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By Cheri Lucas Rowlands

Since the first operation in Bangkok in 1975, Thailand has become one of the top destinations for gender confirmation surgery (GCS). But what drives people to seek trans healthcare in Thailand, and why would so many patients rather fly across the world for the procedure than do it in their home countries? In her new story for Longreads, “Finding a Path in a Broken System,” Bangkok-based visual journalist Mailee Osten-Tan explores these questions and more. She spent the past year researching and reporting this feature, speaking with 15 trans women around the world about their experiences. I asked Osten-Tan about what attracts her to a story, the challenges she faced working on this piece, and her creative approach as a visual storyteller.

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Your work spans written and multimedia features, on a range of issues in Thailand and abroad. What do you look for when you search for a project?

Growing up in a mixed-race immigrant family in a majority white area in the U.K., I have always felt like I occupied a space somewhere on the periphery — not quite part of the community around me but not completely divorced from it either. The older I become, the more I understand this to be a fundamental part of human nature; that all of us are in various ways searching to find our place in society and to feel like we belong. I think that’s why I find stories of people from marginalized communities, or those in the process of defining themselves, so compelling. Discrimination is often at its core political, but I’m more interested in how discrimination impacts lived human experiences. Wanting the acceptance of others is so universally relatable that it can be an important entry point for anti-discrimination advocacy. I also love visual journalism because it opens doors to worlds I would never otherwise interact with. For example, for Al Jazeera, I’m currently working on a photography feature about a woman cockfighting bird breeder in the north of Thailand, breaking into a very traditionally masculine sport.

When you pitched us, you had already been in touch with a number of trans women who had experienced GCS in Thailand. As you got deeper into reporting, you met and interviewed a few more. How did you widen the scope of this story while taking care to maintain your focus?

* The Suporn Clinic is one of the leading centers for GCS in the world and is discussed in Osten-Tan’s story.

I wrote this piece with two purposes and two audiences in mind. Firstly, I wanted to unveil what getting GCS could look like for those who do decide to go to Thailand. I was spurred on by the trans women I interviewed; some of them told me they wished information on getting GCS in Thailand was more readily available from a verified source. This is not to say there isn’t information out there — for example, an expansive account of someone’s experience with the Suporn Clinic* is still widely shared within the community, although that patient’s surgery was from 2015. The r/TransSurgeriesWiki on Reddit is also a really great place to start. Secondly, I wanted to build a non-trans audience’s understanding as to why so many trans women would rather undergo major reconstructive surgery abroad. I came to this story assuming that low costs were behind Thailand’s popularity, but after speaking to six sources, I realized it was a lot more complicated than that. To get a fuller picture, I knew I had to speak to as many trans women as I could, after which I started to notice trends: For example, some were seeking a different technique than penile inversion, while others were desperate after spending years on waiting lists.

By focusing my reporting on bigger trends, it meant that there were things that didn’t end up in the story. For example, I had the impression some felt they couldn’t trust their doctor to have their best interests at heart. This might have influenced their decision to seek care elsewhere. One patient told me that a GCS surgeon in the U.S. had told her to consult “her boyfriend’s penis size” when she asked what kind of vaginal depth she could expect from surgery. She said she felt that medical staff were placing a higher value on prospective men’s pleasure than her own. But I was also told how a clinic staff member in Thailand was providing dilation demonstrations with a Fleshlight; using a sex toy for people with penises to show GCS patients how to keep their new vaginal canal open feels really inappropriate to me. Regardless of where you are in the world, the language and behavior of those in the medical field toward trans patients shows that even when barriers to access are addressed, it’s changing peoples’ implicit biases that’s the real challenge.

A woman with red hair sits on a bed in a hotel room in Bangkok
Dissatisfied with her care in the U.K. through NHS England, Amy traveled to Thailand for GCS under Dr. Kamol Pansritum at the Kamol Cosmetic Hospital. Here, she sits on her bed in a hotel room in Bangkok.

From the beginning, you envisioned Amy’s journey as the narrative backbone of this piece. Can you say a bit more on that?

I wanted to find someone who might be open to me reporting on their GCS experience in real time. I was lucky; someone put me in touch with Amy a few weeks before she was due to fly out in June 2021. Unfortunately, COVID-19 cases in Thailand surged after her arrival, leading to new lockdown measures. It became impossible for me to keep her company in person, but I waved at her from behind a glass barrier in the arrivals hall of Bangkok Suvarnabhumi Airport after she landed. We chatted online throughout her stay, and being in the same time zone was helpful. I was so glad when we finally got to meet three weeks later.

As you followed Amy on her journey and spoke with other trans women, like Penny and Yui, what were some of the biggest challenges in reporting this piece?

As a cisgender woman, I spent a lot of time debating whether I was the right person to report the story. I came to an uneasy truce; more opportunities should be provided to trans journalists, but I also felt I owed it to those I interviewed to help make their experiences heard. The process also widened my eyes to the extent of my own ignorance. I had considered myself an ally, but the hours I spent speaking to different trans people over the last year made me realize how passive that definition can be. Reporting this story was a humbling learning curve. That’s also why I’m really grateful for the time my sources gave to this story and the trust they instilled in me. I was floored by their kindness.

Wanting the acceptance of others is so universally relatable that it can be an important entry point for anti-discrimination advocacy.

What was something you learned while working on this story?

I definitely became conscious of my own biases about the gender spectrum and how that was affecting the way I was writing this story. We are as a society still uncomfortable with people who do not fit into the gender binary. Phrases like “woman trapped in a man’s body” or thinking of GCS as the “process of becoming a real woman” are common to a point that many don’t even realize they’re exclusionary. People often have a difficult time consolidating the urgency some trans people feel around receiving the surgery they need with the understanding that those same trans people may not want to “do a complete gender switch.” Some identify as trans and want to keep the sex they were assigned at birth in addition to receiving GCS. There are people who identify as trans and who are uninterested in GCS. That doesn’t invalidate their identity or their needs. Within the trans community, some of my sources told me they felt conflicted by the idea of “passing” or being perceived as the gender they identify as, rather than the one they were assigned at birth. Passing is sometimes a question of safety, not only preference. Others felt indignant about needing to pass just to satisfy society’s expectations. Gender identity is expressed and experienced differently from person to person. I had to keep checking that I was being cognizant of that.

I had considered myself an ally, but the hours I spent speaking to different trans people over the last year made me realize how passive that definition can be.

As a photographer, what’s your creative approach or philosophy when taking portraits of people? 

Many of the trans women I spoke to wanted to remain anonymous, so I knew that building rapport would be an important first step. But I also wanted to be mindful not to overstep boundaries. I always asked if I could take a source’s picture after having interviewed them, not before, to give them some time to get used to me being in their space. Even then, Amy was a little hesitant at first but I showed her the images and she had a say in what I submitted. Something I’m still working on is projecting my personal feelings about photography onto my subjects — I hate having my own picture taken. This can sometimes prevent me from being more assertive even when I have consent. But I think being compassionate is really important; I’m sensitized when my subjects seem uncomfortable. I’m still figuring out that balance, especially when reporting on a community that has experienced so much stigma. As a self-taught documentary photographer I’ve also realized that getting images that feel authentic takes time. Pressing the shutter takes just a second, but what people don’t see is the amount of time photographers spend building rapport with their subject to get to that point.

Photo of the back/side of a woman's head as she looks out of a window in Chonburi, Thailand
Yui, one of 15 trans women that Osten-Tan spoke to for this story, traveled from Norway to Thailand for GCS. Here, Yui looks out the window of her hotel room in Chonburi, a province in eastern Thailand.

In addition to your story on Longreads, you’re working on other projects that tell and amplify the stories of women and nonbinary people. What’s one thing you’ve learned from your reporting within these communities, and from talking with trans people across countries, that you’d like to pass on to other journalists?

A few years ago, I volunteered for a sexual assault helpline which had a huge influence on me; part of our training talked about leaving our own lives and judgements at the door so that we could hold space and really listen to someone else. That concept has shaped my reporting practice today, especially the stories I’ve covered that have been on sensitive issues. Last year, I shot a short film, The Diver, about a woman coming to terms with her LGBTIQ+ identity and redefining her self-inflicted scarring. I collaborated with the Sexual Assault Response Services of Southern Maine on a video about the misconceptions people might have around supporting survivors of violence. It helped that I had an intimate understanding of what these kinds of helpline services do already. While reporting for Longreads, I met the subject of my current short film: a trans woman from Pittsburgh in the U.S. who has just undergone GCS here in Thailand. These are all tough topics to tackle in their own ways — especially through film which can be more time-intensive and feel more invasive. When I’m interviewing, I let my sources know at the very beginning that I won’t be offended if they don’t want to answer something, and if that happens I don’t push them. I try to be careful about how I frame my questions, and ask as many open-ended questions as I can, adapting to what they want to talk about. Some of my interviews can be more than two hours long, but it feels necessary in the moment. Interviews will tend to come to a natural end anyway. Being conscientious of trauma-informed reporting approaches is something I want to keep working on.

Cheri Lucas Rowlands

Cheri has been an editor at Longreads since 2014. She's currently based in the San Francisco Bay Area.