Think Piece

Islamic History and Medicine in Trans Muslim Lives

By Shireen Hamza

“Without desire, …research would never take place: we would be unable, literally unable, to discover anything. But at the same time, we have to bring this under control.”
— Carlo Ginzburg, Twelve Snapshots from a Conversation with Carlo Ginzburg

“For too long, Black trans people have fought for our humanity, and for too long, cis people have been acting like they know what the fuck are talking about.“
— Ianne Fields Stewart, rally in Brooklyn, NY, on June 14th, 2020

In the year 952 AH/1545-1546 CE, writes the historian al-Muḥibbī, ‘Alī ibn al-Rifā’ī, a brown-skinned boy who had yet to grow a beard, was binding books in the Damascene district of al-Qaymariyya. A man named ‘Abd al-Raḥmān ibn al-Ẓannī was passionately in love with ‘Alī. By the end of al-Muḥibbī’s tale, ‘Alī – now a woman called ‘Aliyyā – had given birth to several children with ‘Abd al-Raḥmān, and most of Damascus could attest to this. In al-Muḥibbī’s telling, ‘Alī’s gender shifts after both doctors and the jurist presiding over the court declare ‘Alī to be a woman,  ‘Aliyya. However, the marriage contract that would have been drawn up for them would likely have shown a neater and more normative reality: that a man named ‘Abd al-Raḥmān wed a woman named ‘Aliyya. Reading about ‘Alī/’Aliyya makes me wonder: how many other stories of “non-binary” Muslims are hidden in plain sight in the documentary record of Islamic history? What keeps historians from seeing them? And who stands to benefit from an increasing awareness of the history of sex and sexuality in the Islamic world?

Many scholars of Islamic history acknowledge that gender and sexuality are historically contingent, and that the process of gendering people was enacted primarily through “social and legal discourses,” for example by Islamic law. However, scholarship on the premodern Islamic world often rests on the implicit assumption that there are, now and historically, only two “real” sexes – which many historians would contest. The process of premodern “sexing,” or medical sexual differentiation, was determined by physicians whose understanding of the body was rooted in a largely Galenic paradigm in which “ideas about conception easily explained nonbinary sex,” and the determination of sex “did not necessarily depend on genital morphology,” but also on a variety of other physical attributes. 

Physicians’ understandings of sex did not automatically sort humans into men and women but included other sexes in between. These views in turn influenced jurists as well as authors of lexicons like Ibn Manẓūr and popular encyclopedias like al-Qazwīnī, for whom sex differentiation could lead a fetus to develop into one of five sexes: woman, masculine woman, khunthā, effeminate man or man. Thus, their discussions of surgery on a khunthā’s body are not described as corrections of sex or gender, but rather seek to relieve discomfort, enable intercourse for married people, and overall, to serve “an individual’s health and religious needs.” Paired with the understanding that one’s sex (and depending on whether this caused social disruption, perhaps also one’s gender) could change through the course of one’s life, medieval Islamic understandings of sex start to seem quite different from biological sex. 

Stories like ‘Alī/’Aliyyā’s and ‘Abd al-Raḥmān’s have great importance for queer and trans Muslims, to whom a range of conservative institutions suggest that Islam and LGBTQI+ identities are incompatible. Iran and Pakistan have received significant attention for their government programs providing specific kinds of trans affirming healthcare (in contexts in which homosexuality is illegal). Such government programs are grounded in a legal synthesis of biomedical and classical Islamic legal understandings of sex. Although official government policy has not led to widespread societal affirmation of trans, hijra or khwaja sira people in these countries, these institutional changes are a crucial part of a broader transformation. Iran’s legal stance on trans people has enabled contemporary Iranian filmmakers like Negar Azarbayjani, director of Facing Mirrors, to tell stories of contemporary trans people cinematically. Historians have the power to access and amplify narratives from the past that may inform both institutional and societal change today.

Historians of the premodern Islamic world study different configurations of law, medicine and state power. The work of historians shows that when the state has intervened on issues of ambiguous sex, the outcomes for those whose sex is called into question are not always positive, as with the wife of Muḥammad ibn Sallāma in 1506 CE. Amīr Ṭarābāy called on women, presumably women with medical training, to determine the sex of Muḥammad ibn Sallāma’s wife. After determining that she was not a woman or a khunthā but a man, the Amīr brutally punished the couple, who died as a result. Although difficult to read for queer and trans people who are subject to myriad forms of violence, this story is nonetheless one which shows that people troubled binaries of sex and gender in the Islamic past, thus suggesting that the presence of gender nonconforming and trans Muslims today is no aberrance. 

But these stories are also important for physicians to hear. The history of medicine includes episodes of harm and coercion as well as of care, healing and ingenuity. There is growing historical research on how binary sex and heterosexuality were conceived of and enforced by nineteenth century physicians, scientific sexologists, psychoanalysts, science-writers for the popular press, and many actors of colonial and/or national governance in the Middle East, South Asia, Africa, Latin America, and here, in the settler colony known as the US. There is a history to the “straight” understanding of sex and sexuality – the social and medical views that there are only two true, fixed biological sexes in humans and that heterosexuality is natural. Just recently, as Sean Saifa M. Wall, an intersex activist, says:

Variation in sexual anatomy… should show us how beautifully diverse nature is. It should remind us that anatomical sex is not fixed, but fluid. …But sometimes it feels like debating ethics with butchers. Too many in the medical profession see surgery as their duty.

It is striking how wondrous some writers in the medieval Islamic world considered this fluidity of sexual anatomy to be, while this fluidity has been considered an aberration or monstrosity in other times and places, including our own. Physicians, public health officials and historians are increasingly acknowledging scholarship on the “coloniality of gender” as relevant to their professions – a scholarship which shows how race, gender, sexuality and other emerging categories were co-constructed for marginalized people in both metropole and colony. Physicians in precolonial contexts operated within medical systems that did not rest on binary sex, but within legal and social systems which did tend towards binary gender. Historical accounts of healthcare before colonialism may also provide healthcare workers today with food for thought. While ethicists are calling healthcare providers toward practicing “justice, beneficence and nonmaleficence” by following specific actions in their treatment of trans and gender nonconforming patients in systems not built to accommodate them, the distant past may help us imagine futures beyond the confines of the present. 


‘Alī was a boy until he was a khunthā; he was a khunthā until she was a girl. In this description, I follow the gender pronouns ascribed to ‘Alī by al-Muḥibbī. No explicit reason is given as to why ‘Alī and ‘Abd al-Raḥmān were called before the judge, Kamāl al-Dīn al-’Adawī, but al-Muḥibbī suggests that it had to do with ‘Abd al-Raḥmān being in love with ‘Alī. The judge said, upon first consideration, that ‘Alī seemed to be a khunthā, and that he “tended towards being female.” He called in physicians to examine him. These physicians discovered a vulva, hidden beneath a (skin) covering with “three small nipples,” which they cut away. The judge ruled on ‘Alī being a woman, and they named him ‘Aliyyā. al-Muḥibbī then starts referring to ‘Aliyyā with the feminine pronouns, to say she was married to her lover, ‘Abd al-Raḥmān. 

حكم الحالكم الشافعي بأنوثته و سموه عليا و زوجوها بعاشقها عبد الرحمن 
The Shafi’i Judge ruled on ‘Alī’s womanness, and they named him ‘Aliyyā and married her to her lover ‘Abd al-Raḥmān. 

al-Muḥibbī offers no explanation as to who this “they” is, but the sentence implies that it was people other than the judge who did so.

In this story, the authority of physicians and the law, combined, officially changed ‘Alī’s gender with almost no surgical intervention. As al-Muḥibbī reports, most of the people of Damascus knew about these events and could attest to their veracity – implying, perhaps, that rather than any public outcry, the story was considered strange, wondrous, marvelous. al-Muḥibbī’s account, and many other stories involving physicians, leave many important questions about medical ethics unanswered. Was the love ‘Abd al-Raḥmān had for ‘Alī requited? Did ‘Alī consent to the examination and intervention by doctors? Did ‘Alī want to live as ‘Aliyyā, and as ‘Abd al-Raḥmān’s wife? And yet, this story – by no means an ideal for doctors and courts today – has the power to unsettle people’s presumptions about sex, gender and sexuality. 

Several kinds of texts and documents form a fragmentary and checkered archive for understanding the lives of khunthā, people neither men nor women of a “medial sex” in the premodern Islamic world. Both medical texts and juridical texts speak to what the doctor and jurist should do when encountering someone whose sex is ambiguous. As Saqer Almarri writes in his translation of the passages about khunthā in one such legal text, “evidence of the historicity or the specificity of the lives of people” is rare, but legal manuals still tell us something about the social and cultural contexts that shaped them. Surviving legal documents, however, show us glimpses of law in practice, as records of events like marriage, divorce, business transaction and partnerships, disputes, the purchase or sale of enslaved people, and inheritance. While some kind of narrative emerges from these documents, they are not always as detailed as the one about ‘Alī/’Aliyyā related by al-Muḥibbī above. In practice, as Sara Scalenghe argues, jurists like al-Ramli in the seventeenth-century often “chose to brush aside the evidence of contradictory signs of maleness and femaleness” in order to enable someone to continue living within a gender role, opting for “the least problematic verdict.” Historical chronicles took biography or “life-writing” of exemplary figures, as well as ordinary and even disreputable people, as the unit organizing history. The stories in these chronicles do not often describe the “adjudication by urination” (ḥukm al-mabāl) test that is ubiquitous in legal manuals as a way to determine whether a khunthā is a man or a woman, casting doubt as to how prominently this was used in practice. In short, none of these texts allow us unmediated access to the lives of people categorized as khunthā in the premodern Islamic world. The best work on the khunthā and other elusive archival figures, like hermaphrodites in early modern Europe, has been done by reading across multiple genres.

The texts and documents themselves may give us reasons as to why some genres are forthcoming, and others entirely silent, about the khunthā. To the best of my knowledge, the mention of someone as a khunthā in marriage or divorce contracts is rare or nonexistent because, as both the historical and juridical manuals show, jurists tried to resolve cases by declaring a khunthā to be either a man or a woman. This enabled a khunthā to live as either a man or a woman, sometimes with a lover who had previously been forbidden, as in the case of ‘Alī/‘Aliyyā’s marriage to ‘Abd al-Raḥmān. Databases make digitized documents in Arabic and Persian, including marriage contracts, increasingly accessible, but this additional awareness of historical realities is also necessary when approaching these kinds of documents. Otherwise, the silencing, first enacted in the creation of the archive, is repeated by the modern historian. As scholar Indira Falk-Gesink says: 

Twentieth-century academic prejudices colonize and efface the sexualities of the past, overwriting authors’ words with “corrective” translations, in the process constructing a palimpsestic narrative laden with heteronormative cisgender assumptions that invalidate the efforts of contemporary Muslim activists to reconstruct authentic bases for pluralism.

Let us rid ourselves of these prejudices in our engagements with people, past and present. 


Recently, the Trump administration sought to establish a definition of fixed, binary sex based on genetic science, thereby making irrelevant “what the medical community understands about their patients – what people understand about themselves.” The administration tried to eliminate transgender civil rights protections to nondiscrimination in healthcare in the middle of a pandemic, and on the anniversary of the massacre at Pulse Nightclub in Orlando. Transgender people have long faced refusal of care and harrassment in medical settings, and if not overruled by the Supreme Court, the suggested changes to the definition of sex would have made discrimination against trans people legal. 

I am not arguing that there is a direct, linear correlation between reading stories of sex and gender diversity in the Islamic world and affirming and accepting behavior towards people today. There is no shortage of literature, scholarly and otherwise, about the ways certain pious Sufis flouted norms of gender and sexuality in their search for earthly and divine love, but this is a vision of the Islamic past that is increasingly decried and censored. And as previous generations of scholar-activists have done, today’s scholars of Islamic Studies need to pair research on past marginalized lives with advocacy for those in the present. 

And for those who are interested in providing medical care that fully addresses the needs of queer and trans Muslims to be affirmed in body, mind, spirit, and history, a collaboration between historians, medical workers, faith workers, archivists and community organizations may be necessary. Too often, LGBTQI+ Muslims are presumed to have automatically left faith behind. Those working in healthcare may find that – despite the gruesome reputation that premodern and especially medieval medicine has in popular culture – there are yet reasons to reflect on these past encounters. There may be resources available therein to stimulate conversations about how to better serve the needs of queer and trans Muslims. 

Most Islamic bioethics is rooted in the literature produced by jurists and ‘ulamā’ broadly, rather than considering the words and actions of ordinary Muslims, insofar as we can discern them, to be a resource. But to the many Muslims living on the margins of the umma, there may be other voices that are important for historians to attend to and amplify, and for bioethicists and physicians to consider. For example, stories like ‘Alī/‘Aliyyā’s are meaningful to many queer and trans Muslims today — although the use of terms like LGBTQI+ to describe people in the past has been interrogated extensively by historians, who prefer us to learn the terms used by those past people, when we can. But the affinity of many queer and trans Muslims with different kinds of “deviant” and marginalized people in the Islamic past runs deeper than finding lexical similarities with the identities some people use today. This June, a month of pride, is also one of the remembrance of ancestors, and mourning for those lost – whether to murder, to suicide or to the indifference of governments during a pandemic

Historians bring our own desires to the texts we read. No longer do those in the ivory tower claim a view from nowhere, an objectivity – this claim, too, has been historicized. The desires of LGBTQI+ Muslims today for stories that may have a bearing on the community’s intense marginalization should be heard as a call to action for those of us with the time, privilege and skillset to be able to heed it. This desire is one to center and respect in our research, whether one believes one works on sex and gender or not. It is a desire that has been, and will be, generative – not only for research, but for the lives of everyday people.

Shireen Hamza is a doctoral candidate in the History of Science at Harvard University, working on the history of medicine and sexuality in the premodern Islamic world. She is also a managing editor of the Ottoman History Podcast and editor-in-chief of Ventricles, a podcast on science, religion and culture.

Featured Image: Poster of Facing Mirrors. Directed by Negar Azarbayjani. Facing Mirrors is defined by The Film Collaborative as “the first narrative film from Iran to feature a transgender main character.”

Think Piece

Remembering MERS in South Korea: Mobilizing Experience of Epidemic Disease

By John DiMoia

Poster at Incheon Airport requesting passengers with MERS symptoms to report themselves to public health authorities (author’s photo: June 2015, Incheon, ROK).

With South Korean elections held in mid-April (April 15th), one of the major issues became the Moon Jae-in government’s handling of the COVID-19 crisis. Though briefly one of the world’s leading countries in terms of the number of cases as of mid-February, the nation has since earned international praise for its ability to “flatten the curve,” quickly reducing the number of cases through an intensive testing and tracing program. Indeed, the government has been quick to claim credit for the collective response of its public health workers, earning public trust, and aiming for electoral success. Still, the question remains: which experiences in the Korean past contributed to this impressive output? Could it be, as some have suggested, that the experience of SARS played a role?

Following the SARS (Severe Acute Respiratory Syndrome) outbreak of 2003, governments throughout the greater East and Southeast Asian region mobilized the lessons they claim to have “learned from SARS.” This was certainly the case with H1N1 (2009) in Singapore; and later, with the MERS (Middle East Respiratory Syndrome) outbreak which took place in South Korea (2015). Although the analogy to SARS is understandable, an easily available comparison, I suggest here that there are much richer possibilities in the Korean past for understanding the present circumstances of COVID-19. Although SARS is clearly an important precedent, the disease carries with it a great deal of ideological baggage, seeking to blame China specifically for a failure to ensure reliable reporting of cases, and for a corresponding failure to be transparent and maintain communication with international institutions. It was MERS, rather than SARS, which helped to reshape the South Korean experience, especially as it surprised a large number of people, including those in charge of the public health system.

Public Health: Origins in Successive Crises
Before touching on MERS, we should first recall the spread of epidemic disease in the late 1940s as the formative context for public health in Northeast Asia, especially following the closing weeks of World War Two. Japan neglected the peninsula’s infrastructure in the later war years, given the need to fight on multiple fronts. In 1945 and following, with the Korean War (1950-1953) soon to come, the migration of refugees between China, Japan, and South Korea led to frequent outbreaks of cholera and typhus. The joint occupations of Japan (1945-1952) and South Korea (1945-1948), along with the resumption of China’s civil conflict (1945-1949), heightened concerns for American military authorities. During the Korean War, the hanta virus, manifesting itself in the form of hemorrhagic fever, led to kidney ailments for combatants regardless of their ideology, and some historians have speculated about linking this development to Chinese and North Korean allegations of biological warfare. As a coda to this story, Dr Ho Wang Lee, a Korean physician, isolated the virus in 1976, bringing a successful result to a quest beginning with the war.

If the rapid spread of epidemic disease in the region lingers powerfully in Korean memory, a related point concerns the South Korean public health system as an ongoing set of bureaucratic institutions, a significant number of which derive their origins in part from late Japanese colonial rule (1910-1945) and the subsequent period of Korean military rule (1961-1987). The period spanning the late 1940s through the 1970s witnessed the gradual introduction of national health insurance (1963, 1977), with major reforms coinciding with the arrival of democratization (1989). At about the same time (1954-1960) as the earliest forms of health insurance, many South Korean hospitals received international aid in the aftermath of the Korean War, and began transforming their approach to clinical practice with new resources and medical pedagogy from Europe (Norway, Sweden, and Denmark) and the United States (University of Minnesota). If South Korea now possesses biomedical facilities more than capable of handling any crisis, the practices and institutional norms at these sites were nonetheless acquired under very different conditions at mid-20th century. This was medical care directed at an emergency situation, one filled with refugees, bodies, and the exigencies associated with wartime conditions and its immediate aftermath.

With these difficult circumstances, beginning in the late 1950s, South Korea pursued a series of ambitious national health campaigns, first targeting chronic disease, such as leprosy, tuberculosis, and malaria, often working in conjunction with the WHO (World Health Organization). These campaigns were followed by additional schemes, associated with a heavy dose of social engineering, here including Family Planning (1964-mid 1980s), and Anti-Parasite Campaigns (1968-early 1990s). Once again, efforts were carefully coordinated with international partners and institutions, including the Population Council and Japanese technical cooperation (JICA, Japan International Cooperation Agency). Moreover, the second of these campaign, targeting parasites, focused on school-age children, requiring them to submit stool samples on a bi-annual basis, with teachers collecting the “data” before it was analyzed. The stories from these campaigns indicate that there was a good deal of unfamiliarity with the Korean state’s goals, and sometimes, embarrassed students avoided school, or submitted a pet’s sample in place of their own. Only through concerted efforts, including posters, print ads, and public outreach could the government make its public health intentions clear. The generations of Koreans raised in the post-Korean War era through the early 1980s soon learned to become familiar with frequent health interventions (inspections, vaccinations, samples), whether at school, the office, or comparable public institutions.

The MERS Mishap (May-June 2015)
Give this successful legacy of national campaigns, and a developmental trajectory often assumed to be “progressive,” the MERS scenario began modestly, with health authorities assuming that it would not represent a major problem. The disease was framed as a “foreign” problem, with MERS manifesting itself in 2012, and only three years later appearing in Korea. Posters placed at Incheon airport, and also at rail and bus stations, typically depicted a camel and a palm tree (see Figure One) to underscore the external nature of the virus, which would require a Korean to travel through the region to be exposed. One famous poster illustrated the disease with a bactrian, or two-humped camel (see Figure Two), which is not the species associated with the spread of MERS. A relaxed attitude, and the freedom of movement permitted to possible cases, caught the system by surprise, leading to a genuine health problem, and a related political problem for the government of President Park Geun-hye. This series of events soon became the largest outbreak of MERS to occur outside its original setting.

South Korean poster illustrated with a two-hump Bactrian camel (author’s photo).

The diverse stories emerging during the spread of MERS illustrate a strong continuity with earlier historical developments, as the first patient traveled to four hospitals over a nine-day period, seeking a diagnosis, with uncertain symptoms. In the course of this movement, this individual, along with others to follow, some of whom broke quarantine, infected surrounding individuals, and also the surrounding space of health care facilities. In turn, after the outbreak became public knowledge, Korean patients sought to gain access to major health facilities in Seoul, often with crowded, inhospitable conditions in the wards. The structural inequities of the nation’s health care system—the rural / urban divide, geographical isolation, access to public health care in a system strongly favoring its more lucrative, private side—are certainly not new, and very likely exacerbated conditions as MERS made its way rapidly through hospitals, ultimately killing thirty-eight individuals, out of one hundred eighty-five confirmed cases. The largest MERS outbreak to take place outside of the Middle East, this incident served as a critical wake-up call.

Sign posted in a Korean church, southern Seoul, asking church-goers to understand that the facilities are temporarily unavailable due to COVID-19 (author’s photo, March 2020).

As South Korea grapples with COVID-19, receiving a great deal of praise for its series of rapid testing, drive-in checkpoints, contact tracing, and the distribution of masks, we should remember that these developments cannot be attributed to culture, a set of attitudes, or be credited to a narrow set of political interests. If it is reasonable to screen for elevated temperature and related symptoms, we also need to be careful about assuming ready consent upon the part of all Koreans, and to recognize that much of the domestic criticism of the Moon Jae-in government does not make the international press. In fact, the link of the virus to the Shincheonji church has been controversial, with some elderly Koreans complaining about their treatment, and the disruption of church services (see Figure Three).

Ultimately, the MERS outbreak in the region, tied to a longstanding legacy of institutional and structural inequities, brought much-needed attention to these kinds of issues within the Korean health system. A bureaucracy with a lengthy history, health care in South Korea derives from the period of transition following colonialism and two wars—Korean participation in Vietnam (1964-1973) was also extensive, and featured the nation’s first overseas medical outreach—and it holds onto a deeply ingrained set of practices, many of which require periodic updating. MERS became the critical factor calling attention to this need, and the renewed practices of 2020 started only in the intervening period, especially the use of rapid and effective testing.

Coda: This analysis was written prior to the ROK elections held on April 15,,2020. The ruling party of President Moon went on to win an electoral majority. The ROK government has since issued its version of the COVID-19 story as a pamphlet, and it can be found here:

How Korea responded to a pandemic using ICT: Flattening the curve on COVID-19

Suggested Readings:

John DiMoia is Associate Professor in the Department of Korean History at Seoul National University. He is the author of Reconstructing Bodies: Biomedicine, Health, and Nation-Building in South Korea since 1945 (Stanford University Press / WEAI 2013), and with Hiromi Mizuno and Aaron S Moore, one of the co-editors of Engineering Asia: Technology, Colonial Development and the Cold War Order (Bloomsbury / WEAI 2018).