2008;