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Original Research 


Basrun et al, 2018;2(3):75–79.

International Journal of Medicine in Developing Countries

Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016

Aiman bin Basrun, Bayan Mohammed Aljawi*

Correspondence to: Bayan Mohammed

*International Islamic University Malaysia, Kuantan, Pahang, Malaysia.

Email: aimanbasrun@gmail.com

Full list of author information is available at the end of the article.

Received: 14 May 2018 | Accepted: 25 May 2018


ABSTRACT

Background:

Smoking is one of the major risk factors for the occurrence of life-threatening diseases. Although there is prevalence of adult smokers, the data on smoking among transgenders in Malaysia are not widely available.


Methodology:

A cross-sectional study was conducted among 45 transgenders in Kuantan town, Pahang from 18 July 2016 to 26 August 2016 using convenience sampling. A self-administered questionnaire consisted of socio-demographic status, smoking status, smoking dependency behavior, and smoking cessation was distributed among the respondents. Data were analyzed using IBM SPSS Statistics for Windows Version 23.0. Descriptive analysis and bi-variable analysis were described for different variables and chi-square test, independent t-test, and one-way ANOVA were the tests used.


Results:

Out of 45 male-to-female transgenders, 44.4% were identified as smokers, either current smokers or former smokers. Majority of them were moderate smokers (50%) while only 5% had a high dependency. There was no significant difference (p > 0.005) between smoking status and age, income and educational background. For smoking behavior, 40% had a strong smoking behavioral score while there was a higher percentage (55%) of smoking transgenders who had never attempted smoking since its cessation in the past 12 months.


Conclusion:

The smoking prevalence among transgenders is almost equal to non-smoking transgenders.


Keywords:

Smoking, transgender, dependency, behavior.

Introduction

Gender dysphoria is the condition of being in a state of conflict between gender and physical sex; it is also extensively known as transgender. A transgender is an individual having sex-related structures of the brain, that classify gender, that are exactly opposite to the physical sex organs of the body. It is also stated that transsexual is defined as a person who feels passionately that they want to live and dress as a member of the opposite sex, especially those who have operation to change their sexual organs [1]. They can be male-to-female transgender (MTF) or female-to-male transgender. In Malaysia, the native term for MTF is maknyah, a term averred by this community themselves to differentiate them from pondan or bapok, which refers to men who are effeminate and, therefore, includes homosexuals [2]. The transgender community in Malaysia every often uses the term “transsexual,” because the ultimate goal of the majority is sex transformation operation or sex reassignment surgery. Transgender people currently in Malaysia are approximately 10,000 in number with about 70%–80% of them as Malays, followed by Chinese, Indians, and other minority ethnic groups. As the Malays hold the majority, most of them are Muslims.

The disputes concerning transgender, often grouped as lesbian, gay, bisexual, and transgender (LGBT), have gained growing attention among researchers. Over the past 30 years, this concern has surfaced as an important and critical area within the study of adolescence [3]. Consequently, numerous factors allude that transgender group may be at peril for high smoking prevalence. Past research has suggested that sexual minority status (including individuals with LGBT identity, and individuals with same-sex relationships and attraction), is associated with higher risk of smoking. Many reasons were given on the factors influencing smoking among transgenders. The most frequent cited reasons were stress, socializing, and peer pressure. Other commonly cited reasons were tobacco marketing, socializing with smokers, and having family members who smoke [4]. Smoking has been found to be more prevalent among groups that experience high level of stress, indulge in places where smoking is prevalent [5].

Lower socioeconomic status is associated with a greater probability of smoking. This was supported by a study that revealed transsexual respondents, with lower household income, had higher cigarette smoking prevalence than those respondents who had higher household income [6]. Prevalence of smoking in transsexual decreased as educational attainment increased, as it does in the general population. This is shown by a study, where respondents among transgenders with lower education attainment had higher smoking prevalence than those with higher education [6].

By contrast, sexual minority men (transsexual) were far more similar to straight male peers (heterosexuals) on smoking behavior outcomes. A large proportion of participants, especially youth, who currently smoke, were ill-acquainted with LGBT non-smokers and could not imagine avoiding tobacco. Among the youth who refrained, had refusal skills and avoided from smokers, and situations or circumstances where tobacco was used, were the most commonly mentioned approaches. The personal experience of knowing someone who suffered the adverse effects of smoking was also considered important by both categories of respondents [4]. Transsexuals had 2.3 times increased chances of being nicotine dependent as compared to heterosexuals [7].

Studies of LGBT adults showed 1.1–2.4 times elevated rates of smoking than that of the general population and a California study found a 30.7% smoking rate for chronic smokers among transgender people [8].

Subjects and Methods

This is a cross-sectional study that was conducted on MTF community in Kuantan town, Pahang. Respondents were chosen among the transgenders in Kuantan, Pahang. All MTF individuals in Kuantan town, Pahang aged above 18 years of age and who were able to understand Bahasa Malaysia or English language were included in this study. Transgenders who refused to take part in this study were excluded.

Data were collected from 18 July 2016 till 22 July 2016 in the selected area of Kuantan town through a structured questionnaire.

SPSS version 23.0 software package, IBM Corp. Release 2015, IBM SPSS Statistics for Windows, Version 23.0 Armonk, NY: IBM Corp. was used to analyze the data. Both descriptive and bi-variable statistics were used.

Results

Mean age of the transgenders was 32 years old (SD ± 11.16) with minimum age of 17 and maximum age of 66 years. Majority of the transgenders were Malay (84.4%) followed by transgenders from Thailand (8.9%), whereas Chinese, Indians, and Indonesians were represented with 2.2% only. The gross monthly income [Ringgit Malaysian (RM)] of the participant was 2033.33. As for the socioeconomic status, most of them were of low-income group which made more than 90% of the population. With regard to the education level of the respondents, more than half had completed secondary school with 31.1% having an education background of at least SPM/O-level. However, only one-third had an education background of tertiary education as diploma and degree holders represented 15.6% and 6.7%, respectively. Table 1 shows the socio-demographic characteristics of transgender in Kuantan town, Pahang.

The Table 2 shows the smoking status among transgender in Kuantan town, Pahang. There were total of 45 respondents. Slightly more than half of the respondents (55.6%) did not smoke.

Table 3 shows the relationship between smoking status, age, gross monthly income, and educational level. Of all the parameters, only income had a significant relationship with smoking status (p = 0.030). However, age and educational level showed no significant relationship to smoking status (p = 0.773 and p = 0.363).

Table 4 represents smoking dependency among transgender smokers in Kuantan town, Pahang. 50% of respondents (N = 20) had a moderate smoking dependency, while only 5% of respondents had high smoking dependency.

Figure 1 illustrates the smoking dependency behavior score of transgenders in Kuantan town, Pahang. Majority of respondents (40%) had a strong smoking dependency behavior score, while only few of them had a mild smoking dependency (10%).

Table 1. Socio-demographic characteristics of MTF in Kuantan town, Pahang.

Variables Category N (%)
Race Malay 38(84.4)
Chinese 1(2.2)
Indian 1 (2.2)
Indonesian 1 (2.2)
Thailand 4 (8.9)
Income group (RM) Low (< RM3860) 4 1(91.1)
Moderate (RM3860–RM8319) 4 (8.9)
Educational level Finish Primary School 3 (6.7)
Finish Secondary School (SRP/PMR) 10 (22.2)
Finish Secondary School (SPM/O-Level) 14 (13.1)
STPM/Matriculation/A- Levels 3 (3.7)
Certificate 5 (11.11)
Diploma 7 (15.6)
Bachelor Degree 3 (6.7)

Table 2. Smoking status for transgender in Kuantan town, Pahang.

Smoking status N = 45 %
Yes 20 44.4
No 25 55.6

Table 3. Association of smoking with socio-demographic characteristics.

Smoking status
Yes No
Variables Category n % n % p
Age (years)* 20 44.4 25 56 0.773
Gross monthly income (RM)* 20 44.4 25 56 0.030
Educational Level** Finish Primary School 2 66.7% 1 33.3% 0.363
Finish Secondary School (SRP/PMR) 7 70.0% 3 30.0%
Finish Secondary School(SPM/O-Level) 6 42.9% 8 57.1%
STPM/Matriculation/A-Levels 1 33.3% 2 66.7%
Certificate 2 40.0% 3 60.0%
Diploma 2 28.6% 5 71.4%
Bachelor Degree 0 0.0% 3 100.0%

* Independent t-test,

** Pearson’s chi-squared test

Table 4. Smoking dependency among transgender smokers in Kuantan town, Pahang.

Smoking dependency n %
Low 6 30.0
Low to moderate 3 15.0
Moderate 10 50.0
High 1 5.0

Discussion

The prevalence of smoking among transgenders in Kuantan town, Pahang was found to be 44.4%. This data corresponds with the evidence from the previous studies where they compared the two populations between transgenders and heterosexuals, as literature review clearly claims that transgenders have a higher cigarette smoking prevalence than their heterosexual counterparts.

Based on the findings, it is reported that half of the respondents had a moderate dependency towards tobacco while one-third of the respondents had low to moderate dependency. This result did not correspond to previous research [8] in which it was specified that 30.7% had a high dependency towards smoking. This might be due to the use of cigarettes only at the workplace, as a means to socialize and interact with clients while being able to withhold from smoking in off hours.

It is known that nicotine is the main contributor in causing smoking dependency. A minimal dose of nicotine is required for initiation and attaining smoking dependency. It is interesting to note that Fallin et al. [7] reported that smoking first cigarette at young age contributes to dependency on nicotine. This contradicts with the findings of this study as it was found that there was no significant difference (p > 0.005) in the age of initiation of smoking with dependency. Although the result does not prove any significance, it is of great importance that most of the respondents started smoking at a very young age. This prompts that further research needs to be done to fully understand the pattern of smoking dependency among transgenders in Kuantan. The fact that smoking is a major contributor to non-communicable diseases, with the effort needed for prevention, it is significant to outline the strategy to curb smoking dependency among transgenders.

The participants of this study had a mean age of 32 years. Based on the findings, there was no significant association (p > 0.005) between the age of transgenders and the prevalence of smoking. The findings did not correspond to a previous study in which male-born LGBT youth were more likely to smoke, with transsexual youth smoked at a higher rate than bisexual youth [9]. The findings also contradict with the findings of another research [4] which concluded that youth transgender were at a higher risk of smoking as compared to their older counterparts. The findings portray that age does not affect the prevalence of smoking among transgenders. Youth transgenders are said to have a higher level of stress due to adjustments of life, which is the most cited reason for smoking. However, in the population of this study, stress affects the whole community regardless of the age as they competed with each other on the same grounds and basis of their economic finances.

Majority of the transgenders were classified under low income and less than 10% of the transgender population were of moderate income. Their primary source of financial income is from prostitution as they are regarded as sex workers. The mean income of the population is roughly of RM2000 per month and various factors play a role in determining the monthly average income. Factors include frequency of going to work, demand, and some clients that affect the overall income. The study also proves that there is no significant association (p > 0.005) between socioeconomic status with the prevalence of smoking among transgenders. The findings contradict with Tang et al. [6] as his research revealed transsexual respondents with lower household income had higher cigarette smoking prevalence than those respondents with higher household income.

Figure 1. Smoking behavior score of transgender smokers in Kuantan town, Pahang.

Approximately half of the respondent transgenders attained education up to secondary school level and did not pursue tertiary education. Only one-fifth of the respondents had certificate, diploma, or bachelor’s degree as their educational background. This is because of the lack of motivation to pursue education as this population is content and happy with their environment of living. Previous studies have revealed significant association between educational background and prevalence of smoking as reported by Tang et al. [6], where respondents among transgenders with lower education attainment had higher smoking prevalence than those with higher education. However, the association was proved non-significant (p > 0.005) in this study where economic background did not influence the prevalence of smoking. Despite the non-significant association, a similar trend could be seen as respondents with higher educational background had a higher percentage of non-smokers as compared to smokers. Transgenders with bachelor’s degree had a 100% of non-smokers as compared to transgenders who only completed primary school which recorded a percentage of 66.7% smokers. Although the association was proved insignificant, the trend of non-smokers with increasing education background may give a different perspective on the severity of the problem.

The majority of smoking transgenders had a moderate smoking dependency of 40%. This is followed by strong, very strong, and mild smoking dependency with 35%, 15%, and 10%, respectively. This study uses the Glover-Nilsson smoking behavioral questionnaire. It is to assess behavioral dependence and determine its association with successful smoking cessation. A tool for distinguishing behavior from physical nicotine dependence.

Moderate behavioral dependence can result in a more successful cessation outcome. The components of this questionnaire such as smoking rituals, environmental triggers, daily routines, and stress relieving, all lead to nicotine dependency when comparing transsexuals to heterosexuals [7].

In this study, about 55% of the respondents (n = 20) said they had attempted to quit smoking within the past 12 months. This study is almost consistent with Grant et al. [8] where more than 50% respondents answered they would like to quit. This might be due to health concerns as reported in a study done by Greenwood et al. [10]. However, this study contradicts with a study done in comparison with heterosexuals, where only 45.2% had reported a past-year quit attempt [11].

Transgender is not a new culture in Malaysia, but it needs everyone’s attention. This research managed to add some knowledge regarding behavioral pattern on smoking among transgender in only Kuantan town, Pahang. This is important to assess the level of behavior among respondents, so that some control measures could be taken. However, due to small sample size (n = 45), the result does not represent all transgenders in Malaysia. The limitation in obtaining a much more accurate prevalence is due to small sample size, the unknown total number of transgender in Kuantan town, Pahang, and the unavailability of previous studies regarding this topic in the state of Pahang. Furthermore, since this is relatively a taboo in our culture, thus not many research studies are found on transgenders. Hence, lack of good references about transgender issues in Malaysia is a limitation of this study. However, this opens an opportunity for this study to be the baseline for further study on smoking habit among transgenders.

Conclusion

The smoking prevalence is almost equal to non-smokers. It is concluded that more extensive research needs to be done addressing the safety and the adverse effects of smoking among transgenders in Malaysia. The idea of modifying behavior in curbing the smoking dependency and its sequelae should be given attention.

Acknowledgment

None


List of abbreviations

LGBT Lesbian, gay, bisexual, and transgender
MTF Male to female
RM Ringgit Malaysian

Funding

None


Declaration of conflicting interests

None


Author details

Aiman bin Basrun, Bayan Mohammed Aljawi*

  1. International Islamic University Malaysia, Kuantan, Pahang, Malaysia

References

  1. Malib’dan MA, Mustafa MSA. Transsexual symptoms: alarming implications, how concern are we? J Bus Soc Dev 2014; 2:48–61.
  2. Teh, Koon Y. The Mak Nyahs: male to female transsexuals in Malaysia. Eastern Universities Press (Times Publishing), Singapore; 2002.
  3. Horn SS, Kosciw JG, Russell ST. Special issue introduction: new research on lesbian, gay, bisexual, and transgender youth: studying lives in context. J Youth Adolesc 2009; 38:863–6. https://doi.org/10.1007/s10964-009-9420-1
  4. Remafedi G. Lesbian, gay, bisexual, and transgender youths: who smokes, and why? Nicotine Tob Res 2007; 9(Suppl 1):65–71. https://doi.org/10.1080/14622200601083491
  5. Ryan H, Wortley PM, Easton A, Pederson L, Greenwood G. Smoking among lesbians, gays, and bisexuals—a review of the literature. Am J Prev Med 2001; 21:141–9. https://doi.org/10.1016/S0749-3797(01)00331-2
  6. Tang H, Greenwood GL, Cowling DW, Lloyd JC, Roeseler AG, Bal DG. Cigarette smoking among lesbians, gays, and bisexuals. how serious a problem? (United States). Cancer Causes Control 2004; 15(8):797–803. https://doi.org/10.1023/B:CACO.0000043430.32410.69
  7. Fallin A, Goodin A, Lee YO, Bennett K. Smoking characteristics among lesbian, gay, and bisexual adults. Prev Med. 2015; 74:123–30. https://doi.org/10.1016/j.ypmed.2014.11.026
  8. Grant JM, Mottet LA, Tanis J, Min D, Herman JL, Harrison J, et al. Findings of a Study by the National Center for transgender equality and the National Gay and Lesbian Task Force. National Transgender Discrimination Survey Report on Health and Health Care. National Gay and Lesbian Task Force, Washington, DC; 2010. pp 1–24.
  9. Newcomb ME, Mustanski B. Racial differences in same-race partnering and the effects of sexual partnership characteristics on HIV risk in MSM: a prospective sexual diary study. J Acquir Immune Defic Syndr 2013; 62:329–33. https://doi.org/10.1097/QAI.0b013e31827e5f8c
  10. Greenwood GL, Paul JP, Pollack LM, Binson D, Catania JA, Chang J, et al. Tobacco use and cessation among a household-based sample of US urban men who have sex with men. Am J Public Health 2005; 95:145–51. https://doi.org/10.2105/AJPH.2003.021451
  11. Johnson SE, Holder-Hayes E, Tessman GK, King BA, Alexander T, Zhao X. Tobacco product use among sexual minority adults: findings from the 2012–2013 National Adult Tobacco Survey. Am J Preven Med 2016; 50:91–100. https://doi.org/10.1016/j.amepre.2015.07.041


How to Cite this Article
Pubmed Style

Basrun Ab, Aljawi BM. Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016. IJMDC. 2018; 2(3): 75-79. doi:10.24911/IJMDC.51-1518969658


Web Style

Basrun Ab, Aljawi BM. Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016. http://www.ijmdc.com/?mno=291414 [Access: November 21, 2018]. doi:10.24911/IJMDC.51-1518969658


AMA (American Medical Association) Style

Basrun Ab, Aljawi BM. Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016. IJMDC. 2018; 2(3): 75-79. doi:10.24911/IJMDC.51-1518969658



Vancouver/ICMJE Style

Basrun Ab, Aljawi BM. Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016. IJMDC. (2018), [cited November 21, 2018]; 2(3): 75-79. doi:10.24911/IJMDC.51-1518969658



Harvard Style

Basrun, A. b. & Aljawi, . B. M. (2018) Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016. IJMDC, 2 (3), 75-79. doi:10.24911/IJMDC.51-1518969658



Turabian Style

Basrun, Aiman bin, and Bayan Mohammed Aljawi. 2018. Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016. International Journal of Medicine in Developing Countries, 2 (3), 75-79. doi:10.24911/IJMDC.51-1518969658



Chicago Style

Basrun, Aiman bin, and Bayan Mohammed Aljawi. "Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016." International Journal of Medicine in Developing Countries 2 (2018), 75-79. doi:10.24911/IJMDC.51-1518969658



MLA (The Modern Language Association) Style

Basrun, Aiman bin, and Bayan Mohammed Aljawi. "Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016." International Journal of Medicine in Developing Countries 2.3 (2018), 75-79. Print. doi:10.24911/IJMDC.51-1518969658



APA (American Psychological Association) Style

Basrun, A. b. & Aljawi, . B. M. (2018) Smoking and male-to-female (MTF) transgenders in Kuantan town, Pahang 2016. International Journal of Medicine in Developing Countries, 2 (3), 75-79. doi:10.24911/IJMDC.51-1518969658