Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study

Stigma- and discrimination-driven inequities suffered by transgender people (e.g., insufficient or nonexistent rights and protection, inadequate healthcare services, poor educational and professional opportunities, victimization, rejection, and isolation) [1‐5] can lead to mental problems, negative health outcomes, and negative behavioral consequences (e.g., depression, psychological distress, suicidal ideation, poor self-worth, substance use, and taking sexual risks) [6‐13]. It has previously been reported that transgender individuals also experience health inequality in the treatment of HIV, mental health problems, and drug and alcohol use compared to cisgender individuals [8, 14‐18]. Several researchers have also reported that transgender individuals experience a higher prevalence of discrimination compared to gay, lesbian, and bisexual individuals, which adversely affects their health and well-being throughout their lives [19‐21]. Hughto et al. [6] clearly explained how social stigmatization (the process of labeling, stereotyping, and marginalizing as a form of social control) can impact transgender people's well-being. It can occur at the structural, interpersonal, and individual levels and is a fundamental cause of adverse health outcomes among the transgender population.

The number of transgender individuals seems to have been underestimated due to social barriers against recognizing gender identities outside of the usual gender binary model (a person can only be a biological male identifying as a man or a biological female identifying as a woman) and the reluctance of transgender people to disclose their gender identity [22, 23]. Thus, the amount of healthcare data available on the transgender population is limited as only gender binarism has historically been applied (with a few exceptions) for data collection in population-based studies. Emerging findings on transgender people's differential healthcare experiences have revealed important disparities among gender identity/expression subgroups. Transgender men were twice as likely as transgender women to postpone needed healthcare due to anticipated discrimination [24, 25]. Although non-binary individuals are less likely to delay receiving healthcare than transgender women [25], they are also significantly less likely to report being treated with respect by healthcare providers after disclosure of their transgender identity compared to cisgender individuals [26]. To the best of our knowledge, no studies have been conducted on the healthcare experiences of transgender people in Thailand.

It has been reported that poor healthcare and/or discriminatory treatment of lesbian, gay, bisexual, transgender, and others (LGBT +) individuals in the healthcare system are primary associated factors of mental health issues [27]. Both direct and indirect discrimination by healthcare providers toward LGBT + individuals were reported in a previous study in Thailand including (1) inappropriate disclosure of private information, (2) a lack of awareness and competence when addressing LGBT + health issues, (3) applying unequal standards of care to LGBT + versus cisgender individuals, (4) characterizing LGBT + status as a mental illness, and (5) outright refusing to treat LGBT + people [27].

The Tangerine Community Health Center in Bangkok, which opened in November 2015, is the first clinic in Thailand to provide trans-specific healthcare and counseling [28]. Currently, more gender-affirming healthcare services (i.e., access to counseling, hormone treatment, gender-affirming surgery, and other transgender-related surgical procedures) are being established in both public and private hospitals, as well as transgender-exclusive non-profit organizations [29]. Moreover, the Thai Ministry of Public Health has reported on transgender people’s access to HIV and sexually transmitted infections (STIs) services and found that around 15% of healthcare providers had negative attitudes toward transgender women who sought HIV-related services. These negative experiences were circulated and communicated within the community, and consequentially, many transgender people delay or avoid seeking healthcare services [30].

We hypothesized that experience and stigma issues are associated with the willingness to seek and the expectation concerning healthcare services among the transgender population in this study. Previously, the findings from studies in several countries (i.e., Argentina, Australia, Jamaica, the US, and Thailand) have revealed that transgender individuals who experience stigma and discrimination when accessing healthcare services avoid/delay accessing general healthcare or seek non-traditional healthcare services [27, 31‐37]. Gender identity is an interesting variable. Researchers in the United States found that the transgender men were 1.29 times more likely than transgender women to attend a transgender-specific care provider [33]. Hormone usage and the pathway to access it are also interesting. Previously, researchers in the US and Thailand reported that transgender women were less likely than transgender men to attend a hormone management program and transgender-specific care [33, 37, 38]. In addition, in previous studies in the US and Canada, the authors also found that the avoidance of accessing healthcare services by transgender individuals resulted from the lack of healthcare providers who understand transgender concerns [26, 39]. Although the discriminatory experiences of transgender people seeking healthcare services have been well-documented in several studies, differentiating them based on gender identity/expression and related factors has been limited. The experience, attitude, and expectation toward accessing healthcare services and healthcare providers might be different between transgender women and transgender men, and to the best of our knowledge, no study has been conducted to examine the relationship between discrimination experiences and the attitude and expectation toward accessing healthcare service in this context in Thailand. The aim of this study was to compare the characteristics, experiences, attitude, and expectation of transgender women and transgender men in Thailand toward accessing healthcare services and healthcare providers. We also investigated the effects of characteristics, gender identification, and discrimination experiences on gender-affirming healthcare avoidance and the expectation that healthcare workers/staff can fulfill transgender healthcare needs.

This cross-sectional study was conducted on transgender women and transgender men in Thailand to compare their characteristics, as well as experiences, attitude, and expectation toward accessing healthcare services, and investigate their effects on the gender-affirming healthcare avoidance and expectation that healthcare workers/staff can fulfill transgender healthcare needs. Our findings show that experience of unfair gender discrimination from healthcare providers toward transgender individuals was relatively higher (51.4%; 95% CI = 63.4–88.2) than that reported in previous studies in the US and Australia (approximately 10–41%) [31‐35]. The discrimination experience when accessing healthcare services was also higher compared to the general population in Thailand (5%) [45]. Our findings also show an association between experience of discrimination from healthcare providers and buying hormones or medicines without a physician’s supervision. This is consistent with findings from previous studies suggesting that transgender individuals avoided or delayed seeking medical care due to their concern about discrimination from the healthcare providers [36, 46]. The results of previous studies also suggest that the experience of stigma and discrimination from accessing healthcare services might affect them to avoid/delay accessing general healthcare or to switch using healthcare services from non-traditional healthcare services [31‐37].

Our results show that transgender women were fourfold more likely to buy hormone treatment from non-traditional healthcare services (cOR = 3.89; 95% CI = 1.18–12.83) than transgender men. This is consistent with the outcomes of previous studies in Thailand and other countries inferring that transgender women were less likely to attend a hormone management program and transgender-specific care than transgender men [33, 37, 38]. A previous survey in Australia showed that 31% of transgender individuals thought that accessing hormones was too difficult, 17% thought that the cost of a doctor’s appointment was too expensive and 16% were unable to find a doctor to prescribe hormones [31]. Meanwhile, most feminizing hormones can be purchased over the counter without a physician’s prescription in Thailand [47], which might have influenced the decision of transgender individuals to obtain hormone treatment without the physician’s prescription.

Although the transgender men had a significantly higher monthly income than the transgender women in our study, income was not associated with the decision to access healthcare among the transgender individuals. The cost of accessing the healthcare service might be one of the factors related to avoidance or delays in assessing general healthcare. The findings from a previous study in the US infer that transgender men are more likely to avoid accessing healthcare services than transgender women due to the cost (34.8% versus 25.0%). In addition, there is also a barrier when transgender individuals try and attain health insurance. The outcomes of previous studies suggest an association between avoiding accessing healthcare services and health insurance issues among transgender populations [36, 48]. In Thailand, gender-affirming surgery and other related healthcare services are non-reimbursable in both the public and private health insurance systems, so transgender individuals will have to pay for it themselves [49]. However, the costs and access to health insurance for transgender individuals were not included in this study. Further study to explore the influences of these factors on the decision to access traditional healthcare services would be interesting.

Other than the barriers due to the cost of healthcare services and health insurance, other barriers might influence the decision to access healthcare from traditional healthcare providers, such as affordability, service accessibility, the healthcare provider, and the waiting period [50]. The outcomes from a previous study in the US indicate that transgender men are 1.29 times more likely than transgender women to visit a transgender-specific care provider [33]. This is consistent with our study, in which transgender women were significantly more likely to receive general healthcare service from non-traditional healthcare providers (cOR = 4.28; 95% CI = 1.55–11.81) and received healthcare counseling from non-traditional healthcare providers (cOR = 5.16; 95% CI = 1.42–18.75) than transgender men in the previous year. A lack of specific knowledge of transgender health, inclusive policies, standards of trans-competent healthcare, and specific healthcare services available for transgender people might produce barriers to accessing traditional healthcare services. We found that more than 70% of transgender individuals agreed that seeking a healthcare provider who understands transgender concerns is not easy (71.9%; 95% CI = 64.8–78.2). Similar to the results of a previous study in the US and Canada, a major barrier to accessing healthcare services among transgender individuals is due to healthcare providers not understanding transgender healthcare issues [26, 39].

Although there are several services in the healthcare setting for transgender people (i.e., access to counseling, hormone treatment, gender-affirming surgery, and other transgender-related surgical procedures), approximately 15% of transgender individuals who participated in our study did not know that gender-affirming healthcare services were available in Thailand. Moreover, those who did not know about the availability of gender-affirming healthcare services were fourfold more likely to avoid counseling (aOR = 3.70; 95% CI = 1.11–12.36). According to the Thai handbook of transgender healthcare services in 2021, the key recommendations for public health policies were to improve access to healthcare for transgender people by including a transgender healthcare service package in the national health coverage, to treat transgender clients with respect and dignity, to provide access to transgender healthcare services and information for everyone across the country, to educate and train healthcare providers of all levels on transgender-competent care and sensitivity, and to conduct more research on and include transgender people’s health needs [51].

Although transgender women were more likely to buy hormone treatment and receive healthcare counseling from non-traditional healthcare services than transgender men, gender identity was not associated with the willingness to receive counseling from a gender-affirming healthcare service. However, the transgender respondents who disagreed with or were neutral about buying hormones or medicines without a doctor’s supervision were sixfold more unwilling to receive counseling from a gender-affirming healthcare provider than those who agreed (aOR = 5.53; 95% CI = 1.50–20.42). Although the specific reasons for their unwillingness were not considered in the present study, it would be beneficial to investigate them in the future. In addition, since we adjusted the model to account for gender identity, there might be other confounding factors to be investigated in further study.

There are some limitations of this study. First, the data collection using online platforms such as websites and Facebook pages of local transgender and LGBT organizations and groups might have contributed to selection bias. A transgender individual without access to the Internet would not have been able to fill in this online survey questionnaire. In addition, the non-probability sampling methods and self-reporting used in the study limit the generalizability of the results. We used a cross-sectional study design and thus, the recognition of causality cannot be inferred. Second, the relatively small sample size in our study might not have truly covered the demographics, diversity, and variations in the transgender community, such as gender, age, nationality, religion, and city of residence. Finally, we did not include some variables that might have contributed to or have been consequences of healthcare avoidance among the transgender populations, such as the cost, right to treatment, reasons for avoidance, physical and mental health issues, the side effects of long-term hormones usage, and the difference between receiving standard and non-standard healthcare. Therefore, a well-design future study (e.g., a longitudinal study) with a larger sample size and incorporating other factors should be conducted to determine the factors influencing healthcare access and the consequences of accessing healthcare among the transgender population.

The findings from this cross-sectional study indicate that transgender women are more likely than transgender men to receive general healthcare and hormone treatment from non-traditional healthcare services and buy hormone treatment without a physician’s supervision. Although gender-affirming healthcare services exist in Thailand and are established in public and private hospitals, and transgender-exclusive non-profit organizations, we still found that approximately 15% of transgender individuals did not know about gender-affirming counseling services and were less likely to seek counseling via gender-affirming healthcare services. In addition, transgender women were significantly more likely than transgender men to receive hormone treatment and gender general healthcare services from non-traditional healthcare services. Continuing to improve access to healthcare for the transgender community, increasing public relations channels about how to access and locate gender-affirming healthcare services may encourage transgender people, especially transgender women, to access them more often.